MBS Valuable Medical Works DA COSTA'S MEDICAL DIAGNOSIS. MKPK'AI. DIAGNOSIS, with Special Helen-nee to Practical Medicine. A (iuido to flu Knowledge ami OiM-riniinat ion of Diseases. My .[. M. I>A ( '' >STA, M.D., Lecturer on Clinical Medicine, and Physician to the Philadelphia Hospital; Follow of tin- Colli-icr of Physician:- i -ideiphia. AC. AC. Hlustrated with Numerous Engravings, l vol. svo. .-o.no. "No luanu; pivpai at Un- made : styli- < . . . T< it^ n:i- "Th, style The ai intclli or vi-i-1 short < oil) )>r; Fro ai'.lhoi ^^ Presented by George L Hampton, D. 0. COLLEGE OF OSTEOPATHIC PHYSICIANS AND SURGEONS LOS ANGELES, CALIFORNIA in an thor, as i ii- its or recent M-C are that will find it : well meets ; the reader knowledge o the dian- he may be nl it to our d to hold ;i dical litera- we can only e us is ,-, r- fact ilioiier. !S teaclihm-s If Mich was result and profe-- i .jeopardy. his manual vice. Kach '.ed. and the ' plain, that tentive s|u- RKPOKTfflR. y, ami c\a- Plal liberty . K >k 1 1 1 " 111 tin- li" i;ilo\vlc(lr :ili'l <1: ,-,(! in : illllal every i-\ iio ctlng- merit, exhitiitini; a close oul\ with the philosophy of disease in neiie- ral, but a familiarity with the detailed evi- dences of 1he derangements of the various nd functions, indicativeof a Iar^ei-\- and accurate study. The /.ylonraph ic illustrations of the anatomical lesions which Hive rise to various sinus of disease of the. ire well drawn, and gi lacilitate the explanation of the I. From the Press of J. B. Lippincott & Co. ^* THOMAS'^TtfONOU^ING MEDICAL DICTIONARY. A COMPKKI1KNSIYK MKDH'AL DICTIONARY. < oiitaining the Promtncia' ' ,logj-, \ "aiuLSigniticjition of the Terms made use of in Medicine and [lie Kindred Scieii'-, - \v; . Appendix, comprising*^ Complete List or all the more important Article- Mcdica, arranged according to their Medicinal Properties. Also, an i Latin Terms and Phrases occurrnm in Anatomy, Pharmacy, Are. Together with soi , sary Directions for writing Latin Prescriptions. A.-C. I'.v .I.THOMAs, M.D., Auth Qf Pronunciation in "Lippincott's Pronounchu of the World." Demi svo. cloth, >.v>o. sneep_. S.-J.T.-,.. ^ * v WASH i xi rrox < 'rrv. D. c. February 10, !MM. I 'Siu: In accordance with the ivcom- , mendation of the Army Medical Hoard, re- nt ly convened at Philadelphia, the issue the Mi-iii,'nl /Hi-tii>iiitrj/, of which you are ie audio.-, to medical officers in I he tield, will be authorized in the Revised Supply ible soon to lie published by this Depart- ment. " P>y order of the surire. >n-< General: " \'ery resi>eet fully, " Your obedient servant, 'W. C. SPKXCKK, '.1W. Snri/rnii I'.S. A nni/. "Di:. .1. TlfoM AS. "Philadelplria." VOr. If. VAN P,ri:i-:x. M.D., Professor of mil in tin' Cuii-i'i-xiti/ of A'rf Ynrl;. Dr. Thomas's Comprehensive Medical Dictionary, recently published by .1. P>. Lippincott i\; Co., as the best Dictionary ot !(< si/.e within the reach of the student and practitioner. Its directions for the pro- nunciation of Latin terms, and for the correct writing of pre< .!/.i and accurate, and I have already : mended it to the medical class of the T'nive; Maryland." From D. HAVKS A(;NKW, M.D.,f 7//I/V"/ Lectun r "ii Hnri/i i-i/, I..'rhii-< r an Ainifmni/, <(<. ",: "1 have examined Dr. Thomas's Medical ''. Dictionary with no small degree of care, i have n. i.re industry, research, and ; scholarship compressed into so small a com- | In my ran ire of readimr, I know of no '*.' book which combines so pre-eminently tho- '' roughness with brevity, conciseness with p. spicuity and copiousness without redu; dancy, as this work. I anticii of no ordinary chani' in tli' ::. A. !'. PKNKOSK, M.D., /'- xMricx in lh>> {.'i>ii-"rxiti f of ]>,,< "I have evamined Dr. Thomas's Pro iiiii M.-.lical Dictionary thoroughly. "I tind it eharacteri/.e-l by con r eom]ileteness: while its arra excellent. "AS a work for daily reference, I pi, to all other medical dictiona Dm "ioi:: I thank you for th. of your Comprehensive Medical Dictionary I have given ii an attentive examii and have been so much pleased therewith ihat I shall recommend it to my students. From its convenient si/.e, the eoncisen its definitions, and the pronunciation ami i, it must prove a useful medical student. The Ap- pendi- ly important addition; arts relating to :i termsand phrases,and the ! ,.: presi-;-i]iti requisite for its maintenance upon a level with the progressive condition of medical science, unremitting diligence was essential in prosecuting inquiry and investigation in the whole field of Pharmacology. In addi- tion to the ordinary professional opportunities, he has, for about twenty years, held the office of one of the physicians of the Pennsylvania Hos- ^j pital, which has given him facilities for testing the value of remedies greater than any amount of private practice could afford. Few persons have had greater advantages or stronger inducements than himself for acquiring the knowledge requisite for the production of a work of this (v) vi PREFACE TO THE FIRST EDITION. kind. Of the extent to which he has availed himself of these oppor- tunities, and his ability to make a proper use of them, the reader will form his own opinion, either from what he may find in this Treatise, or from what he may know of former works of the author. In preparing the present work for the press, the author claims to have been actuated, in part at least, by motives higher than those of personal credit, or pecun r ary advantage. Though he pretends to no insensibility to these ordinary influences, he believes that he is obeying a call of duty in laying before the profession those results of his research, experience, and reflection upon the subject of Therapeutics, which have heretofore been confined to the narrower limits of classes of medical students. His former lectures constitute the chief substance of the present Treatise, though considerably extended, and much elaborated. Perhaps he may be laying himself open to a charge of overweening self-estimation, in supposing that he can add to the existing mass of knowledge, or improve existing views in this department of medicine, in a degree which may justify the publication of a book like the present; but he is unwilling to leave the world without giving some degree of permanency to what he has so long taught, and consoles himself with the consideration that. should the work prove of less value to the profession than he ventures to hope or anticipate, it is not likely to do serious injury, and, at the worst, will be merely superfluous. A few words of explanation may be necessary to a correct appreciation of the character of the Treatise. Though aiming at considerable fulness in all that concerns the effects of remedies, the nature of their operation, and their therapeutic application, it has no pretension whatever to be considered as a complete exposition of the Materia Medica, properly so called. Of the natural and commercial history, the sensible and chemi- cal properties, and the pharmaceutical preparation of drugs, the author has endeavoured to select such parts as are of direct and immediate interest to the medical practitioner, and without a knowledge of which, he can scarcely be said to be prepared to enter upon the duties of his profession. All, therefore, that is said on these points may be considered as, in the opinion of the author, requiring the particular notice of the student. He has given much attention o this branch of the subject, in reference both to the general value and the accuracy of the facts stated ; having, in many doubtful instances, practically verified their correctness. In the prosecution of investigations for this purpose, he has pleasure in acknowledging his indebtedness to Professor William Procter, Jr., who has, at his suggestion and request, performed many experiments in rela- tion to the chemical properties, reactions, and incompatibilities of the medicines described. The work will not be found rich in formulas. Nothing would have PREFACE TO THE FIRST EDITION. Vll been easier than to attach numbers of prescriptions to every important medicine described. But the author has always considered that a mul- tiplication of these precise combinations is productive of much more in- jury than good. It leads to an indolent reliance on mere authority, by sparing the trouble of thought ; and greatly conduces to an empirical and routine practice, neither creditable to the physician, nor profitable to the patient. The author has preferably sought to give principles, by which the physician, himself may construct formulas, suitable to each special occasion. He has endeavoured to point out, in reference to each medicine, the peculiar circumstances which render its use appropriate, and the modifications in dose or form which it must undergo, to adapt it to the varying circumstances of different cases, or of the same case at different times. He has also Called attention to the medicines with which, in each special case, it may be appropriately combined, to aid or qualify its operation. 'With this knowledge, and that of the patholog- ical condition to be corrected, the educated physician will be qualified to form much more appropriate associations or combinations of medi- cines, and to regulate much more correctly the proportions of the several ingredients in correspondence with the indications, than any formulary can possibly do for him ; nor can any medical man be considered as duly instructed, until he is capable of constructing such formulas for his own purposes. To any one familiar with the author's Treatise on the Practice of Medicine, it will be obvious, in the perusal of the present work, that the same great principles of pathology pervade both, and constitute in fact the very basis of whatever belongs to the general subject of Therapeu- tics in the latter. The author has avoided an elaborate representation of these principles on the present occasion ; as it would render neces- sary a repetition of much that is contained in his observations on gen- eral pathology in the former Treatise, to which, therefore, he would re- spectfully invite the attention of the reader, if desirous of information on the subject. Finally, it is proper to state that, on a comparison of this work with the Treatise on the Practice, upon the one hand, and the U. S. Dispen- satory on the other, there will be found not a little that is common to it and one or both of the others ; but this overlapping, at the borders, of Treatises on closely allied subjects is absolutely essential to a full and consistent view of each, and is nothing more than is found in all con- terminous sciences, not only in the great complex science of medicine, but throughout the whole circle of human knowledge. This is probably the last professional Treatise of the author; as, with its publication, he will have exhausted what he has had to communicate in those departments of medicine to which he has given a special atten- vili PREFACE TO THE FIRST EDITION. tion ; and advancing years warn him that the time is fast approaching, when a failure of faculties, or the termination of life, will render labour in any new field impracticable. He asks for it only the same kindly con- sideration which he has had occasion to acknowledge for his other works, and which has bound him to the profession by the strong ties of grati- tude, in addition to those of duty and affection. PHILADELPHIA, August, 1856. PREFACE TO THE THIRD EDITIOX I\ consequence of pressing engagements in the revision of his other works, which could not with propriety be postponed, the author has been compelled in some degree to neglect the present, which has now for several months been out of print. About seven years have elapsed since the second edition was given to the public ; and, as this period has been one of extraordinary activity in the cultivation of medicine, it will be readily perceived that much labor was necessary, on the part of the author, to bring the work fully up to the level of the present time. For nearly a year, with a short intermission rendered unavoidable by family affliction and his own impaired health, he has devoted most of his time to this object ; and the reader will perceive, by the additions made to the Treatise, and the numerous modifications necessary to keep pace with the advance of the science and the change of opinion, that the task of revision has been no sinecure. Besides many of minor im- portance, the following remedial substances have been treated of, and some at considerable length ; to wit, coca, nitrous oxide, antimoniated hydrogen, gelsemium, calabar bean, bromine and its preparations, lithia and its carbonate and citrate, ozone, peroxide of hydrogen, per- manganate of potassa, and sulphurous acid and the sulphites with car- bolic acid in their antizymotie relations. The progress of the science has rendered advisable the formation of two new classes, in order prop- perly to arrange several substances of peculiar powers ; one embracing the disinfectants, which now hold an important place among the means of encountering disease; and the other named antizymotics, because endowed with extraordinary powers in arresting fermentative pro- cesses, which are recognized as exercising a most noxious influence in the causation of disease. The size of the type used in the former editions has been so much reduced in the present, as to enable the quantity of matter contained in each page to be increased at least one-tenth ; and yet, to accommodate the new material, it has been found necessary to add considerably to the bulk of the book. The subjects of subcutaneous injection, and of the introduction of liquids into the air-passages by 1* (ix) X PREFACE TO THE THIRD EDITION. bringing them to the state of fine spray, which are now for the first time fully considered in this Treatise, involve so large a number of sub- stances in their practical application, that a constant watchfulness was necessary, in the revision, not to allow important medicines to pass un- noticed in this relation. The author is not aware that any topic, having a direct bearing upon the subject of the work, has been neglected in preparing it for the press; and he thinks he may justly say that, what- ever may have been the merits of the former editions, as exhibiting the condition of the Materia Medica at the periods respectively when they were issued, the present will not be found to have deteriorated as representative of the existing state of the science. The author wishes once more to repeat the assurance of his warm interest in the^advancc- ment of the profession and its prosperity in all respects, and of his grateful feelings towards its members personally for the kindness which his labours have always received at their hands. PHILADELPHIA, Oct. 15th, 1867. There are a few abbreviations used throughout the work which require explana- tion. The letters U.S., attached to a medicinal name or process, are to be under- stood as referring to the authority of the existing United States Pharmacopoeia ; Br., to that of the first British Pharmacopeia published in 1864; and Lond.,Ed., Dub., to that of the last Pharmacopoeias published by the London, Edinburgh, and Dublin Colleges respectively, but now superseded by the British. In an Appendix will be found tables showing the differences between the British Pharmacopoeia recently published, and tho first edition of that work, published in 1864, which has been recognized throughout this Treatise as the British standard. The reader is requested to supply two omissions, from inadvertence, in the fol- lowing pages; one, of Moschus Moschiferua, the name of the animal described as furnishing musk (vol. i. p. 690), and the second, of Cephaelis Ipecacuanha, as the botanical title of the ipecacuanha plant (vol. ii. p. 465). TABLE OF CONTENTS. PART I. GENERAL THERAPEUTICS AND PHARMACOLOGY. CHAPTER I. OPERATION OF MEDICINES. Section I. PRIMARY OPERATION OP MEDICINES. Subsection I. PRIMARY OPERATION THROUGH THE CIRCULATION, OR BY ABSORPTION. Subsection IT. PRIMARY OPERATION THROUGH THE KERVES. Subsection III. PRIMARY LOCAL OPERATION. Subsection IV. MODES OF PRIMARY OPERATION. 1. Mechanical or Physical. 2. Chemical. 3. Physiological, Vital, or Dynamic. Section II. SECONDARY OPERATION OP MEDICINES. 1. By Depression after Excitement. 2. By Reaction following Depression. 3. Through Dependence of Function. 4. Through Sympathy or Nervous Transmission. 5. Through Revulsion or Derivation. 6. Through the Repair of Injuries. 7. Through the Removal of the Cause. CHAPTER II. EFFECTS OF MEDICINES. > Section I. ESTIMATION OP THEIR POWERS OR EFFECTS. 1. Through their Sensible Properties. 2. Through their Chemical Relations. 3. Through their Botanical Affinities. 4. By Experiments and Observations on the Lower Animals. 5. By Observations of their Effects on Man. Xli TABLE OF CONTENTS. Section II. WHETHER THE EFFECTS ARE ORGANIC OR FUNCTIONAL. Section III. CHARACTERISTIC EFFECTS OF MEDICINES. Section IV. INFLUENCES MODIFYING THE EFFECTS OF MEDICINES. 1. Age. 2. Sex. 3. Temperament. 4. Idiosyncrasy. 5. Disease. 6. Cli- mate. 7. Habit. 8. Modes of Living. 9. Mental Action. CHAPTER III. APPLICATION OF MEDICINES. Section I. MODES OF THERAPEUTIC ACTION, OR THERAPEUTIC PROCESSES. 1. Depletion. 2. Repletion. 3. Dilution 4. Elimination. 5. Stimulation. 6. Sedation or Depression. 7. Revulsion, Derivation, and Counter-irriia- tion. 8. Supersession or Substitution. 9. Alteration. 10. Contra-causa- tion. 11. Chemical Influence. 12. Mechanical Influence. Section II. FORMS IN WHICH MEDICINES ARE USED. Subsection I. SOLID FORMS. 1. Powders. 2 Electuaries. 3. Conserves. 4. Pills. 5. Lozenges. 6. Cata- plasms. 7. Ointments, Cerates, and Plasters. 8. Extracts. Subsection II. LIQUID FORMS. 1. Mixtures. 2. Solutions. 3. Waters. 4. Infusions. 5. Decoctions. 6. Tinctures. 7. Spirits. 8. Wines. 9. Vinegars 10. Syrups. 11. Honeys. 12. Oxymels. 13. Fluid Extracts. 14. Glyceratesor Glyceroles. 16. Spray. Subsection III. IN THE AERIFORM STATE. Section III. PARTS TO WHICH MEDICINES ARE APPLIED, AND MODES OF APPLICATION. Subsection I. TO THE ALIMENTARY CANAL. 1. to the Stomach. 2. To the Rectum. Subsection II. TO THE EXTERNAL SURFACE OF THE BOOT. 1. By Contact with the Sound Skin. 2. By Friction. 3. Endermic Application. TABLE OF CONTENTS. Xlll Subsection III, TO THE LUNGS. 1. By Inhalation. 2. Use of Liquids in the form of Spray. Subsection IV. TO THE SUBCUTANEOUS ABEOLAE TISSUE. Hypodermic or Subcutaneous Injection. Subsection V. TO VARIOUS OTHEK SURFACES. 1. The Eyes. 2. Nostrils. 3. Mouth. 4. Blood-vessels. CHAPTER IV. CLASSIFICATION OF MEDICINES. 1. Uses of Classification. 2. Plan of Classification. PART II. SPECIAL THERAPEUTICS AND PHARMACOLOGY. Division I. SYSTEMIC REMEDIES. Subdivision L GENERAL REMEDIES. CHAPTER L GENERAL STIMULANTS. Section I. PERMANENT STIMULANTS. CLASS I. Astringents. I. General Observations, including the consideration of Cold as an Astringent. II. VEGETABLE ASTRINGENTS. Galls with Tannic and Gallic Acids; Oak Barks; Kino; Catechu with Gambir; Rhatany ; Logwood; Cranesbill; Blackberry and Dewberry Roots; UvaUrsi; Pipsissewa; Red Roses; Tormentil; Water Avens; Hardhack; Pomegranate Rind; Bistort; Alum Root; Marsh Rosemary; and Persimmon. III. MINERAL ASTRINGENTS. Alum; Lead and its Preparations ; Sulphates of Iron, Zinc, and Copper, and other salts of the same metals ; and various other mineral substances, as Nitrate of Silver, Corrosive Sublimate, Sulphuric Acid, and Lime with its Carbonate. xiv TABLE OF CONTEXTS. CLASS II. Tonics. I. General Observations, including the consideration of Diet, Exercise, Pure Air, Mental Influence, Travelling, Cold, and Transfusion of Blood, as tonic agencies. II. TONICS OF ANIMAL ORIGIN, of which only Cod-liver Oil is considered. III. VEGETABLE TONICS, subdivided into, 1. Pure or Simple Bitters, comprising Quas- sia, Simaruba, Gentian, Star-grass or Aletris, Chiretta, American and European Centaury, American Columbo, Columbo, Goldthread, and Yellow Root; 2. Pecu- liar Sitters, comprising Peruvian Bark with Qiiinia and its other preparations, Nectandra, Dogwood, Willow Bark, Hydrastis, Barberry, Hops, Wild Cherry Bark, Chamomile, German Chamomile or Matricaria, Eupatorium, Serpentaria, Arnica, Myrrh, Angustura Bark, Cascarilla, Contrayerva, Wormwood, Tansy, Horehound, Catnep, and Yarrow; and 3, Aromatics, comprising Orange-peel, Lemon-peel, Bergamot Oil, Cinnamon, Canella, Winter's Bark, Cloves, Xutmeg, Black Pepper, Cubebs, Matico, Pimento, Cardamom, Fennel-teed, Caraway, Coriander, Anise, Star Aniseed, Dill, Lavender, Rosemary, Peppermint, Spearmint, European and Amer- ican Pennyroyal, Horsemint, Marjoram, Thyme, Sage, Balm, Partridge Berry, Gin- ger, Zedoary, Turmeric, Calamus, Wild Ginger, and Vanilla. IV. MINERAL TONICS, subdivided into, 1. those acting specially on the Stomach and Bowels, to which belong the Mineral Acids, comprising the Sulphuric, JTitric, Muriatic, Nitromuriatic, Phosphoric, and Carbonic Acids; 2. those operating on the System generally through its Vital Properties, comprising the Preparations of Silver, Copper, Zinc, and Bismuth; and 3. the Reconstructive Tonics, to which belong Iron and its Preparations. Section If. DIFFUSIBLE STIMULANTS. 1. General Observations. 2. Division of these Stimulants into the Arterial, Nerv- ous, Cerebral, and Spinal. 3. Consideration of Heat and Electricity as Dif- fusible Stimulants. CLASS I. Arterial Stimulants. I. Cayenne Pepper. 2. Oil of Turpentine. 8. Carbonate of Ammonia with the Water, Spirit, and Aromatic Spirit of Ammonia. 4. Phosphorus. CLASS II. Nervous Stimulants. I. General Observations, with the consideration of Emotional and Sensational Influ- ences, including those of Cold and Electricity as Nervous Stimulants. II. Medicinal Nervous Stimulants Musk, Castor, Assafetida, Sagapenum, Galbanum, Ammoniac, Valerian, Valerianate of Ammonia, Garlic, Coffee, Tea, Rectified Oil of Amber, Draconlium, Cypripedium, Saffron, Cochineal, and Coca. CLASS III. Cerebral Stimulants. I. General Observations. TABLE OF CONTENTS. XV II. Individual Cerebral Stimulants Alcohol and its Preparations; Ether; Nitrous Oxide; Camphor; Opium and its Preparations, including Morphia, Codeia, and Narcotina; Hemp of India; Hyoscyamus; Belladonna with Atropia, and Stra- monium. CLASS IV. Spinal Stimulants. Nux Vomica and Be an of St. Ignatius, with Strychnia and Brucia. CHAPTEE II. GENERAL SEDATIVES. General Observations, with the consideration of Cold, Water, and Depletion, direct and indirect, as sedative agents. - CLASS I. Arterial Sedatives, or Eefrigerants. 1. Preparations of Antimony, including Tartar Emetic, Oxysulphuret of Antimony, Oxide of Antimony, and Antimoniated Hydrogen. 2. Refrigerant Salts, with a particular account of Nitrate of Potassa. 3. Vegetable Acids, comprising the Citric, Acetic, and Tartaric Acids. CLASS II. Nervous Sedatives. 1. Digitalis with digitalin. 2. Tobacco. 3. Lobelia. 4. Aconite with Aconitia. 5. American Hellebore. 6. Veratria, with White Hellebore and Cevadilln. 7. Black Snakeroot or Cimicifuga. 8. Gelsemium. CLASS III. Cerebral Sedatives. I. General Observations, with the consideration of Mental Influence, including Arti- ficial Somnambulism, as a Cerebral Sedative. II. Medicinal Cerebral Sedatives 1. Hydrocyanic Acid, with Bitter Almonds, Cherry Laurel Leaves, and Cyanide of Potassium; 2. Chloroform; 3. Conium or Hem- lock; and 4. Lactucarium. CLASS IV. Spinal Sedatives. Calabar Bean. CHAPTER III. ALTERATIVES. I. General Observations. II. Mercury and its Preparations. III. Preparations of Arsenic. IV. Iodine and its Preparations. V. Chlorine and its Preparations, comprising Gaseous Chlorine, Chlorine Water, Chlorinated Lime, Solution of Chlorinated Soda, Solution of Chloride 'of Cal- cium, Solution of Chloride of Barium, Chloride of Sodium or Common Salt, Mu- riate of Ammonia, and Chlorate of Potas&a. XVI TABLE OF CONTENTS. VI. Bromine and its Preparation!, including Bromide of Potassium and Bromide of Ammonium, VII. Sulphur and its Preparations Washed Sulphur and Precipitated Sulphur, Sul- phurous Acid, Hydrosulphuric Acid, and Sulphuret of Potassium. VIII. VEGETABLE ALTERATIVES Colchicum, Sarsaparilla, Guaiacum, Mezereon, Sassa- fras, Bittersweet or Dulcamara, Stillingia, False Sarsaparilla, and Hemidesmus. Subdivision II. LOCAL REMEDIES. CHAPTER I. LOCAL REMEDIES AFFECTING THE FUNCTIONS. CLASS I. Emetics. I. General Observations on Emetics, and Auxiliary Emetic Measures. II. VEGETABLE EMETICS Ipecacuanha, Gillenia, Bloodroot, Euphorbia Ipecacuanha and Corollata, Lobelia, Mustard, Squill, and Tobacco. III. MINERAL EMETICS Tartar Emetic, Sulphate of Zinc, Sulphate of Copper, and Turpeth Mineral. CLASS II. . Cathartics. I. General Observations, with the division into Laxatives, Purges, and Drastic Purges. II. LAXATIVES, subdivided into, 1. those which operate physically, as White Mus- tard Seed, Wheat Bran, and Metallic Mercury; and 2. those operating dynami- cally, as Sugar, Saccharine and Acidulous Fruits, Manna, and Cassia Fistula, among vegetable substances, and Sulphur, Carbonate of Magnesia, and Mag- nesia among the mineral. III. PURGES, subdivided into, 1. the Vegetable, which comprise Castor Oil, Rhubarb, Butternut, Aloes, Senna, American Senna, Jalap, and May-apple or Podophyl- lum; 2. the Saline, to which belong, Sulphate of Magnesia, Sulphate of Soda, Sulphate of Potassa, Bitar Irate of Potassa, Tartrate of Potassa and Soda, Tar- trait of Potassa, Phosphate of Soda, and Citrate of Magnesia ; and 3. the Mer- curial, of which Calomel or the Mild Chloride of Mercury is the only one con- sidered. IV. DRASTICS or DRASTIC PURGES Scammony, Colocynth, Black Hellebore, Gamboge, Elaterium, and Croton Oil. V. Cathartic Enemata. CLASS III. Diuretics. I. General Observations, with the consideration of various diuretic agencies, as Gold, Vascular Fulness, Arterial Stimulation, and Menial Emotion. II. Individual NON-STIMULATING VEGETABLE DIURETICS comprising Digitali^, Squill, Broom, Juniper, Parsley Root, Dandelion, Fleabane, Carrot Seed, etc. TABLE OF CONTENTS. XV11 III. REFRIGERANT DIURETICS Bitartrate of Potassa or Cream of Tartar, Nitrate of Potassa or Nitre, Acetate of Potassa, and the Carbonates and Bicarbonates of Potassa and Soda, to which may be added Spirit of Nitric Ether or Sweet Spirit of Nitre. IV. STIMULATING DIURETICS Turpentine with its volatile oil, Tar, Creasoie, Copaiba, Buchu, Pareira Brava, Cantharides, Horse-radish, Mustard, and Garlic. CLASS IV. Diaphoretics or Sudorifics. I. General Observations, with the consideration of Heat and Water as diaphoretic agents. II. NAUSEATING DIAPHORETICS Tartar Emetic, Ipecacuanha, the Powder of Ipeca- cuanha and Opium or Dover's Powder, etc. III. REFRIGERANT DIAPHORETICS Citrate of Potassa in the forms of Neutral Mixture and Effervescing Draught, Solution of Acetate of Ammonia, Nitrate of Potassa, and Spirit of Nitrous Ether or Sweet Spirit of Nitre. IV. STIMULANT DIAPHORETICS Sarsaparilla, Guaiacum, Mezereon, Sassafras, Prickly Ash, and Serpentaria, with Asclepias or Pleurisy Root, though not stimulating. CLASS V. Expectorants. I. General Observations. II. NAUSEATING or DEPRESSING EXPECTORANTS Ipecacuanha, Tartar Emetic, and other nauseating Emetics. III. STIMULANT EXPECTORANTS Squill, Seneka, Ammoniac, Assafetida, Garlic, Bal- sam of Tolu, Balsam of Peru, Benzoin with Benzoic Acid, Storax, Copaiba, the Turpentines, Tar, Creasote, and Resin. CLASS VI. Cholagogues. General Observations, and reference to the particular articles of the Class, described under other heads. CLASS VII. Emmenagogues. I. General Observations. II. TONIC EMMENAGOGUES Iron, Myrrh, and Tansy. III. PURGATIVE EMMENAGOGUES Aloes and Black Hellebore. IV. STIMULANT DIURETICS WITH EMMENAGOGUE PROPERTIES Cantharides. V. SPECIAL EMMENAGOGUES Savine, Rue, Seneka, Guaiac, etc. CLASS VIII. Uterine Motor- Stimulants. I. General Observations. II. Individual members of the Class Ergot, and, with less certainty, Extract of Hemp, Tansy, Root of the Cotton Plant, etc. CLASS IX. Sialagogues. al Observations, and reference to special articles described elsewhere, besides Pellitory particularly described. Xviii TABLE OF CONTENTS. CLASS X. Errhines. I. General Observations. II. Particular Errhines Aromatic Powders, Tobacco, Atarabacca, White Hellebore, Euphorbium, and Turpeth Mineral. CHAPTER II. LOCAL REMEDIES AFFECTING THE ORGANIZATION. CLASS I. Epispastics. I. General Observations on Blisters, and reference to Heat as a vesicating agent. II. Particular Epispastics Cantharides, and Stronger Water of Ammonia. CLASS II. Rubefacients. I. General Observations, and consideration of Heat, Friction, Acupuncture, and Electricity, as rubefacients. II. SIMPLE INFLAMMATORY RruEFACiEXTS Mustard, Cayenne Pepper, Oil of Tur- pentine, Burgundy Pitch, Canada Pitch, Tar, Creosote, Resin, various Aromatics and Gum-resins, Acrid Substances, Ranunculi, Common Nettle, and Preparations of Ammonia. III. PUSTULATING RUBEFACIENTS Tartar Emetic and Croton Oil. CLASS III. Escharotics. I. General Observations, with the consideration of Heat as an Escharotic, and specially of the Actual Cautery, Moxa, and Galvanic Cauterization. II. Particular Escharotics Potassa, Potassa with Lime, Nitrate of Silver, Sulphate of Copper, Arsenious Acid, Chloride of Zinc, Sulphate of Zinc, Corrosive Subli- mate, Solution of Nitrate of Mercury, Sulphate and Iodide of Cadmium, Dried Alum, and Sulphuric, Nitric, Muriatic, and Chromic Acids. CHAPTER III. LOCAL REMEDIES ACTING MECHANICALLY. CLASS I. Diluents. * General Observations, with reference to Water as the only true Diluent. CLASS II. Demulcents. I. General Observations, and division into the Mucilaginous, Saccharine, Amylaceous Demulcents. TABLE OP CONTENTS. XIX II. MUCILAGINOUS DEMULCENTS Gum Arabic, Gum Mesquite, Tragacanth, Flaxseed, Quince Seed, Slippery Elm Bark, Sassafras Pith, Benne Leaves, and Marsh- mallow. III. SACCHARINE DEMULCENTS Sugar, Molasses, Liquorice and Liquorice Root, and Glycerin. IV. AMYLACEOUS DEMULCENTS Wheat Starch, Arrow-root or Maranta, Sago, Tapioca, Pearl Barley, Iceland Moss, Irish Moss or Carrageen, Sweet Almonds, and Wheat Bran. CLASS III. Emollients. I. General Observations, and reference to Water as the main emollient agent. II. Particular Emollients Bread and Milk, Flaxseed Meal, Slippery Elm Bark, Marshmallow Root, Oatmeal, Indian Meal, Boiled Potatoes, Carrots, etc. CLASS IV. Protectives. I. General Observations, and division of the Protectives into the Direct and In- direct. II. DIRECT PROTECTIVES Olive and Almond Oil, Lard, Suet, Spermaceti, Wax, Lead Plaster, Resin Plaster, Soap Plaster, Collodion, Caoutchouc, and Gutta Percha. III. INDIRECT PROTECTIVES Nitrate of Silver, Iodine, and Creasote. Division II. NON-SYSTEMIC REMEDIES. CLASS I. Antacids. I. General Observations on the Antacids, and consideration of the dynamic effects of the Alkalies. II. Particular Antacids Solution of Potassa; Carbonate and Bicarbonate of Potassa; Carbonate and Bicarbonate of Soda; Borax; Lithia with its Carbonate and Ci- trate; Water, Spirit, Aromatic Spirit, and Carbonate of Ammonia; Lime-water; Precipitated Carbonate of Lime ; Prepared Chalk and Prepared Oyster-shell ; and Magnesia with its Carbonate and Bicarbonate. CLASS II. Absorbents. I. General Observations. II. Particular Absorbents Charcoal and Animal Charcoal. CLASS III. Solvents. I. General Observations. ^L Particular Solvents Gastric Juice, Rennet, Pepsin, Lactic Acid, and Yeast. XX TABLE OF CONTENTS. CLASS IV. Disinfectants. I. General Observations. (II. Agents Operating Mechanically Cleanliness, Ventilation, Charcoal, Lime. III. Agents Operating Chemically 1. Oxidizing Disinfectants, comprising Ozone, Chlorine, Bromine, Iodine, Permanganate of Polassa, Peroxide of Hydrogen, and Mineral Acids with their Metallic Salts; 2. Deoxidizing Disinfectants, com- prising Sulphurous Acid and the Sulphites, Nitric Oxide, Sulphate of Protoxide of Iron, and Ammonia; 3. Neutralizing Disinfectants, including Carbolic Acid with analogous substances, Chloride of Zinc, and Chloride of Iron. CLASS V. Parasiticides. General Observations, and Division into two SUB-CLASSES, viz.; SUB-CLASS I. Anthelmintics. 1. General Observations. 2. Particular Anthelmintics Pinkroot or Spigelia, Wormseed, Azedarach, European Wormseed with Santonin, Cowhage, Male Fern, Pomegranate Root, Oil of Tur- pentine, Koosso, Pumpkin Seed, Calomel, Kameela, etc. SUB-CLASS II. Antizymotics. 1. General Observations. 2. Particular Antizymotics Sulphur, Sulphurous Acid, the Sulphites and Hyposul- phites, Carbolic and Cresylic Acids and Creasote, Tar with Impure Pyroligneous Acid, Smoke, Petroleum, and Saccharine Solutions. A TREATISE THERAPEUTICS PHARMACOLOGY. INTRODUCTORY OBSERVATIONS. PHARMACOLOGY, or the science of MATERIA MEDICA, treats of medi- cines in all their relations; THERAPEUTICS, of remedies in general, and their application to the' cure and alleviation of disease. Medicines are substances capable of producing, as an ordinary result, and by their own inherent power, changes in the healthy vital functions, which render them available for curative purposes. All these conditions are essential. Medicines are substances, or, in other words, are material. Influences not material, though efficient in the cure of disease, are not medicines. Substances necessary for the support of life, such as food, drink, atmospheric air, solar heat and light, are capable, if unduly ap- plied, of deranging the vital functions : but this is not their ordinary operation ; and they do not, therefore, belong to the category now under consideration. Again, bodies which have no inherent power of disturb- ing the functions may be rendered noxious, or remedial, by some extra- neous agency. Thus, the dagger which destroys life in the hands of the in, and the knife which saves it in the hands of the surgeon, are incapable alike of injurious or beneficial action, when merely placed in contact with the body without any foreign impulse. Such bodies are evidently not entitled to the rank of medicines. There are, moreover, many substance* which have the inherent power of even violently dis- turbing the system when brought into connection with it, which, how- ever, have not been proved to possess remedial properties, and are never employed in the treatment of disease. These may be poisons, but they are not medicines. It is thus seen that all the conditions stated in the definition are essential. There arc, indeed, a few substances, usually denominated medicines, which do not strictly fulfil these conditions. Such are anthelmintics, which are not used to modify the functions of VOL. i. 1 J INTRODUCTORY OBSERVATIONS. the human system, but to act on certain foreign bodies which happen to be contained within it. Such, too, are the antacids given to neutralize acid in the stomach and bowels. But it happens that most of these substances really have medicinal properties, which render them useful for other purposes ; and, so far as they are employed merely as anthel- mintics or antacids, they may be regarded not as medicines, but as sim- ply ranking in the more general category of remedies. Remedies are agents, or influences of any kind whatever, capable of being usefully employed in the treatment of disease. Of course all medi- i-ines may be remedies ; but there are very many remedies which are not medicines. To constitute any agent a remedy, it is not even n< .-ary that it should be material. It may be a process or action whether mental or physical, a state or condition, a change of circumstance, even a negative quality, or the absence or diminution of some positive agency. Thus, we may class with remedies not only medicines, and the various substances, which, though not strictly medicinal, are yet employed ther- apeutically, as water, heat, electricity, etc., but also such influenct - blood-letting, abstinence, exercise, rest, position, change of residence, cold, darkness, mental emotion, and many others that might be mentioned. Pharmacology, which as before stated treats of medicines in all their relations, including of course their application to the cure of disease, has nothing to do with remedies not medicinal ; whereas Therapeutics, which treats of all remedies in their remedial capacity, leaves out of view the properties of medicines not essentially belonging to them as such ; their natural and commercial history, for example, their sensible and chemical properties, and their various modes of officinal preparation. There is an advantage, therefore, in combining the two sciences in one treatise; as .arh supplies the deficiencies of the other, and both combined convev all desirable information in relation to the origin, qualities, and uses of remedies. In the present treatise, however, though some notice will be taken of those branches of the subject peculiar to Pharmacology, yet, as the l'nitcd States. Dispensatory, in the preparation of which the author par- ticipated, is especially devoted to that science, and treats in sufficient detail of almost everything exclusively belonging to it, he proposes to devote a more particular attention to therapeutics, which is but partially treated of in the Dispensatory, and in many important points has been quite overlooked. Indeed, the work which he now submits to the medi- cal public, may be looked on as, in some measure, supplementary to the IT. S. Dispensatory, affording by its arrangement a convenient plan for the perusal and study of that work, supplying its therapeutical defi- eiencies, and noticing those relations and properties of medicines having no immediate connection with therapeutics, only so far as may be essen- tial to the practical physician ; reference being made to the Dispensatory INTRODUCTORY OBSERVATIONS. 3 for information of general or pharmaceutical interest, and for minute detail on all exclusively pharmacological points. The work will consist of two parts. As there are many subjects, both in Therapeutics and Pharmacology, which are of a general nature, and cannot without inconvenience of arrangement, or the necessity for con- stant repetition, be considered in connection with special remedies, or even classes of remedies, it is proposed to treat of these preliminarily under the heading of General Therapeutics and Pharmacology, which will, therefore, constitute the first part of the work. The second part, much more extensive than the first, and forming, indeed, the main body of the treatise, will be devoted to the subordinate divisions and special- ties of the two sciences, under the name of Special Therapeutics and Pharmacology. PART I. GENERAL THERAPEUTICS AND PHARMACOLOGY. CHAPTER I. Operation of Medicines. THE operation of medicines is either primary or secondary ; the primary operation being that which results from their immediate in- fluence on the system ; the secondary, that which follows their original and characteristic impression, in consequence of certain physiological laws. Thus, purgation is the primary operation of a cathartic ; deriva- tion of blood from the head, with the attendant relief of any existing cerebral congestion, is a secondary operation, and a simple consequence of the first, just as the same result would follow an equal amount of intestinal irritation with diarrhoea from other causes. SECTION I. Primary Operation of Medicines. One of three events must occur when a medicine is applied with effect to any part of the body. Either it must enter the circulation, and be carried with the blood throughout the system, acting upon such parts as may be susceptible to its influence ; or the local impression, first pro- duced by it, must be conveyed through nervous communication to the parts, more or less distant, in which its effects are to be displayed ; or, finally, it must act exclusively in the vicinity of its application. Each of these modes of operation requires to be considered. (5) 6 OPERATION OF MEDICINES. [PART I. SUBSECTION I. Primary Operation through the Circulation. Absorption. It was at one time thought by many that medicines never entered the circulation. The absorbents were supposed to afford the only avenue of foreign bodies into the system. Substances incapable of being assimilated to the blood, were believed to penetrate no further than the absorbent glands, which were so many sentinels placed to guard the system against the intrusion of noxious agents. This notion was purely theoretical ; and, even at the time when it was most strenu- ously maintained, was opposed by known facts which prevented bs universal adoption. Subsequent experiments and observations, ex- tremely numerous, and diversified in almost every conceivable manner, have established the conclusion, beyond all possible doubt or cavil, thai medicines are very frequently absorbed, and, entering the blood-vessels, are circulated with the blood throughout the body. The following proofs of this truth may be adduced. 1. When medicines are applied directly to any surface of the body, and produce their characteristic effects elsewhere, it may often be noticed that portions of them have disappeared, without any possibility of accounting for their disappearance except by their absorption, or at least their entrance into the system. 2. The sensible properties of the medicine, its odour, taste, and colour, are frequently perceptible, either unchanged, or somewhat modified, in the breath, the secretions, and even in the various solid tissues. The effect of garlic in diffusing its odour and taste is universally known ; rhubarb gives to the urine the property of staining linen yellow ; and madder not unfrequently imparts its red colour to the bones. 3. The peculiar medicinal or poisonous effects of certain substances are occasionally produced, by taking into the stomach the liquid secre- tions of individuals under the influence of these substances. Thus, medi- cines given to the mother not unfrequently operate on tin- suckling; and numerous other illustrations of a similar kind might be adduced. 4. Effects, produced by medicines in distant parts, may be prevented by ligatures around the blood-vessels proceeding from the part with which the medicine is brought into immediate contact, 5. In many instances, the characteristic effects of medicines, exhibited in the ordinary way, may be obtained by injecting them into the bloud- "1s. ;. But the most irresistible evidence is that afforded by chemical in- vestigation, which has in almost innumerable instances detected medi- cinal substances taken into the stomach, or applied to other parts of tin- body, not only in the perspiration, saliva, urine, and other secretions, CHAP. I.] PRIMARY OPERATION OF MEDICINES. 7 and in various solid tissues, but in the blood itself. Indeed, the list of substances, which have thus been proved to have been circulated through the system, is so large as to authorize the inference, that all medicines, capable of extending a direct action beyond the original surface of con- tact, may be absorbed, and carried with the blood to the part or organ which they affect. It 1ms been said that the effects of some medicines and poisons are so rapid, as to preclude the idea that they could have been absorbed, and conveyed to the seat of their action by the ordinary route of the circu- lation. But comparatively recent experiments, by proving the extreme rapidity with which the blood makes a complete circuit in the body, have invalidated that objection. Professor Bering, of Stuttgard, found that ferrocyanide of potassium, injected into the jugular vein of a horse, might be detected in the opposite jugular vein in a period of time vary- ing from twenty to thirty seconds (Zeitschrift fur Physiologic, iii. 122); and Dr. James Blake, formerly Professor of Anatomy in the Saint Louis University, has proved that "the time required for the blood to pass from the jugular vein, and to be circulated through the body, was, in the horse sixteen seconds, in the dog twelve seconds, in the fowl six seconds, and in the rabbit four seconds." (Am. Journ. Med. Sci., N. S., xviii. 100.) The latter experimenter also found that the most rapidly fatal poisons, introduced into the veins of the animals referred to, gave rise to no signs of their action within less than the periods of time mentioned as occupied, in the several animals, by one round of the circulation. (Ibid., p. 101.) Having introduced some hydrocyanic acid into the v mouth of a rabbit, Dr. Blake noticed that its first effects on the system were evinced in two seconds and a half, and death followed in five seconds. (Ibid., p. 106.) It is scarcely possible that any medicine can act more speedily than this ; and, considering that the acid probably acted through the lungs, and, by entering the pulmonary veins, might reach the left side of the heart by a route much shorter than that of the general circulation, it is not too much to infer, that the time mentioned was sufficient for it to arrive at the brain through the medium of the blood. Vierordt, after experiments with a great number of animals of different species, came to the conclusion, that the mean duration of a round of the circulation in the several mammalia is equal to the average time in which the heart completes twenty-six or twenty-eight pulsations. (B. & F. Medico-chir. Rev., July, 1859, p. 167.) It may be assumed that in man this time does not exceed thirty seconds. From these facts the inference may be fairly drawn, that no medicine acts with such rapidity as to preclude the possibility of its having reached the part affected through the circulation ; and, the accuracy of the state- ments being admitted, the objection urged upon this ground against the universality of the mode of operation through the blood must be abandoned. 8 OPERATION OF MEDICINES. [PART I. Medicines are absorbed from mucous membranes, the areolar tissue, the skin, the pulmonary air-cells, and probably from any other part of the body to which they may be applied. The rapidity of their absorp- tion is proportionate to the thinness and delicacy of the tissue interven- ing between them and the blood-vessels. Hence, of all the surfaces with which they are habitually brought into contact, that of the pulmonary air-cells affords them the most speedy entrance into the circulation. Every one knows the great rapidity with which ether and chloroform act when inhaled. Next to the air-cells in this respect are probably the areolar tissue and the alimentary mucous membrane, especially that of the stomach, which, as a general rule, admits the entrance of medicines more readily than that of the rectum. Absorption takes place most slowly from the skin. This might be inferred from the firmness and thickness of the epidermis. It has indeed been maintained that this tissue is impermeable by medicines in its healthy state. But experi- ments have satisfactorily shown that they do enter the system through the epidermis; and the constitutional impression, sometimes resulting from the wearing of a mercurial plaster, is of itself a sufficient proof. There can be no doubt, however, that the epidermis opposes a great impediment to absorption ; and, without such a protection, the system would be constantly exposed to the most deleterious influences from without. The impediment may be much diminished by softening the tissue with water, or by mechanically deranging it ; and hence medi- cines applied to the surface by a local or general bath, or in the form of cataplasm, or by means of friction, may often be made to act efficiently on the system.* 'Deprived of its epidermis, the skin admits the en- trance of medicines with great facility, though, even in this state, some- what less readily than the gastric mucous membrane, probably because it is less vascular. * At the time of the appearance of the second edition of this work, the result of recent, experiments had not been favourable to the opinion, that medicines applied to the skin by means of baths, whether local or general, can, to any considerable extent, find an entrance into the system through absorption. For a condensed account of these experiments, the reader is referred to (he British and Foreign Medico -chirunjical Review fur January, 1859 (Am. ed., page 108). Numerous sub- stances, mineral and vegetable, were employed in baths and foot-baths; and the uniform remit, when care was taken to prevent, any possible absorption through the liinjrs, v a- that neither the substances themselves, nor any of their const i men is. could be found in the urine. The medicines thus experimented with were iodine, iodide of potassium, chloride of sodium, ferrocyanide of potassium, sulpliuret of potassium, acetate ol lead, alum, borax, carbonate of potassa, nitric acid and nitre, sulphate of magnesia, sulphate of quinia, digitalis, and belladonna. 1.5m I did not. at the time. eon>ider I lie experimenis as conelu--ive against the absorption, by means ''baths, of many mil ried medicines, noreMMi, in tome degree, of those tried; for. though not detected in the urine, some of them might have been eliminated by other CHAP. I.] PRIMARY OPERATION OF MEDICINES. 9 Means of Absorption. The lymphatics and lacteals were formerly supposed to be the exclusive agents of absorption. Magendie proved that foreign substances are also received from without directly into the blood-vessels ; and multiplied experiments have since shown that most medicines enter the system in this way. It is probable that the capil- laries, in consequence of the extreme delicacy of their walls, are chiefly concerned in the process ; and that medicines enter them upon the same principles of endosmose by which liquids pass through dead membrane out of the body. Attempts have even been made to establish the con- ditions based on the rules of physical endosmose, upon which medicines in contact with the capillaries will either enter the blood-vessels, or cause the extravasation of the liquid contents of the vessels themselves, and thus to explain the effects of a medicine, if not indeed to deduce & priori its probable operation from its physical qualities. But, admitting to a certain extent this principle of operation in medicines, there are so many circumstances, physical, chemical, and vital, which modify the result, that no previous conclusions can be relied on ; and even explanations upon this basis must be received with great caution, lest they lead into serious error. It must be remembered that the condition of a living membrane is very different from that of the same membrane out of the body ; and there can be little doubt that the vital forces have such a control over the tissues, as greatly to modify their endosmotic relations to the fluids on opposite sides of them. For example, in a certain condition of vital influence the membrane may be contracted and firm, in another relaxed and loose; and it is impossible to say that some modifying power may not be exerted on the fluids themselves, in and around it, by the life- forces, as we know that the electric forces modify chemical conditions out of the body. In the present state of our knowledge, therefore, it is quite premature to attempt to explain the phenomena of medicinal ab- sorption in every case, or to anticipate the results in any particular case, on simple physical principles. emunctories, or have been retained in the system; and, if not absorbed in the in- stances submitted to trial, they might possibly be so in others. Certain substances had by former experimenters been shown to be absorbed in this way ; and it would require very numerous experiments, with different individuals, and under various circumstances, to determine positively that there is nny soluble substance 'which can never enter the system, when applied by means of baths to the- surface of the body in a perfectly sound state. Since that time, numerous experiments, performed with ^:eat care to avoid all sources of error, by Dr. Willemiu. of Vichy, in France, have established, beyond reasonable doubt, the possibility of absorption, by means of baths, through the skin, not only of water, but of various remedial substances. (Arc/iii'es Generates, 6e sor., ii. 5, 105, 177, 313.) Nevertheless, it must be admitted, as stated in the text, that the epidermis opposes a very strong impediment to ab- sorption; and tha: Saths do not offer a very efficient method of medicating the ~\ -tern. (Note to the second and third editions.) 10 OPERATION OF MEDICINES. [PART I. It is highly probable that the principle which governs the process of dinlyti*, discovered by Mr. Graham, may have some influence in the absorption of medicines. Crystallizable substances may thus find an entrance into the capillaries, while the uncrystallizable are excluded. For an explanation of this principle the reader is referred to the U. S. Dispensatory (12th ed., p. 896). The comparative facility with which saline substances and the active principles of vegetables, which an- generally crystallizable, enter the circulation, may be in some measure thus explained.* After the entrance of the medicine into the capillaries, it is carried forward in the course of the circulation, and sooner or later mingles with the blood in the heart, with which it is transmitted over the whole sys- tem, and consequently reaches the part on which it is destined to act. But it may be asked whether medicines, are not also taken up by the absorbents, and conveyed by them into the blood. It would seem to be the legitimate function of these vessels, to select from the alimentary liquid in the bowels, and from the disintegrating tissues throughout the body, those principles which may assimilate with the blood, and thus contribute to the sustenance of that fluid in its requisite state and quan- tity. In order that this function may not be interfered with, they have the power to reject in great measure noxious substances, and medicino among others.^ Tiedemann and Gmelin found that, of numerous colour- ing and odorous substances given to animals with their food, a large pro- portion imparted their colour and odour to the blood of the pnnul v.'ins, but not one to the chyle. Of a number of salts tried in the same man- ner, though many could be detected in the veins, a few only had entered the thoracic duct. Drs. Lawrence and Coates, of Philadelphia, in a series of carefully conducted experiments, proved that ferrocyanide of potassium was taken up from the bowels both by the radicles of the vena portae and by the lacteals. (Philad. Journ. of Med. and Phy*. ~- v. 327.) It has been subsequently shown, in repeated instances, that poisons introduced into the alimentary canal, fail to produce their effects on the system when the vena portse is tied. (Pereira, Elcm. of Mat. Med., 3d ed., i. 103.) From these statements it is fairly inferrible that, though the absorbents are capable of taking up a few saline substances, probably not altogether incongruous with the blood, they are not the ordinary agents by which medicines are introduced into the circulation. Circumstances affecting Absorption. Various circumstances more or less affect the facility or rapidity of absorption. Reference has already * Isomorphism in chemical compounds has probably some influence over the ab- sorption as well as the assimilation and elimination of those substance* ; those which have a similar constitution in this respect, obeying the same physiological laws. This may be inferred from the experimeuts of .M. llou-siu on fowls, as recorded in the Journal de. J'harmacie, 3e si-r. , xliii. liiG. (Xote to the third edition.) CHAP. I.] PRIMARY OPERATION OF MEDICINES. 11 been made to the influence, in this respect, of the nature of the surface to which the medicine is applied. The following are other modifying influences. 1. In relation to the blood-vessels, it is highly probable that the vary- ing condition of their coats, under varying nervous influence, or different degrees of vital force, may considerably modify the process ; but too little is precisely known on this subject to justify any definite statements. 2. The condition of the blood as to density may not be without effect, upon the principles of endosmose, in favouring or opposing the entrance of fluids from without. 3. The fact has been abundantly proved, that fulness of the blood- vessels is opposed to absorption ; and hence, in a plethoric state of the circulation, medicines sometimes act with difficulty, because not readily taken into the system. It is well known that, in a state of high febrile excitement, the abstraction of blood very much favours the action of dia- phoretics and diuretics, probably in part, at least, by removing an im- pediment to their absorption. Substances, too, which act powerfully as local irritants, by causing congestion of the blood-vessels in the part, im- pede their own absorption, and thus fail to act on the system ; while, if applied in a dilute state, so as not to irritate, they may find a ready entrance. Diminution of atmospheric pressure upon the surface impedes absorption, by causing distension of the vessels. Consequently cupping- glasses, placed over a poisoned wound, delay or diminish the action of poison on the system. Compression, on the contrary, is said to favour the process. Whenever the blood-vessels are relatively empty, absorp- tion is promoted. Hence, medicines act more powerfully after fasting, and in reduced states of the system generally, than in its ordinary con- dition.* 4. Age and sex have some influence on absorption. M. Briquet has found the process more active in the young than in the old, and in man than in woman. In the former case, the greater activity might be ascribed to greater rapidity of the circulation ; but this explanation will not hold in the latter. (Archives Generales, 5e ser., x. 611.) 5. Fodera has proved that galvanism or electricity promotes ab- sorption. * Some experiments recently made by Kohler, at Marburg, might seem to invali- date this conclusion. He found that, in starving animals, the symptoms of poison- ing from strychnia, hydrocyanic acid, etc., to whatever surface applied, are retarded, instead of being accelerated. But this, if true, may be ascribed to other causes than to diminished absorption, as, for example, to the slower circulation of the blood, and possibly to modified susceptibilities in this condition of the system. (B. and F. Med.-chirurg. Rev., July, 1859, Am. ed., p. 168.) The nerve-centres, oc- cupied by the agonies of starvation, would probably resist much more strongly than in their normal state impressions from the poison, just as violent neuralgic pains im- pede the action of anodyne remedies. (Note to the second and third editions.) 12 OPERATION OF MEDICINES. [PART I. 6. The character and state'of the medicine itself have also great effect. Allusion has been already made to the influence of density in opposing the absorption of medicines. Volatility appears in general to have an opposite effect; the most volatile medicines usually operating with great- est rapidity. Hence in part probably the very speedy effect of ether, chloroform, and hydrocyanic acid. Gases are readily absorbed. 7. Greater or less affinity between the medicine and the blood appears also to affect the facility of absorption ; and substances which unite with that fluid with difficulty, are scarcely admitted into the system. Castor oil may be cited as an example. 8. The fluid form is usually considered essential to absorption, and consequently to medicinal activity, so far at least as the general system is concerned. It is true that many solid substances, nearly or quite in- soluble in water, are powerful medicines. But they must undergo changes which bring them into the liquid state, before they can gain access into the blood-vessels. Such changes are often effected by the liquids of the alimentary canal. Thus, metals, in themselves insoluble and inert, often act energetically in consequence of oxidation and union with an acid in the stomach and bowels. But some recent experiments would seem to show that this principle is less universal than has been imagined. Rabbits were fed on finely powdered wood charcoal; and fine particles of this substance were afterwards found abundantly in the blood, the liver, and the lungs. Starch mixed with charcoal was given to froirs; and the corpuscles of the former were observed in the blood of the mi'st'iiU'ric veins, by the aid of the microscope, having their character- istic form, and exhibiting their characteristic reaction with iodine. Simi- lar results, though less decisive, were obtained with mercury and sulphur, taken into the stomach, and applied by friction to the surface of dogs and rabbits.* It is conceivable that mercury, being liquid, though insoluble, should be able to penetrate the tissues ; but it is impossible, with our present views of the capillaries, that solid visible particles should enter them without some solution of continuity in their coats. It is not im- probable that such particles, passing mechanically between the epithelial or epidermic cells, and thus separated from the blood of the capillaries only by the extremely tenuous coats of the.- . and the equally tenuous basement membrane, may, by their contact with this delicate minute openings in it, so as to admit their passage, by a >>rt of physiological action such as that which causes two cells in con- tact to communicate together; and these openings, after the entrance of the particles, may close under the influence of the same vital law. * These experiments were made chiefly in Germany. Begun by Oesttrlein, they were repeated and varied by Eberhard, Kollikcr, .Meyer, Donders, an the cerebral centres, and secondarily occasions general prostration. Now certain medicines of great violence, as for example the corrosive poisons taken largely into the stomach, may produce a similar shock upon the nervous centres, followed by a similar general depression, which, with- out a knowledge of this principle, might be mistaken for the result of a directly depressing agency, and treated as such with very serious consequences. The operation upon the system at large of medicines which act by changing the character of the blood, is another example of the same kind. The general effects result from the state of the blood, and not from the immediate influence of the medicine, and are, therefore, second- ary effects of the latter. 4. Through the Principle of Sympathy, or Nervous Transmission. Though it is not probable that special or peculiar impressions of medi- cines are, to any considerable extent, conveyed from the part impressed through the nerves to the nervous centres, and thence transmitted to other parts, yet mere excitative impressions, or those consisting in pure irritation or inflammation, are undoubtedly thus conveyed. What is special in the influence of the medicine is, therefore, mainly limited to its surface of contact; while it is only the pure irritation, such as may result from any irritating cause whatever, that is conveyed away, and propagated through the nerves. This transmission of irritatjon arises from a general physiological law, and is, therefore, a secondary effect of the medicine. Thus, a rubefacient or epispastic may excite so much local inflammation as, through the nervous centres, to bring many of the organs into sympathy, and in this way to produce general excitement, and even fever. The increased frequency of pulse, heat of skin, cerebral disturbance, etc., which enter into this excitement, are secondary eflVi t> of the rubefacient or epispastic, the primary action of which is limited to the portion of skin to which it was applied. This principle is also of extensive application in explaining the effects of medicines. 5. Through the Principle of Revulsion or Derivation. There is in the system but a limited amount of blood, and of nervous power. When these are concentrated, or accumulated in undue amount, by the influence of a local irritant or otherwise, in some one part or organ, they must be deficient elsewhere; and a depression must ensue in those functions which are not irritated by sympathy with the part or organ originally affected. Supposing the local accumulation of blood and nervous power CHAP. I.J SECONDARY OPERATION OF MEDICINES. 25 to be the result of the action of a medicinal agent, the depression pro- duced elsewhere is a secondary effect of that agent. Now it may have happened that the parts depressed were previously in a state of morbid excitement, which has thus been diminished, and perhaps entirely re- moved by the direction given towards the seat of the primary influence. The name of revulsion or derivation has been given to this forced trans- fer of morbid action ; and we frequently avail ourselves of the principle in the treatment of disease. It is upon this principle that a blister relieves internal inflammation. It is upon this, also, in part, that a cathartic, by producing a moderate irritation along the whole course of the intestine, draws off morbid excitement from other organs, and especially from the brain. Indeed, whatever remedy occasions a local irritation may thus prove the means of unseating irritation elsewhere. It is quite obvious that the diversion of disease, thus effected, is a secondary operation of the remedy. Upon the same principle exactly, operating reversely, a depression of any part or organ, by diminishing the blood and nervous power in the part affected, must cause their accumulation elsewhere ; and thus, de- pressing or sedative medicines, acting locally, may, through a secondary operation, cause irritation in some other position. For example, cold water applied to a gouty foot, by diminishing the inflammatory excite- ment there, may secondarily occasion inflammation of the stomach. Medicines are not often employed in reference to such effects ; but this mode of secondary action should be understood, if on no other account, at least in order that its injurious effects may be guarded against. 6. Through the Efforts of Nature to Repair Injuries. It may be considered as a general law of the animal economy, that, when any in- jurious influence is exerted upon the system, actions are induced with the object, and frequently with the effect, of obviating the injury, or repairing the damage inflicted. It is probable that many diseases are nothing more than the struggles of the system to free itself from some noxious agent, or to counteract its influence. The abnormal impressions made by medicines are often, no doubt, upon this principle, followed by resisting or corrective efforts of nature, which must rank among the secondary effects of the medicine, and may sometimes be taken advant- age of for remedial purposes. Thus, the death of a part produced by an escharotic is the primary effect of the medicine; the subsequent inflammation, ulceration, sloughing, and suppurative discharge, are sec- ondary effects, intended for the repair of the injury, and useful in reference to pre-existing disease, upon the principles of revulsion and depletion. 7. Through the Removal of the Cause. Very many of the morbid actions or states of the system are secondary, depending upon the exist- ence of some other action or condition, upon the removal of which the effect also ceases. It is obvious that a medicine, which by its primary 26 OPERATION OF MEDICINES. [PART I. operation removes the cause, and thus cures the disease, acts secondarily in relation to the latter effect. Thus, acid in the stomach often occasions severe headache, which is cured by an antacid, or an emetic. The neu- tralization or evacuation of the offending agent is the primary operation of the medicine, the cessation of the headache a secondary effect. This is a very extensive remedial principle. It is very often difficult to determine which are primary and which secondary effects of medicines; and the decision of the question will often rest on the view which may be entertained of the mode of action of the remedy. In the instance, for example, of a sedative depressing the cerebral functions, the question of its primary or secondary action on the brain will be determined by our opinion upon the point, whether it is merely carried by the blood to the brain, or operates on that organ exclusively through changes first produced in the blood, incapacitating that fluid for the performance of its proper functions. In the latter case, the characteristic sedative operation of the medicine must be con- sidered as secondary. But it is the safest rule to consider the obvious effects of a remedy as primary, unless some intermediate stage in its operation can be positively demonstrated, or rendered extremely probable by observed facts. CHAP. II.] EFFECTS OF MEDICINES. 27 CHAPTER II. Effects of Medicines. SECTION I. Estimation of their Powers or Effects. IN treating of the effects of medicines, the first point which offers itself for consideration is the method by which they can be ascertained. Is it possible to determine, before trying a medicine upon the human system, what will be its effects? Do its sensible or chemical properties, its botanical relations, or its action upon inferior animals, afford us any facilities in this respect ? 1. Through their Sensible Properties. Much importance has been attached by some to the sensible properties of colour, taste, and smell. In relation to the first, it is probably altogether useless. The times are long past, when a correspondence between the colour of a medicine, and that of the fluids or solids of the body, was considered as indicative of a therapeutic relation ; when, for example, dragon's blood was thought useful in hemorrhage because it was red, and turmeric in jaundice because it was yellow. The smell and taste, however, are more significative; substances resembling each other in these respects, having in maey in- stances a similarity of medicinal effect. Thus, aromatics are usually excitant, carminative, and anti-emetic ; fetid substances, often antispas- modic ; sweet substances, demulcent ; those having an astringent taste, styptic ; and bitters, tonic : but, in such general statements, allowance must be made for so many exceptions as to deprive them, in a great measure, of practical value. 2. Through their Chemical Relations. Analogy in chemical consti- tution is also not unfrequently attended with similarity in medical vir- tues. The preparations of any one of ttie ordinary metals have a remarkable correspondence in their effects upon the system ; and there are several metals which greatly resemble one another. The mineral acids, the vegetable acids, the inorganic alkalies, and the neutral salts of the alkalies, constitute groups, of which one individual may often be substituted for another without disadvantage. But in this respect, as well as in relation to sensible properties, there is so much uncertainty, 28 EFFECTS OF MEDICINES. [PART I. that no practical conclusion in reference to the properties of any par- ticular medicine should be relied on without careful trial. 3. Through their Botanical Affinities. The same may be said of botanical affinities; though more importance has perhaps been attached to these than to either of the preceding grounds of judgment, It might indeed be inferred, that the similarity in internal constitution, which gives to plants those resemblances in obvious structure which serve as the basis of their arrangement into natural families, would also give them a certain identity in other respects, and among the rest, in their opera- tion upon the system ; and observation has, to a considerable extent, confirmed the truth of the inference Plants belonging to the same genus yield very frequently not only similar, but identical medical pro- ducts. Thus, the oaks yield tannic acid, the pines oil of turpentine, the cinchonas quinia and cinchonia, the different species of strychnos strych- nia and brucia, the gentians gentianin, the poppies morphia, and the garlics a characteristic volatile oil. This resemblance extends also very frequently to much larger groups ; and many of the natural orders of plants have great similarity in medical virtue. Examples of this we have in the Malvaceae, which are demulcent, the Oentianacese tonic, the Convolvulacese purgative, the Solanacese narcotic, the Euphorbiacese emeto- cathartic and acrid, the Pinacese stimulant, the Brassicacese stim- ulant, pungent, and acrid. Yet in almost every family there are instances, and, in some, very striking instances, in which not only are the charac- teristic medical properties wanting, but others wholly different, and even in some measure opposite are possessed ; while similar and even iden- tical medical virtues belong to plants having no botanical affinity what- ever. Thus, in the Convolvulacese above mentioned, there are some species wholly destitute of purgative properties, as the esculent sweet potato; and among the Solanacese is capsicum, which is simply stimu- lant, without being in the least narcotic. Among the Ranunculacem is Hepatica, which is slightly astringent, tonic, and demulcent; Helleborua, powerfully purgative ; Zanthorrhiza and Coptis, simply tonic; Aronitum. acrid, sedative, and narcotic ; and Gimicifuga, chiefly nervine. Of medi- cines having analogous properties, yet derived from different families, we have examples in the volatile oil of Pimpinella anisum, belonging to the Umbelliferse, and that of Illicium anisatum, belonging to the Anonacese; in the oil of turpentine proceeding from the Pinacese, and from Pistacea Terebinlhus of the Anacardiacex; in the aromatic products of the Um- belliferse, Mi/risticacese, Myrtacese, and Zingiberacese; in the astringent roots and juices of plants belonging to the Fabacese, Polygonacex, Cin- chonacese, Geraniacese, and many other families; and in the simple bit- ter tonics obtained from the Oentianacex, Simarubaceee, Ranunculacese, and Menixpermacese. But in reference to each of the analogies above alluded to, the sensible, CHAP. II.] EFFECTS OF MEDICINES. 29 the chemical, and the botanical, though none should be relied on in esti- mating the virtues of a medicine, yet each may be frequently suggestive, and, in relation to any new subject of inquiry, may be valuable by giving a proper direction to experimental investigation. / 4. By Experiment or Observation on Inferior Animals. The effects produced on the inferior animals are more to be relied on, and will gen- erally be a safe guide to the employment of medicine in man ; but even thi.s rule is not without exceptions. It is well known, for example, that sheep, goats, and cows eat with impunity the leaves of Hyoscyamus niger, which are highly narcotic, and in large quantities poisonous to the human subject. 5. By Observation of their Effects on Man. The only certain means, therefore, of judging of the effects of medicines, is to observe carefully their operation in man ; and, even in this mode, multiplied observation under diversified circumstances, and a most cautious comparison of re- sults, are necessary in order to arrive at the truth. From the want of these precautions, many errors in relation to the action of medicines have originated, and been handed down from writer to writer for many years ; and, even at the present time, there are medicines which have been long in use, upon the precise virtues of which opinion is yet unsettled. SECTION II. Whether the Effects are Organic or Functional. The effects of medicines, in other words, the changes produced by them in the system, must be either organic or functional ; that is, must consist in an alteration, either of the organization or structure, or of the function or actions of the body, or of some one or more of its parts. Some have denied that there can be any change of action, or any action whatever, in the system, without change of structure, and consequently that the effects of medicines can ever be exclusively functional. This denial is founded upon the assumption that, in every operation of a living system, there is necessarily a chemical action, an oxidation perhaps of some por- tion, however minute, of the part or tissue acting, by which it becomes disintegrated and thrown off; while its place, in the healthy state, is supplied with new structure. This may be true, but it has not been proved ; and, in the mean time, cannot be received as the basis of a gen- eral theory of the action of medicines. But, even admitting its truth, it does not follow that in all cases of physiological action there must be an alteration of structure. Suppose an organ to be secreting. The general opinion now is that the function is performed by the agency of cells, which, abstracting the material of the secretion from the blood, elaborate it when elaboration is necessary, and then, breaking up themselves, are 30 EFFECTS OF MEDICINES. [PART I. thrown off with the secreted matter; their place being supplied by new cells. There has not been necessarily in this case any change of structure. One or more cells have disappeared, and their place has been supplied by one or more new cells of the same character exactly. The organ is precisely as before. There has been change of matter, but no change of structure or organization. Now it may be readily conceived that a medicine, affecting the secre- tory function of an organ, shall act simply by increasing or diminishing the rapidity of the cell-action; that, in the time required in health for the throwing off and replacing of a certain number of cells, twice the number may undergo the same process in the one case, or only half the number in the other; and yet the organ shall remain precisely as in health, and in no degree altered ; the only appreciable difference, even in its condition, being the greater or less amount of blood contained within it, or passing through it in a given time, and the greater or less amount of the secreted product. Medicines may, therefore, change the action of an organ, as regards the degree of rapidity, without altering its structure; and the same may be said of the nature of the action, as indicated, for example, by the character of the secretion ; for a cell may elaborate different secretory products, according to the quality of the blood, or of the foreign materials brought with it, without differing in the least in its characteristic form or structure from the normal cell. But, throwing aside this refinement of discussion, we may assume as functional effects all that are not attended with appreciable structural change; and as organic, all that are attended with such change; and this is the meaning which I attach to these terms, as employed in the present work. In the sense just referred to, the effects of the great majority of medi- cines, as ordinarily used, are exclusively functional ; and it is chiefly those employed externally, to inflame, vesicate, or cauterize, that can be said to operate essentially by a change of structure. SECTION III. Characteristic Effects of Medicines. Medicines either increase, lessen, or alter the healthy functions; and, in reference to these several effects, are called tKmulants, sedatives, and alteratives; the effects themselves being distinguished by the names <>l stimulation, sedation, and alteration. It has been maintained iliat, from the very nature of the vital functions, medicines can affect them in no other way than either by increasing or diminishing them, and that they differ from each other only in the degree in which they produce t hex- effects respectively, or in the s<-at of their action. But this doctrine ir- CHAP. II.] EFFECTS OF MEDICINES. 31 purely hypothetical, and is opposed, apparently at least, by numerous facts. Nothing: is more common than to witness peculiar effects from different medicines, without any observable increase or diminution of the vital functions; and this difference may often be observed in medicines acting on the same part. Besides, in relation to those which are essen- tially either stimulant or sedative, we observe characteristic peculiarities which cannot be ascribed either to the degree or direction of their action. Thus, in relation to medicines the effects of which are visible, we have intense redness with comparatively little tendency to vesication from mustard, a less degree of redness with large vesication from cantharides, a copious vesicular eruption from croton oil, a peculiar pustular eruption from tartar emetic, and the production of urticarious wheals from the nettle, all acting on the same portion of the surface, and all excitant in their operation. Now it is possible that, in these and similar cases, the result may be owing to the direction of the action of the irritants severally to some distinct constituent of the skin ; but this has not been proved; and, in reference to a great number of the peculiar effects of medicines, such a direction to distinct constituents of the structure is altogether insusceptible of proof. In the present state of knowledge, therefore, it is best to admit, as the result of observation, that medicines do materially differ in the nature of their effects, independently of degree and position ; and to leave to further investigation the determination of the precise nature of the causes which occasion such difference. Another opinion denies the existence of directly sedative or alterative medicines, maintaining that all substances which act on the system are essentially stimulant, and that whatever sedative effects may be pro- duced are purely secondary. According to one view, medicines operate on the vital excitability, producing primarily an elevation of action, which is followed by secondary depression in consequence of the exhaus- tion of the excitability; and whenever a direct depression takes place, it is in consequence of the diminution of the ordinary healthy excitants, as through the influence of cold, abstinence, etc. According to a second view, medicines operate as foreign bodies, offensive to the economy, in which, consequently, an excess of action is induced in order to rid it of the offending cause ; in other words, all medicines operate by calling forth vital reaction, as inflammation is induced in a part by the presence of a foreign body, in order either to isolate it by a coating of coagulable lymph, or to throw it off through the agency of suppuration and ulcer- ation. But in opposition to all such purely hypothetical views is the simple fact, that certain medicines, when brought into contact with cer- tain parts or organs of the body, are immediately followed by a depres- sion of function in those parts or organs, without any other discoverable intervening derangement; just as, under similar circumstances, certain other medicines are followed by immediate increase of function ; and the 32 EFFECTS OF MEDICINES. [PART I. obvious explanation is, that the susceptibilities of the parts are such that the presence of a body constituted in one mode occasions depression, that of another, differently constituted, excess of excitement. But, admitting that some medicines are stimulant, others sedative, and others again alterative, we are not called on to believe that any one medicine is essentially one or the other under all circumstances. Much and very unnecessary discussion has taken place in relation to particular medicines, whether they were stimulant or sedative. It might all have been spared by the admission of the simple truth, that the same medi- cine may be stimulant or sedative according to the part upon which it acts, or the state of the system, or parts of the system, at the time of its action. Thus, tartar emetic is stimulant to the skin or mucous coat of the stomach, but sedative to the heart ; digitalis, which depresses directly the circulation and nervous system, excites the kidneys; and opium, at the same time that it stimulates the heart and brain, diminishes secre- tion. These different primary effects of the same medicine are dependent on the different susceptibilities of the parts affected, rendering them liable to opposite impressions from the same cause; and, as these susceptibili- ties are often different in disease and health, the same medicine may 'produce opposite effects in these two states. Thus, Cayenne pepper, which produces in the healthy fauces redness and burning pain, an a sedative in the sore-throat of scarlet fever. A mere difference in the mode in which a medicine is employed may cause it to be either stimu- lant or sedative. A concentrated solution of acetate of lead applied to the skin denuded of its epidermis, or to a mucous membrane, acts as an irritant; while the same solution, very much diluted, will operate as a sedative through the peculiar powers of the medicine. This principle is of great importance in therapeutics, as will be hereafter more particularly shown. The consideration of the special phenomena, w r hether of stimulation, depression, or alteration, produced by particular medicines or classes of medicines in the several functions, belongs to the department of special therapeutics. , It is obvious that they must be extremely diversified, from the difference in the degree and nature of the action of the medi- cine, from its direction to one or to several functions at the same time, and from the great diversity in the character of the functions affected. SECTION IV. Influences Modifijiny iJte Effects of Medicines. The circumstances which are calculated to modify the ordinary and characteristic action of medicines should always be taken into account by the physician. These may be divided into such as relate especially CHAP. II.] EFFECTS OF MEDICINES. 33 to the medicines, and such as relate to the system. The former will be more conveniently treated of when the medicines themselves are con- sidered. A few general remarks, in relation to the latter, will be appro- priate in the present place. To enter into minute particulars would be quite impossible ; as there is scarcely a change, whether consequent upon the healthy progress of the body from birth to old age, or upon the operation of morbid causes, which does not in some measure influence the effects produced by medicines. Many of these influences will be referred to in connection with the several medicines or remedies de- scribed; but much, in practice, must always be left to the observation, experience, and judgment of the physician. The modifying influences may bfi such as are essentially connected with our bodily constitution in health, or such as are more or less acci- dental. The first may be ranked under the heads of age, sex, temper- ament, and idiosyncrasy ; the second under disease, climate, habit, modes of life, and mental action. 1. Age. It is a general, though not universal law of nature, that sus- ceptibility to the influence of medicine is inversely proportionate to the size of the animal. This probably results chiefly from the greater amount of a medicine required to give a certain degree of impregnation to the blood of the larger animal than the smaller. The medicine acts on dif- ferent bodies, not in proportion to its absolute quantity in the blood, but to the quantity of it which is brought to bear upon each point acted on, in other words, to the strength of its solution in the blood. Under the rule here referred to, the child should be more susceptible to the in- fluence of medicines than the adult, and should consequently be affected by smaller quantities. But there is another reason, also, for the greater susceptibility of early life. In the growing state, greater impressibility and mobility are essential, in order that there may be a more rapid assimilation of external material, and a due arrangement of the organism. The higher susceptibility to impression must extend to medicines, as well as to all other impressing agents. Still another cause of difference, in this re- spect, between the young and the old, is the absence or less degree, in the former, of the influence of habit in diminishing susceptibility. I do not here allude to the habit of using medicines; for the cause operates though no medicine may ever have been taken. The general impres- sibility of the system diminishes by time under the necessary influence of external agents ; and this law holds good even in relation to particular agents to which the system may never have been exposed, though it would be less operative in reference to these than to others. It is impossible to give any precise rule for proportioning the dose to the age ; because different individuals exhibit a great difference in this respect; and there is a remarkable diversity in reference to medicines; VOL. i. 3 34 EFFECTS OF MEDICINES. [PART I. some, as opium, producing in children more thnn the mean proportionate effect; others, as castor oil and calomel, much less. It may be said, in general terms, that the dose for an individual under maturity should be proportioned to the years of his age. This holds good in relation to all ages between 12 and 24, at the latter of which periods of life, the full dose may be given. From the age of twelve downwards to two years, the rule of Dr. Young is perhaps as good as any that can be given ; namely, that the dose proper for an adult should be diminished, for a child, in the proportion of the age increased by twelve to the age. Thus, the age being three years, and the dose for an adult 20 grains, the diminution must be in the proportion of 3+12 = 15 to 3; or, the quantities being reduced to their lowest terms, of 5 to 1 ; that is, the dose for the child must be one-fifth of that for the adult, or in the present instance 4 grains. At one year the dose may be one-ninth ; at nine months, one-tenth ; at six months, one-twelfth; at three months, one-fifteenth; at one month, one-twentieth ; but it must be admitted that these numbers are nothing more than safe approximations. From full maturity to the commence- ment of declining life, that is, from about twenty-four to forty-eight, the dose may remain unchanged ; but, after the latter period, it should be somewhat diminished with the increasing age, not because the system becomes more susceptible; for, as a general rule, it is less so; but be- cause it is less able to sustain, without injury, a given impression from medicines than in the full vigour of life. 2. Sex. It is necessary to say but little under this head. There are certain conditions in the female which require attention in the prescrip- tion of medicines, which, however, cannot be said to exert any materially modifying influence over their effects, and do not, therefore, require par- ticular attention in this place. Such is pivgnancy, which demands especial caution in the use of all medicines having a direct influence on the womb, and which, in its advanced stages, contraindicates the use of any medicine whatever of a powerfully perturbating character. Such, too, is the menstrual state, in which care is required, in the employment of remedies, to guard against any interference with the uterine function. Another important point, of a similar bearing, is the caution requisite, in the cases of nursing women, not to use medicines which might injure the suckling ; and a similar caution may be very properly extended to pregnancy, in which, while prescribing for the female, we should al \vays bear in mind that there is another being to be affected by the remedy employed. So far as concerns the modifying influence of sex upon the effects of medicines, the only circumstance of importance is. that women, being smaller, more delicately organized, and in general more susceptible than men. require a smaller amount to produce a given etVeet. The dose for females should, therefore, be somewhat reduced. From one-Mxth to CHAP. II.] EFFECTS OF MEDICINES. 35 one-quarter may be deducted for them from the dose proper for the male at the same age. 3. Temperament. Temperament should receive some attention in the administration of medicines ; but the judicious physician will probably be influenced in relation to it more by his general principles than by any special precepts. The sanguine temperament obviously demands caution in the administration of stimulants, and the nervous in that of evacuants: while the phlegmatic, being characterized by a general deficiency of sus- ceptibility, admits and requires a freer use of medicines in reference to a given effect. 4. Idiosyncrasy. Individual peculiarity, technically denominated idi- osyncrasy, is of much greater importance, and can scarcely receive from the physician a too careful attention. In very many individuals, per- haps it may be said in nearly all, there is some peculiarity, in relation to the effects of a particular medicine, or possibly of more than one, which, if unknown or neglected, may lead to serious inconvenience or injury, and even to fatal results. This peculiarity sometimes consists merely in an excessive susceptibility, or in an abnormal insusceptibility to the action of the medicine or medicines; so that an ordinary dose might, in the former case, act with dangerous violence, and in the latter not act at all. This is strongly illustrated in the not unfrequently unex- pected results from the use of the mercurial preparations. In more than one instance that might be adduced, a moderate dose of calomel or other mercurial has acted so powerfully, in consequence of a remarkable con- stitutional susceptibility to its influence, as to occasion death; and every experienced practitioner, who has used this medicine habitually, must have witnessed instances of unexpected violence in its action; while, in other cases, from defective susceptibility, it is quite impossible to bring about its peculiar effects on the system by any quantity that can be given, with any regard to prudence. The instance of mercury has been brought forward simply as a striking example ; but there is scarcely an efficient article of the materia medica, in relation to which there does not exist, in some one or more persons, a similar excess or deficiency of susceptibility. But the idiosyncrasy is not unfrequently also of such a nature as to vender the effects of a medicine altogether different from those which it ordinarily produces. The well-known and often-cited example of ipe- cacuanha, in causing by its mere smell an asthmatic paroxysm in certain persons, is strikingly illustrative of this fact. Other examples are offered in the cutaneous eruption produced in some individuals by copaiba and the turpentines, the irregular and very inconvenient effects sometimes resulting from opium, and the occasional peculiar and poisonous opera- tion of mercury, altogether different from its proper action. I have known so innocent a medicine as pipsissewa (Chimaphila umbellata), 3C EFFECTS OF MEDICINES. [PART I. given in the form of decoction, in the dose of a wineglassful, to cause a most violent attack of erythematous inflammation of the mouth and face. These idiosyncrasies are sometimes also developed by disease, so as TO render individuals susceptible to effects from medicines quite different from those expected, and sometimes even directly opposite. Whether original or acquired, they should claim the careful attention of the practitioner, who should never neglect information in reference to such peculiarities that may be volunteered by the patient, and should lay up in his memory, for future use, all that he may witness in his own experience or observation. A physician thoroughly acquainted, from habitual attendance, with all the constitutional peculiarities of his patient in reference to the effects of medicines, often has great advantages in treatment over others without any experience of the kind. 5. Disease. Reference has already been more than once made to the influence of disease in modifying the effects of medicines. Not only is the susceptibility to their influence greatly increased in some instances, and greatly diminished in others, but new susceptibilities are occasionally awakened, and effects wholly abnormal, or at least apparently so, are ex- perienced. Thus, inflammation of the stomach so much increases the susceptibility to the influence of emetics, that a minute fraction of the ordinary dose will often operate; while, in certain nervous affections, as delirium tremens for example, there is an almost equal diminution of susceptibility, and, in some instances, enormous doses are required to produce vomiting. In certain morbid conditions of the brain, a little opium will excite to phrensy ; in others, it is with the utmost difficulty that the medicine can be brought to operate, as in tetanus and certain forms of mania. In diarrhoea, opium often cheeks the evacuations, in colic, on the contrary, favours the action of cathartic medicine. Certain conditions of disease have a powerful influence over the effects of medi- cines by impeding their absorption. Thus, any morbid state of the liver, which retards the circulation of the portal blood through that orjMii. must produce general congestion of the bowels, and consequently offer a strong impediment to the entrance of the medicine into the circulation. But, in this place, all that is necessary is simply to notice the modifying influence of disease, and to impress on the mind of the student the indis- pensable necessity of attending to it. The peculiarities in this respect of different morbid states, must be studied along with the several dis- (MH'S iii which, or the several medicines in reference to which, they displayed. 6. Climate. Climate acts by altering the state of the system. S times the change is so great as to amount to di-casc; and then the influence of this modifying cause is merged in that of the one last con- sidered. But climate also affects the functions in a manner which can CHAP. II.] EFFECTS OF MEDICINES. 37 scarcely be considered pathological ; as the result is experienced more or less by the whole community; and, though the state of system under any particular climatic influence may be less vigorous, or less perfectly balanced, than under more favourable circumstances, it is nevertheless the health of that region where the influence prevails. The following may be mentioned as examples of the modifying influence of climate over the eifects of medicine. In cold climates the susceptibility to alco- holic stimulants is much less than in the hot ; probably because, in the former, much of the stimulant is consumed in the lungs for the pro- duction of heat, and thus thrown off from the system; while in the latter, in which heat is already in superfluity, none of the alcohol is con- sumed in the lungs, and more of it is consequently retained to act upon the brain. ]n hot climates, calomel acts less energetically on the liver than in cold, probably from the diminished general susceptibility of that organ, consequent upon its habitual over-excitement. In miasmatic districts, blood-letting and other evacuant measures are, in general, not so wejl borne as in regions exempt from malarial influence ; while quinia may be given with a freedom which elsewhere might be hazard- ous. But the modifications produced by climate in the operation of medicines have not been investigated with sufficient accuracy and pre- cision, to justify anything more than very general statements upon the subject. 7. Habit. This is a powerful agency. Its effect is almost uniformly to lessen the susceptibility to the influence of medicines, and thus to require an increase of their dose for the production of a certain amount of impression. In relation to medicines which are purely functional in their operation, this augmentation of the dose, under the influence of habit, may be carried on almost indefinitely. The quantities of alcohol and of opium to which the system may become accustomed, with present impunity, are enormous. It is not exactly the same with medicines of powerful chemical action, corrosive mineral substances for example; for, though the quantity may, through the agency of habit, be very con- siderably increased beyond what could be borne without its aid, yet, at a certain point, the chemical forces necessarily overcome the vital re- sistance of the tissues, and decomposition must take place. The mineral acids, therefore, the caustic alkalies, and the corrosive metallic salts, such as nitrate of silver, corrosive sublimate, and sulphate of copper, cannot be indefinitely increased without the danger of great organic mischief. But it must be remembered that, even with those acting functionally, the ultimate eifects are in the highest degree injurious, either through chronic inflammation, induced at length by the constant irritation sustained, or by the failure of susceptibility to the ordinary vital stimuli, and the consequent loss of all power of action. The rule in relation to the effect of habit in diminishing susceptibility 38 EFFECTS OF MEDICINE?. [PART I. is probably universal. There are, it is true, some apparent exception > -. as in the case of emetic substances, which often operate, on successiv occasions, in successively diminishing doses; but the exception is only apparent; for the result in this case is ascribable not directly to the medicine, but to a diseased state of irritation produced by it, which itself is sufficient to induce vomiting. If an emetic substance is given at first in a small dose, and afterwards gradually increased, the stomach becomes accustomed to it, and very large quantities may be given with- out provoking vomiting. The practical inferences from this effect of habit are, 1. that when it is desirable to maintain for a long time a given medicinal impression, the dose should be gradually, but at the same time cautiously increased. BO as not too rapidly to wear out the susceptibility; 2. that when one medi- cine has been given so long as materially to impair its powers, another of analogous mode of action, but exerting its influence on a differ tissue or part, should be substituted, until the susceptibility to the firs: returns; and 3. that, in omitting a medicine which has been long- -giver. in gradually increasing quantities, it should be withdrawn gradually its place should be supplied for a time with another of similar but feebler powers, lest the system or part should suffer from the want of an influ- ence to which it had become habituated, and which might be essential to the performance of its proper functions. 8. Modes of Living. The occupation and mode of life of an indi- vidual modify the action of medicines, in so far as they affect the condi- tion of his system. But it would be quite impossible, in the pre- place, to follow out this influence into all its results. Little more can In- done here than to call attention to its existence. One consideration, however, is worthy of notice, as it has a general bearing, and can }> brought forward nowhere else so appropriately. Firm and vigorous health affords the strongest resistance to all disturbing influences, and consequently to the action of medicines, which must, therefore, be given more freely, to produce a certain effect, than in conditions of the system either above or below that standard. This is true in relation not only to medicines which stimulate, but to those also which depress or alter the vital functions. Thus, persons in full health will bear both the stimulan: influence of alcohol, and the sedative operation of digitalis, better than the plethoric or the feeble. But it must be remembered that full healti does not consist in that richness and abundance of blood, and that high activity of the functions, which are sometimes mistaken for itT Th indeed a condition, if not itself morbid, at least closely bordering on dis- ease, and capable of being excited into positive disease by slight causes. The system is most healthy when all its parts and all its functions are in due relation; when tin- quantity and quality of the blood are in exa- -. accordance with the offices it has to perform in the economy : when the CHAP. II.] EFFECTS OF MEDICINES. 39 nervous system has no higher nor lower activity than is sufficient to maintain every function in its just vigour and subordination ; and when no one organ or apparatus is excessively or deficiently developed. It is in this condition of system that medicines are best borne, and that, upon the occurrence of disease, vigorous treatment may be most safely adopted. Modes of life, therefore, which tend to produce an over-elevated condition of system on the one hand, or a debilitated condition on the other, render peculiar caution advisable as to the quantity of medicines employed, and the energy of the treatment in general. 9. Mental Action. The influence of the mind over the operation of medicines is often very considerable. As a general rule, they will act with greater certainty when their legitimate effects are known and ex- pected. An emetic will be more likely to vomit, if the patient anticipate this effect from it. The co-operation of faith with. the medicine will often favour its action. This is more especially true when the nervous system is prominently concerned. The full belief in the efficacy of quinia in intermittent diseases aids considerably in the prevention of the parox- ysm. But mental causes sometimes interfere with the regular operation of a medicine. When this is given to procure sleep, especially in divided doses, at certain intervals, if the patient is made acquainted with the ob- ject, his anxiety for the result may tend to prevent it. I have noticed, when I have directed, with the knowledge of the patient, a certain dose of opium to be given at bedtime, and repeated, at intervals of an hour, until sleep is produced, or a certain number of doses have been exhibited, that the whole quantity prescribed is generally taken. The nervous dis- turbance occasioned by the expectation of the next dose, and the watch- fulness for the appointed time, tend to keep the patient awake. Hence, in prescribing an anodyne in this way, particular care should be taken that the patient shall not know that the dose is to be repeated if requi- site. It is to mental influence that empiricism is partly indebted for its seeming triumphs, especially in nervous diseases; and regular practi- tioners sometimes employ bread pills, with the happiest effect, in accom- plishing certain results which the patient has been previously taught to expect. 40 APPLICATION OF MEDICINES. [PART I. CHAPTER III. Application of Medicines. MEDICINES have hitherto been considered in relation, not so much to their application to the cure of disease, as to their modes of affecting the system in health. It now remains to consider them more especially in the former capacity; and, in doing this, it will be convenient to treat first of the several modes in which they may operate in the cure of disease, secondly of the forms in which they may be applied, and thirdly of the parts through which, and the means by which they may be introduced into the system. The remarks which follow apply not only to medi< strictly so called, but to all other remedies. ' SECTION I. Modes of Therapeutic Action, or Therapeutic Processes* These may be arranged under the heads of 1. depict / >n ; 2. repletion ; 3. dilution; 4. elimination; 5. stimulation; 6. sedation; 7. revulsion; 8. supersession; 9. alteration; 10. contra-causalion ; 11. chemical ac- tion; and 12. mechanical action. SUBSECTION I. Depletion. 1. Nature of Depletion. By this term is here meant diminution of the blood, in relation either to the whole mass, or to some one or more of its constituents. As it is these constituents of the blood to which, * The reader who may be familiar with my Treatise on the 1'raetice of Medicine, in any of its editions before the fifth, will recognize, in the observations Which fol- low, many things which he has met with in that work. These were not .introduced into the present treatise inadvertently. They essentially belong to it. and could not be omitted without leaving the treatise imperfect. Their insertion here, moreover. gave me the opportunity, in revising the work on the Practice for the fifth edition, of dropping in the revision the subjects here treated of, and supplying the space thus gained with new matter of a practical nature, which is ever in the course of discovery and accumulation. CHAP. III.] APPLICATION OF MEDICINES. 41 both through the material they furnish, and the stimulus they apply, all the vital functions owe their support, and the organs their due nutrition, the abstraction of them must necessarily occasion, in the ordinary state of the system, a depression of action and reduction of strength. It is not only, however, by diminishing the quantity of blood that depletion oper- ates, but also by altering its quality. When a portion of the blood is abstracted, the place of the solid constituents withdrawn is rapidly sup- plied by the process of absorption, so that its former volume is soon restored ; but, as water is absorbed in much greater proportion relatively than the solid ingredients, the blood becomes diluted, and is, therefore, less capable of performing its due office in the economy. Depletion de- presses especially the force of the heart, and of the whole circulatory system. It diminishes also digestion, respiration, secretion, nutrition, calorification, and the functions of animal life. This last effect is ren- dered obvious when the depletion is carried far. Languor, impaired sensation, deficient emotional and intellectual energy, muscular weak- ness, even faintness, and positive syncope, result from the failure of the due influence of the blood upon the brain. But, with this general diminution of the vital powers and actions, there is one function which depletion promotes, that, namely, of absorp- tion. To supply the loss of blood, the liquids and solid tissues of the body are taken up with more than the usual rapidity, and water is co- piously absorbed from the contents of the alimentary canal, and perhaps also from the external air. Notwithstanding what has just been stated, depletion is not always purely sedative ; and this is a very important therapeutical fact. The general rule may be considered as holding true, whenever the blood is in excess as regards its animalized or vital constituents; also, in the ordi- nary state of the blood, so far as concerns the immediate effects of de- pletion, and even in its ultimate effects when it is moderately used and properly guarded. Bat excessive depletion may act as an excitant in- stead of a depressing agent to certain functions, and especially those of the circulatory and nervous systems. The functions of the system gen- erally, feeling the want of their ordinary support from the blood, make this want known to the nervous centres, which then transmit a stimulant influence to the heart, while, at the same time, they give evidence of their own disturbance by various irregular nervous phenomena. Under no circumstances, is the heart thrown into more violent commotion than, sometimes, through an impoverished condition of the blood. Depletion, therefore, especially the more direct and powerful kinds of it, should be employed with reserve in anemic states of the circulation, even though strongly indicated by other considerations. Another important rule is that, when a purely sedative effect is desired from this remedial measure, all the functions should be kept as quiescent as possible; so that, con- 42 APPLICATION OF MEDICINES. [PART I. sumiug little blood, they may not, from a feeling of deficiency, excite the nervous centres and through them the heart into a state of irritation. Rest should ho enjoined, the food diminished, and strong mental action or emotion avoided ; so that the muscles, the digestive organs, and the brain may be content with less than the ordinary supply of their essen- tial pabulum. 2. Applications of Depletion. The therapeutic applications of deple- tion are obvious. It is the groat rornedy in plethora, and in an excess of local vascular excitement, whether that excess amount to irritation merely, or to inflammation. Sanguineous determination and active congestion, hemorrhage, morbidly increased secretion, and other derangements of function, so far as these disorders are the result of vascular irritation, are to be corrected by it. In the treatment of inflammation it is inval- uable, not only lessening the force with which the blood is driven into the inflamed part, but impairing those qualities of the vital fluid which most powerfully support that morbid process. Another application of depletion, dependent on its influence over the absorbent process, is to the treatment of morbid effusions ; the different forms of dropsy, for example, in which it is often employed with great efficacy, though requiring caution. Upon the same principle, it may be used in polysarca or morbid obesity. 3. Means of Depletion. Depletion may be effected either directly, by taking blood or promoting secretion, or indirectly, by diminishing the supplies through which the natural losses of that fluid are repaired. Direct Depletion. Beyond all comparison the most efficient of the measures for direct depletion is general and local bleeding. The char- acter of this remedy, its peculiar applications in disease, and the methods of employing it, will be fully considered in the second part of this work. Another important mode of direct depletion, is increased secretion. It not only unloads the circulation in general, but, in some cases, has the advantage over bleeding, of directly depleting from the diseased ves- sels themselves, and thus imitating a very frequent process of nature in the relief of irritation and inflammation. Thus, cathartics relieve mucous enteritis, expectorants bronchitis, and diuretics nephritis. It is not merely the watery parts of the blood that are thus evacuated, but its animalized constituents also, though the red corpuscles seldom pass. Upon the whole, this mode of depletion is much less efficacious than bleeding, in the relief of plethora and active congestion. But, for tin- purpose of promoting the absorption of effused fluids, it is even more efficacious; as a much larger amount of liquid may be safely abstracted from the blood-vessels by increased secretion than by bleeding, and con- sequently a greater amount of absorption produced. The remedies most efficaciously employed with reference to depletion, upon this principle, are cathartics, diuretics, and diaphoretics. But all CHAP. III.] APPLICATION OF MEDICINES. 43 that increase secretion are occasionally useful, including expectorants, emmenagogues, sialagogues, errhines, epispastics. issues, and setons. It is upon this principle, in part, that the warm, hot, and vapour baths act usefully in certain inflammatory affections. In the application of these various remedies there is much room for discrimination ; some being better adapted to one condition, others to another, and some being posi- tively injurious where others are highly useful. This, however, is not the proper place to discuss their properties; and the reader is referred to the second part of the work. It may be proper to mention here, that such as are employed for the reduction of plethora, or inflammatory ex- citement, should be destitute of general stimulating properties, and that the most efficient are those which unjte a sedative influence over the cir- culation with the power of increasing secretion. Such especially are the saline cathartics, and the antimonial diaphoretics and expectorants. A general rule applicable to all these medicines is, that, in cases of high vascular excitement, when the pulse is full and strong, and bleeding is otherwise indicated, they should be preceded by that remedy. Secretion is often checked by excess of excitement in the secreting organ, and favoured by a reduction of the excitement. Besides, medicines are not easily absorbed when the blood-vessels are full to distension. If the object be to reduce active congestion or inflammation by promoting secretion from the part or organ affected, preference should always be given, at least in the earlier stage, to those stimulants of the secretory function which are least irritant in their action. Thus, sulphate of mag- nesia should be preferred to gamboge, scammony, or elaterium, in the treatment of dysentery ; tartar emetic or ipecacuanha to squill or seneka, in the earlier stage of bronchitis ; and cream of tartar to oil of turpentine, in acute nephritis. Indirect Depletion. This is effected by whatever prevents the usual amount of solid organic material from entering the circulation. Emetics and cathartics act in this way, by discharging the partially digested food from the alimentary canal before it has been absorbed. Still more effi- cacious is a temporary abstinence from food, or a reduction of its quan- tity and quality. But the subject of diet as a means of indirect depletion belongs to special therapeutics, and will be considered hereafter. SUBSECTION II. Repletion. This term is here employed, rather in reference to its origin than in accordance with its accepted meaning, to signify an increase in the quantity of the blood in general, or of its solid animalized ingredients. The circumstances of disease under which this remedial process is de- sirable are the opposite of those requiring depletion ; namely, general 44 APPLICATION OF MEDICINES. [PART I. debility, a too scanty blood, and a condition of that fluid in which, though its bulk may be sufficient, there is an undue proportion of the watery ingredient. The means by which it may be accomplished are the free employment of a highly nutritious diet, and the use of remedies calculated to invigorate digestion and sanguification, such as moderate exercise, tonic and stimulant medicines, frictions, and the cold bath. SUBSECTION III. Dilution. By this is meant the copious internal use of water, whereby the liquids of the body are diluted, and rendered less excitant. The contents of the stomach are first diluted, then the blood through absorption of the water, and lastly, the secretions, especially those of the skin and kidneys, in consequence of its passing out through these emunctories. The thera- peutic effect is to relieve irritation or inflammation of the surface with which the diluted fluid may be in contact, as the mucous membrane of the stomach, and that of the urinary passages, and to moderate general excitement by attenuating the blood. SUBSECTION IV. Elimination, It is well known that, in the course of various diseases, matters accu- mulate in the blood, either altogether foreign to that fluid, or existing in it during health only in almost inappreciable quantities, and in the course of spontaneous elimination from the system. Thus, urea and uric acid, which are the results of the disintegration of the tissues, or the super- fluous residue of the food in its conversion into blood, are, in the healthy state, present in the circulation only until they can be thrown off by the kidneys ; and the same may be said of the colouring matter of the bile, which is separated and excreted by the liver. These accumulate ab- normally in the blood, when their respective emunctories fail in their office of excretion, and become sources of inconvenience and danger. It is highly probable that other noxious principles, not well understood, in like manner vitiate the blood, either forming special diseases, or com- plicating those resulting from other causes. In febrile complaints, a sour odour is often observable in the breath and perspiration, arising from the escape of acid matters from the blood. In typhus fever, small- pox, and many cases of disordered digestion and obstinate constipation, the breath and other secretions have an offensive odour, indicating, no doubt, an impure condition of the circulating fluid. Now the existence of such morbid matters in the blood affords a well-grounded indication CHAP. III.] APPLICATION OF MEDICINES. 45 for the use of remedies calculated to effect their elimination ; and there can be no doubt that this is not unfrequcntly a very useful therapeutic process. The remedies alluded to are such as stimulate the several emunctories; and cathartics, diuretics, diaphoretics, and cholagogues. add this mode of action to their other beneficial influences in disease. There is another mode of elimination which has recently begun to attract attention, and which may possibly hereafter prove a highly im- portant method of cure. It has been shown that certain substances, having a noxious influence upon the health, are sometimes incorporated with the tissue of the organs, and probably thus impair their efficiency by a constant unhealthful influence. Such are various metallic poisons, as the preparations of arsenic, lead, copper, and mercury. To separate these from their seat in the tissues is an important'indication ; and there is reason to believe that this may sometimes be fulfilled, not only by medicines calculated to promote absorption and secretion, or to alter the nutrition of the organ, but also by others which modify the condition of the foreign matter, so as to render it soluble in the blood, and thus ca- pable of being eliminated from the system. It is believed, for example, that lead is thus displaced, when producing colica pictonum or paralysis, by the exhibition of iodide of potassium. More will be said on this subject under the head of the several remedies employed on the principle referred to. SUBSECTION V. Stimulation. Stimulation, as here understood, is the exaltation of any or of all the vital functions above the state in which they may happen to exist, at the time when the stimulating measure is resorted to. There is a vast diver- sity in this process. It differs in direction, degree, duration, and char- acter. Perhaps the most convenient primary division of it is into general and local; the former being felt, to a greater or less extent, throughout the body, the latter confined originally to a particular part or organ. A property common to all stimulation is, that it is followed, in the ordinary state of the system, by a degree of depression bearing some proportion to the previous excitement. There are conditions of tem- porary prostration, in which stimulation may put the system in the power of resuming its ordinary grade of action without subsequent de- pression ; but these do not come within the general rule. The depression is dependent upon the temporary diminution of excitability, resulting from excessive action. If the stimulant influence; be continued, it follows, as a consequence of the diminished excitability, that a greater amount of the stimulant agent must be employed to produce the same effect, and the excitability is thus still further diminished ; until, in the end, the 46 APPLICATION OF MEDICINES. [PART I. <-m refuses entirely to respond to the ordinary healthy excitants, and morbid and often fatal debility results. This is an evil against which it is necessary to be constantly on our guard, in the use of stimulant meas- ures. Another, scarcely less important, is the production of inflammation by the excessive or repeated excitement to which the stimulated organ or sy-tem is exposed. 1. General Stimulation. It is barely possible that stimulation should b.- absolutely universal. In whatever degree the functions generally may be excited, there is almost always some one or more that become de- -sed, or remain quiescent. Stimulation may be considered general, when any one of the vital properties or functions which belong to all parts of the frame is exalted, as contractility or nutrition; or when one of the anatomical systems which pervade the whole body is excited into increased action, as the circulatory or nervous. In such cases, the ex- citement is felt throughout the frame, though not in every function. The lowest grade of general stimulation is that produced by astringents, which operate on the organic contractility, and produce a general con- densation or shrinking of the tissues. Tubes and orifices are thus con- tracted, the flesh becomes firmer, and the pulse somewhat more tense. The therapeutic applications of this power of astringency, with the requisite cautions, will be hereafter fully considered. Somewhat higher in the scale of general stimulation is the action usually denominated tonic. This is a moderate increase of the vital functions generally, produced rather slowly, and lasting for a consider- able time. It is of vast importance in the treatment of moderate or chronic debility. For an account of its special applications, the reader i^ referred to the second part of the work. Among the agents by which it is effected is a class of medicines denominated tonics, which may act directly on the whole system, or especially on the digestive function, thereby enriching the blood, and making that fluid the immediate ex- citant. Some medicines probably also give tonic power to the blood by a direct action on that fluid. Such are the chalybeates. But there are other very important tonic agents besides medicines. Cold operates in this way secondarily, through the reaction which follows its direct de- pressing influence. A wholesome, and nourishing diet, succeeding an impoverished one, and pure fresh air with those who have been con- fined to a close and vitiated atmosphere, have a powerful tonic operation. So also has moderate physical exercise, under similar circumstances of ious deprivation. Gentle electrical excitation may be placed in the >;nue category. Mental influences, moreover, have great ff>'<-\. No tonic is, under many circum-tunn s. more efficient than the cheering in- fluence of social pleasure.-, domestic enjoyment, and a gentle exercise of iitellectual faculties, and all the kindlier emotions. A quicker and more rapid stimulation is sometimes distinguished by CHAP. III.] APPLICATION OF MEDICINES. 47 the name of diffusible. It usually affects more or less, at the same time, the functions both of organic and animal life; though, as proceeding from one cause it may be more especially felt in the circulation and its dependent functions, from another, in the nervous system. This special direction is sometimes so far exclusive as to justify the division of diffu- sible stimulants into those operating more particularly on the circulation, and those upon the cerebro-spinal functions. It will be found, hereafter, that this distinction serves as the basis of an arrangement in the plan of classification which I have adopted. For want of a better name, the medicines acting on the circulation especially, with little tendency to the nervous system, may be denominated arterial stimulants. Stimulants which act chiefly on the nervous system may diffuse an ap- parently equable action over the whole of that system, or may concen- trate their influence especially on the brain. The former may be called nervous stimulants, though more commonly designated as antispas- modics; the latter I propose to call cerebral stimulants, preferring this title to that of narcotics, which has reference to the property of stupefy- ing, that belongs also to medicines of wholly different powers. It will be perceived hereafter that the above arrangement of stimulant medi- cines is not only natural, in relation to their physiological effects, but has also an important practical bearing. Other influences besides those properly medicinal are susceptible of very useful employment in reference to general stimulation. Heat and electro-magnetism are agencies of this kind ; and stimulating food is yet more important. These will be fully treated of under Special Ther- apeutics. 2. Local Stimulation. Local stimulation may have the effect of merely irritating or inflaming a part; or of exciting it to an increased performance of its peculiar function. In the former case, the object is usually to act revulsively, or to pro- duce general stimulation through the sympathy of the system with the part affected. The agents employed for either purpose, so far as the ex- ternal surface is concerned, are the rubefacients, epispastics, and escharo- ties. Occasionally, however, the object is entirely local. The vessels of a part may become relaxed and congested with blood, and, in conse- quence, an imperfect sort of inflammation may be sustained; or there may be ulceration, and the surface too feeble to take on the action necessary for the healing process. In either case, local stimulation sometimes answers an excellent purpose in removing the evil. But still more frequently this remedial process is employed for the increase of function. The surface may be pale, dry, and inactive; the muscles may be enfeebled to paralysis ; the senses of smell, taste, and touch maybe imperfect from weakness; digestion may be feeble, and tin- bowels costive fr.in deficient secretion, or want of due peristaltic 48 APPLICATION OF MEDICINES. [PART I. movement; the liver, kidneys, or other secretory glands may be inert. The means used to restore the weakened functions are medicines and other remedies, having a special influence over the functions severally. Hence the use of friction to the surface ; the hot bath ; the cold bath used with a view to reaction; diaphoretics; errhines: masticator' gastric stimulants, such as bitters, aromatics. and the mineral acids : emetics; cathartics; diuretics; expectorants; emmenagogues; and chola- gogues to excite the liver, as mercury and nitromuriatic acid. Hence the employment of ergot to stimulate the uterus to contraction. Sometimes a local stimulant is employed to produce general di sion ; as in the case of the hydragogue cathartics, which, though they stimulate the secretory function of the bowels and promote the peristal- tic movement, depress the system in consequence of the depletion they produce. SUBSECTION VI. Sedation or Depression. This implies a diminution of action. Like stimulation it may In- general or local. General sedation may affect especially either the cir- culation and its dependent functions, or the nervous system. The agents which produce the former effect I denominate arterial sedatives. They are the refrigerants of other writers ; as they reduce temperature along with vascular action. Those operating upon the nervous system produce their depressing effect in two ways; in one, by directly allecting the functions of the nervous tissue wherever they encounter it : in the other, by acting primarily on the brain, and through the cerebral centres depressing the dependent nervous functions. The former may he called simply nervous sedatives, the latter may be distinguished by the title of cerebral sedatives. It is important to understand that general nen sedation may result even from the cerebral stimulants, through this de- pendence of function. In this case, the nervous centres are overwhelmed by an active congestion, which cripples their power both of receiving im- pressions and transmitting influence ; and sensibility, muscular motion, and in fact all the functions which derive a necessary support from the brain are more or less impaired. This distinction is of great practical value. Thus, hydrocyanic acid, tobacco, and acetate of lead might In- used as sedatives, when it might not be altogether safe to employ alcohol or opium. The agents of sedation will be enumerated" and described hereafter. It is here sufficient to say that, besides sedative medicines, we are in possession of two powerful remedies of this kind ; viz. cold, in relation to its primary effects, and water. Local sedation may affect all the constituent tissues of a part, or CHAP. III.] APPLICATION OF MEDICINES. 49 more especially the nervous. In the former relation, it is employed to repress inflammation, or vascular irritation as shown in morbid secre- tion, hemorrhage, or simply congestion ; in the latter, to relieve neuralgic- pain, and allay spasm. Many of the general sedatives may be employed locally for these purposes. SUBSECTION VII. Revulsion. Derivation. Counter-irritation. Revulsion consists in the diversion of disease from one part of the system, by the production of inflammation or irritation in another part. The term derivation is applied to the same process, but may be ex- tended also to cases in which the diversion is effected by a degree of excitement, which may still be within the limits of health. Counter- irritation, strictly defined, applies to the revulsive impression rather than to the revulsion itself. The system has only a certain capacity of nervous action, and a certain amount of blood. When either the former or the latter is strongly directed to a particular part of the body, there is a tendency to its diminution elsewhere. This is absolutely necessary of the blood : and it is true, to a great extent, in relation to nervous action. Such a direction is given by the application of irritants of any kind. Hence, in order to relieve inflammation, any of the forms of vascular irritation, or mere nervous disorder as indicated by pain or spasm, in any particular part of the body, we apply irritants, which under these circumstances are called revulsives, to some other part. This principle is of very extensive applicability to the cure of disease. It often comes into play as an auxiliary force, in cases in which the remedy is used for other purposes. Thus, while emetics are employed to relieve spasmodic affections of the air-passages, in consequence of the relaxation they pro- duce, they are probably also useful by a revulsive influence towards the stomach. Cathartics act very powerfully, upon this principle, in the relief of inflammations and active congestions, though they may be em- ployed chiefly in reference to their depleting power. There is no remedy whatever, allowing it to have the power* of producing excitement in any part of the body, which may not act as a revulsive. But the remedies usually employed, in special reference to this principle of action, are external irritants, such as hot water, rubefacients, epispastics, and caus- tics. Derivation may often be advantageously effected by exercise, calling off undue excitement from internal organs to the exterior, or from one part of the body to another, and thus producing an equilibrium of the vital actions. The application of the principle of revulsion requires discrimination. VOL. i. 4 50 APPLICATION OF MEDICINES. [PART I. When the local affection consists rather in a determination of blood to the part affected than in inflammation, as in cases of vertigo threaten- ing apoplexy,, and of frequently recurring epistaxis or haemoptysis, the indication is to divert the general current of excitement, and of the blood, towards the most distant parts of the body. Hence the use of strongly stimulating pediluvia, and of sinapisms to the legs, in cases of cerebral affection of the character just alluded to. But, when the disease is fixed in a part in the form of inflammation, it is necessary to bring the revulsive impression into nearer contiguity with the dis- eased part, though it may be proper also to employ remote revulsion as an adjuvant. Hence, in inflammation of the lining membrane, or of the contents of the great cavities, the revulsive remedy is most advantage- ously applied over the outer surface of the walls of those cavities, as over the abdomen in cases of peritonitis or enteritis, the chest in cases of pleurisy or pneumonia, and the scalp in those of encephalic inflam- mation. The revulsive influence of remedies is peculiarly indicated in cases of metastasis, or of diseases which are especially liable to assume the metas- tatic form. In these cases, the agent should be applied to a portion of the body towards which there is a natural tendency of the morbid action to flow, and in which it would be safe; as, in gouty cases, to the feet, and in retrocedent eruptions, to the part of the surface from which the retrocession has taken place. Another important principle is not to employ a highly irritative revul- sive agent, in inflammatory cases, during the greatest violence of the disease. A strong impression upon the surface may sometimes prove useful in a commencing inflammation, before any febrile action has been excited, and in the declining stages, when the fever has in some measure yielded to depletion, or subsided spontaneously. But, during the ex- istence of high constitutional excitement, the revulsive agent is not suffi- cient to unseat the inflammation, and, if itself very irritant, as in the instances of the more powerful rubefacients and of blisters, may add t<> the existing excitement by the sympathy of the system with the super- ficial inflammation it produces. But, when the revulsive impression is conjoined with copious depletion, as in the case of the saline hydragogue cathartics, which produce a revulsion towards the whole lining mem- brane of the bowels, while they evacuate the contents of the blood- vessels, it may be resorted to in the greatest height of the inflammation. The copious secretion prevents the production of an intestinal irritation sufficient to bring the constitution into sympathy. When the local affection to be remedied is a mere nervous irritation, such as spasm or neuralgic pain, it is generally best to produce a quick, powerful, and transient revulsion; when inflammatory, especially when the inflammation is severe, to sustain a more moderate impression for a longer CHAP. III.] APPLICATION OF MEDICINES. 51 time. Hence, the more active rubefacients, such as mustard and am- monia, are applicable in the former case, and epispastics in the latter. SUBSECTION VIII. Supersession or Substitution. By this process is meant the displacing or prevention of one affection by the establishment of another in the seat of it. It is a general, though by no means universal pathological law, that two powerful diseases, or forms of abnormal action, cannot exist in the whole system, or in any one part of it at the same time. If, therefore, we can produce a new disease, or new mode of abnormal action, in the exact position of one that may be existing or expected, we may possibly supersede the latter; and, if the new disorder subside spontaneously without injury, we cure our patient. The operation of numerous remedial agents may be ex- plained in this way. It is thus, for instance, that mercury has been sup- posed to cure syphilis. But we have better examples in the powerful influence of certain antiperiodic remedies, such as quinia and arsenic, in tin- cure of intermittent diseases. They establish their own morbid im- pression in the absence of the paroxysm ; and the system, being thus occupied at the moment when the disease was to return, is incapable of admitting it. In the same way may be explained the effects of blisters, opiates, emetics, or indeed any violent impression from any source, in the cure of paroxysmal diseases, if caused to be in full action at the time of the expected recurrence of the paroxysm. Mental influences are sometimes very powerful in the superseding not only of intermittent diseases, but of continued disease also, when of a merely functional character. The excitement of any strong emotion may have this effect ; and the pre-occupation of the nervous system resulting from a strong faith has often exhibited a wonderful influence. The same law holds in cases of purely local diseases. It is probable that many cutaneous eruptions, and diseases of the mucous membrane of the alimentary canal and urinary passages, yield, upon this principle -'ipersession, to certain applications made to them directly, or, in the '('urinary diseases, through the route of the circulation. si 15SECTION IX. Alteration. This name may be given to that operation of medicines by which they change existing morbid actions or states, without any observable effect on the system to which the result could be ascribed. The medicines are usually called alteratives. They may produce their effects by changing 52 APPLICATION OF MEDICINES. [PART I. the character of the blood, or the condition of the solids. Their precise mode of action is unknown, or at best conjectural. It will be perceived that the employment of the term is merely a convenient mode of classi- fying certain unintelligible results, which depend altogether for their acceptance upon the evidence of observation. In certain states of dis- ease we administer certain remedies, without other observable effect than a cure. It is often very difficult, in such cases, to decide whether the result has proceeded from the remedy, or has happened in the ordinary course of the disease. It is at least highly probable that a great many medicines have acquired a credit as alteratives, which was due exclu- sively to nature. Among the most striking illustrations of this operation of medicines is that of mercury in the cure of inflammation. After due depletion, or when depletion is not indicated, no remedy has so powerful an antiphlo- gistic influence as mercury, urged to the point of affecting the system. Other examples are offered by iodine in scrofula, sarsaparilla in venereal disease, colchicum in gout, etc. It is apparent that supersession and alteration may often lay claim to the same results. Thus, does mercury cure syphilis and inflammation by the substitution of its own transitory morbid effects for the existing disease, or does it merely alter the morbid into healthy action ? Upon the solution of this question it depends, whether the remedy is to be looked upon as a supersedent or an alterative. SUBSECTION X. Contra-causation. I use this term to express that operation of a remedy which consists in the cure of a disease by the removal of its cause. It very often hap- pens that one morbid state depends upon another; and the cure of the latter, by any process whatever, results in the cure of the former. This is not, however, the influence to which allusion is here made. To bring any case under the present head, the cause must not itself be a disease, ami the remedy removing it must do so by a special agency. Thus, antacids cure headache by neutralizing acid in the stomach, which produces the headache. An emetic will cure spasm of the stomach caused by indigestible food by evacuating the offending matter, and cathartics often relieve colic on a similar principle. An alkaline car- bonate will relieve irritation of the urinary passages dependent on the precipitation of uric acid, and certain acids the same condition pro- duced by the presence of undissolved phosphates ; each operating on the offending cause by neutralizing it, or rendering it soluble. Anthelmin- tics cure various disorders, dependent on worms in the bowels, by destroy- CHAP. III.] APPLICATION OF MEDICINES. 53 ing or expelling the worms. In like manner, the class of parasiticides act by destroying the microscopic parasites, whether animal or vegetable, which infest the skin and various internal structures ; and under the same head may be classed the remedies which render inert or destroy those poisonous agents, now generally believed to be organized beings, which, entering the circulation, and there acting as ferments, give rise to the various zymotic diseases. SUBSECTION XI. Chemical Influence. This might, perhaps, be included in some one or more of the processes already referred to. Substances may be employed therapeutically, in reference to their chemical influence, for three purposes ; first, for the destruction of the tissues, as in the formation of issues, the removal of morbid ulcerated surfaces, etc.; secondly, for the neutralization, or other chemical change of substances contained within the body, but not form- ing an essential part of it, as when excess of acid in the prima? viaB, the blood, or the urine, is obviated by alkalies, or an insoluble metallic com- bination in the tissues is rendered soluble by the chemical agent admin- istered; and, thirdly, through their reaction with the constituents of the blood or of the tissues, to produce changes in them favourable to the removal of disease. But their influence in all these methods of action may be resolved either into contra-causation, elimination, or alteration ; except in the formation of issues, in which instance the chemical action is not in itself curative, but simply operates by setting on foot certain physiological processes which constitute the real remedy in the case. In relation to the process of alteration, it is highly probable that, in many instances, it is purely the result of chemical reactions set on foot by the remedy in the interior of the system ; but we have little positive knowl- edge upon the subject, and theoretical speculations can lead to little practical good, except in so far as they may serve as a guide to inquiry and experiment. They should not be allowed to serve as the basis of curative methods, until the chemical reactions have been experimentally traced out, and demonstrated beyond reasonable doubt. SUBSECTION XII. Mechanical Influence. This is often very important in the treatment of disease. Upon care- ful examination, however, of its effects, it will be found in general to act upon some one or more of the principles already considered. The fol- lowing are the different modes in which this kind of influence may be remedially employed. 54 APPLICATION OF MEDICINES. [PART 1. Position may be made to favour or counteract, through the agency <>f gravitation, the entrance of blood into a part. Thus, when fainting is threatened from a want of the due pressure of the blood upon the brain, by placing the patient in a horizontal posture, the pressure is favoured, and the apprehended result prevented. Much more frequently, how- ever, the object is to diminish congestion or inflammation in a part, by diminishing the access of blood ; and this is accomplished by elevating the part affected above its usual position. Thus, in an inflamed limb, the extremity should be raised, instead of being allowed to retain its ordinary dependent position of health. It is clear that the remedy oper- ates, in the latter of these cases, upon the principle of local depletion, and in the former, upon that of local repletion. Position is occasionally useful in other modes, as in obviating intussusception of the bowels, hi favouring the passage of calculi, in relieving painful pressure or ten- sion, etc. Compression is another useful mechanical process, which may he- made to diminish or increase the quantity of blood in a particular part of the body, and thus to accomplish in some degree the same object as the former remedy. Thus, the access of blood to a part may be lessened or cut off by pressure upon the arterial trunks which supply it; or the capillaries themselves may be emptied by direct and equable pressure made upon them. In the latter mode especially, much good is often done in obstinate inflammation and passive congestion. An accumulation of blood may be produced by pressure upon the veins, and not upon the arteries, as when the tourniquet is applied not very tightly. This pro- cess may sometimes be useful by abstracting temporarily a quantity of blood from the general circulation, without its ultimate loss. It is a mode of general depletion. Compression upon nervous trunks has been used as an anaesthetic agent in surgical operations. Other advantageous effects of this agency are to promote absorption, and to afford mechanical support to relaxed parts, as in varicose veins of the legs, and to the abdomen after the operation of tapping. Distension sometimes also operates usefully by stimulating a part to increased action ; as when large fluid injections are thrown up the bowels. It may, however, be carried so far as to produce paralysis of the muscu- lar fibres, arid thus to prevent all contraction. This is an important therapeutical fact. Distension is used to enlarge passages, strictured or otherwise, as by means of bougies ; and substances are also used for this purpose which swell \\lien they become moist, as compressed sponge, .^lippery-elm bark, and gentian root. Friction may be considered as a mechanical remedy. It acts partly by compression, partly by stimulation. Employed for the latter effect, it is often a powerful agent in rousing and supporting the system in low dis- , and in exciting the part itself when enfeebled; but it is more f're- CHAP. III.] APPLICATION OF MEDICINES. 55 quently and usefully employed for its effect in producing revulsion from within outwardly. The covering of surfaces, so as to protect them against irritating sub- stances, and the contact of the air, is another useful mechanical process. Thus, demulcents protect inflamed mucous surfaces ; and collodion, cata- plasms, plasters, cerates, and thin layers of gutta-percha and caoutchouc, are applied for the same purpose to the skin. It is not improbable that the effect of nitrate of silver and iodine, in subverting superficial inflam- mation, may be partly owing to a chemical change in the epidermis, rendering it less pervious to the air. How the exclusion of the air proves useful it is not easy to determine. Perhaps it may be partly by maintaining the moisture which would otherwise be evaporated ; per- haps, as suggested by Dr. Latour, by diminishing calorification to which the presence of the air may contribute, if it be not essential (Archives Oenerales, 4e ser., xxvii. 237) ; or, possibly by preventing any direct in- fluence which the atmospheric oxygen may have in supporting the inflam- matory process. SECTION II. Forms in 'which Medicines are Applied. Medicines are used in the solid, liquid, and aeriform states. In the solid state, they arc employed, internally, in the several shapes of powder, electuary, con serve.,, pill or bolus, and lozenge; and externally, of cata- plasm, ointment, cerate, and plaster. In the liquid state they are either originally liquid, or rendered so by mixture or solution. In the aeriform state they have the form either of gas or of vapour. For ample details upon each of the Solid and liquid forms mentioned, the reader is referred to the U. S. Dispensatory. It will be sufficient, in this place, to make a few general observations, calculated to facilitate to the learner the study of the practical application of medicines which is to follow. SUBSECTION I. Solid Forms. 1. POWDERS (pulveres) are medicines finely comminuted by the pro- cesses of pounding, grinding, levigation, elutriation, precipitation, etc. This is a convenient form for the administration of insoluble substances, not very disagreeable to the taste. It is unsuitable for deliquescent sub- stances, as carbonate of potassa, and for combinations consisting of in- gredients which become liquid or semiliquid by chemical reaction, as is the case when acetate of lead is mixed with sulphate of zinc. Light powders, readily miscible with water, may be given diffused in that liquid, 56 APPLICATION OF MEDICINES. [PART I. either pure, or rendered more agreeable to the taste by sugar and aroma- tics. Resinous powders, in order to be diffused, require that the water should be rendered somewhat viscid by saccharine or gummy additions. Heavy powders, as the metallic, are more conveniently exhibited in the form of electuary. 2. ELECTUARIES (electuaria) are preparations in which the medicine is brought into the condition of a soft solid, and may be conveniently made by mixing powders, extracts, etc., with syrup, molasses, or honey. They are included among the confections in the U. S. Pharmacopoeia. Liquids may be brought into the same condition by admixture with sugar and gum. Any medicine may be exhibited in this form which is not too bulky, or too offensive to the taste. In forming powders into electuaries, the proportion of the semiliquid vehicle must vary with the nature of the article used. Thus, dry vegetable powders usually require twice their weight of syrup, gummy and resinous powders an equal weight, and the metallic a still smaller proportion. In the last case, it is well to add a small quantity of some conserve ; as the tenacity of syrup or honey alone is scarcely sufficient to prevent a separation, by the subsi- dence of the heavier ingredients. 3. CONSERVES (conserves) are preparations in which fresh vegetable substances are beat up with sugar, as well for the sake of preservation, as for convenience of Administration. They are included, along with electuaries, under the confections of the U. S. Pharmacopoeia. Yen- few medicines are exhibited in this way. 4. PILLS (pilulse) are small, spherical, solid bodies, of a convenient size for swallowing. Medicines of which the dose is small, and the taste (ii-agreeable, may be appropriately given in this form ; but it is not suit- able for deliquescent substances, nor, indeed, for those which are copi- ously efflorescent, unless previously deprived of their water of crystalli- zation. Hence, when carbonate of soda or sulphate of iron is given in pill, the dried salt, from which the water of crystallization has been driven off by heat, should be preferred. Care should be taken, in prescribing a substance in this form, that the adjuncts should be such as not to render it too hard, and of difficult solubility in the liquors of the stomach. As a general rule, pills recently made are preferable to the old, as being ><>t'ter and more soluble; but occasionally, when the object is that the medicine should act very slowly, and consequently that it should be ^lowly dissolved, old and hard pills may be advantageously administered. The weight of the pill, it' Composed of vegetable substances, should not generally exceed three or four grains ; if of metallic ingredients, it may be from four to eight grains. It will sometimes be useful, when the in- gredients of the pill are very offensive to the smell or taste, to give it a coating of some material, either tasteless or not disagreeable, which may lie ivailily dissolved in the stomach. Gelatin and sugar answer this pur- CHAP. III.] APPLICATION OF MEDICINES. 57 pose very well, and are easily applied. Gold leaf, formerly employed, is objectionable from its insolubility. Boluses are preparations similar to pills, but larger, and may be pre- ferably used where the dose is large, and the patient can swallow them without difficulty. Their size is limited only by the patient's capacity of deglutition. 5. LOZENGES, or TROCHES (trochisci), are solid masses of various shape and size, which may be conveniently held in the mouth, and there allowed slowly to dissolve. They are adapted for the administration of medicines of agreeable taste, or of which the taste, if disagreeable, can be qualified or covered by pleasant additions. They should be made with materials which, without being wholly insoluble, are dissolved slowly by the saliva. Demulcent medicines are often administered in this form ; and it is con- venient in all cases, in which the object is to sustain a slight impression steadily on the interior of the mouth and fauces. Sir J. Y. Simpson, of Edinburgh, informed me that he was much in the habit of administer- ing certain medicines, especially to children, in the form of biscuit, the powder being incorporated with the dough, and then baked with it. Of course, this method of administration is applicable only to substances not injured by heat. 6. CATAPLASMS, or POULTICES (cataplasmata), are intended only for external use. They should be soft and moist, somewhat tenacious, and of such a consistence as to accommodate themselves accurately to the part to which they are applied, without being disposed to spread, or to adhere firmly to the skin. They may be employed solely in reference to the sedative influence of the water they contain, or to protect the dis- eased surface from the air, or to produce the peculiar impression of a medicine either on the surface, or, through the medium of absorption, upon the system. 7. OINTMENTS (unguenta), CERATES (cerate), and PLASTERS (em- plastra) are preparations also intended exclusively for external use. As the terms will be frequently used, the student should have a precise idea of their meaning at the outset. Ointments are soft solids, always con- taining fatty or oily matter, and capable of being applied by gentle rub- bing, or, to use an appropriate phrase, by inunction. Cerates are of a tinner consistence, generally contain wax (cera), from which they derive their name, and are capable of being spread by means of a spatula, at common temperatures, upon suitable dressings, in which state they are usually applied. Plasters differ from cerates in possessing a still firmer consistence, requiring heat in order that they may be spread, and, though quite firm and brittle at common temperatures, becoming softish, tena- cious, and adhesive at the temperature of the skin. Either of these prep- arations may be employed exclusively for local effect, or with a view to act upon the system. For the latter purpose, the ointments are preferable 58 APPLICATION OF MEDICINES. [PART I. when the cuticle remains; as, by the friction with which their applica- tion is often accompanied, they may be forced between the epidermic scales, and thus brought more completely within reach of absorption. 8. EXTRACTS (extracta) are rather modes of pharmaceutical prepara- tion, than forms for administration. They consist of the active ingre- dients of complex medicinal substances, extracted by water, alcohol, or acetic acid, or by expressing the juice of plants, and then evaporating to the solid consistence. Some of them are so dry that they may be readilv reduced to powder, and given in this state. All of them may be admin- istered in the form of officinal mixture. But the most common method of exhibition is in the shape of pill, to which they are often very readily brought, in consequence of their soft, somewhat cohesive consistence. SUBSECTION II. ) Liquid Forms. In the liquid form medicines may be given internally, or applied to the surface. In the former case, if taken in any considerable quantity, they receive the name of POTION (polio), or DRAUGHT (haustus); the former being sometimes applied to a quantity of liquid which may be taken in divided doses, the latter exclusively to a single dose. Applied to the sur- face, they receive the name of LOTION (lotio) when thin and watery, and of LINIMENT (linimentum) when of a soft oleaginous consistence, fitted for application by gentle friction with the hand. One of our late officinal liniments (Linimentum Saponis Camphoratum, U. S. 1850) was of the consistence of a soft solid when cold, but became quite liquid at the tem- perature of the body. Some medicines are essentially liquid, as castor oil, glycerin, etc.; others are brought to the liquid form by admixture and suspension, or by solution. The following are forms of officinal liquid preparations. 1. MIXTURES (miaturse), in the sense of the term as employed in the U. S. Pharmacopoeia, are preparations in which a medicine, insoluble in water, is suspended in that fluid, pure or variously medicated, by means of viscid soluble substances, as gum arabic, sugar, and the yolk of eggs.* The term julep embraces both these preparations and others in which the mixed substances may be dissolved. The form of mixture is one of the most common and convenient for the administration of insoluble medicines. As a general rule, the medicine is so proportioned in the mixture as to render the dose a tablespoonful (fgss) for an adult. * In the U. S. Pharmacopoeia of I860, one preparation was admitted, in deroga- tion of this rule, among the Misiur-x. that, namely, of Mixiuni I'otasxte Citratix, which Is strictly, as it was called in the Pharmacopoeia of 1850, a solution of citrate of potassa. (Note to the third edition.) CHAP. III.] APPLICATION OF MEDICINES. 59 2. SOLUTIONS (liquores) are preparations in which the medicine, or its active principle, is dissolved in water or other menstruum. The officinal Solutions (LIQUORES, IT. S.), now first adopted as a pharmaceutical class in the U. S. Pharmacopeia, are exclusively aqueous solutions, with one single exception, that of Liquor Gutla-perchse, in which chloroform is the menstruum. In relation to medicines which are wholly soluble, the process is extremely simple ; and the only rule requiring attention is not to mix, in the same solution, substances which will undergo mutual decomposition, so as to form an insoluble precipitate. In administering in solution substances, the absorption of which is desirable, it is import- ant that, if irritant in their character, they should be so far diluted as to produce as little irritation as may -be of the alimentary canal. Medi- cines generally find a readier entrance into the system when largely diluted than when concentrated. Under the head of solutions may be considered various officinal preparations, in which the soluble and active principles of a medicine are extracted, leaving behind the insoluble and inert. Such are the waters, infusions, decoctions, tinctures, spirits, wines, vinegars, syrups, honeys, oxymels, fluid extracts, and oleoresin* of the pharmacopoeias. 3. WATERS (aquse) are forms of solution which have been long in use, and which, with a somewhat peculiar signification, constitute a class of preparations in our Pharmacopoeia. Formerly, the name was somewhat indefinitely applied, embracing certain solutions of solid bodies, as lead- water, lime-water, tar-water, etc., and was occasionally extended in com- mon language to spirituous preparations, as cologne-water, lavender- water, etc.; but, so far as it had a distinctive meaning, it was used to de- signate watery solutions of volatile substances, obtained by distillation; as mint-water, rose-water, etc. In the present Pharmacopoeia, the title WATERS or Aquae is restricted to preparations in which volatile or gas- eous substances arc held in solution by water, no matter how the solution may be effected, whether by distillation with water, by simple trituration, or other method of impregnation ; the condition being essential that the preparation might be made by distillation, as it often was originally. The medicines most frequently thus treated are the volatile oils of aro- matics, as of mint, cinnamon, fennel, etc.; but the category also em- braces other medicines, as the waters of ammonia, carbonic acid, and chlorine; while solutions of non-volatile substances formerly called wa- ters, as lime-water (aqua calcis) and potassa-water (aqua potassse), are now designated as solutions (liquores). 4. INFUSIONS (infusa) are aqueous solutions made by treating with water, without boiling, medicines containing principles soluble in water, with others insoluble. They air either cold or hot, the former being prepared with water at ordinary temperatures, the latter with the same liquid previously heated to the boiling point. Hot water acts more 60 APPLICATION OF MEDICINES. [PART I. rapidly than cold under circumstances otherwise the same, and may, therefore, be preferred when speedy action is desirable. But it is some- times objectionable in consequence of dissolving starchy matters, which are insoluble in cold water, and the presence of which may render the infusion more liable to speedy change. On the contrary, cold water is liable to the same objection in reference to vegetable albumen, which it dissolves, while hot water coagulates instead of dissolving it. Heat injuriously affects the virtues of certain medicines, and should not, there- fore, be employed in preparing them. These considerations should be allowed some weight in the choice between cold and hot infusion. Many of the infusions are most elegantly and efficiently prepared by the pro- cess of percolation or displacement. The U. S. Pharmacopeia uses both the method of percolation and that of simple maceration, preferring one or the other according to the nature of the substance used ; and sometimes it presents the alternative of either method in reference to the same substance. Where percolation is used, the plan pursued is to moisten the medicine, in powder, with a little of the menstruum, then to pack it in a percolator, and pour on water till the infusion passed measures a given quantity, which is generally a pint. (See U. S. Dis- pensatory.) In domestic practice the method of maceration should generally be preferred ; as that of percolation requires a degree of skill possessed only by the practical pharmaceutist. 5. DECOCTIONS (decocta) differ from infusions simply in the circum- stance that boiling is used in preparing them. They arc liable to the same objections as the hot infusions in a still greater degree, but are convenient when haste is requisite, and the active principles of the medi- cine are not likely to be materially injured by the heat. As atmospheric air, at a high temperature, is liable to act injuriously on various vegeta- ble principles, the process should be performed in a covered vessel, and should not be continued longer than is necessary to the end in view. Hard, tough, fibrous substances are often most conveniently treated in this way; but the process is altogether inapplicable to those medicines whose activity depends upon a volatile principle, as, for example, upon a volatile oil. In the present Pharmacopeia, a somewhat modified plan of preparing the decoctions has been adopted. The substance treated is boiled with water generally for fifteen minutes ; after which the whole is placed upon a strainer, and sufficient water added, through the strainer, to make the decoction measure a certain quantity, which is generally a pint. More precision in the result is thus obtained than by the old method of merely boiling and straining. 6. TINCTURES (tinclurse) are alcoholic solutions of medicinal principles. As, in consequence of the preservative inllneiice of the alcohol, they may generally be kept, in well-closed bottles, an indefinite length of time, they are almost always prepared by the pharmaceutist, and very seldom extern- CHAP. III.] APPLICATION OF MEDICINES. 61 poraneously. In much the larger proportion of them, the process of percolation is employed, somewhat varied according to the nature of the medicine used. It should be remembered that some of them are prepared with officinal alcohol (sp. gr. -835), and others with diluted alcohol, made by mixing equal measures of the officinal alcohol and water. The former are of course more stimulating than the latter, so far as concerns the menstruum ; and this circumstance may be occasionally of practical im- portance. The officinal tinctures (U. S. Pharmacopoeia) of the pure resins, gum-resins, balsams, aconite root, hemp, nux vomica, American hellebore, ginger, castor, and iodine are made with the stronger alcohol; almost all others, including those of the roots, barks, leaves, and fruits of plants, with the diluted. This set' of preparations is applicable only when some degree of stimulation is admissible, or when the active prin- ciple dissolved in the alcohol is so powerful as to render the amount of the menstruum employed in each dose insignificant, as in the instances of tinctures of aconite root and opium. They are especially useful as adjuvants to other forms of preparation, when it is desirable to render these somewhat more stimulating. Thus, tincture of Peruvian bark may, in low forms of disease, be very appropriately added to the infusion or decoction, or to the solution of sulphate of quinia. In relation to the long-continued employment of tinctures, the practitioner should be aware of the danger of establishing a habit of intemperance, and should be on his guard accordingly. The resinous and camphorous tinctures become turbid on the addition of water, in consequence of the precipitation of the resin or camphor, and should therefore be given with a viscid liquid, as mucilage, syrup, or sometimes milk, or, if diluted with water alone, should be taken immediately after admixture. 7. SPIRITS (spiritus) are closely analogous to tinctures, being, like them, solutions of medicinal principles in alcohol, but diifering, as for- merly understood, in being prepared by distillation. As many of the spirit* are now prepared by simply dissolving in alcohol the principles originally separated from the substances containing them by distillation, and as this mode of preparation is recognized in the present U. S. Phar- macopoeia, the meaning of the term must be considered as having been officinally extended so as to include all alcoholic solutions of volatile principles, whether made by means of distillation or otherwise. Thus. the term spirit of peppermint, originally applied to the liquid obtained by distilling peppermint with alcohol, is now used to designate the simple alcoholic solution of the volatile oil, which in the previous Pharmaco- poeia was denominated tincture of oil of peppermint. 8. WINES (vina) differ from the tinctures simply in being prepared with wine as the menstruum, instead of alcohol or diluted alcohol. These are also usually the subjects of officinal preparation. The advantages of wine, in the cases to which it is applicable, are that it is less stimulant 62 APPLICATION OF MEDICINES. [PART I. than alcohol, while it is more effectual than water in counteracting the tendency of the organic medicinal principles to decomposition, and, in consequence of the alcohol it contains, is sometimes more effective as a solvent. For the purposes of a medicinal solvent, the stronger wines are preferred to the weaker; as the latter are apt to contain principles incompatible with the substance dissolved. Thus, Madeira, sherry, or Teneriffe should be preferred to claret or the Rhine wines. Port wine is seldom proper, on account of the tendency of the tannic acid it contains to form insoluble compounds with other bodies. 9. VINEGARS (aceta) are simply infusions made with cold distilled vinegar, or diluted acetic acid. Very few of them are used; and these more in the preparation of other forms of medicine, than for direct ad- ministration. Thus, vinegar of squill is much used as an ingredient in the syrup of squill, seldom alone. This class of preparations is based on the fact, that in certain cases acetic acid favours the solvent property of water, while it also has a preservative effect, though in this respect much less efficient than alcohol. 10. SYRUPS (syrupi) are aqueous solutions of sugar impregnated with medicinal principles. When the term SYRUP (syrupus) is used singly, it implies, officiually, a simple solution of sugar in water, of a certain recog- nized strength, which, according to the U. S. Pharmacopeia, is about t\vo and a half pounds of sugar to a pint of water. The medicated syrups are designated by the name of their chief medicinal ingredient, as syrup or rhubarb, syrup of ginger, etc. The mode in which the medicinal im- pregnation is effected varies much with the character of the medicine. The syrups are generally subjects of officinal direction, and are kept ready made in the shops. Their advantages are that the sugar serves to cover the disagreeable taste of the medicine, and at the same time prevents its spontaneous decomposition. They are favourite prepara- tions in infantile cases; but, in their use, the physic-inn should bear in mind the frequently injurious effect of much sugar in a feeble stomach. 11. HONEYS (melUta) differ from the syrups only in the substitution of honey for sugar. They are at present little used; honey, in consequence of its impurities, being inferior to sugar as a preservative. 1-2. OXYMELS are preparations in which the menstruum cons' honey and vinegar combined. They are now almost out of use; oxymel of squill, which for some time was the only one officinal, having been rereiitly d : .-carded by the Pharmacop- 13. FLUID EXTRACTS (extracta fluida) are highly concentrated solu- tions of the active constituents of medicines, or the active constiti: themselves extracted in the liquid state; and are often very convenient and efficient preparations. They have been introduced into use at a comparatively recent date, and an- at present much employed. There are two kinds of them. In one, the active principles of the medicine arc OH A P. III.] APPLICATION OF MEDICINES. 63 extracted by alcohol or diluted alcohol, sugar is often added as a preser- vative, and to improve the flavour, and the alcohol is afterwards to a greater or less extent evaporated. These are concentrated alcoholic solutions, or aqueous solutions with a little alcohol remaining;. The other kind consist mainly of volatile oil and resinous matter, extracted by ether from the medicine, and subsequently freed from the solvent by evaporation. To the latter division the name of OLEORESINS (oleore- sinse), expressive of their composition, has been applied in the latest edition of our Pharmacopeia. 14. GLYCERATES (Glycerolex) are preparations, recently introduced, in which glycerin serves as the menstruum. Advantages of these prep- arations are that glycerin dissolves , substances which water will not, that it does not evaporate spontaneously like water and alcohol, and that it contributes to the preservation of the substance dissolved, without being stimulating or irritating like spirit. Several of the glycerates are more or less used, as those of iodine, aloes, and tar ; but they do not as yet form a class in our officinal code. 1 5. Spray. As it is desirable, in certain diseases of the air-passages, to bring various substances into contact with the diseased surface in the liquid form; but, from the great sensitiveness of the respiratory or- gans, it has been found extremely inconvenient to introduce liquids in an aggregate condition beyond the glottis; the expedient has been adopted of bringing the liquid into a state of extremely minute division, and then causing it to be inhaled admixed in this condition with the at- mospheric air. The names of atomization, pulverization, and nebuliza- lion have been given to the different processes by which this minute division is effected; and instruments adapted to the purpose are called atomizers, pulverizers, etc. In treating of the forms in which liquids are used, it was necessary to call attention to this method of applying them; but it will be found more convenient to consider the subject fully in con- neetion with the lungs, as one of the parts to which medicines are applied ; and the reader is accordingly referred to the subsection in which inha- hition is treated of. SUBSECTION III. Aeriform. State. This may be a state either of gas or vapour. GASES are aeriform fluids which retain their condition at common temperatures. VAPOVRS arc likewise aeriform fluids, but require an elevated temperature, under the ordinary degree of atmospheric pressure, to enable them to retain that state, and, upon the diminution of their temperature, become liquid or solid. Both gases and vapours are employed as medicinal agents, the former seldom, the latter very frequently. Gases are used chiefly by inhalation; vapours both in this manner, and by application to the surface of the body. 64 APPLICATION OF MEDICINES. [PART I. SECTION III. Parts to which Medicines are Applied, and Modes of Application. The parts to which medicines are applied, in order to affect the sys- tem, are chiefly 1. the alimentary canal, 2. the skin, 3. the bronchial tubes and pulmonary air-cells, and 4. the subcutaneous areolar tissue. When applied to other surfaces, it is generally with a view to local effect. SUBSECTION I. Alimentary Canal. Medicines are applied to the two opposite extremities of the alimentary canal ; to the stomach, namely, and to the rectum. 1. The Stomach. This is the most convenient, generally the most effective, and by far the most frequently employed avenue for medicines into the system. To this, as to any other part, they may be applied with the view exclusively to a local effect; but much more frequently the object is to act on the system at large, or on some distant part, for which the stomach affords great facilities, both by the readiness with which absorption takes place from its inner surface, and the sympathies which connect it, beyond any .other accessible organ, with all parts of the body. The forms in which medicines are introduced into the stomach have been already referred to. The modes of administering them are in general too obvious to require notice. Two or three remarks, however. upon this point will not be irrelevant. 1. Sometimes patients are coma- tose, and cannot voluntarily swallow medicines. In these cases, there is sometimes danger of the medicine passing into the glottis, and pro- ducing embarrassment of respiration. Substances, however, which act in small doses, as croton oil, may be placed upon the tongue towards its further extremity, where thev excite the reflex action of deglutition, and are often swallowed. 2. Children not (infrequently refuse to take medi- cine into their mouth, and cannot be prevailed on by any persuasion. They can generally be made to swallow, without great difficulty, by taking them in the lap, closing the nostrils so as to compel them to open the mouth, and then introducing the medicine by a teaspoon. 3. In the cases of adults who, from insanity or the purpose of suicide, will not, or from paralysis or insensibility, cannot take medicine, the physician may sometimes be justified, in order to save life, in forcibly injecting it into the stomach by means of the stomach-tube and a syringe. CHAP. III.] APPLICATION OF MEDICINES. 65 Attempts have been made, in cases of impervious and incurable stric- ture of the oesophagus, to prevent starvation by making a fistulous opening from without into the stomach, through which food might be introduced ; but the experiment, though not without some encouraging circumstances, has not hitherto proved successful. Considering that, in several instances, such openings have resulted from accidental wounds, and the patient afterwards recovered, with a permanent fistulous orifice, or even an aperture of considerable size, the operation of gastrotomy would seem to be justifiable in otherwise necessarily fatal cases. (See Guy's Hospital Reports, iv. 1.) 2. The Rectum. Medicines are employed by the rectum with two distinct objects; one to evacuate the bowels by simply irritating the part, the other to produce their peculiar and characteristic impression either on the rectum itself, or, through absorption or sympathy, upon other parts, or the whole system. These two objects are often incom- patible ; and it is necessary, therefore, when the latter effect is desired, to administer the medicine in such a manner as not to produce the former. But, in either case, the patient should be directed to resist the immediate impulse to evacuate the bowels ; as, even when the cathartic effect is aimed at, time should be allowed for the influence of the medi- cine to be extended to the higher portions of the large intestines, which might otherwise not be affected, and only the rectum emptied. Medi- cines may be administered by the rectum either in the liquid or solid form. In the former case, they are called enemata, injections, or clysters ; in the latter, suppositories. In either of the forms mentioned, the dose of the medicine, when given in reference to its peculiar effects, may be about three times that given by the mouth. But, as the relative susceptibility of the stomach and rec- tum varies, it would be a safer course, when the medicine is very active, as in the instances of the poisonous alkaloids, to administer at first about the same dose as by the stomach, and increase afterwards if necessary. There is another important consideration in regard to the relative dose by the stomach and rectum. When an individual has become habituated to very large quantities of the more active medicines by the mouth, as opium, for example, it might be very dangerous to triple the quantity, xvlu'ii administering it per anum. Though, undoubtedly, the loss of susceptibility is mainly in the nervous centres, it is very probable that the stomach experiences the loss in a greater degree than other organs, and that, applied to another part, the medicine might be found to exor- cise a much greater proportionate influence. It would be best, therefore, in such cases, not only not to triple the dose, but not to increase it at all, and at first even to administer the medicine in much smaller quantity by the rectum than the stomach, until the relative susceptibility of the two VOL. i. 5 66 APPLICATION OF MEDICINKS. [PART I. parts, or the relative facility of absorption from them, shall have been tested by trial.* The circumstances under which medicines may be administered by the rectum, in reference to their peculiar effects, are the following : 1. when the stomach is unable to retain them, or from any cause they may be thought injurious to that organ ; 2. when it is desirable to produce a very rapid or powerful impression on the system, and thus to seek an entrance into it by every avenue; 3. when, from the long continuance of the in- dication for the use of any medicine, it is advisable to vary the surface of application, in order to avoid wearing out the susceptibility of the stomach, and thus to prolong the period during which the effects of the medicine may be sustained; 4. when the seat of disease is in pans neighbouring to the rectum, and the disease itself is of such a character as to be relieved by impressions made in its vicinity more speedily and effectually than through the system at large, as in painful affections of the urinary and genital organs; and 5. when the indication is to produce the effects of the medicine upon the rectum itself, as in neuralgia or spasm of that bowel, and chronic inflammation and ulceration of its lining mem- brane. Medicines are also exhibited in this way, in order to weaken or destroy the thread-worm which infests the rectum. Enemata. When intended to evacuate the bowels, the enema should measure for an adult a pint or somewhat less, for a youth of twelve years about half the quantity, for a child one or two years old two fluidounces, and for an infant at birth one fluidounce. Too great a quantity, if used habitually, may injuriously distend the rectum, and diminish its power of contraction. Upon the subject of cathartic enemata more will be said under the head of cathartics. When the object is to obtain any characteristic effect from medicines, other than purgation, the bulk should be small, say from one to four iluidounccs, and the vehicle very bland, consisting of pure water, or of some mucilaginous or starchy fluid; and. when there is danger of its being rejected, from twenty to forty drops of laudanum, or an equivalent * Experiments performed by Mr. W. S. Savory on the lower animals, especially the rabbit, guinea pig, and rat, show that certain medicines injected into the rectum act much more vigorously, in these animals, than when introduced in the same dose into the stomach. This was true especially of strychnia; but the same results, though in less degree, were obtained with other medicines, as cyanide of |.(>t:i-siiim and hydrocyanic acid. (Lancet, May 9, 1863, p. 510: also Ibid. p. 548.) Mr. Savory, however, states that, in order to obtain these results, the ni<-y the alternate expansion and compression of the bag. (See Boston Mcd. and Surg. Jmirn., liii. 274.) A still more convenient instrument, which is a modification of Dr. Mattson's, is Ic-cril.cd in the London Lancet (March 31, 186G, p. 349). It consists of a stout oval gum-elastic bag, communicating at one end with a rectum tube, and at the other with a water-proof bag containing the liquid to be injected, a valve opening inwurd being placed at the orifice connected with the receiver. By alternate ]>ivsuro with the hand, it is obvious that the gum-elastic bag will be alternately emptied into the rectum and filled from the receiver until any desirable quantity <>t liquid is made to enter the bowel. (Note to the third edition.) 68 APPLICATION OF MEDICINES. [PART I. injected, if a soluble substance, it should be dissolved ; if a solid, or liquid not soluble in water, it should be thoroughly and equably incorporated with the liquid vehicle by means of some suspending substance. When an irritating substance, such as oil of turpentine, is injected, the yolk of eggs is an excellent intermedium. Advantage might sometimes ensue, in cases in which a speedy opera- tion of the medicine is essential, and the stomach will not retain it, from introducing it by means of a long flexible tube far up into the colon. Being thus diffused over a greater extent of surface, it might possibly be absorbed more rapidly, and in greater amount, and consequently pro- duce a more speedy and powerful effect. Suppositories. Like enemata, these may be used simply to evacuate the bowels by irritating the rectum, or to produce the peculiar effect of the medicine employed. For the former purpose, they may be of a cylindrical, oval or conical form, an inch or two in length by about half an inch in diameter, and made of some softish material, like soap or cacao butter. For the latter, they should be as small as is consistent with due effect, and preferably of the pilular form; the object being that they should irritate as little as possible. Opium is not unfrequently em- ployed in this way. Suppositories, with a view to systemic effect, have recently come into more extended use. They have even been adopted as officinal in the British Pharmacopoeia. For a fuller account of this set of preparations, see the U. S. Dispensatory (12th ed., p. 1361). Gaseous Injection. Aeriform substances have sometimes been injected into the rectum, though this method of medication is rare. Atmospheric air thrown up largely has been found useful in overcoming obstruction of the bowels; tobacco smoke has been employed to produce relaxation: and carbonic acid gas has been recommended in certain morbid states of the rectum. Electric action may also be developed in the rectum, either by intro- ducing a complete metallic galvanic arrangement in a compact form, or by passing a wire connected with one pole into the bowel, and applying the other at some point on the back or abdomen. SUBSECTION II. The Skin. Next to the alimentary canal, the skin is most frequently resorted to for the application of medicines. The object may be either to affect the system or some unconnected part through absorption, sympathy, deple- tion, revulsion, etc., or to act exclusively on the skin itself. The modes of application are various, both in relation to the state of the skin and the substance employed. Thus, the skin may remain undisturbed, the CHAP. III.] APPLICATION OF MEDICINES. 69 medicine being merely brought into contact with it; or the epidermic scales may be disturbed by friction at the time of application ; or the epidermis may be removed, and the medicine placed upon the denuded cutis. The substance employed may be solid, semiliquid, liquid, or aeri- form, and, if solid, may be of different degrees of consistence. 1. Simple Application to the Sound Skin. Of such application we have examples, with reference to solids, in cataplasms, cerates, and plasters; with reference to liquids, in lotions, fomentations, general baths, local baths, the douche, affusion, and sponging; and, with reference to aeri- form substances, in the hot air bath, the general and local vapour bath, and the vapour douche. Of the different solid forms mentioned, as well as of lotions, enough has been already said. Fomentations or sto^s are heated liquids, applied by means of flannels or other cloths saturated with, or wrung out of them. They are usually employed to obtain the effects of water and heat, but sometimes also for the specific effects of medicines, as when the decoction of poppy-heads, or infusion of tobacco is applied. Raths consist in the direct application of water, either pure or medi- cinally impregnated, more or less extensively to the surface ; the general bath being applied to the whole surface, the head perhaps excepted; the vmicupium or half-bath, to the lower half of the body ; the coxseluvium or hip-bath, to the pelvis and upper part of the thighs; the pediluvium or foot-bath, to the feet and legs; and the maniluvium or hand-bath, to the hands and forearms.* When the water is made to fall upon the body generally from above, in minute currents or streams, as through a colander, the application is called a shower bath ; when a single stream of greater or less size is directed upon one part with more or less force, it is named, from the French, the douche. In all these, the water may be cold, warm, or hot; and we thus have the cold bath, the warm bath, and the hot bath, which are very different in their effects, and employed for a great diversity of purposes. Of the principles of operation, and of the applications of the different forms of baths, I shall have occasion to treat, at some length, under the different classes of remedies to which they re- spectively belong. It is sufficient here to state that the bath, when below 75, may be called a cold bath ; when between 85 and 98, a warm bath : and from 98 to 112, a hot bath. Some make a distinction between the tepid and warm baths, the former being of a somewhat lower temperature than the latter. * The means of employing the varieties of local bathing mentioned in the text are well known; but the application of water to other limited parts than those referred to may be indicated, and some ingenuity would be requisite to fashion apparatus suitable for the purpose. The reader may find it useful to consult, upon this subject, a paper on the "Localization of Baths ," by Dr. Conrad Mayor, con- tained in the New York Journal of Medicine (3d ser., ii. 182). Note to the second edition. 70 APPLICATION OF MEDICINES. [PART I. Water may also be applied to the surface more or less extensively by means of wet sheets, or cloths, which may be wrapped around the whole body, so as to obtain .in some degree the effect of the general bath, or folded and applied around the waist like a belt, with a view to local effect. The douche acts not only by the temperature of the water, but also by the shock and pressure, consequent upon the force with which the liquid falls. When continued long, or from a considerable height, say ten or twelve feet, it becomes after a time extremely painful, so as to be quite intolerable ; and, on this account, has been employed as an instru- ment of fear or punishment to criminals and maniacs. So far as it acts mechanically, it is primarily excitant, and secondarily depressing. Liquid in the form of spray, or pulverized by minute division in a current of air, has been of late used in the mode of a douche, and pro- duces analogous, but milder effects. Independently of the mechanical results of percussion, and the peculiar local effects of the medicine, it is asserted that substances applied to the surface in this way are some- times absorbed, and act characteristically on the system. Directed to the conjunctiva, they are said to enter the lachrymal passages and even to reach the nostrils. (Archives Gen., Juin, 186(5, p. 725.) When the liquid employed is very volatile, an intense degree of cold may be pro- duced by its rapid volatilization, which has recently been applied to important practical purposes, as will be more fully stated hereafter. Affusion consists in the pouring of water, at various temperatures, from pitchers, buckets, etc., more or less extensively over the body. It differs from the douche in being more diffused, and in falling with less force upon the surface. It has been highly recommended in certain febrile and inflammatory diseases, but requires caution in its use, of which more will be said hereafter. Sponging is a term sufficiently expressive without definition. It may be employed locally or generally, with water, spirit, or other liquid, at different temperatures. It is often extremely useful. Healed atmospheric air has been employed as a remedial ugent, in the form of a warm or hot air bath. When the object is. that the patient shall breathe the heated air, as well as experience its effects externally, it may be most conveniently accomplished by simply placing him naked in a confined apartment, raised by the introduction of hot air to the re- quired temperature, which may vary from 90 to 150. More frequently the application is made to the external surface alone, while the patient is allowed to breathe air at ordinary temperatures. This may be done by inclosing the body in a cell, box, or closet of suitable dimension.-. arranged that the head shall project through an open ing, which is accu- rately closed around the neck, while the confined air is heated by any convenient plan. An extemporaneous bath of this kind may be prr- CHAP. III.] APPLICATION OF MEDICINES. 71 pared, by supporting the bed-coverings, over the patient in bed, upon two or three pairs of crossed half-hoops, so as to form a vacant space around him ; and then either introducing heated air, by means of a tube, from some exterior source, or heating that around the patient by hot bricks, bottles filled with hot water, or bags filled with heated salt, oats, or other suitable material. Medicated hot air baths may be applied, in the same way, by impreg- nating the air with gaseous bodies, as chlorine and sulphurous acid, or with the vapours of volatile solids, as cinnabar, iodine, etc. The vapour bath, like the hot air bath, may be so employed that the patient shall or shall not breathe the vapour. In the former case, the heating effect upon the body is greater from a certain temperature of the bath than in the latter; for the natural refrigerating effect of the pul- monary exhalation is prevented. The bath is much more frequently employed in reference to the external surface alone. Various modes of obtaining the effects of the vapour bath have been practised. One of the most simple is to make a space around the patient in bed, by ele- vating the coverings by means of crossed half-hoops, in the manner above mentioned, and tucking them well in at the sides of the bed or mattress, and then to introduce into this space bricks previously heated, immersed in water, and covered with flannel, taking care that they do not touch the body of the patient. The vapour from* the heated bricks soon fills the empty space. Another mode of introducing vapour is by means of Jennings' apparatus, which consists of a tin tube, much broader at one extremity than the other, curved so that the smaller end may be inserted into the space around the patient, while the larger end may be supported on a stool without the bed. A lighted spirit lamp is placed within the broad end of the tube, in the side of which an opening is left for the entrance of air. As the spirit burns, a current of heated air, with the aqueous vapour and carbonic acid resulting from the combus- tion, passes through the tube, and envelopes the body. A different mode of accomplishing the same end, is to seat the patient on a stool or in a chair, placed either over or in a tub or bucket containing hot water, and then, by blankets descending from his shoulders to the floor, to enclose together his body and the whole apparatus. The heat of the water may be increased by introducing into the tub or bucket heated bricks, as they may be required. Caution, however, is requisite not to scald the patient. A case occurred in Philadelphia, under the care of an empiric, in which a child, subjected to a vapour bath of this kind, was scalded to death. Where convenience permits, a better vapour bath may be arranged, by making a frame of wood-work, and covering this with cloth imper- vious to vapour, so as to enclose a space within which the patient may conveniently sit upon a stool or chair, while the vapour is introduced into the lower part of the enclosure, by means of a tube proceeding from 72 APPLICATION OF MEDICINES. [PART I. a kettle of boiling water. The heat of the vapour mar vary from 100 to 150, and has been increased with impunity beyond the latter tem- perature; but it is better, in this respect, to err on the side of caution. Medicated vapour baths may be formed by introducing volatile sub- stances into the water evaporated, so that their vapour may rise with that of the water. The vapour douche is a stream of vapour directed with some force upon a particular part of the body. 2. Application with Friction. The friction here alluded to is em- ployed not to excite the surface, but, by deranging the epidermic scales, to force an entrance for medicinal substances to the absorbent tissues beneath. It is made by the hand protected by a leather glove, or by means of a piece of flannel, or of coarse linen. Substances applied in this way are most frequently in the unctuous form, as in the case of the mercurial and iodine ointments ; but oleaginous, aqueous, and spirituous medicines and solutions are also not unfrequently used. The medicine employed, if insoluble, should be brought to the finest possible state of division. The parts usually selected for the application are those in which the cuticle is most delicate, as the inside of the upper and lower limbs, especially the inner surface of the thighs ; but reference should be had to the special object in view; and, when a particular org'an or part is to be acted on, or a tumour to be dispersed, it is usually deemed best to apply the medicine as nearly as may be over the seat of disease. In affections of the absorbent glands, the portion of surface from which lym- phatics run through the diseased glands should be preferred. This mode of using medicines is uncertain in its results, and, in con- sequence of the irritation produced in the skin, is often inconvenient. But it may be resorted to in aid of internal medication, or when from circumstances this cannot be employed ; and it is often very efficient in the cure of local affections, as of neuralgic pains, for example, and tume- factions of various kinds. 3. The Endermic Method of Application. In this mode of employing medicines, the epidermis is first removed, and the medicine then applied to the denuded surface. It is by far the most efficient external method. Medicines are rapidly absorbed ; and produce their effects in some in- stances as quickly as when taken by the mouth, or even more so. In cases of great irritability or phlogosis of the stomach, and when t Im- patient cannot or will not take medicines by the mouth, it is an invalua- ble resource. Other indications for its use are afforded by insusceptibility of the stomach, arising from a long-continued or excessive employment of the medicine, by the necessity in urgent cases of introducing medicines by every practicable avenue, and by the existence of serious local affee- tions, which have refused to yield to remedies addressed to the constitu- tion. The last indication is often very agreeably fulfilled by endermic CHAP. III.] APPLICATION OF MEDICINES. 73 medication. I have known, for example, vomiting which had resisted all other means, yield to a salt of morphia sprinkled upon a blistered surface in the epigastrium. This method of medication had long been partially employed, as exemplified in the frequent application of mer- curial ointment to blistered surfaces ; but it was first systematized by Dr. A. Lembert, of France, whose experiments were repeated and ex- tended by Dr. Gerhard, of Philadelphia, by whose essay on the subject the attention of the profession in this country was first extensively called to it, as a useful mode of employing a great number of medicines. (N. Am. .1A' the material to be evaporated, is placed in a small water-bath over a spirit lamp. Another mode, applicable to very volatile liquids, such as ether and chloroform, intended for temporary use, is to place them upon a large sponge, or piece of linen cloth, a handkerchief or towel for example, and apply this, fully charged, over the mouth and nostrils, so that the patient may inhale their vapour along with the atmospheric air Sometimes the saturated sponge is enclosed in an apparatus, so arranged that all the vapour which escapes from the liquid shall be inhaled, and thus unneces- sary loss be prevented, while a due supply of atmospheric air is insured. In the exhibition of the narcotic vapours, it is of the utmost importance, in order to avoid the most serious consequences, to attend strictly to this latter caution. The patient, rendered more or less unconscious by the medicine, is not sensible of the want of air, and does not, therefore, give warning of his danger to the operators, as he would do under other cir- cumstances. There can be little doubt, that death has sometimes re- sulted from an insufficient supply of atmospheric air, in this method of using anaesthetic agents. The pure gases, and the vapours of very volatile substances, such as Hher, may also be inhaled by means of an air-tight bag, supplied with a mouth-piece and stop-cock, so as to regulate the escape of the confined gas or vapour. The patient is made to breathe into and out of the bag ; but it is obvious that, unless there be a large admixture of atmospheric air or oxygen, life could be sustained but a very short time during such a process, which, therefore, should be of short continuance, and always carefully watched. The vapour of water, pure or impregnated with various volatile matters, may be inhaled by means of an instrument called the inhaler. Madge's inhaler, which has been much used for this purpose, consists of a pewter quart mug, with a metallic removable lid, in which is a small opening to admit the air, and another larger one to which a flex- ible tube with a mouth-piece is affixed. Water, alone or variously im- pregnated, is introduced into the instrument, which may then be placed in a vessel containing water, heated to whatever point may be necessary sufficiently to volatilize the confined liquid, the vapours of which are in- haled by the patient, along with the air admitted through the small opening. A better apparatus for the same purpose may be made from a Wolfe's bottle, with three tubulures at top, into one of which is fitted a flexible tube with a mouth- piece, into a second a glass tube extending from the air without to a point beneath the surface of the liquid in the bottle, and into the third a glass stopper, to be removed when there is occasion to pour liquid into the bottle. It is obvious that, when t In- patient inspires, the air from without must pass through the liquid, and thus become more thoroughly loaded with the vapour than it would be 76 APPLICATION OF MEDICINES. [PART I. likely to be in Mudge's inhaler. An extemporaneous inhaler may be made, as formerly suggested by Dr. Physick, by fitting a cork into any broad-mouthed common bottle, making three openings through the cork, and supplying these with tubes in the manner mentioned in reference to the Wolfe's bottle, only that the breathing tube may be straight, and, if glass is not at hand, common pipe-stems, or pieces of goose's quill, lengthened sufficiently by insertion into one another, maybe substituted. As in, the Mudge's inhaler, a proper temperature of the contained liquid may be maintained, if necessary, by setting the bottle in a water-bath. Besides those mentioned, several other inhalers have been invented, and more or less employed, all, however, acting on the principles re- ferred to * Finally, certain fumes and vapours may be inhaled through a com- mon smoking pipe, as those of stramonium and camphor for example, the former being set on fire in the bulb, the latter volatilized in the same position by the current of air passing through it. Another mode of effecting the same object is by the smoking of cigarettes, made by rolling into the form of small cigars narrow strips of paper, previously impreg- nated with a solution of the substance the fumes of which are to be in- haled, and then drying them. Use of liquids in the form of spray. Reference has already been made to a new process by which liquids are brought into contact with the air-passages, mixed, in a state of extremely minute division, with atmospheric air, or aqueous vapour, but still retaining the liquid form. Liquids in this condition are said to be pulverized, atomized, or nebu- lized; and the instruments by which the effect is produced are variously named atomizers, pulverizers, or nebulizers; the first of these terms being preferred by English writers, the second by the French, and the third by the Germans. As this subject has been pretty fully considered in the recently published edition of my Treatise on the Practice of Medi- cine (6th ed., vol. i. p. 949), it is unnecessary to do more here than to make a few observations, calculated to give the reader a general knowl- edge of the subject. It is well known that various substances in solu- tion, or othen\yse in the liquid state, often have a curative effect when brought into contact with local diseases, whether of the skin, or of acces- sible mucous surfaces. It has, therefore, been a desideratum to find a method by which these substances might be applied to the air-passages within or beneath the larynx. Attempts have been made to accomplish this object, to a certain extent, by the injection of liquids into the trachea * Among these may be mentioned Chixholni's inhaler (N. Y. Medical Record, Jan. 1, 18C7, p. 509); Nelson's inhaler (Lancet, Feb. 11, 1865); Curtis'* inhaler (Med. T. and Gaz., Dec. 1861, p. 624); and Thompson's hydro-pneumatic inhaler (Lancet, Jan." 28, 18(10), which, howerer, acts on a different principle. (Note to the third edition.) CHAP. III.] APPLICATION OF MEDICINES. 77 and bronchia, or by penetrating the rim a glottidis with moistened sponge at the end of a long handle; but the inconvenience if not danger of these methods is very great, and their success very problematical. But when the idea suggested itself that the end might be safely attained by imitating certain processes of nature, by which liquids in a state of ex- tremely minute division, still holding soluble substances in solution, might be intimately mixed with air, and in this state safely introduced into the air-passages in ordinary respiration, a.s when we inhale the spray from breakers on the sea-shore; it was an obvious conception, that this process might be artificially imitated, and medicinal liquids in this way be brought into direct contact with the interior of the lungs. Two methods of accomplishing this object suggested themselves to experi- menters ; one by causing a small stream of the liquid to be forcibly im- pelled against a solid body, and thus to be broken into minute particles and diffused in the surrounding air ; and another, by which a strong cur- rent of air should, at the point of issue from a tube, be made to bear upon a slender column of liquid, and to carry this along with it in the form of spray, expanding into a cone with a constantly increasing base till lost in the atmosphere. Instruments were contrived on both of these principles, and have come into extensive use ; those, however, based upon the second plan being generally preferred. For an account of the instru- ments and their mode of use, I must content myself with referring to my Treatise on the Practice, and to the various published monographs on the subject.* There is reason to believe that good may be effected by this method of inhalation, not only by the curative influence exerted in the diseased membrane by the contact of the medicine, but also through its absorption into the circulation, and the exercise on the system at large of its peculiar powers. It has been objected to this mode of medication, so far as concerns its action on the pulmonary air-tubes, that the pulverized liquid never really passes below the glottis ; being deposited before it reaches the respiratory passages. This, how r ever, is not exactly true. Abundant proof has been offered that some substances do in fact reach the bronchia, and beneficial therapeutical effects have been obtained; but it is true, nevertheless, that much of the liquid separates before reaching the interior of the larynx, and very little of it is carried to the ultimate ramifications * I would especially call attention to two essays; one by Dr. J. M. Da Costa, of Philadelphia, in the X. Y. Med. Journ. (Sept. and Oct. 1866, pp. 401 and 29): the other by Dr. Ephraitn Cutter, of Boston, in the Med. and Surg. Reporter (July 14 and 21, 1866, pp. 38 and 60). In the Boston Med. and Surg. Journal (Dec. 27, 1866. p. 434) a variety of the apparatus has been described, denominated the "hydros- tatic atomizer," in which the pressure of a column of water is employed in order to give requisite force to the current of air, instead of pressure by the hand, by a forcing pump, or by steam, which is employed in other instruments. 78 APPLICATION OF MEDICINES. [PART I. of the bronchia ; so that wo must bo satisfied with less practical result, as regards pulmonary diseases, than may have been anticipated by some in the beginning. By certain modifications of the apparatus, the pul- verization may be effected in the cavity of the mouth, and even in the fauces; so that the spray may be brought to bear with its entire inten- sity, upon the pharynx, the posterior nares. the entrance of the Eustachian tube, and the exterior glottis; and will probably also pass more deeply into the air-passages than when inhaled, as it ordinarily is, from with- out. The particular medicines adapted to this mode of exhibition, and the strength of the solutions to be atomized, will be more appropriately considered under the heads of the several medicines employed. Besides the remedial advantages above mentioned as resulting from this method of applying medicines, other useful results have been ob- tained. For disinfecting purposes the atomizer has been found very effi- cient, diffusing as it does the disinfecting material equably through the air of the apartment, and thus causing it to act on every particle of the offensive or noxious agent. Another effect is the production of extreme cold by the rapid evaporation of volatile liquids, brought into this suite of minute division ; and the anaesthetic influence of the cold, thus generated upon the surface of the body, has been taken advantage of to a considerable extent by surgeons. More will be said of both of these effects hereafter in this work. SUBSECTION IV. The Subcutaneous Areolar Tissue. Subcutaneous Injection. Hypodermic Method. These names have been given to a plan of medication, first announced, in 1855, by Dr. Alexander Wood, of Edinburgh, consisting of the injection of remedial substances into the subcutaneous areolar or cellular tissue. Though ap- paivntly aware that medicines might be employed in this way with a view to their effects on the system at large, Dr. Wood confined his views practically to their local influence, and especially to the relief of neuralgic pains by anodynes injected into the areolar tissue, as near :is possible to the seat of the affection. He no doubt believed that the relief obtained depended on the local action of the medicine. To Mr. Charles Hunter is due the credit of having generalized this plan of medication. He soon satisfied himself that the anodyne effect was obtained by in- jecting the medicine at a distance from the seat of pain, as well as in its immediate vicinity; and hence concluded that the medicine operated, not immediately on the painful nerve, but through the medium of the circu- lation, being absorbed into the blood, and carried with it to all parts of the system. He ascertained, moreover, that substances, employed in this way, exercised their ordinary remedial influence over systemic CHAP. III.] APPLICATION OF MEDICINES. 79 diseases; and the important fact was thus established, that the areolar tissue might be resorted to as an avenue for the introduction of medicines into the system, in all cases in which their relations with this tissue allowed them to be applied to it in a condition permitting their absorp- tion in sufficient quantity, without injurious local effects. It must, never- theless, be admitted that certain medicines, especially anodynes, such as morphia and aconitia, while they operate on the system generally through absorption, do exercise a peculiar influence in the neighbourhood of their application. This was proved by experiments of Dr. Eulenberg, who found that the sensibility of the parts into which morphia was injected, on one side of the body, was much more diminished than that of the cor- responding parts on the other side. (Am. Journ. of Med. Sci., April, 186B, p. 432.) It would probably be a good practical rule, to inject the areolar tissue as near as possible to the seat of the disease, whenever there is good reason to believe that this is exclusively local, and in the arm ^or any other convenient spot, without reference to the precise locality of the pain, when this depends on disorder of the nerve-centres, ;i morbid state of the blood, or some other systemic derangement. Alter the discovery of the method of subcutaneous injection by Dr. Wood, it came rapidly into use, and is now almost universally re- soiled to under favouring circumstances. From the abundance of the capillaries distributed in the areolar tissue, it affords extraordinary facili- ties for absorption; and suitable remedies, applied in this way, act much more rapidly, and consequently with greater energy in equal quantities, than the same remedies introduced into the stomach or rec- tum, or employed endermically. One cause, no doubt, of the greater rapidity of the action hypodermically, is that substances taken up from the alimentary canal are for the most part conveyed through the portal vc-ns into the liver, and are distributed through that organ before reach- ing the general circulation, while from the areolar tissue they probably enter immediately into the veins. Another advantage possessed by this method is that the medicine enters the circulation unchanged, and there exercises purely its legitimate effects on the system; while, when given by the stomach, it is liable to be modified by the action of the various and often powerful agents it finds in the alimentary passages; and, besides, the effects it produces directly on the stomach and bowels, which are often much disordered by it, complicate its proper systemic influ- enoes. Mr. Hunter states that the remedial effects of medicines, hypo- dermically administered, are often more permanent than those from the ordinary methods of exhibition. Thus, he has repeatedly effectually cured cases of disease, by injecting certain medicines into the areolar tissue, which had long resisted the same medicines given by the stomach ; being relieved, indeed, for a time by the latter method, but returning constantly with uniuipr.'.ed force. It has been asserted that narcotics. 80 APPLICATION OF MEDICINES. [PART I. especially opiates, are less apt to disturb the brain, than when given by the mouth. Notwithstanding these various advantages of the hypodermic method, the number of remedies to which it is applicable is limited. Many art- altogether unsuited to it on account of the large quantity required to operate; others from their insolubility; and others, again, from their irritant properties, which at the same time occasion local inflammation, and interfere with absorption. It is now well known that crystalline bodies in solution are diffused through animal membrane much more readily than gelatinous or glue-like substances (the colloids of Graham). which pass with great difficulty if at all. Hence it may be inferred that active principles of medicines, capable of assuming crystalline forms, are much better adapted than others not crystallizable, to this mode of ad- ministration, as likely to find easier admission into the capillaries; and the fact is, that the vegetable alkaloids, as morphia, atropia, quinia, etc.. are peculiarly fitted for subcutaneous injection. The following circumstances are peculiarly favourable to this method of medication. It is called for in cases of great severity, where tin- prompt relief of pain is required, or immediate interference may be neces- sary to save life; and, under these circumstances, it may either be de- pended on as the chief agency, or may be used as auxiliary to the ordi- nary measures. As examples, may be adduced the excruciating pain attendant on the passage of a urinary calculus,- and a case of pernicious fever in which life may depend on the prompt and efficient action of quinia. When the stomach rejects all suitable remedies, or the patient obstinately refuses or is unable to swallow them, subcutaneous injection is a most valuable resource. When, moreover, remedies by the mouth and rectum have been used without satisfactory results, there is a strong indication for this method. Indeed, it may be resorted to in almost all instances, otherwise not unsuitable, in which it may be preferred by the patient. There are, however, circumstances which considerably limit its ap- plicability. The danger of producing great local irritation, inflammation, or gangrene, is extremely slight, when due attention is paid to the choice of medicines, the proper introduction of them, and the state of the system. Non-irritant remedies, in a liquid form, may almost always be injected without the least inconvenience ; or, if a slight irritation be produced, it subsides rapidly, without leaving any unpleasant effect. But substances in themselves irritant, or rendered so by their solid state interfering with absorption, may excite inflammation, ending in suppuration, or perhaps in gangrene, and should, therefore, never he employed in this way, in reference to their systemic influence. Besides, when the sy>tem happens to be in a state threatening erysipelas or gangrene ; or when these con- ditions either exist, or a tendency to them prevails in any locality, the CHAP. III.] APPLICATION OF MEDICINES. 81 hypodermic method should be avoided, or used only under the most urgent circumstances, from the risk that would be incurred of exciting these affections. In some rare instances, great alarm has been caused by the unex- pectedly rapid and apparently dangerous action of medicines injected into the areolar tissue. Thus, morphia has sometimes operated, in the ordinary dose, with extreme violence, so as to threaten life itself, though I have not found recorded any absolutely fatal case from this, or any other medicine used in the same way. This occasional violence is ascribed, and probably with justice, to the penetration of a minute vein, and the consequent injection of the whole dose at once into the current of the circulation. Caution should, therefore, always be observed to avoid any visible blood-vessel ; and, when the effect of the medicine is experienced immediately, the instrument should be at once withdrawn. It has been advised, in reference to this danger, to inject the medicine rather slowly, 80 that the process may be arrested, on the occurrence of violent symp- toms, before the whole dose has been injected. In all instances, extreme caution should be observed not to administer excessive doses of poi- sonous medicines in this way; the danger being greater than when the medicine is swallowed, or given by enema ; as, in either of these cases, it may be evacuated, while no such opportunity would be offered in the hypodermic method. Should alarming phenomena, however, re- sult at any time from too rapid or copious absorption from the areolar tissue, a vacuum should be immediately produced, by the application of a cupping-glass over the puncture, so as to impede or prevent the continuance of the process. In the treatment of systemic diseases, it is often desirable to maintain an equable and steady impression by means of medicine. In this case, the exhibition of the remedy by the mouth would be preferable ; as absorption is maintained continuously from the stomach ; while, given by subcutaneous injection, the medicine acts more or less interruptedly, or by starts. Operation. When circumstances do not indicate a special site for the operation, the arm near the insertion of the deltoid is perhaps as conve- nient a locality as can be chosen. When the operation is to be repeated, the place of puncture should be varied, so as to avoid irritating or in- flaming the part. The pain from the operation is very slight, not ex- ceeding that of the prick of a pin, and by the most sensitive soon in general comes to be disregarded. Sometimes it may for a time be very acute in consequence of the perforation of a cutaneous nerve ; but this rarely happens. The instrument recommended by Mr. Hunter is a small syringe, with a glass barrel and silver fittings, the piston of which is worked by means of a screw, each half turn of which expels half a minim. The pipe, which is attached by a screw, is of silver, with a hardened gold VOL. i. 6 82 APPLICATION OF MEDICINES. [PART I. point, as sharp as a needle, and an opening on one side, near the point, through which the liquid is expelled. No incision or perforation is re- quired, other than that made by the sharp point of the pipe, which is not more painful than the prick of a pin. The liquid to be injected having been introduced into the instrument, the skin is made tense, and the point inserted by a quick movement perpendicularly through the skin, after which any direction may be given to it that may be deemed desirable. Then the required number of minims is injected by as many turns of the screw ; so that the dose may be regulated with the utmost exactness. After this the instrument is withdrawn, and, to prevent the escape of the liquid, the perforation is covered with a small piece of adhesive plaster, previously warmed for the purpose. Different forms of the instrument have been recommended, all having in common the sharp perforated point. In one form, instead of meas- uring the amount of injected liquid by the turns of a screw, the piston is constructed in the ordinary manner, and the dose measured by a grad- uation of the barrel of the syringe, or of the piston itself. Instead of the hardened gold point, this is sometimes made of steel, and may be perma- nently affixed to the instrument, or attached by a screw, and removable at pleasure. It is important that the point should not become blunted by oxidation or other cause ; as the success of the operation, and the avoidance of subsequent injury, depends much on the perfect cleanness and sharpness of this part of the instrument. The syringe, too, should be thoroughly cleansed after each operation, especially when a different medicine is to be injected. A second dose should not be given until the effects 6f the first have subsided ; or, if previously to this time, it should be reduced. Mr. Hunter thinks it advisable, as a general rule, to use a strong solution, so that tlic required dose may be thrown in by three or four turns of the piston. The quantity thrown in at once should never exceed thirty minims, and less than this will sometimes cause uneasiness by disten- sion, and partially escape through the aperture. The whole process need not consume more than half a minute. It is very important to attend carefully to the operation ; as, when the solution is very strong, a few turns of the screw, in excess, may produce serious results. Mr. Hunter recommends that not more than half the full ordinary dose of a narcotic medicine for a man, nor more than a third of it for a woman, should be injected at flrst; as the medicine operates rapidly, and with the entire force of the quantity introduced, the whole being absorbed. The medicines given in this way should always be perfectly dissolved ; and if, as sometimes happens in using the alkaloids, some acid is neces- sary for their complete solution, not more should be employed for the pur- pose than is absolutely required. If the solution is turbid, it should be filtered before being injected. Pure water is the best solvent, though CHAP. III.] APPLICATION OP MEDICINES. 83 tinctures may be used when deemed advisable. It is especially im- portant that the tinctures should be freshly filtered, as, after long standing, they are apt to deposit a portion of their contents ; and this is especially the case with laudanum. In the selection of medicines to be injected, it is desirable to avoid such as give precipitates with the alkaline chlo- rides and albumen, both of which they might encounter in the areolar tissue. A use of the hypodermic method not yet referred to, has been sug- gested and put in practice by Dr. Eulenberg; namely, to facilitate laryn- goscopy by the use in this way of morphia, or other medicine calculated to obtund the sensitiveness of the fauces. (Am. Journ. ofMed. Sci., April, 1866, p. 436.) Still another application of subcutaneous injection has been brought to the notice of the profession by Dr. Luton, of Rheims, in France, under the name of parenchymatous substitution. He refers to the sub- cutaneous injection of irritating substances, with the view of exciting more or less irritation, which, according to the substances injected, may be of three grades; first, simple pain with insignificant local disorder, secondly, an irritative congestion, or, thirdly, inflammation with suppu- ration, etc. The remedial influence aimed at is the substitution of the new excitation for a pre-existing disease of the same part; a principle of therapeutical action identical with that already considered in this work under the name of supersession. (See page 51.) By the first degree of irritation he supersedes neuralgia and other painful affections; by the second, glandular diseases, acute or chronic, and especially strumous engorgements ; and by the third, white swellings, local osteitis or perios- titis, caries, etc. He obtains these gradations of effect by the injection of substances of various degrees of irritating power, from solution of chloride of sodium, alcohol, etc., which occasion rather severe pain, fol- lowed by local swelling, in general readily dissipated, through tincture of iodine, which causes non-suppurative inflammation, sometimes fol- lowed by atrophic absorption, to solution of nitrate of silver, sulphate of copper, etc., which give rise to phlegmons with suppuration. {Arch. Gen., Oct. 1863, p. 285.) It is perceived that this application of subcu- taneous injection is wholly different from those of Dr. Wood and Mr. Hunter, the former of which aimed at the relief of pain by the local action of anodynes, the latter to the production of remedial impressions through the circulation. It is yet comparatively new, and the recorded experience is insufficient to justify, on that basis, a positive decision as to its merits. In relation to the particular substances employed in hypodermic medi- cation, their therapeutic application, and the precise dose and mode of exhibition, the reader is referred to the several medicines as treated of in the second part of this work. 84 APPLICATION OF MEDICINES. [PART I. SUBSECTION V. Other Surfaces of Application. There is no surface attainable from without, to which medicinal appli- cations have not been made, with reference to a curative influence on the surface itself. The conjunctiva, the nasal duct, the nostrils and various cavities communicating with them, the mouth and fauces, the pharynx and oesophagus, the internal auditory meatus, the Eustachian tube, the urethra and bladder, the vagina and uterus, have all been the seats of such applications. Particular names have been given to certain medicines thus employed. Liquid applications to the eye are called collyria or eye-wafers; substances applied to the nostrils, errhines and sternutatories; liquids to the fauces, gargarismata, collutorea, or gargles; solid bodies intended to be chewed, masticatories ; and those applied to the urino-genital passages, if liquids, simply injections, if solids, and introduced into the vagina, pessaries. Of all these surfaces, those of the nostrils and mouth are the only ones to which medicines are habitually applied in reference to any other than a local effect. In consequence of the strong sympathies of the nasal passages with the brain, errhines and sternutatories are not unfrequently employed to rouse the nervous centres, and sometimes also to agitate the respiratory organs by the act of sneezing. Both to the Schneiderian and buccal mucous membrane, medicines are occasionally applied with a view to their revulsive impression, and to the latter sometimes in order to affect the system, as for example by rubbing the medicine upon the gums. It must be confessed, however, that this latter method can- not be looked on as peculiarly efficient ; and it is probable that, when any considerable effect has been experienced, it has been the result rather of the portion of the medicine swallowed, than of that absorbed from the mucous membrane of the mouth. There is reason, nevertheless, to believe that medicines are actually absorbed from this membrane, par- ticularly from the surface of the tongue; and substances applied to this organ, and held there for some time, are asserted to have exercised the same remedial influence as when swallowed, without unpleasant effect upon the stomach. Even to the serous membranes, applications are sometimes made with a view to some alterative effect on these tissues. Thus, injections are thrown into the tunica vaginalis for the cure of hydrocele ; and attempts have been successfully made, in a few instances, to cure dropsy by stim- ulant liquids thrown into the cavities of the pleura and peritoneum; but tliis practice is too hazardous for general adoption. Blood-vessels. Many medicines, when injected into the veins, pro- duce the same effects as when taken into the stomach, but generally CHAP. III.] APPLICATION OF MEDICINES. 85 operate more powerfully. Hence it was long since proposed to ad- minister medicines in this way; and the method has been frequently tried. In some instances it has appeared to do good; but the general experience of its results has by no means been such as to counterbalance its obvious disadvantages; and it is only under the most urgent circum- stances, and in cases otherwise desperate, that it would, in my estima- tion, be justifiable. "When medicines are absorbed into the circulation, they frequently undergo preliminary changes, which probably better adapt them for admixture with the blood. Being taken up gradually, they enter the circulation in extremely minute quantities at one time, so that the whole blood becomes equably impregnated, and the least possible shock is pro- duced either on the circulating fluid, the vessels, or the system. When injected into the veins, it is impossible to introduce them thus gradually and cautiously, and, if the attempt were made, the time consumed would greatly aggravate the danger of the operation. The blood, therefore, at the point of injection becomes too strongly impregnated, and must pro- duce on the tissues more than the desired effect; while it is scarcely possible to calculate what injurious influence may be exercised on its own qualities or constitution. We are too little acquainted with the chemical and vital reactions which take place, under such circumstances, to be able to infer a priori what results would ensue ; and experiments have not yet been sufficiently numerous and varied to supply this defi- ciency. The most violent effects have sometimes been produced by substances which, in other modes of application, are quite bland and innocuous. Besides, there are the dangers of injecting air into the veins along with the medicine, and of giving rise to phlebitis by injury of the vein. Inoculation has recently been proposed as another and safer method of introducing medicines into the blood-vessels; but I cannot conceive of any advantage it possesses over the eudermic method, while it is liable to the great disadvantage that the medicine, to produce any effect on the system, must enter the blood in a highly concentrated state, and thus endanger too strong a local impression. An account of Langenbeck's method of applying medicines by inoculation is contained in the British and Foreign Medico -chirurgical Review for January, 1857 (Am. ed., p. 203). Attention has recently been called by Sir J. Y. Simpson, of Edin- burgh, to the use of medicated pessaries, from which he has found advantage in the production of specific impressions on the uterus and vagina. The medicine is incorporated with some soft solid ; and, as in the case of suppositories, cacao butter is admirably well adapted to the purpose. Opiates, astringents both vegetable and mineral, and various other medicines may be employed in this way. (Edin. Med. Journ., May, 1865, p. 1042.) 86 CLASSIFICATION OF MEDICINES. [PART I. CHAPTER IV. Classification of Medicines. THE use of classification is to facilitate the work both of the author or teacher, and of the student. To the former it is highly advantageous by affording him the opportunity of presenting, in one view, and in a comparatively few words, all the common properties and uses of any number of bodies; so that, in the subsequent description of these bodies severally, he may omit whatever is not peculiar to each, and thus spare himself a vast amount of repetition. To the latter it is almost essential ; as, by fixing in his mind the properties of classes, and thus serving to recall these properties in relation to any individual, upon the recollection simply that it belongs to the class, it aids his memory beyond all other contrivance, and enables him to gather and retain an amount of knowl- edge, which would be quite unattainable were he to study each object in an isolated state. The only kind of works in which classification is un- necessary are those intended, not for continuous study, but for occasional reference, when information is desired upon some particular name or object, such as dictionaries, encyclopedias, and, to a certain extent. dispensatories, in all of which an alphabetical arrangement is most convenient. The advantages and even necessity of classification being admitted, the next point for consideration is the plan to be adopted. Now it nuiy be asserted, without fear of contradiction, that no plan is faultless. Every mode of classification which has been proposed in relation to remedies has its disadvantages; and it is, therefore, no valid objection to any particular one which may be suggested that it is not perfect. That one, it appears to me, is the best, which best promotes the great object of all classification; the facilitating, namely, of the acquisition of knowledge. As different kinds of knowledge are required of the same bodies by different sets of students, it follows that the classification should be different also; for, to be productive of the most good, it must be based upon the relation of the bodies to one another in those proper- ties which are the special object of study. Thus, in reference to medi- cines, the intention may be to study them as objects either of natural history, pharmaceutical management, or therapeutic use; and they should be arranged accordingly. Their classification, therefore, should be based, for the general student, upon their geological, botanical, or CHAP. IV.] CLASSIFICATION OF MEDICINES. 87 mineralogical relations ; for the pharmaceutist, either upon their chem- ical properties, or their resemblance in modes of preparation ; for the therapeutist, undoubtedly upon their effects on the system, through which they become applicable to the cure of disease. It is in the last- mentioned capacity that they are important to the physician ; and in this especially he should be taught, from the earliest period of his studies, to regard them. - As, therefore, the present work is devoted more espe- cially to the therapeutic consideration of medicines, I have, without hesitation, adopted a system of classification, founded upon their rela- tions to one another in their modes of affecting the human system. The question now occurs, admitting the effects of medicines to afford the true basis of classification, whether it is their physiological or thera- peutical effects to which we should have recourse. At the first glance it might be supposed that the latter should be preferred. But a little consideration will decide against them. Formerly, when the notion prevailed that there were specific remedies for particular diseases, or classes of disease, an .arrangement of medicines based on this principle was to a certain extent naturally adopted. Hence the terms antiphlo- gistics, febrifuges, antispasmodics, antiscorbutics, antisyphilitics, anti- lithics, etc. But the fact is, that there is no specific, strictly speaking ; that is, there is no remedy which is especially adapted to one disease, and one only, and no curable disease which will yield only to one remedy; and, in relation to classes of disease, such as inflammations, fevers, and spasmodic affections, there is no one which does not require, in different stages, and under different circumstances, the same medicines found use- ful in the others ; so that classes founded on this basis would be con- stantly clashing, each containing the individuals embraced by the others ; and thus all the advantages of classification would be lost. For example, in the treatment of the three sets of diseases above mentioned, in one or another of their stages or varieties, we employ bleeding, cathartics, emetics, narcotics, tonics, stimulants, revulsives, etc. The physiological effects must, therefore, be resorted to ; and, happily, it will be found that, to one well acquainted with pathology, these very effects, and conse- quently the medicines producing them, are suggested by the therapeutic indications. It will be perceived that, in the following plan, all the old classes founded on the therapeutic basis, as antispasmodics and antilithics, have been abandoned, and, except in the instances of the last five or six, which do not act on the system itself, but on extraneous matters accident- ally contained within it, and operating as causes of disease, all the classes have a purely physiological relation. I wish it to be specially noticed that, in distributing remedies in the following classes, I am fully aware that the members of one class often possess properties which charac- terize another; and that, in deciding in which to place them, I have been in many instances influenced by their practical use, giving them a 83 CLASSIFICATION OF MEDICINES. [PART I. position in accordance with those properties which, if not always most striking, are those which constitute their chief value as medicines, or at least for which they are most employed. Plan of Classification. Remedies are divided primarily into those which operate upon the system, and those upon extraneous bodies accidentally contained within the system. The former division embraces the great body of remedies ; the latter includes only five or six classes, which are retained for the sake of practical convenience ; as it is desirable that the physician should have the substances belonging to them associated together in his memory. I. SYSTEMIC REMEDIES. Some remedies extend their action throughout the whole living sys- tem ; others, operating upon one or more of those functions, as the cir- uhitory and nervous, which pervade the body, are apparently felt in all parts of it, though not strictly universal in their direct influence. All these may be denominated general remedies. Another large division act specially on some one part or organ, or, if they affect the general system, do so only indirectly or secondarily. These may be called local remedies ; and thus we have the basis of the first subdivision. I. GENERAL REMEDIES. The general remedies are necessarily, as before stated, either stimu- lant, sedative, or alterative; that is, either elevate, depress, or alter the systemic actions. These three sets constitute the second subdivision. 1. General Stimulants. If the operation of stimulant substances be closely observed, it will be noticed that, while some are slow, moderate, and lasting, others are, on the contrary, quick, energetic, and proportionably brief in their action ; though the two sets run together by almost insensible gradations. This (liflerence of operation was made by Dr. Murray, of Edinburgh, the basis of a division <>f the general stimulants into two distinct sets, which he named respectively permanent and diffusible stimulants. Though tln-M- terms are neither of them very accurately exprosive of the dis- tinctive characters of the two divisions, yet it may not l>e easy to find letter, and it is advisable not to adopt new names unless upon some real ground of preference. I have, therefore, admitted this division with the nomenclature. CHAP. IV.] CLASSIFICATION OF MEDICINES. 89 1. Permanent Stimulants. There is a very striking distinction between the permanent stimu- lants; one section confining their direct influence to tb vital function of organic contractility, the other operating upon the vital functions gen- erally. The first division is very appropriately denominated astringents, the second less appropriately tonics. They constitute two of the ulti- mate classes of remedies. 1. ASTRINGENTS are medicines which produce contraction of the living tissues. 2. TONICS are characterized by their general stimulating influence over the functions, operating slowly, moderately, and somewhat dura- bly, either directly through the circulation, or secondarily through the digestive function. 2. Diffusible Stimulants. Some of these appear to be universal, such as heat and electricity; but the greater portion, and perhaps all which come strictly under the denomination of medicines, exhibit a special tendency to one or the other of the two great pervading systems or apparatuses of the body, the circulatory, namely, and the nervous. As those which have a tend- ency to the circulation operate directly rather upon the arterial than the venous side of it, I name them arterial stimulants. Those acting specially on the nervous system may be called cerebro- spinal stimulants. 1. ARTERIAL STIMULANTS are scarcely susceptible of further profita- ble subdivision, and therefore constitute one of the ultimate classes. They are characterized especially by their property of increasing the action of the heart and arteries, and, along with this effect, and proba- bly consequent upon it, of causing an elevation of the animal tempera- ture. 2. CEREBRO-SPINAL STIMULANTS. I do not wish, by the use of this term, to intimate that the remedies so called act exclusively on the brain and spinal marrow; they may possibly, and probably do, in some in- stances, affect the ganglionic system, and, indeed, the whole nervous substance wherever they may meet with it. There is a marked differ- ence between the members of this subdivision. Whilst some appear to operate equably upon the whole nervous system, showing no special in- fluence over the proper cerebral functions, others act with great energy on the brain, as evinced by their power of deranging sensation, volun- tary motion, consciousness, and the various intellectual and emotional functions. The former I denominate nervous stimulants, the latter cerebral stimulants. Besides these two sets of cerebro-spinal stimu- lants, there is at least one medicine which acts especially and power- 00 CLASSIFICATION OF MEDICINES. [PART I. fully on the spinal marrow, and for which a distinct class may be formed under the name of spinal stimulants. These three are all ulti- mate ela- a. Nervous Stimulants, characterized by a special but equable influ- ence over the nervous system, generally stimulate in some degree, though not necessarily, the circulation also. They are sometimes called nervines, and not unfrequently antispasmodics. b. Cerebral Stimulants, with more or less influence on the circula- tion, and sometimes a powerful influence, are peculiarly characterized by their control over the special cerebral functions. They arc equiva- lent to the stimulant narcotics of other writers, and embrace some of the most energetic articles of the materia medica, such as alcohol and opium. c. Spinal Stimulants act specially, so far as their operation is known, on the reflex motor function. 2. General Sedatives. These are remedies which directly depress the vital functions. While A ft 1 w operate universally, as cold and water, most of them, like the cor- responding stimulants, act especially or exclusively on one of the two great systems, the circulatory, namely, and the nervous; some prominently ulVe. The attention of the reader is particularly requested to a few con- siderations, which are necessary to a proper understanding of the scope of the present arrangement. I have said that the classification is not perfect. In the first place, the remedies attached to the several cla- while they agree in the possession of the particular property which characterizes the class, often differ very much in otl: the similar effect of cold upon the skin is transmitted to certain internal parts. But this explanation is not necessary to account for the result. Experiment has satisfactorily proved that astringents are absorbed ; and the probability is that they are conveyed everywhere with the blood, and thus act everywhere by direct contact. The fact, recently ascertained through the experiments of Bernard, that one of the functions of the sympathetic nerve-system is to produce contraction of the capillaries, very much facilitates the explanation of the general action of astringents. It is highly probable that, reaching the sympathetic centres through the circulation, they excite these centres to increased action, and thus, in part at least, produce the contraction which is their most characteristic effect. This explanation does not in any degree invalidate the idea that they act also directly on the tissues through the blood. There is nothing in the least inconsistent in these two modes of operation, which may be in action at the same time, and thus conjointly produce greater effects than either separately. 1. MODE OF OPERATION. Dead animal structure, submitted to the action of astringent sub- stances, especially to those of vegetable origin, has long been known to undergo condensation, in consequence of chemical combination between constituents of the tissue and the astringent substance. In relation to the vegetable astringents, their tannic acid unites with the albumen and gelatin of the animal product, to form insoluble tannates, as in the prep- aration of leather from hides; in relation to the mineral, the metallic salt or its oxide also combines with albumen, producing compounds insoluble in water. The chemical therapeutists suppose that this same reaction takes place between the astringent and the living tissue, and ascribe the effects of the medicine to this agency. But there is no proof whatever that such a combination takes place in life. It could not do so, to any considerable extent, without destructively disorganizing the part affected. The force of life opposes these chemical reactions, and suc- cessfully so long as the medicine is moderately employed. If this be applied abundantly, it may fir-4 exhaust the vital forces by the excess of vital reaction it excites; and the chemical affinities may then triumph, with the effect of d.-t raving the life of the part. But, under such cir- cumstances, it ceases to be a medicine, and becomes a poison. The rapidity, moreover, and amount of local astringent effect are far greater than can be explained on the chemical principle. Every one knows how CHAP. I.] ASTRINGENTS. 99 sudden and great is the contraction produced in all the tissues of the mouth by a very minute quantity of alum. It appears to me absurd to ascribe all this effect to chemical combination. Even were the whole of the alum which could possibly be absorbed in such a case to combine chemically with the tissues, it could not produce an amount of contrac- tion in any degree approaching to that really experienced. Besides, the contraction, if chemical, would be much more permanent than it really is. The following appears to me to be the true explanation of the phe- nomena, so far as they are at present susceptible of explanation. All the living tissues have a certain degree of vital cohesion essential to the due performance of their functions; and this cohesion probably depends on a property of organic contractility, which is called into action and sustained by the healthy stimulus of the blood and nervous influence. If these fail, the cohesion diminishes, and a condition of relaxation takes place. Now astringent substances have the peculiar property of stimu- lating this organic contractility; and it is this property by which they are characterized as a class of medicines. All that we know upon the subject is that, in consequence of the contact of these substances with the tissues, the contractility of the latter is called into action, and they shrink. The effect is in no degree more singular than that a similar shrinking should take place under the influence of cold. It is a very singular mistake, which still prevails with some writers, that astringents act especially or peculiarly on the muscles. It is true that they do increase the vital cohesion of this structure, rendering the muscle firmer, but they also act equally on every other tissue capable of shrinking; as may be distinctly seen in their effects upon the skin, and felt in their effects on the mucous membrane of the mouth. 2. EFFECTS ON THE SYSTEM. The observable physiological effects of astringents are, beside the gen- eral condensation of tissue referred to, or rather as a part or result of it, shortening of fibres ; diminished caliber of the arteries, veins, capillaries, absorbents, and ducts; diminished secretion, exhalation, and absorption; constipation of the bowels ; and increased firmness along with contraction of the pulse. The blood becomes more coagulable, in consequence, probably, of the same influence exerted by them on the organized con- stituents of this fluid as on the solids. It is supposed also to be less disposed to putrefaction after death. The astringents are said to increase the appetite, and invigorate digestion. This effect they undoubtedly have, in debilitated states of the function, connected with relaxation of tissue. It is reasonable to suppose that, even in health, with a very moderate degree of their peculiar influence, they may produce some slight increase of the functions. Their effect is to bring the molecules 100 GENERAL STIMULANTS. [PART II. more closely together; which may thus be rendered capable of a more enenretic vital reaction. But. whatever may be the case with the per- fectly pure astringents, it is certain that many of the medicines ranked in this class do exercise a tonic influence; and for this reason, that they unite positive tonic powers with their astringent property. Such is the case with the vegetable astringents, which, beside their characteristic ingredient, not unfrequently contain a bitter principle also, and with the preparations of iron, which are essentially and powerfully tonic, while they are in some degree astringent. It must be obvious, upon a little consideration, that, though astrin- gents are stimulant to the organic contractility, they may really prove sedative to the healthy functions, when employed too freely, or continued too long. The digestive function is necessarily impaired in consequence of the diminished secretion of gastric juice, the restrained peristaltic movement of the stomach and bowels, and the impeded absorption. AH a result of this defective digestion, if from no other cause, the circulation is enfeebled, nutrition suffers, emaciation takes place, and a general reduction is experienced in the forces and functions of the system. The above results flow from an excess of the proper astringent influ- ence. But a still greater abuse of this class of medicines leads to other and very different effects. When applied to delicate surfaces in great excess, instead of acting simply as astringents, they become irritants. In the denuded skin they excite inflammation, and, taken into the stom- ach, cause gastric and intestinal pains, nausea, vomiting, and some- times diarrhoea; their astringent influence being either prevented or overwhelmed by the irritation. As already stated, some of them, in very great excess, overcome the vital resistance of the tissue to their chemical affinity for one or more of its constituents; and disorganization, with the death of the part, ensues. It is said that, under such circumstances, putrefaction does not readily take place, being prevented in part by the previous expulsion of the liquids, but probably in chief by a direct preservative or antiseptic effect, arising from the union of the astringent with the animal principles. 3. INDICATIONS, AND THERAPEUTIC APPLICATIONS. The indications for the use of astringents are such as might be inferred from their physiological effects. They are three in number; 1. to check morbid discharges, 2. to obviate morbid relaxation, and 3. to check inflammation in its earliest stage. For the first two purposes they may be used either generally or locally; for the third, they must In- applied directly to the seat of the inflammation. It will be most convenient to treat first of their internal, and afterwards of their external use; including under the former head only what has reference to their entrance into the stomach, under the latter all their direct local applications from without. CHAP. I.] ASTRINGENTS. 101 It must not, however, be forgotten that, in their operation upon the mu- cous membrane of the alimentary canal when taken into the stomach, they act as directly as upon the external surfaces; the only difference being that they cannot be applied so freely to the former, in consequence of its greater sensitiveness, the greater danger of any excess of action, and the impossibility of limiting the extent of their application, or readily removing them if found to be injurious. a. Internal Use of Astringents. 1. To Check Morbid Discharges. In fulfilling this indication, astrin- gents act by contracting the pores in the blood-vessels through which the discharge takes place. Two distinct kinds of morbid discharges are affected by them; the one consisting in excessive or deranged secre- tion or exhalation, the second in hemorrhage. In reference to their influence in checking the latter, the astringents are denominated styptics. In both, some cautions are required in their use. When the discharge depends upon some local or general disorder which it is intended to relieve, as plethora, active congestion, inflamma- tion, or the presence of noxious matters in the blood, the astringents are as a general rule contraindicated; and the same remark applies to what have been denominated critical discharges; though, strictly speak- ing, these belong in fact to one of the preceding categories. As the astringents operate in general by merely closing the avenues by which the fluid escapes, and have no effect in removing the disorder which the discharge is intended to relieve, it is obvious that they may, under these circumstances, do much mischief. If they check the discharge, they may increase the real pathological condition; if they fail, their own irritative effect is superadded to that previously existing. Again, a discharge, though originally morbid, may have become hab- itual ; and the processes of digestion and sanguification having taken on increased activity, the system may have accommodated itself to the drain. Astringents in such cases might disturb this balance, and give rise to dangerous local congestion, or general plethora. If resorted to, therefore, they should be applied cautiously and gradually, so as to per- mit the system to accommodate itself to the change ; or the apprehended evil should be counteracted by other measures, as by cathartics, issues or setons, a regulated diet, and increased exercise, which may have the effect of consuming the excess of blood. Astringents are applicable when the discharge is purely local, and dependent on no coexisting disease ; as, for example, in the hemorrhage consequent upon an accidental rupture of a blood-vessel, either from direct violence, or from a sudden and temporary congestion produced by straining, position, etc. They are also applicable when the affection depends upon debility or 102 GENERAL STIMULANTS. [PART II. rrhixation of the coats of the blood-vosscls. either original, or consequent upon previous excessive excitement, which has quite disappeared. This is a very common condition in the advanced stages of inflammation; and it is, perhaps, under such circumstances that astringents are upon the whole most useful. Another condition which sometimes imperiously calls for them, even under otherwise opposing indications, is when the discharge is so copious as itself to become the main source of danger. Thus, a hemorrhage- from the rectum, intended as a relief to serious plethora or portal con- gestion, may be so frequent or abundant as to put life at risk: and, in this case, should be arrested without hesitation. It is not unfrequently necessary to choose between such opposite indications; and the prudent practitioner will always prefer what may seem to him the least of the two evils. The position, moreover, of the discharge may sometimes be such as to render this the greatest danger; as in a case of haemoptysis which threatens to overwhelm the lungs. Here astringents may be employed, though the hemorrhage might have been the result of a congestion, and may have a tendency to relieve it. In such cases, however, tin- use of the styptics should be accompanied with measures, calculated, in a safer way, to accomplish the end for which the hemorrhage was intended. 1'inally, there are certain individuals of this class which, with their astringent property, unite others calculated to relieve the affection in which the discharge originated, and against which, therefore, the contra- indication above mentioned has less force than against thejinembers of the class generally. Thus, acetate of lead, while powerfully astringent. is also antiphlogistic, and may sometimes be advantageously employed to arrest morbid secretion from inflamed surfaces, when others would prove only injurious. It is unnecessary to detail minutely all the diseases in which astrin- gents may be useful, and the circumstances in each, which modify the indication for their employment Guided by the above principles, the practitioner will judge for himself when the occasion may be offered. It will be sufficient, for the sake of illustration, to trace a single disease through its various therapeutical relations with astringents, in conformity with the foregoing rules, and afterwards simply to enumerate the other diseases in which they may be required, to meet the indication now in view. Diarrhoea is one of the complaints in which astringents are most fre- luently employed. But this affection often depends on inflammation of the bowels, or congestion of the liver and whole portal circulation, which it has the purpose and effect of relieving. Astringents, if they succeed in checking the increased secretion, which is at once the agent of relief, and the cause of the diarrhoea, will act injuriously on the inflammation CHAP. I.] ASTRINGENTS. 103 or congestion; if they fail, they will add their own irritation to that pre- existing. They are, therefore, as a general rule, improper under such circumstances. In certain kidney affections, urea accumulates in the blood, and sometimes seeks an outlet through the bowels, producing diarrhoea, which thus protects the system, in some measure, against the fatal influence of that agent upon the brain. Diarrhoea is sometimes critical ; that is, occurs at the termination of certain diseases, such as -idiopathic fever, and is probably one of the processes by which the sys- tem relieves itself of its morbid condition. In either of these cases, astringents might do serious injury. Lastly, the diarrhoea may have existed so long that the system has accommodated itself to the increased discharge, the sudden checking of which might occasion dangerous con- gestion of the liver, lungs, or brain, or perhaps dropsical effusion. Here, though astringents may not be altogether contraindicated, they should be used with caution, so as gradually to bring about the cure of the complaint; while, in the mean time, measures may be taken to obviate any threatened injurjfc There is reason to believe that diarrhoea sometimes results from a pure relaxation of the mucous membrane of the bowels, permitting the liquid parts of the blood to pass through the walls of the capillaries, almost as through dead membrane. Very frequently inflammation of the mucous coat ends in such a state of debility or relaxation. The ves- sels, dilated in the active stage of the disease, with pores also probably enlarged so as to admit the passage of the liquor sanguinis, retain this condition upon the cessation of the excitement; and the extravasation and consequent diarrhoea continue long after the occasion for them has ceased. .It is under such circumstances that astringents prove most useful in this affection. Another very frequent occasion for their use in diarrhoea is when the discharge, no matter what may have been its origin, is so profuse as to endanger the safety of the patient. Such is the case in epidemic cholera; and I have repeatedly known patients in danger of their life from copi- ous white alvine evacuations, dependent on portal congestion from inert- ness of the capillaries of the liver. Here astringents are sometimes indispensable. In cases of diarrhoea connected with vascular irritation of the mucous membrane, perhaps with some degree of acute inflammation, and very often in chronic inflammation, it may be proper, even though the dis- charge may not be immediately dangerous by its quantity, to employ astringent medicines, having along with their astringency a sedative or alterative property, which renders them useful in the treatment of the irritation or inflammation itself; and, when a very exhausting discharge, originating in such causes, imperiously demands the employment of astringents, it is to this set of them that we should preferably have re- 104 OENKRAL STIMULANTS. [PART II. course. Acetate of lead is indicated in the more acute of these cases, and sulphate of zinc, sulphate of copper, or alum in the more chronic; the first from its sedative, the three latter from their alterative action upon inflamed surfaces. Dysentery is another complaint in which astringents are frequently recommended by writers. But a cautious discrimination is here neces- -ai-y, in order to avoid the most serious consequences; and, in ordinary acute dysentery, in the earlier stages, it is I think best to avoid entirely their internal use, -even that of acetate of load, which has been com- mended by some. In the advanced stages, when the discharges have become more copious, the grade of the inflammatory excitement greatly reduced, and the patient's strength exhausted, they may sometimes be employed with benefit; though, even under such circumstances, caution should always be observed. In the chronic form of the disease they are not unfrequently useful, particularly in warm climates, where there is greater laxity of system, and especially of the bowels, demanding the use of this class of remedies. The metallic alterative astringents are most effi- cacious in these cases, though the vegetable are also not unfrequently tjmployed. Other morbid secretory affections, in which the internal use of astrin- gents is called for, are diuresis or excessive secretion of urine, profuse and exhausting sweats, catarrh of the bladder, excessive bronchial accretion, and sometimes possibly dropsical effusion dependent on re- laxation of the tissues. In these complaints they are less obviously efficacious than in those of the bowels ; because, in the latter, they are brought directly into contact with the diseased tissue, while, in t In- former, they must reach it through the medium of absorption. A rule in these cases is to select the particular astringent which experience ha> shown most readily to reach the seat of the discharge. Thus, uva ursi and chimaphila are especially useful in the affections of the uriirary pas- sages, from their well-known quality of impregnating the urine. Hemorrhages often demand the use of astringents; and the general rules before given hold, in relation to this set of discharges, as well as t<> morbid secretions and exhalations. When active, and connected with plethora or local vascular irritation, unless alarming by their quantity, or injurious by their position, they should be treated hesitatingly with astringents ; and, should this class of remedies be indispensable, t host- should be selected which are sedative as well as styptic, such as cold, and the preparations of lead. After the relief of the plethora or con- gestion, and a sufficient reduction of the active character of the hemor- rhage, either by depletory nie;i large irregular masses, which, after importation, are broken up into small irregular fragments, less sharply angular, glistening, and dark-coloured than the E. India variety, and in these respects closely resembling that from the W. Indies. In taste and smell, solubility, the character of its active principle, and in general chemical relations, it resembles the pre- ceding variety. Besides those varieties of kino, there is the Botany Bay kino, from Eucalyptus resinifera of New South Wales, and a product named Bu- tea gum, from Butea frondosa of Hindostan, both of which have the general properties of this drug, but are little used in the United States. (Sec U. S. Dispensatory.) Effects on the System. So far as they have been investigated, the effects of kino are not essentially different from those of galls; but it is doubtful whether they exert an equal influence through the circulation ; as their tannic acid is not capable, like that of galls and oak bark, of being converted into absorbable gallic acid, but passes, through the reagency of oxygen, into the state of a tasteless, insoluble, and inert matter. Therapeutic Application. Kino is one of the best of the vegetable astringents for internal use, on account of its purity, and general accepta- bility to the stomach. It is employed chiefly in diseases of the alimen- tary canal; and, though occasionally prescribed internally for haemopty- sis, menorrhagia, and leucorrhcea, it probably, for reasons already given, exerts little influence in these complaints. In those forms of diarrhoea and advanced or chronic dysentery, in which astringents are indicated, it is a very useful remedy, and much employed in this country. It may also be sometimes used advantageously in epidemic cholera, in order to check the excessive evacuations. Pyrosis, hxmatemesis, and intestinal hemorrhage are among the complaints in which good effects may be expected from it. In the last-mentioned affection, occurring in the ad- vanced stages of low fevers, it is an admirable remedy. I have seen it promptly check the most alarming hemorrhage attendant on enteric or typhoid fever; but it must be given very freely, much more so than 124 GENERAL STIMULANTS. [PART II. under ordinary circumstances. In all those complaints it should gener- ally be associated with opium. ily, in the form of powder, it is sometimes efficacious in arresting hemorrhage from bleeding surfaces. In a bloody tumour of the roof of the mourh. which bled alarmingly upon being cut into, I once succeeded in checking the hemorrhage, after trying other means unsuccessfully, by filling the incision with the powder, and causing a piece of patent lint, on which the powder was thickly sprinkled, to be pressed firmly by the tongue against the tumour. In the same form, it may sometimes be sprinkled beneficially upon the surface of flabby ulcers. In the form of infusion also it is sometimes topically applied, as in cases of epislaxia, relaxation of the uvula, aphthae, leucorrhoea, and obstinate gonorrhoea; but its liability to stain everything which it touches is some objection to this mode of employment Administration. The dose is from five to thirty grains, which may be repeated every two, three, or four hours in cases of urgency, and three or four times a day in the more chronic. In bowel complaints, it is fre- quently associated with prepared chalk or oyster shell, and one of the liquid preparations of opium, in the form of mixture, made by suspending the insoluble ingredients in some aromatic water, by means of gum arabic and loaf sugar. In the form of pill, kino may be given, combined with acetate of lead and opium, in cholera and diarrhoea. Though the salt of lead is probably decomposed by the tannic acid, experience has proved the efficacy of the combination. Kino may also be prescribed in the form of an electuary, made by mixing the powder with syrup or molasses; and powdered cinnamon, powdered opium, and prepared chalk, one or all, may be added as cir- cumstances may seem to require. A more elegant preparation is an infusion, made in the proportion of two drachms of kino and a drachm of powdered cinnamon to eight fluid- ounces of boiling water, and filtered when cold. Of this one or two table-spoonfuls may be given for a dose, sweetened with loaf sugar, and mixed, in cases of diarrhoea, with a fluidrachm of camphorated tincture of opium, or an equivalent quantity of some other liquid preparation of that narcotic. If the effects of chalk are required, this antacid may be mixed with the infusion by the intervention of powdered gum and sugar. Tincture of Kino (TiNCTURA KINO, U.S.} is an officinal preparation, and, in cases where the alcoholic menstruum is not objectionable, may l>e -riven, in the dose of one or two fluidrachms, added to rivtari-uiis mix- tmvs. or other liquid astringent preparation. It should, however, be ; recently madr; as it is apt to gelatinize by time, and to lose its astringency. CHAP. I.] ASTRINGENTS. CATECHU. 125 IV. CATECHU. U.S. CATECHU NIGRTIM. Black Catechu. Acacia Catechu. />?*. Origin and Properties. Catechu is an extract prepared from the inner wood of Acacia Catechu, a small tree growing in Hindostan, Pegu, and other parts of India. It is in masses or fragments of diversified shape and si/e, usually rusty-coloured externally, reddish-brown internally, with a fracture generally smooth and somewhat shining but sometimes rough, inodorous, and of a bitterish very astringent taste, with a sweetish after-taste. It yield? its virtues to water and alcohol. Active Principle. This is fannic acid, of the variety which yields with the salts of sesquioxide of iron a greenish-black or olive-black precipitate, and may be called catechu-tannic acid. Another constituent, to which it probably owes its sweetness, is catechuic acid, which, however, is not known to possess any medical virtues. Its chemical relations are the same as those of kino. Effect* on the System. So far as the effects of catechu upon the sys- tem can be traced, they are almost precisely those of the medicine last described. Therapeutic Application. Its therapeutic uses are almost the same as those of kino, and need not, therefore, be repeated here. It is, how- ever, I believe, less used internally in this country, probably because less elegant in appearance, and usually less pure. Some writers speak of it as specially advantageous in checking excessive expectoration; but I cannot think that it has much power of this kind. As a topical applica- tion, in the form of infusion, it has the advantage over kino of staining less. Ffom its greater hardness, it is better adapted to the treatment of chronic angina, with relaxation or elongation of the uvula, in which it sometimes proves very useful by being held in the mouth between the cheek and teeth, and allowed slowly to dissolve. Its solution in the saliva is thus brought constantly, as it is swallowed, into contact with the diseased parts, and keeps up a steady astringent action upon them. In the same way it is said to be used by professional singers and speak- ers, to relieve the hoarseness consequent on an excessive use of the voice. In the form of powder, it is also occasionally useful in spongy gums, to which it may be applied by means of a camcl's-hair pencil. The tincture is preferable to that of kino, in consequence of being less liable to change by keeping. The dose of the powder is from ten to thirty grains, that of the officinal Tincture (TINCTURA CATECHU, U. S.), from thirty minims to three flui- drachms. An infusion (IxrusuM CATECHU COMPOSITUM) is directed both by the U. S. and British Pharmacopeias, made, according to the former, with half an ounce of catechu and a drachm of cinnamon to a 126 GENERAL STIMULANTS. [PART II. pint of boiling water. The dose is one or two fluidounccs three or four times daily. The modes of administration, not specially noticed, are precisely the same as those already sufficiently described under kino. GAMBIR. CATECHU PALLIDUM. Pale Catechu. Uncaria Gambir (Nauclea Gam- bir). Br. This is probably the old terra Japonica. It is usually ranked with the varieties of catechu, which it closely resembles in virtues ; but it has a wholly different origin, being an extract from the leaves and young shoots of Nauclea Gambir (Uncaria Gambir, De Candolle), which is a native of Eastern India. It is in the form of cubes, of about an inch in size, light and porous, of a yellowish or reddish-brown colour, lighter within, an earthy fracture, and a strongly astringent, bitter, and sweetish taste. It is closely analogous in composition to catechu, and may bo used for the same purposes, and in the same dose. V. RHATANY. KRAMERIA. U. S., Br. Origin and Properties. Rhatany is the root of Krameria triandra, a shrub growing in Peru. It is usually in long, cylindrical pieces, from the size of a straw, to half an inch or more in diameter, sometimes in the form of radicles attached to a short, thick, common head. The root con- sists of a reddish-brown bark, in which the virtues chiefly reside, and of an interior lighter-coloured, but still reddish ligneous portion. It yields a reddish powder, is inodorous, but of a slight peculiar srncll in decoction, and has a bitter, very astringent, and slightly sweetish taste. Its virtues are extracted by water and alcohol, but are impaired by boiling. The infusion and tincture are reddish-brown. Active Constituents Its chief active principle is a variety of tannic acid, somewhat peculiar in properties, affording a deep grayish-brown precipitate with the salts of sesquioxide of iron, and converted by oxida- tion, especially at an elevated temperature, into an inert apotheme. It contains, also, bitter extractive, which may have tonic virtues; and a peculiar acid called krameric, for which some influence over the .system ha* been claimed, but of which little is known. hemical reactions are the same essentially as those of the other vegetable astringents in general. Effects on the System. Rhatany combines the effects of a powerful astringent with those of a gentle tonic, and does riot, in these respects, differ observably from kino and catechu. Like these, also, it may operate less forcibly, through the route of the circulation, than the taunic acid of CHAP. I.] ASTRINGENTS. RHATANY. 127 galls or the astringents containing it; because its active principle, in- stead of being converted by oxidation into gallic acid, which is at once absorbable and astringent, becomes under that process an insoluble and inert apothcme. But this view of its action on the system must be con- sidered as somewhat theoretical. Therapeutic Application. Rhatany has been employed for all the purposes of the vegetable astringents generally, and may be considered as identical in its therapeutic application, both internal and external or topical, with kino and catechu. To mention, therefore, in this place, the several affections for which it has been recommended would be mere repetition. There is one use of it, however, which requires special notice; as, though there can be little doubt that either of the astringents just mentioned would answer the same purpose, yet they have not been put so fully as rhatany to the test of experiment. The use referred to is in the cure of that most painful and obstinate affection, known by the name of fissure of the anus. M. Bretonneau found injections of kra- meria an almost certain remedy in that complaint; and his experience has been confirmed by that of M. Trousseau. The injection employed by him consisted of a drachm and a half of the extract of rhatauy, dis- solved in five fluidounces of water, to which about a fluidrachm of the tincture of rhatany was added. This was administered daily, the rectum having been previously cleared out by an enema of warm water, or some mucilaginous fluid The patient usually experienced relief in the course of a week, and was effectually cured in two or three weeks. In the use of the remedy, the pains are at first sometimes aggravated; but this should not prevent a perseverance with it. Great care must be taken, after the cure, to keep the evacuations, by means of laxatives if neces- sary, in a soft state, so as to prevent a reproduction of the fissures. MM. Trousseau and Blache have employed the same remedy, with great benefit, in the treatment of fissures and excoriations of the nipple in nursing women. They first wash the part with a liquid consisting of 5 parts of the extract, 10 of the tincture, and 100 of water, and then in- troduce into the fissures the extract brought into a proper consistence by means of the white of eggs. Administration. The dose of the powdered root might be from a scruple to a drachm ; but the medicine is seldom used in this form. The most elegant preparation, and one of the most useful of all the vegetable astringents, is the officinal Extract (EXTRACTUM KRAMERIJE, U. S.), pre- pared according to the directions of our national code. The dose of it is from ten to twenty grains. The Tincture of Rhatany (TINCTURA KRA- MERS, U. S.), and Syrup of Rhatany (SYRUPUS KRAMERT^, U. S.), are also officinal preparations, the former of which is given in the dose of one or two fluidrachms, and the latter, which is especially adapted for children, in that uf half a fluidounce for an adult, and twenty or thirty minims for a child a year or two old. 128 GENERAL STIMULANTS. [PART II. VI. LOGWOOD. H^EMATOXYLON. U. S. H^MATOXYLUM. Br. Oriyin. This is the inner or heart-wood of H&matoxijlon Campechi- anum, a tree of medium size, growing; in Campeachy and on the shores of the Bay of Honduras, in the Peninsula of Yucatan, and in Jamaica and other West India islands, into which it is said to have been in- troduced from the Continent. Sensible Properties. It comes in billets of various magnitude, hard, compact, and heavy, of a red or yellowish-red colour, becoming darker and almost black by exposure, of a peculiar not disagreeable odour, and a sweet somewhat astringent taste. As kept in the shops for use, it is in small chips, or in the form of a coarse powder produced by rasping. It yields its virtues, with a deep purplish red colour, to water and alcohol. Active Principles. Its chief constituents are a variety of lannic acid in small proportion, in which its astringency resides, and a peculiar colouring principle called h&matoxylin, to which it owes its colouring properties and sweetness. Chemical Reactions. The decoction of logwood produces precipitates with lime-water, acetate of lead, and alum, a deep-violet blue with the salts of sesquioxide of iron, and reddish curdy flakes with a solution of gelatin. Effects on the System. The effects of logwood on the system are those of a pure mild astringent, without bitterness, and without irritant prop- erties. The colouring principle appears to be absorbed, as the urine is reddened by the internal use of the medicine. Therapeutic Application. This astringent is applicable to mild cases of diarrhoea and chronic dysentery, in which simple astringency is re- quired, and more irritating substances might be injurious. It is especi- ally suited to the diarrhoea of children, and has been considerably em- ployed in that form of it which succeeds cholera infantum, after the violence of the disease has been subdued. It may be used also for the general purposes of the vegetable astringents, but is too feeble for much effect, unless in cases of the kind above referred to. Administration. The only two forms in which it is used are those of the Decoction (DECOCTUM H^EMATOXYLI, U. S.) and Extract (EXTRACTUM H/EMATOXYLI, U. S.), both of which are officinal. In the former U. S. Pharmacopoeia, the process of which I prefer, the decoction was pre- pared by boiling an ounce of the rasped wood with two pints of water to a pint ; and two drachms of bruised cinnamon might sometimes be usefully added at the end of the boiling. The dose is two or three fluid- ounces for an adult, two or three fluidrachms for a child of two years, to CHAP. I.] ASTRINGENTS. GERANIUM. 129 be repeated three or four times a day, or more frequently if required. The dose of the extract is from ten to thirty grains. It may be given in the form of pill or solution ; but, if pills are preferred, they should be taken freshly prepared ; as they are said to become so hard, by long keeping, as sometimes to pass through the bowels unchanged*. VII. CRANESBILL. i GERANIUM. U.S. Origin and Properties. This name has been given to the root, or rather rhizome of Oeranium maculatum, a small, herbaceous, perennial plant, growing in woods throughout the United States. It is in pieces from one to three inches long, somewhat flattened, wrinkled, tuberculated, com- pact, externally brown, internally reddish-gray, inodorous, and of a pure astringent taste, without bitterness, or other disagreeable quality. Active Principle. This is tannic acid, having the general properties of that principle, but of what precise character is yet undetermined; though if it be true, as stated by some, that the root contains also gallic acid, it must be of the kind found in galls. From a recent analysis of the root by the Messrs. Tilden, who recognized the presence both of tannic and gallic acids, it may be inferred that these are its only active constituents. Effects and Uses. Cranesbill has the effects on the system of an effi- cient and pure astringent. From its want of unpleasant taste, it is particularly suited to infants, and persons of delicate palate and stomach. It may be used for all the purposes of the vegetable astringents already detailed, whether external or internal ; but has been most highly recom- mended, as an internal remedy, in chronic diarrhcea and dysentery, and, as a topical application, in cases of aphthous ulceratiov >f the mouth and fauces. It is peculiarly applicable to the looseness of bowels fol- lowing cholera infantum, in consequence of its exemption from irritant properties. Administration. The dose of the powdered root is from twenty to thirty grains. It is, however, more frequently given in the form of decoction, which may be prepared by boiling an ounce of the bruised root in a pint and a half of water to a pint, and given in the dose of one or two fluidounces, repeated three or four times a day. For infants the decoction in milk, in the proportion of an ounce to a pint, is an eligible preparation, and may be given to a child a year or two old in the dose of one or two fluidrachms, or more largely if required. An extract and tincture have been recommended, but are little used. VOL. i. 9 130 GENERAL STIMULANTS. [PART II. VIII. BLACKBERRY ROOT. RUBUS. U.S. Origin. Under this name the present IT. S. Pharmacopoeia unites the roots of the Rubus villosus or common blackberry, and the Rubus Gana- densis (R. trivialis, Pursh) or dewberry ; and, as there is no known dif- ference in effects between them, they have been very properly consoli- dated, instead of being designated, as in the old Pharmacopoeia, by distinct officinal titles. These two species of Rubus are indigenous briers, growing in different parts of the United States. Properties. The roots are cylindrical or branching, with a brown or ash-coloured bark, and a central woody portion, the former of which is of a bitter and strongly astringent taste, the latter is tasteless, and both are without smell. The woody part is inert; and either the smaller roots, or the bark only of the larger, should be employed. Water and alcohol extract all their virtues. Active Principles. These are tannic acid, and probably a peculiar bitter principle, which, however, has not yet been isolated. Effects on the System. There is no observable difference in the effects of these roots. Both are gentle tonics, and energetic astringents. Therapeutic Application. Blackberry and dewberry root may be em- ployed for the same purposes generally as the bitter vegetable astrin- gents; but are seldom given except for bowel complaints, in which they are highly esteemed popular remedies. I have used them in diarrhoea with advantage. They are applicable only to chronic cases of this dis- ease, or to such as are connected with intestinal debility ; and should not be employed when there is general fever, or any acute inflammation of the mucous membrane of the bowels. They are a favourite domestic remedy in the diarrhoea which follows cholera infantum. Administration. They are usually given in the form of decoction, made by boiling an ounce of the bruised roots in a pint and a half of water to a pint, and administered in the dose of a wineglassful for an adult, a dessert-spoonful for a child two years old, three or four times a day, or more frequently. It may be well to add to the decoction, at the end of the boiling, half an ounce of bruised orange peel, or two drachms of bruised cinnamon, in order to qualify the flavour, arid render the preparation more acceptable to the stomach. CHAP. I.] ASTRINGENTS. UVA URSI. 131 IX. UVAURSI. U.S.,Br. Origin and Properties. Uva ursi consists of the leaves of Arcto- staphylos Uva Ursi, or bearberry, a low evergreen shrub, growing in the northern parts of Asia, Europe, and America, and extending in the United States as far south as New Jersey, where it is found abundantly. The leaves are from half an inch to an inch long, somewhat wedge- shaped, thick and coriaceous, with a smooth rounded margin ; on the upper surface smooth, shining, and brownish-green, on the lower lighter coloured and reticulated ; inodorous when fresh, of a hay-like smell when dried, and of a strongly astringent, bitterish, and ultimately sweetish taste. Water and officinal alcohol extract all their virtues. Active Principles. These are tannic acid of the kind found in galls, gallic acid, a bitter substance, and, according to Mr. Hughes, a peculiar crystallizable principle called by him ursin, which he found diuretic in the dose of a grain. (Am. Journ. of Pharm., xix. 90.) Two other crys- tallizable principles, denominated by their discoverers respectively arbu- tin and ursone, have been detected in the leaves; but, as they have not been proved to possess active properties, they cannot be considered of much importance. (See U. S. Dispensatory.) The incompatibilities of uva ursi are essentially the same as those of galls. Effects on the System. Uva ursi is astringent and gently tonic, with the property of slightly increasing the secretion of urine, and at the same time altering its colour. Its astringent principle is said to have been detected in the urine ; but it was probably the gallic acid. In over- doses it is apt to produce nausea and vomiting. Therapeutic Application. This medicine is probably capable of pro- ducing, in a greater or less degree, all the effects of the vegetable astrin- gents, but is less powerful than most of those already described. Towards the close of the last, and at the beginning of the present century, it was very highly esteemed and much employed in various affections of the urinary and genital apparatus, and even acquired some reputation in pulmonary consumption, which, however, it soon lost. It was used in chronic inflammation and ulceration of the kidneys, gravel, diabetes, cystirrhcea, strangury and bloody urine, paralysis of the bladder, in- continence of urine, leucorrhcea, and menorrhagia ; and was believed by many, if not to dissolve stone in the bladder, at least greatly to relieve the symptoms of that affection. That its virtues were over- estimated there can be no doubt ; but, in the natural reaction which has followed, it has appeared to me that the credit which it now enjoys is scarcely equal to its merits. The circumstance that it changes the char- acter of the urine would seem to show, that some one or more of its 132 GENERAL STIMULANTS. [PART II. constituents passes out with that fluid ; and it is not improbable that it thus directly exercises an astringent, somewhat corroborant, and per- haps alterative effect upon the surface of the mucous membrane, lining the pelvis of the kidney, the ureter, and the bladder. Experience has, I think, shown that it possesses this power; and it is probably to this alone that it owes any peculiar therapeutic efficacy which it may possess. No one now believes that it is capable of materially modifying the symp- toms of stone in the bladder, in any other way than by invigorating the kidneys when relaxed or debilitated, or by relieving the attendant inflam- mation of the urinary passages ; and any efficacy which it may possess in gravel must be ascribed to the same cause. It should not be em- ployed in acute inflammation of these organs, as its excitant property, under such circumstances, could prove only injurious ; but in chronic affections, when the membrane is relaxed, when atonic ulceratiou may be suspected, and the urine is loaded with pus or mucus in excess, it may be used with great propriety, and with reasonable hope of ad- vantage. The complaints in which it has proved most efficacious, in my experi- ence, are chronic inflammation of the pelvis of the kidney with puru- lent impregnation of the urine, and the similar affection of the bladder, known as catarrh of that organ, or cystirrhcea. In cases of this kind, persevered in for a long time continuously, for several months if neces- sary, I believe that it will occasionally effect cures even unaided, and will often prove a serviceable adjuvant to other measures. Though apparently indicated in atonic hsematuria, I have not found it equally efficacious. It sometimes appears to do good in spermatorrhoea, prob- ably by an invigorating effect upon the mucous membrane at the neck of the bladder, or origin of the urethra; and, by a similar influence, extended sympathetically to the sphincter, it is occasionally useful in nocturnal incontinence, though it must be confessed that it much more frequently fails. Administration. The dose of the powdered leaves is from a scruple to a drachm ; but the Decoction (DECOCTUM UVJE URSI, U. S.), made in the proportion of an ounce of the leaves to a pint of water, is a more eligible preparation. It may be given in the dose of one or two fluidounces, three or four times daily. A fluid extract (EXTRACTUM UV^E URSI FLU- IDUM, U. S.) is directed by our officinal code, the dose of which is from thirty minims to a fluidrachm. CHAP. I.] ASTRINGENTS. PIPSISSEWA. 133 X. PIPSISSEWA. CHIMAPHILA. U.S. Origin and Properties. This consists of the leaves of Chimaphila umbellata, a low evergreen plant, growing in the northern parts of Asia, Europe, and America, and abundant in the United States. These leaves are about an inch and a half long, wedge-shaped, pointed at the end, notched on the border, coriaceous, shining and of a bright sap-green colour on the upper surface, paler beneath, of a peculiar odour when fresh and bruised, and of an astringent, bitterish, somewhat sweetish, and not disagreeable taste. Water and alcohol extract their virtues. Active Principles. These are tannic acid, and bitter extractive. It is probable that the matter indicated by the latter title is really complex, and that among its constituents is a peculiar principle, upon which all the virtues of the medicine, not connected with its astringency, depend. A cry stall izable principle was obtained from the leaves by Mr. Samuel Fairbank, and denominated by him chimaphilin, though its claims to this title are doubtful, as it is probably destitute of active properties. (See U. S. Dispensatory, 12th ed.) Effects on the System. The fresh leaves, bruised and applied to the skin, are said to be rubefacient and even vesicating. Internally, they are mildly astringent and tonic, with the property of somewhat increasing the secretion of urine, to which they probably impart some degree of remediate power. It is, I think, scarcely doubtful that their peculiar active principle, through which they stimulate the kidneys, passes off, either changed or unchanged, with the urine. TJierapeulic Application. Pipsissewa was much employed by the aborigines of this country, to whom it owes the name by which it is now generally designated. It is sometimes called wintergreen; but, as this name has also been applied to Gaullheria procumbens, it should be abandoned for both. From the Indians the medicine passed into popu- lar use, whence it was adopted by the profession. It was used chiefly in scrofula, rheumatism, and affections of the kidneys and urinary passages. Its diuretic powers have recommended it in dropsy, and it has been employed with asserted advantage in cases of this disease attended with debility ; but little reliance can be placed upon its efficacy ; and at best it should be used only as an adjuvant to other more powerful diuretics. In scrofula, it is, I think, a valuable remedy. The late Dr. Joseph Parrish used it very extensively in this affection, and had great confi- dence in its powers. I have myself been in the habit of employing it, in cases of external scrofula, during the whole period of my practice, and have found few remedies which have appeared to me more efficacious. 134 GENERAL STIMULANTS. [PART II. Its mildly astringent and tonic properties adapt it admirably to the treat- ment of the scrofulous cachexia, in which a general laxity of the tissues, and debility of the functions, call for these two remedial influences; while the chronic character of the affection requires that the medication should be gentle, in order that it may be long sustained, without injury to the organs. In the earlier stages of the disease, I have been in the habit of directing, in connection with its use, a saline laxative twice or three times a week, and in anemic cases have had recourse also to the chaly- beates; but in many instances the pipsissewa has been the remedy mainly relied on. It has seemed to me to exercise a favourable alterative influence in scrofula, independently of its astringency and tonic power; but it is extremely difficult to discriminate, in affections of this kind, between the course of nature and the effects of remedies, so that it is proper to speak of the latter with some reserve. Fully aware of the necessity of this caution, I am still of opinion, as the result of considerable experience, that pipsissewa deserves to rank next to cod-liver oil, and the prepara- tions of iodine and of iron, in the treatment of scrofula; and may often be usefully combined with one or more of these remedies. In order that its full effects may be obtained, it should be long continued, with inter- ruptions now and then, should any considerable degree of fever super- vene. In cases attended with ulcers of an indolent or flabby character, it may be used with advantage in decoction as a wash, at the same time that it is administered internally. The resemblance in properties between pipsissewa and uva ursi would suggest the employment of the former also in complaints of the urinary organs ; but I have had little experience with it in these affections, and cannot, therefore, speak with confidence of its utility, though it has been recommended by others. Administration. The Decoction (DEOOCTUM CHIMAPHIL.E, U. ), pre- pared by boiling an ounce of the bruised leaves in a pint of water, for fifteen minutes, and then adding enough water to make a pint, is the most eligible form for administration, and may be taken in the dose of from two to four fluidounces four times a day. A pint may generally be taken by an adult in twenty-four hours without inconvenience. Some recommend the medicine as an ordinary drink in scrofula, in the form of beer, which may be made by fermenting together sugar, water, and the bruised leaves, with the addition of yeast An extract has also been recommended, and may be given in the dose of twenty or thirty grains. The vegetable astringents above described are those probably most used in the I" ultra States, and are numerous enough to afford all desira- ble latitude of choice to the physician. There are, however, several others having similar virtues, and some not less efficient than the preced- CHAP. I.] ASTRINGENTS. RED ROSE. 135 ing, with a general notice of which I shall content myself, from the fear of needlessly embarrassing the memory of the student, referring him for a particular account of them to the United States Dispensatory. 1. RED ROSE (RosA GALLICA, U.S., Br.) consists of the unex- panded petals of Rosa Gallica, a European species of the rose, occasion- ally cultivated in our gardens as an ornamental plant. They are used chiefly in preparing a Confection (CoNFEOTio ROS.E, U. S.), much em- ployed as a vehicle for substances made into pill, and one of the ingre- dients of the officinal mercurial pill; and the Compound Infusion of Hoses (INFUSUM Ros^; COMPOSITUM, U.S.), which consists of an infusion of the flowers made with the addition of a small proportion of sulphuric acid, and the virtues of which depend mainly on the latter ingredient. There is an officinal Honey of Roses (MEL ROS.E, U.S.), and a Syrup (SYRUPUS ROS.E GALLICS, U.S., Br.), both of which are used as agreea- ble additions to liquid astringent mixtures, such as mouth-washes and gargles, "but have no great merit of their own. 2. TORMENTIL (ToRMENTiLLA, U.S.) is the root or rhizome of Polentilla Tormentilla, or septfoil, a European plant. This is a simple and powerful astringent, formerly much employed, but neglected since the general introduction of kino and rhatany into use. 3. WATER AVENS, the root of Geum rivale, indigenous in Europe and the United States, is tonic and powerfully astringent. 4. HARDHACK (SpiR^iA, U.S.) is the root of Spiraea iomentosa, an indigenous shrub, all parts of which are bitter and astringent, though the root only is officinally recognized. 5. POMEGRANATE RIND (GRANATi FRUCTUS CORTEX, U. S.) is the rind of the fruit of Punica Granatum, or pomegranate tree, indigen- ous in the warmer latitudes of the old continent, and cultivated in the southern section of the United States. This is bitter and astringent, and is used chiefly as a gargle in sore-throat, in the form of decoction. 6. BISTORT, the root of Polygonum Bisiorta, growing in Europe and Northern Asia, was formerly much more used than at present, and is now seldom imported. It is an efficient astringent. 7. ALUM-ROOT (HEUOHERA, U.S.) is the root of Heuchera Ameri- cana, an indigenous plant, very strongly astringent. 8. MARSH ROSEMARY (STATICE. U.S.) is the root of Statice Car- oliniana, an indigenous maritime plant. It is an active astringent, and is used to a considerable extent in some parts of the United States. 9. PERSIMMON (DIOSPYROS, U.S.) is the unripe fruit of Diospyros Virginiana, an abundant indigenous tree. This fruit, though sweet and edible when quite mature, is in the unripe state exceedingly astringent, and may be beneficially employed whenever a simple vegetable astrin- gent is indicated. 136 GENERAL STIMULANTS. [PART II. XL ALUM. ALUMEN. U.S.,Br. Origin. Alum is a double salt, composed, in the crystalline state, of one equivalent of sulphate of alumina, one of sulphate of potassa, and twenty-four of water; and denominated, chemically, sulphate of alumi- na and potassa. It is prepared either by the direct combination of its constituents, or by various processes from certain minerals called alum ores, containing ingredients, by the mutual reaction of which, under favourable circumstances, and with necessary additions, the salt is generated. Sensible and Chemical Properties. The salt is in octohedral or more rarely cubic crystals, or, as it is usually found in commerce, in irregular crystalline masses or fragments, whitish and translucent, slightly efflo- rescent, inodorous, and of a strongly astringent, sweet, and acidulous taste. Exposed to heat, it first melts, then boils up, loses its water of crystallization, and becomes white and opaque, and readily reducible to powder. In this state it is called burnt alum, or, officinally, Dried Alum (ALUMEN EXSICCATUM, U. ). By a strong heat it is quite decomposed. In the crystalline state, it is soluble in about eighteen parts of cold, and three-quarters of its own weight of boiling water; is entirely insoluble in absolute alcohol, and very nearly so in proof spirit. It has an acid reaction with vegetable colours. Incompalibles. Alum is incompatible with alkalies and their carbo- nates, lime-water, magnesia and its carbonate, tartrate of potassa, phos- phate of soda, and acetate and subacetate of lead, with all of which it produces precipitates. Those thrown down by the alkalies are dis- solved by an excess of alkali. It also precipitates solutions of albumen, gelatin, and many of the vegetable astringents, and coagulates milk. Effects on the System. When applied externally, or taken internally in such manner and quantity as not to excite irritation, alum acts, so far as can be observed, purely as an astringent, contracting the tissues, diminishing the caliber of the blood-vessels, and thus lessening the colour of the part, and diminishing secretion and exhalation. On the mucous membrane of the mouth and fauces its astringent effect is strong, and the impression which it leaves behind it durable. I have often observed that, when used as a gargle at bedtime, it so affects the tongue and palate that the sense of taste remains much blunted in the morning. Acting directly on the alimentary mucous membrane, it lessens the number and quantity of the stools. There can be no doubt that, when taken internally, it exerts its pecu- liar action also on the whole system, though its general is much less powerful than its local operation. The probability is that it is absorbed, CHAP. I.] ASTRINGENTS. ALUM. 137 as alumina has been found in the urine and viscera of animals to which it has been administered ; but in what state precisely it enters the cir- culation has not been determined. Its effects upon the system at large are more observable in disease than in health ; but dryness of the throat and fauces, with thirst, has been noticed as one of the results of its inter- nal use. It is believed by some, and not, I think, without reason, to be some- what refrigerant or sedative in its influence on the circulation. Some ascribe the astringent effects of alum to its chemical reaction with the tissues. Considering how instantaneous and considerable is the shrinking of the mucous membrane of the mouth, when a strong solution is applied to it, I cannot conceive that the result is owing to a mere chemical change. Not only in this case, but in every other, I be- lieve that it operates by calling the vital property of contractility into action. When used either outwardly or inwardly in large quantities, though primarily astringent, it becomes irritant after a time, and at length, if continued, may excite inflammation. This effect will follow the appli- cation even of small quantities to a very delicate or unprotected surface,, as to the conjunctiva of the eye, or to the skin recently denuded of the epidermis. In such cases, its peculiar astringent effect is overwhelmed by the inflammatory action. Thus, when swallowed in the quantity of a drachm or more, it not unfrequently causes nausea and vomiting, and sometimes produces griping pains and purging. Devergie found about six drachms of dried alum, given to a dog, to produce death when the oesophagus was tied, so as to prevent vomiting. Under such circum- stances, the mucous membrane of the stomach and bowels has been observed to be much inflamed. The same quantity, when the oesophagus is not tied, is discharged by vomiting without any permanent evil effects. OrTila found that seven drachms of powdered crystallized alum produced vomiting in dogs in from ten to thirty minutes. Dried alum, applied to a denuded surface, acts as a mild caustic, and is sometimes used with reference to this effect-. When used for a considerable time, in doses insufficient to nauseate, alum not unfrequently produces a sense of stricture in the epigastrium, precordial oppression, and other dyspeptic feelings, probably by interfer- ing with the secretion of the gastric juice, and thus impairing digestion. Therapeutic Application. Alum is useful, as an internal' remedy, in those forms and states of diarrhoea and chronic dysentery to which astringents are applicable, and in hemorrhage from the bowels under similar circumstances. It is not so well adapted to hemorrhage of the stomach, in consequence of its liability to produce nausea and vomiting; but might nevertheless be employed in this affection, in considerable doses, should other remedies fail, and the case be urgent. In the treat- 138 GENERAL STIMULANTS. [PART II. ment of the bowel affections, it has not unfrequently been associated with some of the vegetable astringents, such as tannic acid, kino, extract of rhatanv, etc.; and, though it undergoes chemical change through reac- tion with these substances, yet it does not follow that the resulting pro- ducts are inert; and experience has shown that the combination is often effectual. In the dose of ten or twelve grains three or four times a day, with an equal quantity of bitartrate of potassa, it has been found by Sir James Murray very useful in the chronic gastric affection, characterized by vomiting of glairy mucus. In comparing the remedial efficacy of alum with that of the vege- table astringents, it will probably be found to be relatively more effica- cious, when operating through the medium of the circulation, than directly upon the stomach and bowels. It is, indeed, sometimes given very advantageously in menorrhagia or uterine hemorrhage, and in cases of bloody urine. In obstinate haematuria connected with disease of the kidneys, I have known it apparently to produce the happiest re- sults, after vain trials of other methods. There would seem to be no reason why it should not also prove serviceable in haemoptysis; but it is less used in that affection ; and I have myself so seldom employed it, that I should not be justified in giving an opinion, upon the ground of experience. In all the above affections, alum may be used in combination with small doses of opium, which generally co-operates to the same result, and may also serve to obviate, in some measure, its tendency to irritate the stomach. For the latter purpose, one of the aromatics is also not unfrequently conjoined with it, as nutmeg or cinnamon, especially when it is given in powder. With reference to its astringent property, alum has also been given in dilatation of the heart, and aneurism of the aorta, and sometimes, it has been thought, with advantage. Incontinence of urine from debility of the sphincter muscle of the bladder, spermatorrhoea, obstinate leucor- rhoea, colliquative sweating, and diuresis, are other complaints in which it has been used with supposed benefit, and in which it would seem to be indicated. Little good can be expected from it in proper diabetes, in which it has, nevertheless, been recommended. It was formerly supposed to possess febrifuge properties ; and Cullen states that he succeeded with it in intermittent fever , given in connec- tion with nutmeg, in anticipation of the paroxysm. But it is not to be relied on, and is not now employed in that disease. Of much greater importance is it as a remedy in colica pictonum or lead colic. So long ago as the middle of the last century, it was em- ployed in that affection by Grashius, a physician of Holland, and after- wards by Dr. Thomas Percival of England ; but it did not attract par- ticular attention until, at a comparatively recent period, it was brought CHAP. I.] ASTRINGENTS. ALUM. 139 into notice by M. Kapeler, physician to one of the hospitals of Paris. Since that time, it has been extensively used, and experience has pro- nounced decidedly in its favour. I have myself employed it with the best results, even where the opiate and mercurial treatment had failed. Its mode of operating is quite unknown. Some suppose that it cures the disease by converting the poisonous preparation of lead, which may have caused it, into the insoluble and inert sulphate of that metal. But it is by no means always that lead-colic proceeds from a preparation of that metal swallowed. Quite as often, probably, it originates through the inhalation of the fumes of the metal, or of vapours impregnated with one of its salts; and there is in such cases no poison in the bowels to neutralize. Besides, even when the poison has been swallowed, it prob- ably acts much more through absorption into the blood than by mere contact with the membrane. If alum, therefore, act merely as a chemical antidote, it must do so by entering into the circulation, and there pro- ducing the insoluble sulphate, which, in this position, would probably produce as much mischief mechanically as the poison had done physio- logically. But, independently of these considerations, it is a sufficient refutation of the notion of the chemical action of alum, that the same curative effect is not obtained from Epsom or Glauber's salt, or other soluble sulphate, or from sulphuric acid itself, which ought to be equally efficacious, if the chemical theory were true. All that we can say on the subject, in the present state of our knowledge, is that, though alum and lead are both astringent, yet each has its own specific or peculiar mode of action, and that the influence of the former is incompatible with that of the latter; in other words, alum cures the poison of lead on the prin- ciple, already sufficiently discussed, of supersession. (See page 51.) The remedy is asserted to have been found effectual in other forms of colic; and it may be employed, with hope of special benefit, in those cases of intestinal neuralgia which are occasionally met with, bearing a close resemblance in their symptoms to colica pictonum. In this disease, alum is given in doses larger than are thought appropriate to most other cases in which it is used. From a scruple to a drachm or more may be administered every three or four hours, dissolved in some mucilaginous liquid, to which sulphate of morphia may be very advantageously added, in such quantities as may be necessary to allay the sufferings of the patient. Alum has been recommended in hooping-cough by Dr. Davies, editor of Underwood's treatise on the diseases of children. As an emetic, it has been advantageously employed in the treatment of pseudomembranous croup, by the two Drs. Meigs, father and son, of Philadelphia. A teaspoonful of the powdered salt is given to the child every ten or fifteen minutes until it vomits. A second dose is seldom required to produce the effect. 140 GENERAL STIMULANTS. [PART II. But it is topically that alum is most used. In arresting morbid dis- charges, it is among the most effectual of the local remedies in our possession. Epixtaxis very rarely fails to yield to a solution of the salt, containing fifteen or twenty grains to the fluidounce, injected up the nostril. When the bleeding proceeds from a readily accessible part of the membrane, the solution may be applied by means of a piece of lint. In peculiarly obstinate cases, it has been recommeded to snuff or blow up the powder; but the method is I believe less effective, as the remedy cannot be in this manner so thoroughly applied to the whole surface. The- same solution is scarcely less effectual in the hemorrlwidal jlux, and in hemorrhage proceeding from a point higher up the rectum. Three or four fluidounces of it should be injected at once, along with two or three fluidrachms of the solution of sulphate of morphia, of the U. S. Pharmacopoeia. It may also be used in hemorrhage from the mouth or throat, and to arrest bleeding from leech-biles. The latter is, often extremely obsti- nate, and has even proved fatal. A method I have long used, with uni- form success, is to make a saturated solution of alum in hot water, to impregnate a dossil of raw cotton with this before it begins to crystal- lize on cooling, and then to press the cotton upon, the bite. In this way the salt is applied more effectually than it can be by any other method ; as the saturated hot solution is vastly stronger than the cold, and still retains the alum, at a temperature at which it may be well tolerated by the skin. It is even better than the powder itself, which acts probably only so far as it is dissolved, and is less soluble in the blood than it is in hot water. The same application may be made, with prompt effect, in the bleeding from the socket of an extracted tooth, which it is some- times very difficult to arrest. In severe uterine hemorrhage, recourse may also be had to the strong solution of alum as a local styptic; the liquid being injected, or applied by means of a sponge saturated with it, and introduced into the vagina. Morbid secretions may sometimes be advantageously treated by the topical use of alum. Thus, its solution has been employed in leucor- rhcea, gonorrhoea and gleet, profuse salivation, colliquative sweating, to check excessive suppuration from ulcerated surfaces, and in cases of purulent ophthalmia.* As an injection into serous cysts, a solution of alum, containing four or five grains in the fluidounce, has been employed with the effect of pro- * Dr. Pereira states that, "in the treatment of the purulent ophthalmia of infante, no remedy is perhaps equal to an alum wash;" and Dr. F. J. Farre, editor of the abridged edition of Pereira's Materia Medica (p. 103), adds that "the wash should contain eight grains of alum in an ounce of water, and should be introduced between the lids entry quarter of an hour. Thus used," he says, "the wash seldom fails." (Note to the third edition.) CHAP. I.] ASTRINGENTS. ALUM. 141 ducing a cure ; but care is necessary thoroughly to evacuate the cyst afterwards, for fear of exciting inflammation. To obviate relaxation of tissue, alum is locally used, commonly in solution, in flabby and fungous ulcers, and in prolapsus of the uvula, rectum, and uterus. It is employed also in aneurism from anastomosis, in order to produce contraction of the vessels. A cataplasm of aluin- curd may sometimes be preferable, in the cases of ulcer and anastomotic aneurism. On the same principle of obviating relaxation, may be ex- plained the asserted advantage of alum gargles in some cases of loss or alteration of voice. (Bennati, Bullet. Gen. de Therap., i. 256.) In the earliest stage of inflammation, before any other change has taken place than mere congestion of the vessels, alum applied to the part sometimes arrests the disease, by diminishing the caliber of the capilla- ries, and thus excluding an excess of blood. For this purpose, it is much used in mucous inflammation of the fauces, or ordinary angina. A gar- gle made of alum, sage tea, and honey has long been a popular remedy for sore-throat. The remedial impression, however, is due to the alum alone ; the other ingredients simply serving to qualify the taste. Some persons are very liable to these anginose attacks, which not unfrcquently subject them to great inconvenience, and sometimes to danger, by ex- tending to the larynx, bronchia, or even pulmonary tissue. The attack may often be warded off by proceeding immediately, upon the occurrence of the first symptoms, to gargle the throat with a strong solution of alum ; taking at the same time a dose of sulphate of magnesia, and using an exclusively vegetable diet. But when the inflammation has become firmly established, the remedy will generally be useless or worse than useless, until the activity of the symptoms has subsided ; when, if a relaxed state of the vessels remain, keeping up a slight chronic congestion, it may be again resorted to with advantage. The form of lozenge has been sug- gested by M. Argenti, of Venice, as sometimes preferable to gargles. Held in the mouth, and allowed slowly to dissolve, it is kept in constant contact with the diseased membrane, and may be supposed to act more effectually than when the medicine is intermittingly employed. The lozenge may be made by incorporating powdered alum, sugar, and trag- acanth, by means of some aromatic liquid. In the pseudomembranous form of angina and stomatitis, such as attends diphtheria, and in the same condition occurring in scarlet fever, a strong solution of alum, or the salt in powder, is some- times very effectual. The powder may be applied by means of the finger, or more conveniently by introducing it into a tube, and through this blowing it into the fauces. This application of alum in modern times we owe to Bretonneau. It is generally made in cases of in- fants, who are most subject to the diphtheritic affection. It is usually followed by a copious salivation, and by efforts to vomit; but these 142 GENERAL STIMULANTS. [PART II. cease after a few minutes. The remedy is equally effectual when applied to the false membrane, which, during the prevalence of an epi- demic of the disease, is apt to form on other parts, as the nipple, mucous membrane of the generative organs, and ulcerated surfaces in any por- tion of the body. It may be used also in obstinate aphthous incrusta- tions of the mouth. The alternate application of powdered alum and tannic acid, one or the other being used every hour, has also been recom- mended in pseudomembrarious angina. (Ann. de Therap., 1859, p. 114.) Painful caries of the teeth may sometimes be relieved by filling the cavity with a paste made of alum, ether, and a little mucilage, which may be repeated twice a day while the pain lasts. ( Trousseau et Pidoux, 4e ed., i. 137.) In commencing ophthalmia, alum sometimes arrests the disease ; but in this affection, the solution should be much weaker than when used for the throat, or to arrest hemorrhage. When the inflammation is fixed, the remedy is no longer applicable ; but it sometimes comes again into play when, in the advanced stage, the eye remains red, and per- haps blood-shot, from a passive distension of the vessels. Another mode of using alum in ophthalmia is in the form of alum-curd, which may be applied as a poultice over the closed eyelids, between pieces of soft linen or gauze. Reference has already been made to its peculiar efficacy in the purulent ophthalmia of infants. (See page 140 and note,} Other forms of inflammation, in which alum-curd may be employed, are chilblain before the cuticle is broken, and the erythematous redness which results from pressure, as in the cases of patients long confined to bed with diseases of debility. Administration. The dose of alum for ordinary purposes varies from five to fifteen grains, which in chronic cases may be given three or four times a day, and in those more acute, every two or three hours. It may be taken either in powder or solution. In either case, it will often be desirable to make some aromatic addition, to obviate nausea. Five grains of pulverized nutmeg are often added to each dose of the powder; and an equal weight of white sugar may be mixed with it, in order to qualify the taste. Another form of administration is that of alum-whey. This is made by boiling two drachms of the powdered salt with a pint of milk, and straining after coagulation. The dose is from one to three tablespoonfuls. For external use, the curd remaining after straining the milk, in the preparation of the whey, may be employed in the form of cataplasm. Another mode of making an alum cataplasm is to rub the white of egg with a piece of alum, in a saucer, until the albumen coagulates ; or a drachm of powdered alum may be well shaken or beaten with the whites of two eggs. The curd thus prepared may be applied between folds of soft linen. CHAP. I.] ASTRINGENTS. LEAD. 143 The solution of alum for external use is of various strengths, accord- ing to the purpose for which it is employed. In commencing ophthalmia its strength should not at first exceed four or five grains to a fluidounce of water; for application to the urethra from five to ten grains. A much stronger solution, containing fifteen or twenty grains in the fluidounce, has been above recommended for various purposes. Alum is among the substances most used by means of the atomizer. Its solution, containing from ten to twenty grains to the fluidounce, is inhaled in the state of spray, in chronic bronchitis and laryngitis, espe- cially when attended with excessive secretion ; and, containing forty grains, has been found useful in pulmonary hemorrhage. The uses of Dried Alum (ALUMEN EXSICCATUM, U. n up, and removed from the point of application, is its power of irritating, in any given quantity, diminished. This fact has an important practical bearing. If the peculiar effect of lead is wanted, care must be taken that the preparation be as little irritant as possible. Thus, a quantity of acetate of lead, large enough to irritate the stomach, will be much more likely to operate on the system, when administered in small doses frequently repeated, than when the whole is taken at once. In the latter case, not only is absorption impeded by the fulness of the irritated vessels, but the agent is apt to be removed by vomiting or purgation. 1. Irritant Influence. In relation to the irritant effect of the prepara- tions of lead, there is nothing peculiar. They are apt to operate in this way when applied largely, and to delicate surfaces; and the important point for the physician is to be able to regulate the dose of each prepara- tion, according to the susceptibility of the several parts with which it is brought into contact. The skin will bear more than the gastric mucous membrane, and the latter more than the delicate conjunctiva. Some of the preparations act as irritant poisons when swallowed in over-doses. Too highly concentrated, they may indeed occasion the death of a part, either by excess of irritation beyond its vital capacity, or by chemical combination with one or more of its organic constituents. 2. Peculiar Influence. This, so far as it can be generalized, is the in- fluence conjointly of an astringent and sedative. The sedative influence, though felt in some degree in the circulation, is more especially directed to the nervous system, and appears to affect the nerve tissue directly, rather than through the nervous centres, though these may also be involved. When the preparations of lead are given in such doses as gradually to bring the system under their influence, no observable effects may be experienced for some time, in a state of health ; but, after a shorter or longer period, which varies much in different cases, the secre- tions are generally somewhat diminished, and the pulse often lessened in frequency and fulness. These may be considered as their legitimate effects, when they are used therapeutic-ally; and they will sometimes prove useful in restraining morbid discharges, even before any change is noticed in the healthy functions. If longer continued, whether accident- ally, or for medical purposes, they are capable of inducing a poisonous condition, which presents very peculiar phenomena, and not unfrequently CHAP. I.] ASTRINGENTS. LEAD. 145 ends in death if neglected. Practically, this poisonous condition results much more frequently from exposure to the influence of the metal acci- dentally, or in the pursuit of business, than from its use as a remedy ; no doubt because, in the latter case, its operation is carefully watched, and its employment suspended upon the occurrence of unpleasant symptoms. The toxicological influence of lead was investigated, with peculiar care, by M. Tanquerel des Planches; and, though much was known before the publication of his treatise, and many observations have since been made, yet his account of the symptoms has served as the basis of most subsequent descriptions. Poisonous Effects. Among the earlier symptoms of lead-poisoning are dryness of the mouth and nostrils, diminished urine, and a tendency to costiveness, with small, dry, and sometimes light-coloured stools, evincing diminished biliary and intestinal secretion. There are often also uneasy epigastric sensations, impaired appetite, colicky pains, and sometimes nausea and vomiting. If the gums are now examined, they will generally present a bluish or slate-coloured line along their margin, of greater or less extent; and the same discoloration will be found to affect the teeth themselves, where joined by the gums. This appear- ance is ascribed to the formation of sulphuret of lead, probably through the agency of the saliva acting upon the metallic combination in the tissue. It has also been noticed in the mucous membrane of the lips and cheeks. It is said that the habit of cleaning the teeth or gums daily with a brush has some effect in preventing this blue discoloration, the absence of which, therefore, in persons who thus use the tooth-brush is no proof that they may not be labouring under the effects of lead. (Dr. Alexander Smith, Ed. Hed. Journ., July, 1856, p. 10.) Except in such cases, the blue line almost always occurs, sooner or later, under the continued use of lead, even when no poisonous symptoms are ob- served. A sweetish, astringent taste, and a peculiar offensive odour of the breath, are said to accompany the poisonous action of lead, which is also characterized by emaciation, especially of the face, and by a dirty yellowish hue of the conjunctiva and the skin. The circulation is usually somewhat depressed, as evinced by the slow and contracted pulse; and the mind is often dejected. This cachectic condition may exist, for a long time, without any other very striking phenomena ; but much more frequently it is attended either with violent abdominal symp- toms, constituting a variety of colic, with external nervous disorder in the form of neuralgia or paralysis, or with serious cerebral affections. These different complications may exist in the same or in different per- sons, and, in the former case, may occur successively, or in a greater or less degree conjointly. The most frequent of them, and usually the first in the order of time, is the affection called variously, colica pic- VOL. i. 10 146 GENERAL STIMULANTS. [PART II. tonum, painters' colic, or lead colic, which is ordinarily described as a distinct disease. Lead colic is characterized by severe pains about the umbilicus, occur- rinir more or less paroxysmally, in general not increased but rather re- lieved by pressure, with sensations of twisting-, and a feeling of wretched- ness, often strongly expressed upon the countenance. The walls of the abdomen are usually hard and somewhat retracted, and the muscles not unfrequently gathered into knots. The bowels are obstinately consti- pated, though there may be frequent desire to go to stool, with straining and tenesmus. Bilious vomiting is not uncommon. The patient loses sleep, and is extremely restless, often changing his position, and some- times rising and walking about the chamber, with his body stooping, and both hands pressed upon the abdomen. If the cause lie withdrawn, these symptoms will generally subside in a few days, especially under appropriate treatment; but they sometimes assume a protracted form. and, more or less moderated in violence, may run on for weeks or months. Lead palsy may occur among the earlier phenomena, but is generally a sequela of the colic. It may affect sensation and the power of motion severally or conjointly, and, when it affects both, may do so in different degrees. It is frequently accompanied with neuralgic pains in the mus- cles, joints, etc., counterfeiting rheumatism, which are usually continuous, though liable to exacerbations, and are increased by motion, but relieved by pressure. Sometimes there is spasmodic rigidity of certain muscles. The part first attacked with palsy is generally the hand and forearm ; and the extensor muscles are chiefly affected, so as to cause the hand, when the arm is held up, to fall as if strongly flexed. The falling hand is among the most striking diagnostic symptoms of lead-poisoning. The lower extremities are also attacked in some cases ; and there is, particu- larly in the advanced stages, a general defect of muscular power, evinced by tremulous movements, and especially by trembling of the tongue when protruded. The involuntary muscles participate in some degree in the palsy, and the power of the heart becomes at length very sensibly diminished. The external paralytic and neuralgic complications are generally more difficult to cure than the colic. By far the most serious effects of lead are those upon the brain. They usually occur at the close of protracted cases; but sometimes early, either by themselves, or associated with colic or palsy. Among the most prominent are convulsive attacks similar to those of epilepsy, which are generally fatal. Sometimes the muscles become cataleptic; and sudden comatose seizures imitating apoplexy now and then occur. Impaired sight and hearing, complete amaurosis, diminished general sensibility, delirium, stupor, and coma, are usually the last effects of the poison. CHAP. I.] ASTRINGENTS. LEAD. 147 Albuminuria has in several instances been noticed as one of the results of poisoning by lead. It is apt to accompany the cases compli- cated with cerebral disease and amaurosis, and may serve to account in part for these affections, through the uremic poisoning of the blood. Lead-poisoning may end fatally in an acute attack, or may last for years, with alternations of exacerbation and remission, of seeming recov- ery and relapse, or with a more or less continuous course of deteriora- tion of health, under an intermittent or steady exposure to the cause.* Local Effects. Applied locally, and in a quantity insufficient to irritate, the preparations of lead produce contraction with some diminution of f.'iisibility in the surface, and, if continued, generally occasion a bluish colour, probably by penetrating into the tissue, and forming there somt new chemical combination. Anatomical Changes. The blood is deficient in red corpuscles. In one case examined by Andral, they had been reduced to 83'8 parts in 1000. the mean normal proportion being about 1 25. The serum has a yellow- ish hue, as also have the viscera. In some cases, no alteration is observ- able in the bowels; in others, one portion has been found contracted, and another dilated in the same subject. In cases attended with albuminu- ria, there is produced in the kidneys, according to M. Lancereaux, a new formation of connective material, which causes the retrogression or ab- sorption of the epithelial cells. (Ann. de Therap., 1864, p. 215.) No characteristic lesion has been noticed in the brain or spinal marrow; but the muscles long affected with paralysis are usually pale and atrophied, and the heart and blood-vessels are said sometimes to be contracted. Lead has been discovered in the tissue of all the organs which have evinced signs of its poisonous influence during life. 2. Mode of Operation. There can be little doubt that the preparations of lead operate by direct contact with the parts affected, being in the first place absorbed * Tbe influence of the poison, in cases of pregnancy, besides causing abortion, is said either directly or indirectly to extend to the foetus, leading to arrest of devel- opment and even death, and, when these results are avoided, causing various mor- bid conditions in the infant. Thus, of six cases of pregnancy accompanied with lead-poisoning, observed by M. Constantin Paul, three of the offspring perished in the first six months, and of the three which remained, one was epileptic, one scrofu- lous, and the third only two months old, so that time had not been allowed for the development of morbid tendencies. (Arch. Gen. de Med., Mai, I860. p. 530.) In 123 cases of pregnancy, there were 04 abortions, 4 premature deliveries, 5 still-born, 20 infants who died in the first year, 8 in the second, 7 in the third, 1 later, and 14 living, of whom only 10 were more than three years old. (Ibid., p. 532.) M. Paul also states, as the result of his observation, that lead-disease in the father, as well a^ in the mother, serves as the cause of the death of the foetus, and the premature death of the infant. (Ibid., p. 516.) Note to the third edition. 148 GENERAL STIMULANTS. [PART II. into the Mood, and then distributed over the system. By Tiedemann and Ginelin, Orfila, and other chemMs, the metal has been detected in tin- blood, the urine and milk, the brain and spinal marrow, the mus- cles, the bones, tin* liver, spleen, and kidneys, and in the coats of the stomach, bowels, and gall-bladder. As it exists in the tissues, it is sometimes not discoverable by the ordinary tests; incineration being necessary to break up the combination in which it is probably held with organic matter. The precise character of this combination, whether in the blood or the solid tissues, is unknown. The system has in general the power of throwing off the poison sooner or later, unless in quantities sufficient to destroy life. It is eliminated by the kidneys, skin, mamma?, and probably by the various secretory organs which empty into the ali- mentary canal. How long it may remain in the sy-teni is not certainly known; but it was found by Orfila in the liver, intestinal coats, and bones of an animal, eight months after it was administered. (Med. Times and Gaz., iv. 279.) It may operate through the susceptibilities of the parts with which it is brought into contact; but there is reason to think that it sometimes at least enters into elementary combination with the tissues, and thus necessarily modifies their action. (See Arch. Gen., 4e ser., xxvii. 75.) It is probably through its presence in the hours, according to the urgency of the case. 160 GENERAL STIMULANTS. [PART II. my experience with it, in the ordinary forms of this affection, does not accord with theirs. It no doubt appears to act favourably in some ca>i's; but I have often met with others, in which, after an employment of several days, it has increased the griping and uneasiness of the patient, without any beneficial influence over the disease, and in which the symptoms have speedily subsided, under proper treatment, after its omission. But in chronic cases, with rather copious discharges, it is often useful. I shall have occasion directly to refer to a condition of dysentery, in which it may be employed as an injection w r ith the greatest advantage. As in other bowel affections, it should in this also be asso- ciated with opium. In reference to its antiphlogistic effects, acetate of lead has been used with great supposed advantage in pneumonia, especially in the old, and in other cases in which bleeding has been sufficiently employed, or may be contraindicated. (L' Union Medicate, No. 82.) But pneumonia so often ends in recovery under any treatment, that reports of the efficacy of one or another remedy must be received with great hesitation. Excessive sweating, exhausting diuresis, copious mucous or purulent discharges from the respiratory and urinary passages, and abundant suppuration, from whatever source, have been considered as offering in- dications for the astringent influence of acetate of lead. In phthisis it has been recommended for the night-sweats, the muco-purulent expecto- ration, which is sometimes exhaustingly copious, and the diarrhoea, either severally or conjointly. As to the night-sweats, I think they are, in general, more effectually and more safely controlled by other means, less calculated than acetate of lead to disturb the digestive process, which it is all-important to sustain. The same remark is applicable to the expec- toration. In these affections, therefore, separutrly, I would not advise the remedy; but, when they exist in combination with obstinate diar- rhoea, and a chronic sub-inflammatory condition of the gastric mucous membrane, the indication for its use, in reference to the latter conditions, is perhaps strengthened by the possible benefit which may be hoped for from it, in reference to the former. Obstinate mercurial salivation is said to have yielded to the internal use of this remedy; but its local application is preferable. In yellow fever, acetate of lead was strongly recommended by the late Dr. Irvine, of Charleston, S. C. It is only in the second stage, after the subsidence of the first long febrile paroxysm, that the remedy should be employed. At this period, with greatly reduced powers of system, and probable depravation of the blood, there is usually phlogosis of the gastric mucous membrane, with a tendency to prostrating hemorrhage, in the form either of unaltered blood or black vomit. Should the blood be fatally depraved, no medicine could save the patient; but in doubtful cases, where a slight impression might turn the scale in the favourable CHAP. I.] ASTRINGENTS. ACETATE OF LEAD. 161 direction, it seems reasonable to expect benefit from a medicine, calcu- lated, by contracting the vessels, and exercising a sedative influence on the nerves, at once to correct the inflammation and obviate the hemor- rhage. I have, myself, used the acetate of lead under these circum- stances, in a few instances, and in all with favourable results. In one case, there was an appearance, in the evacuations from the stomach, of commencing black vomit. Two grains should be given, with a little opium, every two hours, and continued until thirty-six or forty-eight grains have been taken, or until the dangerous period is past, unless some unpleasant effect of the medicine should be previously experienced. I would repeat, that the acetate is not to be used until the first febrile symptoms have begun to subside, which is usually on the second or third day. In enteric or typhoid fever, acetate of lead would seem to be indi- cated as an alterative and antiphlogistic remedy for the diseased state of the mucous membrane of the ileum. Hence, it has been recommended in this affection by the German practitioners. In this country, it has been employed very successfully by Dr. John L. Atlee, of Lancaster, Pa., who gives it in doses of from one to three grains every two, three, or four hours, commencing, after having first evacuated the bowels by a mild cathartic, and persevering so long as the enteric symptoms con- tinue. I cannot speak of the remedy from experience, having never used it in this complaint. In the irritable stomach of bilious fever, and in other cases of 06- stinale vomiting, the medicine has been employed with supposed advant- age ; though it might be difficult to say, in many instances of this kind, how much was due to the acetate, and how much to the opium usually given along with it. Aneurisms of the aorta and of other large internal vessels have been treated with some advantage by acetate of lead. Introduced into use originally in Germany, the practice was imitated by Dupuytren and others in France; and I have myself tested its efficacy in some degree in this country. The astringent and sedative influence of the preparations of lead would seem to be indicated in this affection ; and several in- stances are on record in which the tumour has very much diminished in size under the use of the acetate. (Arch. Gen., 3e ser., v. 443.) In one of several cases in which I employed it in the Pennsylvania Hospital, an aneurismal tumour, which showed itself projecting from the thorax near the left sterno-clavicular junction, underwent a marked diminution, and became at length scarcely perceptible ; but the patient left the house before any definitive result was obtained. I am not aware that any satisfactory case of a complete cure by this remedy has been reported. Indeed, considering the condition of the coats of the vessels in internal aneurism, altered as they generally are by atheromatous deposit, car- VOL. i. 11 162 GENERAL STIMULANTS. [PART II. tilaginous or bony degeneration, or other organic affection, a cure by this measure would be in most cases impossible; and, even when no insurmountable difficulty of this kind might be in the way, few constitu- tions would probably be found to tolerate, and few patients to submit to the long-continued and persevering use of the medicine which would be necessary to success. The plan is to give six or eight grains of the acetate daily, in doses of one or two grains, at equal intervals, and to continue until nausea or griping pains in the bowels, or other symptoms of lead-poisoning are exhibited ; then to suspend the remedy until these symptoms have subsided ; after which it is to be resumed ; and thus altern- ately, until the end aimed at is effected, or found to be unattainable. Simple enlargement of the heart, independent of disease of the valves, would seem to offer quite as good a chance of success, under this treat- ment, as internal aneurism. I have employed it in cases of this kind; and, in one of great cardiac dilatation in a boy, found the dimensions of the heart, as indicated by percussion, to diminish considerably. What finally became of the case I do not know ; as the patient passed from under my care in the midst of the treatment. Acetate of lead has been used in various nervous diseases, as epilepsy, hysteria, hooping-cough, and even tetanus; but few would at present expect from it any very material benefit in these affections. I remember to have seen somewhere an account of a case of hydrophobia which had ended favourably under its use; but there can be little doubt that the disease was mistaken. 2. Local or External Use. Under this head, it is intended to embrace all those modes of using the remedy, in which it is brought into direct contact with the seat of its intended operation through extraneous agency, including injection into the various passages opening extern- ally, as well as application to the surface of the body. In these it acts upon the same principles as when used internally. But it is more especi- ally for its antiphlogistic effects that it is employed. As a mere styptic, either for arresting hemorrhage, or controlling increased secretion un- connected with inflammation, as excessive sweating for example, it is less efficient than alum, or probably the vegetable astringents. In refer- ence to the mucous surfaces, it is, as a general rule, better adapted to the earliest stage of inflammation, or the very advanced stage when sup- puration has taken place, or to the chronic forms of the affection, than to the condition of acute inflammation in full vigour. But this remark does not apply to affections of the skin, protected by the cuticle. As an eye-wash in ophthalmia, from one to two grains of the acetate may be dissolved in a fluidounce of rose-water, or simple distilled water. In chronic inflammation of the nasal passages, with purulent dis- charge, a solution containing from ten to twenty grains to the fluid- ounce of water, may be injected or otherwise introduced into the nostrils, CHAP. I.] ASTRINGENTS. ACETATE OF LEAD. 163 once or twice daily, with hope of benefit. Care, however, should be taken, in such cases, that none of the solution is swallowed. Chronic suppuration of the auditory meatus may be treated in a similar manner ; though it would be prudent to commence with a weaker solution, say from two to five grains to the fluidounce, and to increase if found necessary. As a mouth- wash or gargle, acetate of lead is chiefly employed in cases of mercurial salivation, in which it is one of the best applications. For this purpose, the solution may have the strength of two or three grains to the fluidounce to begin with. It often blackens the teeth and tongue, in consequence of the formation of sulphuret of lead, through reaction with the sulphur contained in the salivary liquids. But this discoloration is of no serious importance, and gradually disappears. In ordinary ulccration, or pseudomembranous affections of the mouth and fauces, sulphate of zinc, or nitrate of silver, in solution, is more effectual than tlie salts of lead. In certain cases of dysentery affecting the rectum especially, and at- tended with little general disturbance of the system, a solution of acetate of lead, injected into the rectum, often serves an excellent purpose. It will sometimes put an almost immediate end to cases, which have proved tedious under other treatment. From four to six fluidounces of a solu- tion, containing two or three grains of the acetate in each. fluidounce, with thirty or forty drops of laudanum in the whole quantity, should be injected three times a day. The laudanum is useful by facilitating the retention of the liquid, as well as by directly calming irritation. It ie true that the meconate of morphia is converted into the acetate, while a little insoluble meconate of lead is formed; but this result is of no prac- tical importance. It may be obviated, however, by substituting for the laudanum one-quarter or one-third of a grain of acetate of morphia. Encmata composed of ten grains of acetate of lead, dissolved in six fluidounces of warm water, and administered every two hours, are said to have been used, with remarkable success, in strangulated hernia. In gonorrlicea and leucorrhoea, injections of the salt are often very useful. For the effectual treatment, however, of these affections, the solution should be very frequently repeated, so that the impression may be steadily maintained. In gonorrhoea, the injection should be admin- istered not less than six times a day, at equal intervals. It should be at first of the strength of two or three grains to the fluidounce, which may be increased if necessary. Perhaps for no purpose is this salt more employed than for the relief of inflammatory affections of the skin and the subcutaneous tissue. In erysipelas, when the inflammation is very high ; in the more inflam- matory forms of erythema, as E. nodosum ; in certain cases of herpes, eczema, and other cutaneous eruptions attended with much heat, pain, 164 GENERAL STIMDLANTP. [PART II. and redness; in inflammation of the subcutaneous areolar tissue, either arising spontaneously, as in phlegmon, or resulting from sprains, bruises, etc., and in acute swelling of the external lymphatic glands, a solution of acetate of lead is often highly useful in the alleviation or cure of the inflammation. For these purposes, two drachms of the acetate may be dissolved in a pint of soft water; the turbidness being corrected by a fluidrachm of vinegar or diluted acetic acid. In some cases, laudanum or acetate of morphia may be usefully added. The solution may be ap- plied by means of folded linen wet with it, or in the form of the cold poultice, made by mixing the solution with crumb of bread, and en- closing the soft mass in linen or gauze. It is customary, in cases of superficial inflammation, particularly the erysipelatous, to apply mucilaginous solutions with a view to their anti- phlogistic effect. This may be increased by the addition of acetate of lead to the solution ; but it should be remembered that this salt is in- compatible with certain mucilages, particularly with those of slippery elm and quince-seeds, with which it forms precipitates, and thus deprives the liquid of its mucilaginous property. But with the mucilages of flax- seed and the pith of sassafras it reacts but slightly, not sufficiently to impair materially their demulcent properties, or to interfere with its own efficiency. These latter mucilages, therefore, should always be selected, preferably to those first mentioned, for external use in connection with acetate of lead. Thus, we may add this salt with propriety to an eye- wash of mucilage of sassafras pith, often used in ophthalmia, while it would be incompatible with mucilage of quince-seeds, also used for the same purpose. In irritable or inflamed ulcers, and those attended with very pro- fuse discharges, and in inflamed blistered surfaces, a solution of acetate of lead may also be used, but of not more than half the strength of that employed where the cuticle is entire. In these cases, the acetate often reacts with the albumen and salts of the secreted liquid, producing a white insoluble compound. This is ordinarily of no inconvenience; but, in ulcers of the cornea, there is danger that this compound may become permanently incorporated with the tissue, forming an opaque spot, which cannot be removed. In this aflection, therefore, the salt should not be used. Administration. Acetate of lead may be given in pill or solution. The pill is best made with mucilage of gum arabic and syrup, as these are not incompatible with the salt. It should be prepared as wanted for use. Opium is often combined with the salt; and, though mutual decomposition may take place between the meconate of morphia and acetate of lead, no practical disadvantage results. Nor is the addition of the vegetable astringents improper, as the resulting tannate of lead is officient. When the salt is given in solutiou, the preparation is rendered CHAP. I.] ASTRINGENTS. SUBACETATE OP LEAD. 165 more elegant by the addition of a few drops of acetic acid, or a little distilled vinegar; but Dr. Thomson was mistaken in thinking that the poisonous effects of the lead could in this way be prevented. Colica pictonum has followed the use of the acetate thus protected. Indeed, it may be considered nearly certain that the salt is always decomposed in the stomach, whether given with or without a little acetic acid. Lauda- num renders the solution turbid by the formation of meconate of lead; but its efficiency is not impaired. The other incompatibles before re- ferred to (see page 156) should be avoided in connection with the salt in solution, though many of them may be given with it in the pilular form. The dose of acetate of lead is from one to three grains, which, in acute cases, may be repeated every hour, two, or three hours, and in chronic cases, three or four times daily. In the form of ointment or cerate, the acetate of lead may be employed as a dressing for irritable or inflamed ulcers, excoriated surfaces, and blisters, and may be prepared by thoroughly rubbing together half a drachm of the salt very finely powdered, and an ounce of simple oint- ment ; but the cerate of the subacetate is preferable, for the purposes mentioned. II. SOLUTION OF SUBACETATE OF LEAD. LlQUOR PLUMBI SUBACETATIS. U.S.,Br. Goulard's Extract. This is made by boiling litharge or protoxide of lead with solution of acetate of lead, and filtering. It is a solution of diacetate of lead, consisting of one equivalent of acetic acid and two of protoxide of lead. Sensible and Chemical Properties. The solution is a colourless liquid, of a sweetish and astringent taste, of the sp. gr. 1.267 as prepared by the U. S. process, and of an alkaline reaction. Exposed to the air, it absorbs carbonic acid, forming the carbonate of lead, which is deposited at the bottom and on the sides of the vessel. Its constituents are known by the same tests as those of the neutral acetate, from which it is distin- guished by forming a heavy white precipitate with solution of gum arable, which is not affected by that salt, and by being more copiously precipitated by carbonic acid. Incompatibles. These are the same as those of the neutral acetate, with the addition of pure gum arabic, and certain mucilages, as those of sassafras pith and flaxseed, which are strongly precipitated by the diacetate, while, though in some degree affected by the neutral salt, they are scarcely sufficiently so to be incompatible with it. Gum mezquite, brought into notice some years since by Dr. Shumard, as a product of New Mexico, though strongly resembling gum arabic in many of its properties, does not, according to Professor Procter, yield a precipitate with the solution of subacetate of lead. 166 GENERAL STIMULANTS. [PART II. Medical Properties and Uses. This solution has all the effects on the system of the other preparations of lead, but in this country and Great Britain is seldom if ever given internally. In France, it has been pre- scribed by M. Boudin, with some success, in the vomiting of epidemic cholera. Its local effects are the same as those of the acetate, but probably somewhat more intense. In France, it is much employed for all the purposes for which the acetate is used locally with us; for example, as a collyrium in ophthalmia; as an injection in morbid discharges from the nostrils and ear; as a mouth- wash and gargle in different forms of angina and stomatitis; as an enema in chronic mucoid or purulent dis- charges from the rectum, with or without ulceration ; and as a topical remedy in Ieucorrho3a and gonorrhoea. I have long been in the habit of using acetate of lead, by injection, in cases of acute dysentery affecting especially the rectum. M. Barthcz has successfully used the solution of the subacetate in the same way; and the practice has been extended to acute diarrhoea and epidemic cholera, with satisfactory results. Vast quantities were injected, largely diluted with warm water, without any unpleasant constitutional effect; the liquid producing its local impression upon the mucous membrane, but not being retained long enough to be largely absorbed. M. Barthez administered at first somewhat more than a drachm in 100 times its weight of water; but afterwards increased the quantity to one, two, and even three ounces in one injection, without poisonous effects.* (Trousseau et Pidoux.) In this country, the use of the solution of subacetate of lead is con- fined chiefly to superficial inflammations, either of the skin, the subcu- taneous cellular tissue, the lymphatic glands, the tendons and aponeu- roses, or the more superficial vessels, whether absorbents or veins. In the inflammation of sprains, bruises, wounds, etc.; in the more inflammatory states of certain cutaneous eruptions, as erythema, erysipelas, eczema, herpes, and impetigo; in burns, blisters, and excoriations; and in various ulccrative affections attended with irritation, inflammation, excessive secretory discharge, or hemorrhage; it may be used as an antiphlo- gistic, astringent, anodyne, or haemostatic. For the purposes above mentioned, the preparation is usually employed very much diluted, as in the form of the officinal diluted solution. In France, it has recently been recommended, in very strong solution, in mercurial salivation; not less than a sixth, or an eighth part being used in the mouth-water or gargle employed; and a preparation of equal strength is recommended in leucorrboeal discharges, especially connected with superficial ulceration of the neck of the uterus, being applied by means of a sponge or roll of linen saturated with the liquid. * The up. gr. of the present French preparation is 1.32, while that of the U. S. Pharm. is 1.2G7; so that the former is considerably stronger than the latter. CHAP. I.] ASTRINGENTS. SUBACETATE OF LEAD. 167 Great success has been claimed, in the treatment of the inflammation and fungous growth connected with inverted nail, for the solution of subacctate of lead, applied by separating the nail from the flesh, and every hour, two, or three hours, dropping into the vacant space two or three drops of the liquid; the parts in the mean time being covered with a pledget of raw cotton wet with the same liquid, and the cotton changed every day. The following are preparations of the solution now under consider- ation. 1. DILUTED SOLUTION OP SUBACETATE OP LEAD. LIQUOR PLUMBI SUBACETATIS DILUTUS. U.S., Br. Lead Water. This dilute solution, usually called lead water, is at present made by adding three fluidrachms of the strong solution to a pint of water. The carbonic acid in the water causes some turbidness in the diluted prepa- ration, which does not, however, interfere with its virtues. The strength of the diluted solution may often be much increased with advantage; and from half a fluidounce to a fluidounce may be employed to each pint, with perfect impunity, when the cuticle is unbroken. Local paralysis is stated in the books to have resulted from its use; and, though this must be extremely rare, as I have never witnessed nor heard of a well-authen- ticated case of it, still some caution should be exercised in applying the solution to abraded surfaces. It may be applied by means of linen cloths, or in the form of the cold poultice, as the solution of acetate of lead. 2. CERATE OP SUBACETATE OP LEAD. CERATUM PLUMBI SUBACETATIS. U.S. UNGUENTUM PLUMBI SUBACETATIS. Br. Gou- lard's Cerate. This consists of the solution of subacetate of lead, incorporated with wax, olive oil, and a very little camphor. It is an excellent preparation, admirably calculated to produce the local effects of lead, in cases in which the cuticle is wanting. Irritable, inflamed, and painful ulcers are often relieved by it; while by its astringeiicy it favours desiccation in those which are copiously suppurating, and disposes the loose and flabby to take on the healing process. In blisters, burns or scalds, chilblains, inter- trigo and other forms of superficial abrasion or excoriation, herpetic, ecze- matous, and impetiginous eruptions with serous or puruloid discharge, and a similar condition in lichen agrius and other cutaneous affections, it is one of the best applications that can be made. I know nothing equal to it as a dressing for blisters indisposed to heal. In many in- stances, and particularly in the one last mentioned, it may be combined at first with an equal weight of simple cerate. The caution should always be observed not to employ it in a rancid state, in which it be- comes irritant. Hence it should be made with perfectly sweet oil, and used as fresh as possible. It is sometimes combined with opium, or calomel, or both, as an application in skin diseases of a local character. 168 OENKRAL STIMULANTS. [PART IT. 3. SOAP CERATE. CERATUM SAPONIS. U.S. This was made, according to the Pharmacopoeia of 1850, by boiling the solution of subacetate of lead with soap, and, after due evaporation, addinir wax and olive oil. The process yielded a fine white cerate, ca- pable of being spread by a knife upon linen or muslin. The present Pharmacopoeia prepares it by melting lead plaster with wax, and adding olive oil to the mixture. Soap cerate is a mild sedative and desiccant preparation, applicable to similar purposes with the preceding, and employed in scrofulous swellings, and other external inflammations. III. CARBONATE OF LEAD. PLUMBI CARBONAS. U. S., Br. Cerusse. Cerussa. White Lead. White lead is made either, 1. by the reaction of the vapour of vinegar, and exhalations from decomposing stable manure, upon coiled plates of lead, or 2. by passing carbonic acid through a solution of subacetate of lead. Its composition is somewhat different according to the mode of preparation. The neutral carbonate, made by double decomposition between a soluble salt of lead and an alkaline carbonate, consists of one eq. of acetic acid, and one of protoxide of lead ; the white lead of com- merce is generally believed to be a compound of this neutral carbonate with variable proportions of hydrated oxide of lead. Sensible and Chemical Properties. Carbonate of lead is in the form of a white powder or pulverulent lumps, heavy, inodorous, and nearly tasteless, insoluble in pure water, very slightly soluble in water contain- ing carbonic acid,* dissolved with effervescence by nitric acid, blackened by sulphuretted hydrogen, reduced by heat to the yellow protoxide, and by heat with charcoal to the metallic state. Impurities. The commercial carbonate of lead is very often adulter- ated ; the most common impurities being sulphates of lime, baryta, and lead, and carbonate of lime. Effects on the System. This salt, in consequence of its insolubility, is i * To test the solubility of carbonate of lead, the following experiment was per- formed at my request by Professor Procter. A solution of neutral acetate of lead was precipitated by carbonate of potassa, and the carbonate of lead thus obtained WHS thoroughly washed. This was introduced into a bottle containing carbonic ucid water, which was instantly corked. After standing for twelve hours, with occasional agitation, the liquid was filtered, exposed to the air so as to allow that portion of the carbonic acid to escape which had been retained by pressure, and subsequently boiled so as to drive off the remainder. No appreciable deposition took place, nor was the liquid att'ccted by iodide of potassium; but when a current of sulphuretted hydrogen was passed through it, the liquid was perceptibly dark- ened, and upon standing deposited a minute quantity of sulpliuret of lead. Thin experiment proves that carbonate of lead is appreciably dissolved by water impreg- nated with carbonic acid, and is retained by the water after the carbonic acid has been driven off by heat. CHAP. I.] ASTRINGENTS. NITRATE OF LEAD. 189 less apt than the acetates to irritate or inflame the alimentary mucous membrane; but it more readily affects Ihe system at large, and is sup- posed by some to be the most noxious of all the preparations of lead. This proneness to act on the system may possibly, as suggested by Dr. Christison, be owing to the disposition which, from its weight and insol- ubility, the carbonate of lead has to adhere to the membrane, so that it is not carried off with the contents of the bowels, and is more exposed to absorption. Medical Uses. Carbonate of lead is never given internally. Exter- nally, it is employed as a desiccant and antiphlogistic application. Some recommend it to be sprinkled in the state of powder upon excoriated surfaces; but it should be used in this way with caution. I have known it, sprinkled thickly upon an abraded surface on the leg, to produce severe inflammation, with much pain and swelling, and a superficial slough. There is some danger, too, from its absorption; for a case is on record in which death in a child resulted from the external use of the medicine. The best method of application is in the form of an ointment (UNGTJENTUM PujMBi CARBONATES, U.S., Br.), which is made by rub- bing up eighty grains of very finely powdered carbonate thoroughly with a troyounce of simple ointment, previously softened by a gentle heat. In this way it may be used in ulcers, burns and scalds, excoria- tions of different kinds, and irritating cutaneous eruptions. A liniment, formed by mixing it with flaxseed oil to the consistence of cream, has been particularly recommended in burns. A case is reported by Dr. Kunkler, of Madison, Indiana, in which colica pictonum occurred in consequence of the application of carbonate of lead, in the form of com- mon white paint, to an extensive scald of the arm ; but this effect is very rare. (N. Am. 3Tedico-chirurg. Rev., i. 605.) IV. NITRATE OF LEAD. PLUMBI NlTRAS. U. S. This is made by direct combination of litharge and nitric acid. It consists of one equivalent of protoxide of lead and one of nitric acid, without water. Sensible and Chemical Properties. Nitrate of lead is in white, nearly opaque, four or eight-sided crystals, inodorous, sweet and astringent to the taste, permanent in the air, soluble in water and alcohol, and char- acterized by evolving nitrous vapour when heated, and by yielding a white precipitate with fcrrocyanide of potassium, a yellow one with iodide of potassium, and a black one with hydrosulphate of ammonia. Effects on the System. So far as known, these are the same as those of the other soluble salts of lead. Therapeutic Application. Nitrate of lead was long since employed as an internal remedy in asthma, epilepsy, and the hemorrhages; but it is now almost entirely out of use, having been superseded by the acetate. 170 GENERAL STIMULANTS. [PART II. As it possesses the property of decomposing hydrosulplmric acid and the hydrosulphates, it corrects fctid odours dependent upon these sub- stances, and may be employed with that object. Hence it is occasionally sprinkled in the chambers of the sick, and added to offensive discharges to obviate their smell. For this purpose, a solution may be employed containing a drachm in every fluidounce of water. Ledoyen'x disinfect- ing liquid is of this nature. But, though it will correct offensive odours, there is no proof that it will prevent putrefaction, or decompose and render innoxious contagious effluvia, or the malaria of marshes. It should, therefore, never be depended on as an antidote to these noxious agents. Having, with the corrective property above referred to, the desiccant and sedative powers of the saturnine preparations generally, it may be employed, with reference to both, as an external application, in offensive ulcers, and fetid discharges from the nostrils, ears, vagina, and uterus. To these purposes it has been applied by Dr. Ogicr Ward, who uses it also in gleety discharges from the urethra, and in chronic impetiginous affections. He employs, however, an extemporaneous preparation, made by dissolving one scruple of carbonate of lead in as much diluted nitric acid as may be necessary for the purpose, and adding this to a pint of distilled water. It may be applied two or three times daily. In the more obstinate cases, a much stronger solution may be used with im- punity. On the continent of Europe, a solution, containing ten grains of the nitrate in a fluidounce of water, has been advantageously em- ployed in sore nipples, chapped hands, cracked lips, and various ex- coriations. The dose of the nitrate, for internal use, would be from one-quarter of a grain to a grain, to be repeated, in acute cases, every two or three hours ; in chronic, two or three times a day. V. IODIDE OF LEAD. PLUMBI lODIDUM. U.S. This is made by mutual decomposition between iodide of potassium, and nitrate or acetate of lead in solution ; the resulting precipitate being washed with distilled water. It consists of one equivalent of lead and one of iodine. Sensible and Chemical Properties. It is a yellow, heavy, inodorous, and nearly tasteless powder, soluble in somewhat more than 1000 parts of cold water, arid about 200 of boiling water, soluble also in alcohol, fusible and volatilizable by heat, yielding vapours at first yellow, but ultimately violet from the disengagement of iodine. It should be kept excluded from the light. Medical Effects and Uses. Its effects are probably identical with those produced by the other preparations of lead. The preparation has been supposed to produce also the effects of iodine, and, under this impression, has been given in tuberculous affections, but with little advantage. In CIIAP. I.] ASTRINGENTS. SEMIVITRIFIED OXIDE OF LEAD. 171 scrofulous and syphilitic swelling's of the absorbent glands, both external and internal, and in obstinate ulcers, it is said to have proved useful, given internally, and applied locally, at the same time. The dose is from one to four grains three times daily. Dr. O'Shaughnessy gave ten grains without inconvenience, and even thirty grains have been pre- scribed. Externally it is used in the form of an ointment, made by rub- bing one drachm with an ounce of lard. VI. SEMIVITRIFIED OXIDE OF LEAD. OXIDE OF LEAD. PLUMBI OXIDUM. U S. LITHARGYRUM. Br. Litharge. Litharge is prepared by exposing melted lead, at a high temperature, to a current of air from a pair of blast-bellows, which blows off the oxide formed on the surface of the metal into a recipient, where it solidifies in minute scales. It is a protoxide of lead, containing one equivalent of lead and one of oxygen. Sensible and Chemical Properties. This oxide is in small, shining scales, of a yellowish colour usually tinged with red, inodorous and tasteless, fusible and at a high temperature volatilizable, and reducible by heat with charcoal to the metallic state. For practical purposes it may be considered insoluble, though it is said that one part is dissolved by 7000 parts of water. It is wholly dissolved by dilute nitric acid, and is blackened by hydrosulphuric acid. On exposure to the air, it slowly absorbs carbonic acid, and therefore usually contains a little carbonate of lead. Effects on the System. Litharge is capable of producing the peculiar effects of lead upon the system, whether taken into the stomach, or inhaled, in the state of vapour or of powder, into the lungs. But it is never used internally. Locally it has the ordinary sedative properties of the metal. Medical Uses. It has sometimes been used, sprinkled, in fine powder, on the surface of ulcers ; but its almost exclusive employment at present is as an ingredient in various officinal preparations, for which it is very important. I shall notice here those which are considered under no other head. 1. LEAD PLASTER. EMPLASTRUM PLUMBI. U. S. EMPLASTUUM LITHARGYRI. Br. Litharge Plaster. Diachylon. This is made by boiling litharge, olive oil, and water together, over a slow fire, until they concrete into a plaster. According to the views now generally received, olive oil consists of two fatty acids, the oleic and margaric, combined with the oxide of a hypothetical radical denominated glyceryle. During the process, the oxide of lead unites with these acids, and the oxide of glyceryle takes an equivalent of water to form glycerin, which is in great measure separated by kneading under water. The plaster is, therefore, oleate and niargarate of lead, probably with a little 172 GEXERAL STIMULANTS. [PART II. unseparated glycerin, which is useful by giving it more plasticity. As kept in the shops, it is in cylindrical rolls, of a grayish or yellowish- white colour deepening on exposure, brittle when cold, but softening and becoming adhesive by a very moderate heat. This preparation is much employed as the basis of other plasters, but is also itself highly useful as a direct application to the skin. In exco- riations and slight superficial wounds and sores, it promotes healing by its sedative property, and by protecting them from the air. To guard surfaces against friction and pressure, and thus to prevent bed-sores, it is one of the best applications that can be made. Surgeons sometimes employ it to keep the edges of wounds in contact, and for strapping the leg in ulcers of that part, when bandaging is employed in their treatment. For these purposes its freedom from all irritant properties peculiarly adapts it; but it is not sufficiently adhesive without some resinous addi- tion, and should, therefore, be used only when the skin is peculiarly del- icate. It may be spread on leather, linen, or muslin. 2. RESIN PLASTER. EMPLASTRUM RESINJE. U.S., Br. Adhe- sive Plaster. This is made by melting lead plaster and resin together. The British Pharmacopeia adds a little soap, which renders the plaster more pliable, and less apt to crack in cold weather. It is the common adhesive plas- ter of the shops, much used for keeping the surfaces of wounds together, and as a dressing for ulcers by gently compressing them, and gradually approximating their edges. It is usually kept in the shops, already spread, by means of a machine, upon muslin cloths. As it becomes less adhesive by exposure, the fresher it is when used, the better. 3. SOAP PLASTER. EMPLASTRUM SAPONIS. U. S., Br. This is made by incorporating soap with the lead plaster. It is a very mild preparation, sedative, and supposed to be discutient, and hence employed in chronic swellings and indurations, spread usually upon leather. A few other preparations of lead are noticed by authors ; but they are little employed, and probably capable of producing no effect, which could not be as well or better obtained from some one of those already referred to. Among them may be mentioned the chloride, saccharale, and lan- nate of lead, of which an account may be seen in Pereira's Materia Medica; and of the last in the twelfth edition of the U. S. Dispensatory. Tannate of lead may be made with great facility by adding a solu- tion of acetate of lead to infusion of galls or oak bark. It is used exclu- sively as a local application, and for this purpose may be incorporated with glycerin. It may be used in excoriations, as a resolvent in stru- CHAP. I.] ASTRINGENTS. 173 mous swellings, and, in the form of ointment, as a dressing for bed-sores, and gangrenous ulcers. Besides Alum and the Preparations of Lead, there are several other mineral substances which are decidedly astringent; but all of them have other properties, more important, and for which they are more employed; and it is deemed best, in order to give due prominence to these proper- ties, and at the same time to avoid repetition, to classify them with those medicines with which they agree in their greatest efficiency, and to treat of their astringent qualities incidentally. Such are especially the sul- phates of iron, zinc, and copper, and, in a less degree, other prepara- tions of the same metals, nitrate of silver, corrosive chloride of mer- cury, sulphuric acid, and lime. (See Tonics, Alteratives, and Antacids,) 174 GENERAL STIMULANTS. [PART II. II. TONICS. TONICS arc medicines which moderately and somewhat durably exalt the vital actions. They promote the appetite, invigorate digestion, render the pulse fuller, stronger, and sometimes more frequent, raise the temperature of the body, augment in some degree the various secretions, give increased firmness to the muscles, and probably operate also on the nervous centres, especially those of organic life, somewhat elevating, though not always observably, the various functions over which they preside. It is not pretended that all these effects are produced by every tonic medicine, or by any one of them at all times, and under all circum- stances. It will, however, I think, be generally admitted that, as a class, they operate as above stated upon the system in health. They differ from astringents in the universality of thoir action. The latter affect the single vital property of organic contractility; and what- ever other effects they may produce result from their influence upon this. Tonics operate not only on the vital contractility, but upon all the other vital properties, and may be said to be universal excitants to the func- tions. But this very diffusiveness of action prevents a concentration of their influence on anyone function; and consequently their power of producing contraction of the tissues is much less obvious than that of the astringents. A notion formerly prevailed that strength depended on a certain rigidity, tension, or tone, as it was called, of the living fibres, and espe- cially of the muscular; and medicines calculated to increase the strength were supposed to do so by increasing this tension or tone of the fibres, and hence were denominated tonics. But views so mechanical as this are now no longer tenable. There may be a certain physical tension of the muscles, tendons, and ligaments, resulting from mere position; but this has nothing to do with vital force, and an increase of it will not in- crease the general strength. The arteries have an elasticity which, under the pressure of the heart's action, permits a tensive expansion of their coats; and a diminution of this property might lead to a defective condition of the circulation. We may even conceive that, in case of diminished elasticity, tonics might have some effect in restoring it by improving the nutrition of the tissue; but the remedy would not in this case act immediately upon the physical property, but only secondarily through the vital functions. CHAP. I.] TONICS. 175 It is true that there is a certain vital cohesion of the living molecules, in every highly organized tissue, which is essential to the due perform- ance of its office ; and a moderate augmentation of this vital cohesion may give increased energy to the function; but this is very different from the physical property of tension. The muscles possess this kind of cohesion in common with the living tissues generally; but the strength of the system is not more dependent upon its due state in these than in other structures, and probably much less than in some others, as the nervous centres, and the mucous coat of the stomach. If, therefore, we admit the existence of tension or tone in this modified sense, and that tonics may act by increasing it, still, it does not follow that this class of medicines operates exclusively, or even mainly, on the muscles. In the present state of our knowledge, it is best to throw out of view the origin of the terms tone and tonic, and to consider that, by the former, is expressed simply the vital power by which the several con- stituents of the body arc enabled, under the influence of the proper excitants, to perform their function duly; and, by the latter, the means calculated moderately to elevate the several functions, by causing an increase of this power, or an increased exertion of it. In order to estimate properly the operation of this class of medicines, it is necessary to discriminate between strength and action. The former is obviously the capacity to act, the latter the exercise of that capacity. By increasing the latter, we do not necessarily increase the former. Tonics do not, therefore, essentially augment strength, and the name of roborantia or corroborants, by which it has been proposed to designate them, is not appropriate. In a state of perfect health, they cannot be said, in any degree, to increase the vital force or strength. I conceive that the greatest strengtl^of system is that which enables it to perform all its functions in the best manner, and to offer the firmest resistance to all disturbing agencies, of whatever kind, whether excitant, depressing, or perverting. It is in perfect health that this condition is presented. If any function, or any number of functions are exalted, either from a peculiar state of the power, or a peculiar application of excitant agency, beyond the healthy medium, the system generally, instead of being stronger, that is, better able to perform all its offices justly, and to resist noxious influences, is, in fact, upon the verge of disease, and may be brought into that state by causes, which, in its healthy condition, would not affect it injuriously. In health, therefore, tonics are not strength- ening. They may be, indeed, and not unfrequently are indirectly debilitating. They are ranked among the permanent stimulants; but this epithet is only relative. No stimulant is or can be permanent. The excitability of living parts, in other words, their susceptibility to excitant impres- 17C GENERAL STIMULANTS. [PART II. sions, is limited. If called into excessive action, it is proportionally exhausted; and, in this state of exhaustion, the ordinary healthful exci- tants have less than their normal effect. Depression, therefore, necessa- rily follows stimulation. This is obvious in the use of powerful stimu- lants; but it is no less true of tonics; though, in the use of these, as the excitation is more moderate and more slowly induced, the subsequent depression is less in degree and longer delayed. By a constant repeti- tion of the stimulant, we may sustain the excess of action longer; but the result is obtained at the expense of the excitability, which is sooner or later still more exhausted, and may at length be so much reduced that the stimulus ceases to be felt, and depression occurs even under its con- tinued use. This depression can be counteracted only by increasing the amount of the stimulus; but the same penalty is inevitably exacted ; and in the end excitability is worn out altogether, and function ceases. It may be said, however, that excitability is not strength, and, consequently, that the latter does not necessarily diminish with the former. This is to a certain extent true. But the strength of an organ, or its power to act, depends on its due nutrition, on the steady repair of its losses by the assimilation of new material, on the maintenance in fine of its normal state of organization. Now, if its excitability is permanently impaired, it cannot feel duly the influence of the materials essential to its repair, and they cannot, therefore, be suitably appropriated. Its nourishment fails, its structure is impaired, and consequently its ability to perform its function is diminished. This is debility. It follows that a constant use of tonics not only exhausts excitability, and secondarily depresses func- tion, but positively debilitates the system. Other evils arise irom the abuse of these medicines. Allowing that they act equally on the whole system, and equally elevate all the func- tions, they of course promote digestion, increase the quantity and stimu- lant quality of the blood, augment the nutrition of all the organs, and thus put the system into a state in which, from its universal exaltation, a slight irregularity may cause the excess of excitement to fall, with an overwhelming force, on some important organ, and thus seriously en- danger health, if not life, before the compensating provision of impaired excitability has had time to come into play. But supposing, as gener- ally happens, that the tonic operates with especial force on some one organ, or series of organs, the constant excitement sustained in it attracts an excess of blood and of nervous influence, which may in the end occa- sion inflammation. When the stimulation is powerful, the resulting in- flammation may be acute; but, as resulting from tonics, it is generally chronic. Thus, the abuse of the medicine may lead in the end to general debil- ity, and at the same time chronic inflammation of particular organs; a complication which it is difficult to treat, and which can, in fact, be CHAP. I.] TONICS. 177 treated successfully only by withdrawing the cause, either abruptly or gradually, and trusting to the recuperative powers of the system. The principles above stated are strongly illustrated by the results of the abuse of the Portland powder, formerly much employed in the treat- ment of gout. This powder consisted of a combination of vegetable bitters and aromatics, and was to be taken continuously for two years, at the end of which time a permanent cure might be expected. Dr. Cullen states that the cases of nine or ten persons had come under his knowledge, who took the remedy the required length of time, having previously been subject to regular attacks of inflammatory gout yearly, or twice a year. After a longer or shorter continuance of the remedy, they had missed the paroxysms, and, at the end of the two years, were entirely free from them, and had no attack afterwards for the remainder of their lives. But in every instance their health was impaired ; they were much troubled with dyspeptic and nervous disorder, and low- ness of spirits; and, in less than a year from the completion of the course, without exception, they began to exhibit dropsical symptoms, which gradually increased, in the form of hydrothorax or ascites with anasarca, and in two or at most three years proved fatal. (Culleri's Mat. Med.) It is not difficult to explain the result in these cases. The con- stant use of the stimulant impaired and finally exhausted the excitability of the system ; debility with anaemia ensued ; and with these were prob- ably combined chronic visceral inflammation, especially of the stomach, liver, and heart, resulting from the sustained irritation of the medicine, and the superadded irritation of the gout, invited from an external to an internal seat. It is inferrible from the above course of reasoning, the correctness of which has been abundantly confirmed by experience, that tonics should never be given in a state of sound health with the hope of increasing strength, nor for too great a length of time even in diseased conditions, in which they may have been originally indicated, for fear of inducing secondary debility and perhaps chronic inflammation. But, nevertheless, these remedies are of great value in various con- ditions of depressed and forpid function and debility. It may be said that here also, as well as in health, the principles above developed are applicable ; and that the ultimate effect ought to be, by an impairment of the excitability, still further to depress and weaken the system. It can, however, be shown that this is not a legitimate deduction. 1. It has been stated that the characteristic office of tonics is moder- ately and somewhat durably to increase the vital actions. Their first direct effect, therefore, in depressed function, is to obviate this condition. As strength consists in the normal state of the ultimate organic constitu- ents of the tissues, which can be sustained only by a due degree of all the vital processes which contribute to the nutrition or maintenance of VOL. i. 12 178 GENERAL STIMULANTS. [PART II. parts, and tonics have the property of stimulating these processes, it fol- lows that, when they are deficient, and debility has ensued as a result, tonics may prove not only stimulant but positively strengthening, pro- vided the depressing causes do not outlast the excitability of the part or parts affected. Let us apply this principle. In numerous diseases, there is a depressed condition of function, with or without positive debility, which depends upon a cause either essen- tially temporary or removable. Such a condition exists, for example, in low states of fever of a typhoid character, in which a depressing poison is probably acting upon the system, and in the suppurative stage of in- flammation, and in gangrene, in which the strength is exhausted by copious discharge, or prostrated by the sedative influence of the mortifi- cation. In either of these cases, life may be in imminent danger; but, as the operation of the cause is temporary, if the vital functions can be sustained until this ceases or is removed, the patient may be saved. Tonics may afford the support requisite for this purpose. They excite the depressed functions, and strengthen by due nutrition the debilitated structures; and, long before the excitability, through which they operate, has had time to suffer materially from the stimulus, the cause- ceases, and the system is left in a condition in which it can repair itself. 2. We not unfrequently meet with cases of depression and debility, continuing after the cause has ceased. The system, or a part of it is, as it were, left paralyzed. It seems as though a habit of insufficient action had been established, which the inherent force of the system could not throw off. Living, like dead matter, has a sort of vis inertise, which dis- poses it to continue in any condition in which it may have compulsorily continued for a considerable time. Under these circumstances, a little gentle stimulus serves to rouse it out of its torpor; and once again fairly in action, it will go on without further aid. As a watch stopped in the winding, and continuing quiescent, will resume its accustomed motions with a little shaking ; so the system, reduced by disease, and remaining torpid after the disease has ceased, will react with a slight excitation, and enter again into its ordinary round of action. Tonics are often suf- ficient to give the requisite impulse. Hence, in part at least, their use in the torpor of system, or that of a particular organ, so common in con- valescence from acute disease. 3. General drpn-.-.-inn or debility may result from the torpidity of a particular function or organ, upon which, in turn, the general deficiency may react, so as to sustain and even increase its inertness. Thus, tin- stomach, or the function of digestion, may have been di'pn-.-M-d by some cause acting upon it alone. The food, of course, is not properly digested, the quality of tin- blood is impaired, the general function of nutrition suf- fers, and consequently the stomach with other organs. The disease thus runs on in a vicious circle, at each round increasing the local condition CHAP. I.] TONICS. 171* in which the whole originated, and deepening the general debility. By moderately stimulating the digestion, we restore the due qualities to the blood and the due energy to nutrition, the stomach recovers its powers when properly nourished, and the whole evil is corrected. A like train of consequences, and a similar mode of repair, may occur in reference to any one of the great organs or functions. Tonics often operate in this method in the cure of disease. It is seen, therefore, that numerous cases of depression and debility occur in which tonics may be useful. But they are not applicable to all affections of this kind indiscriminately. 1. That tonics may be serviceable in debility, there must be a certain amount of excitability remaining. Otherwise they may be useless, or even worse than useless. Depression and debility, resulting from exhausted excitability, cannot be repaired by tonics. In the debility of drunkards, for example, which is the result of over-stimulation, tonics, if felt at all, could produce only a slight excitement, to be followed by still greater depression : and their habitual use would only hasten the fatal issue. The only hope in these cases is in the cessation of the cause. The habit of stimulation must be abandoned, or there can be no remedy. With future abstinence, if the excitability of the organs has not been fatally impaired, and no de- structive disorganization has taken place, a gradual amendment and ulti- mate restoration may be hoped for, under the recuperative powers of the system. The only principle upon which tonics, under such circumstances, could be used with propriety, rests on the occasional necessity of not too hastily withdrawing all support from the system, lest fatal prostration should ensue. They may sometimes be resorted to, as a feebler stimulus than the accustomed one, in order that the transition may not be too abrupt. 2. Tonics cannot be relied on when the debility results from a con- stantly operating and irremovable cause. They would, in such cases, generally prove injurious by their secondarily debilitating influence, and would probably lead to a more rapid exhaustion of the patient. Tht debility, for example, resulting from cancer cannot be repaired by tonics. They may occasionally be useful in counteracting accidental debility of some one organ, or association of organs, which may be interfering with the proper exercise of the others ; but the general rule holds true. 3. Depression, amounting even to apparent prostration of the system, sometimes depends upon an active and overwhelming congestion, or extensive inflammation of some important organ or tissue, as the brain, heart, lungs, stomach, peritoneum, etc., which either concentrates so much of the blood and nervous force in one part that there is insufficient elsewhere to support the systemic actions generally, or immediately cramps the organ affected so as to arrest its function, and thus prostrate all dependent functions. In either of these cases, tonic medicines could 180 GENERAL STIMULANTS. [PART II. be of no service ; the indication being by depletory measures to unload the congested organ. 4. In cases of great or sudden and transient depression, tonics are of little or no service ; their action being too slow and moderate to meet the indication presented. When stimulation is required, under such cir- cumstances, it is necessary to have recourse to the diffusible stimulants for internal use, and the rubefacients externally. The general rule, then, in relation to the use of tonics, is that they are indicated in all cases of depression and debility, in which tho excita- bility has not been exhausted by previous stimulation, which do not proceed from a permanent and irremovable cause, and in which the depression is neither the result of active congestion or irritation, nor so sudden and transient as to call for stimulation more prompt and fugitive than that which characterizes this class of medicines. Of the particular diseases in which tonics may be used, all that can be advantageously said will come better under the heading of the several individual medicines; as the peculiar character of each medicine very much influences its application. It remains here only to treat of their precise mode of action, so far as that is known. Mode of Operation. Most of the tonics probably act directly on the mucous coat of the stomach and bowels, thus stimulating immediately the digestive function ; and there is reason to believe that some act chiefly, if not exclusively, in this way. It was formerly thought, and some still think, that the impression made on this surface is propagated, to a greater or less extent, over the system by means of sympathy, or the intervention of the nervous centres; and it is not possible to prove that the tonic impression is never diffused in this way. But. when it is considered how slowly the tonics act, and that many of them, particu- larly those of mineral origin, have been detected by chemical reagents in the blood or secretions, it seems most reasonable to suppose that those, the direct influence of which extends beyond the digestive organs, operate through the route of the circulation. The different modes of action of the different tonics may be included under the following heads. 1. I have stated that some appear to act chiefly, if not exclusively, so far as their immediate tonic influence is concerned, on the digestive organs. By promoting the appetite and invigorating digestion, they cause more food to be taken, and that which is taken to be more thor- oughly prepared for absorption and assimilation. They thus enrich the blood, rendering it at once more stimulating to the functions, and nutri- tive to the tissues, and produce indirectly the general tonic effects upon the system at large. Such are the mineral acids, and to a certain extent the simple or pure bitters, which, though they may possibly operate directly on the system through absorption, display their effects much more obviously upon the stomach and bowels. CHAP. I.] TONICS. 181 2. Other medicines of the class operate directly and mainly on the blood itself; not through the agency of the digestive process, but by intimate admixture with that fluid, into which they find admission, either by venous absorption, or through the lacteals or intestinal lym- phatics. They may act either 1. by entering immediately into the composition of some one of the proximate principles of the blood, 2. by modifying the vital condition of its organized constituents, or 3. by favouring, through a stimulant influence on its vital properties, the phy- siological actions which are constantly going on within it, and thus contributing to its full development and maintenance. The blood, thus elevated in its constitution, performs its offices in the economy with more vigour, and operates with a tonic influence on all the functions. Upon this principle it probably is that the preparations of iron chiefly act; and I am disposed to ascribe the peculiar influences of cod-liver oil in disease, in some measure, to analogous modifications produced by it in the blood. 3. Most of the class probably operate directly upon the ultimate organic constituents of the tissues, entering the circulation either un- changed or more or less modified, and being distributed everywhere by the blood as a mere vehicle ; though it is not impossible that they may operate also upon the vital properties of that fluid, through the same power by which they affect the similar properties of solids. How it is precisely that they affect the ultimate organic constituents of the body is conjectural. They may act merely by their presence, or they may enter into a sort of chemical union with the living matter, though I am in- clined preferably to the former of these views. At all events, some of them have been found, on chemical investigation, in the midst of the tissues. It is probable that each distinct function is performed through the instrumentality of a special power in the ultimate organic cells, nuclei, or molecules of the organ, and tonics may operate simply by stimulating this power into a somewhat increased activity. But we may advance one step further, and adopt the very plausible opinion, that in all the tissues there is a certain vital cohesion which is essential to the due performance of the function, and that tonics are moderate stimu- lants to this cohesion. To this mode of action we may ascribe in part the greater firmness of the tissues, especially the muscles and blood- vessels; and to this perhaps also that condition of the nervous centres, resulting from the use of certain tonics, by which they are enabled to exercise their proper functions more energetically, and have greater power of resistance to all kinds of disturbing influences. Such an in- fluence is exhibited in the control evinced by some of the metallic tonics over various nervous diseases, as chorea, epilepsy, and neuralgia. Before considering the several tonic medicines, with their subdivisions. I propose to give a succinct account of various influences of a tonic 182 GENERAL STIMULANTS. [PART II. Character, which, though not strictly medicinal, are often very useful in disease, and must therefore rank among remedies. 1. TONIC DIET. A proper regulation of the diet is indispensable to the obtaining of satisfactory results from the use of tonic medicines. Experience has established the fact, beyond controversy, that a mixture of vegetable and animal food is best suited for man. There can be as little doubt, on the score of experience, that animal food is more supporting to the system, and more stimulating than vegetable. Indeed, the effects of a relative increase of the former in the diet are not dissimilar to those produced by tonic medicines; proceeding at first from a direct excitant impression on the stomach, and subsequently from an augmented richness of the blood. A long-continued excess of animal food leads also, like an abuse of tonics, either to plethora with its dangers, or to a complication of diminished excitability with local inflammation. We may, therefore, rank the use of animal food, beyond the ordinary proportion, among tonic influences; and, when an indication exists for these medicines, there is generally a coincident indication for the kind of diet referred to. As the main object of tonics is usually not merely to stimulate the functions, but to obviate debility by sustaining, through the process of nutrition, a due state of the organization, it is obvious that, in order to produce this effect, there must be nutrient material for them to operate with. It does not, however, necessarily follow, that the quantity or richness of the food taken should be increased; for the patient may have been in the habit of taking more than his digestive powers could manage; and the end desired is attained by a more thorough assimila- tion, and less waste of the nutriment, through the greater energy given to digestion by the medicine. In judging, therefore, as to the propriety of increasing the amount of food, the practitioner must take previous habits into consideration ; and, if the diet should be found to have been in excess, in reference to the digestive and assimilative powers, there would be no propriety in augmenting it, at least until the balance should be restored. The kind of food previously used must also be allowed to modify the prescription. If the diet had been exclusively vegetable, it is obvious that a relatively smaller quantity of animal food should be directed ; if exclusively animal, it would be necessary, in order to obtain the same end, to employ it more freely. Reference must also be had to the habits of the patient in relation to exercise. Food is consumed by bodily exertion, and the invator the latter is, the more will be required of the former. To produce a tonic CHAP. I.] TONICS. TONIC DIET. 183 effect, therefore, a greater elevation of the diet would be necessary in a person of active, than in one of sedentary habits. The quality of the animal food employed is scarcely less important than its quantity. Some kinds are more stimulant, some more nutritious, and some more digestible than others. The most stimulating may pro- duce an excitant effect greater than desired; but food can scarcely be too nutritious, or too easily digested for tonic purposes. A few words, there- fore, on the more common articles of animal food, in reference to these points, may not be out of place here. One of the lowest varieties of animal food in stimulant and nutritive properties, taking bulk into consideration, is milk;* but it is easy of * Milk Cure. Milk has been recently raised, in Russia, almost to the dignity of a panacea. Dr. Philip Karell, "Physician to his Majesty the Emperor of Russia," in a communication to the Medical Society of St. Petersburg, after giving a history of the therapeutical uses of milk by his predecessors in various parts of Europe, some of whom had most extraordinary success, proceeds to offer his own mode of treatment, in the remedial efficiency of which he seems to have unbounded confi- dence. He generally commences the treatment by directing the exclusive use of milk for nourishment, permitting no other food. He prescribes for the patient, three or four times a day, at regular intervals, from two to six ounces of skimmed milk of the best quality. The whole of each dose should not be swallowed at once; but. it should be taken slowly, and in small quantities, so as to be well mixed with the saliva. If the patient digest the milk well, which may be inferred if the stools, before liquid, become solid, the dose is to be gradually increased. For the first week the patient has great difficulty in resisting his craving; but this is removed in the second week, during which two quarts are given daily. If the cure take its regular course, the milk must now be drank four times a day; at eight A.M., at noon, at four P.M., and at eight P.M. If the patient wish other hours, he may be allowed to change; but the same interval must always be enjoined; and on no account should he be left to his own discretion either as to the time or quantity. When the bowels become constipated, as often happens, this may be obviated by injections of warm water, or by the use of castor oil or rhubarb. Should the cos- tiveness be obstinate, a little coffee may be given every morning with the milk, or towards four o'clock stewed preserves or a roasted apple. If, at the end of the second or third week, there is a craving for solid food, a little stale bread with salt, or a small salt herring, may be allowed; and a little stale bread at the dinner-hour. Once a day, the patient is permitted to take some soup made of milk and oatmeal. After five or six weeks, the milk may be given only thrice daily, and once a chop or steak. Dr. Karell has found raw meat to digest the most easily. Great confi- dence on the part of the patient, and a rigid adherence to the rules given, are neces- sary to assure success. The affections to which the milk-cure is applicable are dropsy with impoverished blood; disordered innervation in the forms of hysteria and hy- pochondriasis; obstinate dyspepsia; catarrhal, rheumatic, and gouty affections; nervous maladies dependent on defects in the fluids; chronic irritation of the pharynx and oesophagus, ulcers of the stomach, and similar affections of the bowels. The gastric cases formed the larger portion of those successfully treated. (Edin. M(d. Journ., Aug. 1866, p. 97.) Now I can bear testimony to the great efficiency of an exclusive or almost ex- 184 GENERAL STIMULANTS. [PART II. digestion, and may be preferred in a tonic course when the digestion is feeble, and the previous habits of the patient have been those of absti- nence. The same may be said, in less degree, of its derivative butter. Another derivative, cheese, while probably not more nutritious, is more difficult of digestion, and, in consequence of chemical changes, often much more stimulating. The latter, therefore, should not be given when the stomach is feeble. Next in the ascending scale of nutritive and exci- tant power, are oysters, eggs, and the lighter kinds of fish ; and these are generally easy of digestion, when properly prepared. Haw oysters, particularly salt oysters, are themselves stomachic, often exciting the appetite, generally easy of digestion, and an excellent ingredient in a tonic regimen. The eggs should be soft boiled ; or, if hard, should be grated very finely so as to overcome their cohesion, and render them more easily soluble in the gastric juice. Next come the different kinds of poultry with white flesh, and after these the ordinary meats, as 777 ul- ton and beef. The dark-fleshed poultry, as ducks and geese, and all the varieties of pork, are most stimulant and most difficult of digestion, and, though highly nutritious also, should be used only when the digestive powers are strong, and exercise is taken abundantly. Wild animal food is preferable to the same varieties tame, as being more easily digested. On the same score, adult animal food is preferable to the very young, which is too stringy, and less nutritive, or to the very old, which is often very tough. Beef, mutton, and fowls arc preferable to veal, lamb, and chickens. Very fat meats, though stimulant and nutritious, are not so easily digested, and often unsuitable. Salt meats are less nutritious than the fresh, and also less digestible, and, though often admissible, particu- larly in small quantities as condiments, should be excluded, as main arti- cles of diet, when the digestion is feeble. The mode of cooking, too, has much influence over the quality of the food. Boiling renders meats less nutritious, and therefore less suitable for a tonic diet. Frying, and other modes of preparation, in which butter and fats are heated with the meat to the point of decomposition, are unsuitable, in consequence of the indi- gestible, as well as irritant character, often imparted to the food. Roast- ing, broiling, baking, and slewing are more appropriate modes of treat- ment. Soups, which contain the extractive, gelatin, and other soluble parts elusive milk diet, particularly in morbid states of the blood, and in cases of obsti- nate romiting, and chronic diarrhoea; having 'recommended and employed this rem- edy, under such circumstances, for more than thirty years. In reference to the blood, I have used the remedy on the grounds of the easy digestibility of milk, and its composition, as it contains all the constituents necessary for making wholesome blood; and, in reference to diseases of the stomach and bowels, of its perfect bland- ness, in addition to the properties mentioned. But I am, nevertheless, indisposed to admit its claims to a position of special eminence as the milk-cure. (Note to the third edition. ) CHAP. I.] TONICS. EXERCISE. 185 of meat, are more stimulant and less nutritious than solid flesh, and, though they may be employed, should never be relied on. Meat extracts contain the soluble parts of meat, obtained first in a liquid form, and then evaporated to a solid consistence. They arc in fact concentrated soups, and when used are brought into the liquid form by treating them with boiling water.* The essences arc too stimulating for a mere tonic course, f Whatever food is taken should be thoroughly masticated. Fresh vegetable food of easy digestion should not be excluded; for, though destitute of tonic properties, it imparts qualities to the blood which are indispensable, and without which there would be constant danger of producing a scorbutic character of that fluid. Potatoes, from their highly nutrient and antiscorbutic properties, are very useful in a tonic regimen. 2. EXERCISE AS A TONIC. This is an invaluable tonic measure in debility. There are two kinds of exercise, which, though they produce the same ultimate effect, operate in a somewhat different manner, and are calculated to meet somewhat different indications; active, namely, and passive. Active exercise is that performed under the influence of the will ; passive, that in which the will is quiescent, and extraneous influences operate. Walking, run- ning, leaping, wrestling, rowing, and the various gymnastic movements are examples of the former; riding on horseback, driving, steaming, sail- ing, etc., of the latter. The two are frequently more or less combined. * The noted "extractum carnis" of Liebig, which has the advantage of containing little gelatin, is prepared by digesting meat, finely divided, and deprived^a* far as possible of gelatinous and fatty matter, with twice its weight of water, at 212, for an hour, and separating the liquid by strong pressure; again, digesting and ex- pressing as before; then evaporating to about one-sixth; and, after allowing the residue to cool, removing the fat that congeals on the surface, and finally evaporat- ing to the ordinary consistence of extracts. Ten pounds of meat should yield six ounces of extract. (Pharm. Journ. and Trans., Oct. 1865, p. 207.) Note to the third edition. f Raw meat. Considerable attention has of late been paid to raw meat and alco- hol as a remedy for phthisis and other cacliectic affections, introduced into use by M. Fuster, of Montpellier, France, who claims to have obtained great advantages from it. For the mode of administration, see my work on the Practice of Medicine (6th ed., i. 113). According to M. Fuster, the raw meat favours assimilation and nutriiion, and with alcohol has proved of great advantage in various diseases be- sides phthisis, as chronic ancemia, leucocythemia, allniminuria, diabetes, and typhus and typhoid fevers. How much of the virtues of the remedy depends on the rawness of the meat is exceedingly doubtful; and it is liable to this great disadvantage, that the meat may contain the germs of one of the forms of tsenia, or even those of the Trichina spiralis, and if taken uncooked, may give rise to those serious forms of parasitic disease. (Note to the third edition.) 186 GENERAL STIMULANTS. [PART II. Thus, in the active exercise of rowing, while the muscles of the extrem- ities are operating under the will, the whole frame is jarred by the move- ments of the boat; and in the passive exercise on horseback, while the body is shaken by the motions of the horse, the muscles are employed in regulating the animal, and maintaining the position of the rider. Active exercise is always primarily partial; passive is usually general, affect- ing every part of the body, though this is not necessarily the case in all instances; for a part only of the body may be agitated; as in that kind of exercise of the stomach recommended by Halsted in the treatment of dyspepsia, in which, the body being bent, and the hands pressed back- ward beneath the epigastrium, gentle and quickly repeated succussions are given to the organ by the upward movement of the fingers. It is not difficult to explain the tonic effects of exercise. In the active variety, the cerebral centres are first stimulated; then the muscles; then the heart through the organic nervous centres; and finally all the func- tions indirectly, in consequence of the greater rapidity of the blood flow- ing everywhere through the capillaries, to which these functions are indebted for the supply at once of stimulus and material. A certain amount of exercise, varying according to the state of the individual, is requisite to support the functions in a condition corresponding with the degree of general strength. A moderate excess beyond this amount will produce only a moderate stimulation, or in other words a tonic effect; a great excess gives rise to proportional excitement, and may prove powerfully stimulant. The general laws above given, in reference to tonic medicines, are applicable to this remedial measure. In a state of debility, if the exercise be moderately increased, it will increase strength, by supporting all the organic functions, and among the rest digestion, sanguification, and nutrition. In perfect health, if urged beyond the point requisite for the sustenance of this condition, it leads to the evils before described as the result of the abuse of tonics. In either case, if used in great excess, so as to stimulate actively, it exhausts the excita- bility, and may thus lead to secondary prostration and debility. It is perceived, therefore, that the employment of active exercise as a tonic requires the same judgment and discrimination as that of the medicines belonging to the class. The general rule is to proportion the amount of it to the strength, and never to push it so far as to occasion secondary exhaustion. A slight feeling of fatigue may be considered as an evi- dence that it has been carried sufficiently far for the time. In passive exercise, as a general rule, all parts of the body are excited by the agitation equably and moderately. The blood and nervous power are, therefore, invited in a nearly equal degree to the seat of every func- tion, and a moderate diffusive tonic effect is experienced throughout the system. It may be said that, as there is only a certain quantity of blood, and a certain amount of nervous power in the body, you cannot increase CHAP. I.] TONICS. EXERCISE. 187 these, in the system at large, through any immediate influence, and, therefore, that such a diffusive tonic effect as I have referred to is im- possible. But the whole nervous power is never called into full exer- cise in health, and, though it cannot be indefinitely drawn upon, yet it may be so in a moderate degree, beyond the ordinary wants of the sys- tem; and its influence, therefore, may be everywhere in the same degree augmented. In reference to the blood, if the whole quantity cannot be increased, yet the rapidity of its motion may ; so that a greater amount is present within a given time in all the organs. Besides, so far as con- cerns the smaller vessels or capillaries, where alone the blood is operative in sustaining the functions, the quantity may certainly be increased at the expense of that in the heart and great vessels, which serve mainly for its conveyance, or in the spleen, which probably often acts as a mere receptacle. It is, therefore, quite possible that all the organic functions may be moderately excited at the same time ; and this, I think, is the effect of passive exercise. In consequence of the equable and diffusive character of its influence, it has an advantage over active exercise in cases of great debility. In the latter, a slight excess of muscular action may call the heart into inordinate and even dangerous excitement. Pa- tients greatly debilitated have sometimes fallen dead, upon slight exer- tion, in consequence of the excessive action and consequent speedy ex- haustion of the heart; and, where there is no danger of such a result, there may be liability to serious congestions, to hemorrhage, and even to cardiac hypertrophy. So also, the encephalon may be inordinately stimulated through the influence sent up to it by the excited muscles, demanding through the nervous centres a supply of blood. Again, the over-excitement of particular organs leads to deficiency of action or de- pression in others; as shown in the result of violent exercise taken imme- diately after a full meal ; the powers of the system being concentrated in the muscular, and its immediately subsidiary functions, and withdrawn from the digestive, so that the food remains unacted on. In short, the influence of active exercise is necessarily more or less partial, and there- fore liable to occasion local excess or deficiency of function ; that of pas- sive exercise is general, and more equable, and therefore safer when the object is to correct great general debility, especially when associated with morbid tendencies of any organ, as of the heart, which active exer- tion may serve to aggravate, or call into operation. Yet passive exercise is alone insufficient ; for there are certain func- tions, such as that of muscular motion, which can be performed only through the agency of the will, and which will suffer if permitted to re- main quiescent. Though the instruments of these functions may be in- vigorated, so far as their nutrition is concerned, by passive exercise, yet they will not operate efficiently for their peculiar purposes unless sus- tained in a due habit of action. On the whole, therefore, in order to 188 GENERAL STIMULANTS. [PART II. strengthen a weakened system in all points, it is advisable to combine more or less together both kinds of exercise. Partial or local weakness may always be treated with partial exercise, whether active or passive. Thus, a limb which has become enfeebled, and incompletely paralyzed by long rest, as, for example, an arm or a leg in which the muscles have been restrained by bandaging, may be restored to its original powers by constantly repeated efforts on the part of the patient to use it; and attention has already been called to a useful method of producing passive exercise of the stomach in pure dyspepsia. The above remarks are applicable to the mental, or purely cerebral functions as well as to the others. These may also be divided into the active and passive, the former being voluntary, as the intellectual func- tions, the latter involuntary, as the emotional. In debility of the active functions, it is necessary, in order to restore due vigour, to exercise them actively through the will of the patient; in'that of the passive, to exer- cise them passively, by so regulating extraneous influences as to excite them into operation. It may be proper, before leaving the subject, to say a few words on the several varieties of exercise most resorted to in the treatment of disease. Modes of Active Exercise. Upon the whole, walking is probably the safest and most efficient mode of active exercise, in cases of simple gen- eral debility. It should be continued at one time no longer than may be sufficient to cause a slight sense of fatigue, and should be frequently re- peated. The amount must, of course, be regulated by the strength of the patient. It should never, in debility, be so rapid as to induce much palpitation of the heart. When the weather is such as to forbid the invalid to walk in the open air, he should take the exercise withindoors, throwing up the windows, so as to admit the fresh air, and maintaining a temperature in the apartment, somewhat below that which is com- fortable to him when seated. Other and more energetic modes of active exercise are running, leap- ing, wrestling; the various kinds of bodily labour; athletic games, as those of quoits, ball-playing, bullet-rolling, bar-pitching, etc.; and within doors, dancing, billiards, nine-pins, the use of dumb-bells, baltledore and shuttlecock, gymnastics, calisthenics, etc. It is often necessary, in order that the invalid may be duly amused or interested, to vary the modes of exercise to suit his taste or caprices; and hence the propriety of having a considerable list out of which to choose. To those already mentioned, as suitable for patients confined to their housi-s, may be added, sawing and aplilling wood, rubbing furniture, and various other house- hold operations, which, by amusing the patient with the idea of useful- ness, may lessen the irksomeness of the measure, considered merely hi CRAP. I.] TONICS. EXERCISE. 189 a therapeutic point of view. Indeed, this idea should be carried out in all plans of exercise. There should be some other ostensible object than that merely of improving health. The patient should, if possible, become interested in the act, occupation, or pursuit for itself alone. Other ad- vantages of this diversity of plans are that, by a proper choice among them, we may duly proportion the activity of the exercise to the strength of the patient, and that, in consequence of the various muscles brought into play in the different methods, we may by successive changes operate on the whole- system of voluntary muscles, or bring some particular method to bear upon special muscles or organs, which may stand peculiarly in need of invigoration. But in all the methods referred to, care must bo taken to avoid excess; and this is particularly necessary of those which have in themselves something fascinating or seductive. Serious evils, for example, have sometimes arisen from the abuse of dancing, and gym- nastic exercises. The modes of exercise above referred to are often useful, not only by their tonic influence on the muscular system directly, and other systems indirectly, but also by a derivative influence, tending to draw away an excess of blood and nervous action from internal organs, congested or chronically inflamed Every one of sedentary and studious habits must have been sensible of the great relief, in instances of visceral uneasiness, or oppressed and clouded thought, afforded by rising and walking briskly for some time, or otherwise actively employing the voluntary muscles; and chronic inflammation of the liver, stomach, brain, etc., may often be greatly benefited by a systematic external derivation of the same kind. Modes of Passive Exercise. Horseback exercise is probably the most effective, and generally applicable, of all the different passive methods. It is, however, too fatiguing for great debility. Moderate at first, it should be gradually increased with the increasing strength and tolerance; and a patient who has commenced with less than a mile, may often extend his rides to fifteen or twenty miles daily with propriety. It is more especially applicable to cases in which the ab- dominal or thoracic viscera are enfeebled. No remedy, probably, is more effectual in pure dyspepsia; and, since the times of Sydenham, it has been considered a most valuable prophylactic in phthisis. Indeed, there is reason to think that it often proves useful, and sometimes even curative, after the disease has actually commenced. Hepatic torpor without inflammation, habitual constipation from enfeebled function, and hemorrhoidal affections arising from one or both of the preceding conditions, are often benefited by this mode of exercise. The same may be said of headaches and other cerebral affections, purely functional, and connected with debility. In relation to riding on horseback, the remark before made as to the importance of combining other objects 190 GENERAL STIMULANTS. [PART II. with the pursuit of health, is peculiarly applicable. I have been told that the late Professor Wistar, of Philadelphia, used to recommend his dyspeptic patients to ride out every day to a certain chalybeate spring, several miles from the city; his object being much more the benefit of the ride than that of the waters. A long journey on horseback is an almost certain cure for pure dyspepsia. Carriage exercise is more purely passive than that on horseback, for which, in its rougher modes, it is the best substitute. The jolting of a rough vehicle over smooth roads, or of a smooth vehicle over rough and stony roads, is often highly useful in the cases to which attention was called in the last paragraph. The jarring movement of the railroad car, and that of the steamboat, is next perhaps in efficiency to that just referred to. That of a row-boat is of the same character ; and the ex- ercise of the rower himself, combining the active and passive kinds, is an admirable measure for imparting vigour to the system, if not over- done. Riding in a smooth carriage and sailing arc the mildest methods, applicable to the feeblest condition of system requiring exercix-. Substitutes for these methods may be found within doors. Chair? have been invented which enable the invalid to imitate horseback riding ; and the same effect is in some degree obtainable by the jogging motion of an ordinary chair. The rocking-chair and the swing arc partial sub- stitutes for the smooth carriage and the sailing vessel; but, in these methods, it must be recollected that the peculiar character of the motion gives a special direction to the blood ; in that of rocking centrifugally to the head, in that of swinging in like manner centrifugally from the head. From the former, therefore, injudiciously indulged in, there may be some risk of cerebral congestion ; from the latter, of defective circu- lation in the brain. Friction and shampooing may be considered as local varieties of passive exercise. Friction may be performed by the patient himself, in which case the active is combined with the passive, and more universal effects are obtained. It may be performed with the naked hand, or by means of flannel, a coarse linen towel, the flesh-brush, or any other roughish material ; and should be carried so far as to excite some redness in the surface, but not to abrade or inflame it. The more extensively it is performed over the body the better ; as its influence is thus propor- tionably generalized. It should be repeated once or twice daily in chronic cases. Shampooing is a practice introduced from the East, and consists essentially in a kind of kneading process, performed on the sur- face, but reaching in its effects deeper than mere friction, in fact through- out the soft parts of the body not protected by a bony case. Slapping over the surface with the sole of a slipper, or any slight flat body of a similar character, operates in the same way as the above processes. The effect of all of them is moderately to excite the surface and the soft CHAP. I.] TONICS. PURE AIR. 191 parts near it, thereby attracting the blood and nervous action, and pro- ducing a tonic impression; while they operate derivatively in relation to the internal organs. They are, therefore, especially indicated in ca-t-s of torpor of the skin and muscles, attended with congestion or chronic inflammation of the viscera. 3. PURE AJ & AS A TONIC. This, though a very efficient tonic under certain circumstances, must be considered as acting negatively. In large towns, the atmosphere is impregnated with effluvia, the general effect of which on the system is at first depressing, and ultimately debilitating. By removing from town into country, we escape this influence; and, the cause of weakness being removed, our systems acquire renewed strength through the healthful agency of an uncontaminated atmosphere. This is especially the case with invalids, whose strength has been impaired by disease, and whose systems are often unable duly to react, while exposed to the air of cities. I presume there are few inhabitants of large towns who have not felt, even in their ordinary health, the refreshing and invigorating effect of the country atmosphere, or, to speak more accurately, of an escape from the enfeebling effluvia to which they are habitually exposed. The sick chamber is liable, in a still greater degree than the general atmosphere of towns, to the charge of unwholesomeness ; and, even in the country, therefore, invalids are often greatly benefited by escaping from the confined and sedative air of their lodgings to that of the open fields. These remarks, while applicable to debility in general, are peculiarly so to that of convalescence. But, though pure air may be only negatively tonic at the ordinary atmospheric pressure, yet, by exposure to the atmosphere either much ratified or much condensed, a tonic influence on the respiratory organs is obtained, in the former case indirectly, in the latter directly, from which much good may be expected in debilitated conditions of those organs.* * From observations by Dr. Hermann Weber on the climatic influence of the high regions of the Swiss Alps, he came to the following conclusions. Respiration is increased in frequency and depth, with increasing elevation. The heart contracts more frequently in proportion to the height attained. The appetite, and generally thirst, are augmented. Sanguification is improved. The nervous system is invigorated, and the sleep more healthy. The muscular system acquires increased energy, and is more active. It is inferred ;hat the metamorphosis of tissue is augmented; though the urine does not appear to be materially altered in quantity : the proportion of solids being 192 GENERAL STIMULANTS. [PART II. 4. MENTAL INFLUENCE AS A TONIC. Certain states of the mind are known, from experience, to have a seda- tive effect upon the system at large. Grief, anxiety, and all the various modifications of fear are distinguished, in common nomenclature, as the depressing emotions. Whatever, therefore, in any manner counteracts or removes these feelings, must be indirectly stimulant ; and, even though purely negative in its operation, would rank among tonic influences. But there are also mental conditions which have a directly elevating or sup- porting effect. The more refined pleasures of sense and perception; the appreciation of the beautiful, the picturesque, or the sublime in nature and art; the enjoyment attending the legitimate exercise of all our intel- lectual powers; the pleasurable emotions of love, hope, confidence, joy, of triumphs over difficulties, of temptations resisted, of a legitimate am- bition gratified; all these produce in our physical systems an excitation, which, though, like stimulation from any other source, it may be exces- sive and injurious, is more generally within the limits of a healthful influ- ence, and, in states of debility, is positively tonic and restorative. No practitioner can fully perform his duty towards his patients, who does not avail himself of this instrumentality in cases of debility. It is prob- ably more available, in the treatment of defect of function in the digestive organs, the liver, and the brain, than in pure general debility ; as it is upon these functions especially, that the opposite condition of mind ex- hibits most obviously its depressing tendencies. 6. TEA YELLING AS A TONIC. This agency is merely a combination of those already treated of; but it affords so ready and efficient a method of obtaining their conjoint influ- only probably somewhat increased. (Dublin Quart. J. of Med. Sci., Feb. 1, 1864, p. 42.) Comprested Air as a Remedy. Dr. ine, extremities, cranium, etc., with or without abscess or caries; though the cure is often protracted ; though more or less of deformity may follow from the organic mischief done; and though death will sometimes take place from exhaustion, when the remedy is applied too late, or even, from the great amount of disease, notwithstanding its em- ployment, yet there are few practitioners, I presume, by whom the oil has been tried, who do not consider it more effective than any other remedy previously used, and who have not found these affections much more manageable by its means than they had been before. As in scrof- ulous swellings of the glands, there may here also be tuberculous depo- sition, which adds greatly to the difficulties and dangers of the case; though, happily, it is comparatively rare. Tabes Mesenterica, or Swelling of the Mesenteric Glands. In cachec- tic children, there is often much abdominal distension with more or less hardness, sometimes peritoneal effusion and enlarged liver, great emacia- tion, pallor, and debility, which have generally been ascribed to scrofu- lous disease of the mest-nteric glands. Some of these cases yield quickly und most happily to cod-liver oil, and co-operating treatment ; while others are more or less obstinate, and not a few end fatally. This difference of result may be readily accounted for. Some of the cases depend essen- 208 GENERAL STIMULANTS. [PART II. tially on tubercles, either scattered in the peritoneum or beneath it, or deposited in the mesenteric glands, which they enlarge and harden, or diffused throughout the whole abdomen, causing peritoneal inflamma- tion, which sometimes agglutinates all the viscera together. These are, in general, essentially incurable, except, perhaps, in a few instances, in which the tubercle, originally small in amount, may make its way, through ulccration, into the bowels, or possibly undergo absorption or degeneration. But not unfrequently, also, there are no tubercles; the scrofulous affection of the liver and mesenteric glands being simply of the characteristic inflammatory character; and cases of this kind very often end favourably. The latter cases are most common in infancy, the former in children from two to ten ; and, when adults are affected, it is most commonly in the tuberculous form. Disease of the Bronchial Glands. The same remarks arc applicable to these as to the mesenteric glands. In scrofulous cases without tuber- cle, a cure may be expected; in the tuberculous, the result is more doubt- ful, though there is reason to believe that the tubercle is sometimes eliminated through the bronchia, and that recoveries take place; but in these cases the danger arises, not so much from the tubercle in the glands, as from that deposited also in the lungs. Disease in the Stomach and Bowel*. Diarrhoea, with ulceration of the bowels, is a not unfrequent attendant on tuberculous affections. Some- times this depends on tubercles in the substance of the bowels, leaving ulcers as they are discharged; in other instances, it has been found to be unconnected with tubercles. There is reason to believe that, scrofu- lous inflammation sometimes attacks especially the mucous membranes, showing, when.it does so, a tendency to affect the follicles, and to result in ulceration of these structures. The gastric mucous membrane may be thus attacked, as well as the intestinal, though it is much more rarely tuberculous than the latter. In these cases, whether tuberculous or not, cod-liver oil is indicated whenever it can be supported by the stomach. Even when tuberculous, there may be hope of a favourable result, if the affection is confined to this part. Chronic Bronchitis, Laryngitis, Angina, Ozsena, etc. The remark* made in the last paragraph in relation to the mucous membrane of the alimentary canal, are applicable also to that of the respiratory passages. as well as of the pharynx, though tuberculization is uncommon. Hence, in chronic inflammation of the nostrils or o/ca-na, chronic angina, and chronic laryngitis and bronchitis, when connected with the scrofulous diathesis, cod-liver oil should be tried. Scrofulous Inflammation of the Serous Tissues. This often exists in connection with tubercles, as already stated in reference to the perito- neum. The pleura, pericardium, and syuovial membranes are similarly affected. Whether scrofulous inflammation occupies these tissues with- CHAP. I.] TONICS. COD-LIVER OIL. 209 out tubercles may perhaps be considered uncertain ; but analogy is in favour of the opinion that it does so; and, in relation to the arachnoid, or at least the subarachnoid tissue, and the synovial, analogy is strongly supported by facts. Extensive tuberculization of the proper serous tis- sues is almost always sooner or later fatal ; but the event may probably be postponed by the use of the oil ; and, in cases where the inflammation may be supposed to exist without tubercle, the remedy would probably prove occasionally curative. Hence, in chronic cases of these affections, the oil should be employed, not only to correct the diathesis as far as possible in the positively tuberculous cases, but as a curative measure, in the hope that the symptoms may depend simply on inflammation. I have seen cerebral symptoms in infancy, which seemed strongly to threaten chronic hydrocephalus, and were associated with other evi- dences of scrofulous cachexia, yield happily to this remedy. Phthisis. The principles upon which cod-liver oil is given in this com- plaint have been already stated. All that can be hoped for from it is, by improving the constitution, to correct the tendency to the deposition of tubercle, and to support the system during the exhausting process of its discharge. Unfortunately, the diathesis is often so strong, so inti- mately incorporated as it were with the inherited constitution of the pa- tient, that no known influence is sufficiently powerful to eradicate it; and, though it may be postponed, the fatal result is in most cases inevitable. This much, however, may be said in favour of cod-liver oil, that no one medicine, and no combination of medicines are known, which nearly equal it in efficacy. I believe that, if used before tubercle has been pro- duced, it will not unfrequently prevent it; that, even after a moderate amount has been deposited, it will sometimes arrest its progress, and ultimately save the patient ; and that it may, in some few cases, even in the advanced stage of the disease, and after cavities have been formed, rescue from death, if the quantity of tubercle already existing be not suf- ficient fatally to disorganize the lungs. Of this I have no doubt, that, if begun with early, and used perse veringly, with the aid of other measures calculated to invigorate the general health, it is capable of considerably diminishing the amount of mortality from this fearful disease. All agree that it will often prolong life, when unable to preserve it, and that it very much contributes to the comfort of the patient, especially in the advanced period of the complaint There is no stage, from the beginning to the close, in which it may not be given with reasonable hope of benefit. The misfortune is, that it is often given insufficiently, being abandoned too early, or taken irregularly, or in too small a quantity ; and that pa- tients, in consequence of its unpleasant effects on the palate or the stom- ach, will not, or, from the irritability of that organ, cannot take it in the requisite amount, or for the requisite length of time. No material effect need be looked for under two or three weeks; and it should not be aban- VOL. i. 14 210 GENERAL STIMULANTS. [PART II. doned, unless after a totally fruitless trial of six weeks or two months. When found useful, it should be persevered with for months or years ; and, even after the apparent restoration of health, the least sign of relapse should be the signal for its resumption. In the inherited cases, there is a natural proclivity to the disease, which, though it may be corrected for a time, will again and again evince itself when the restraining cause is removed; and the only chance of safety is in the unremitting use of the proper measures, even when symptoms of disease have disappeared, until, in the spontaneous changes which the system undergoes in the advance of life, the original tendencies may have been subverted. But it is not in the scrofulous affections only that cod-liver oil is use- ful. There are other diseases, connected with a cachectic condition of the system, in which it has enjoyed much reputation. Chronic Rheumatism. This is one of the complaints in which the oil was first used. It has been particularly recommended in chronic lum- bago and sciatica, and in obstinate swellings and deformities of the joints. It is no doubt beneficial in some of these cases ; but I think it highly probable that not a few of the latter, which were taken for rheu- matic, were really scrofulous, and that the remarkable efficacy of the oil may be in part ascribed to that cause. In the Pennsylvania Hospital, I have repeatedly witnessed cases of obstinate and painful swellings of the knee, ankle, or hip, which may possibly have been at first rheumatic, and had been treated as such for months without success, which were attended with great emaciation, a frequent pulse, night-sweats, and other evidences of debility, and were going on in a steady course of de- terioration, that threatened death in the end. These cases, under the impression that they were really scrofulous, having either been such in the beginning, or assumed this condition in their progress, I have treated with cod-liver oil, aided by rest, nourishing food, and auxiliary medicines, as iron, quiuia, and iodide of potassium, and with the happiest results. At the usual period after the commencement of the remedy, they have begun to exhibit signs of amendment, and have gone on, steadily though gradually, to a perfect cure. How much of the result was ascribable to the oil, and how much to the auxiliary measures, it would be difficult to decide; but my impression on the whole is that, without the oil, I should have been much less successful. The remedy has been recommended in chronic gout, but is less efficacious. Rickets. Perhaps in no disease does the oil display greater powers than in this, occurring in early childhood. Infants, affected with the disease, often begin to improve in a few days under its use, and rapidly advance to complete recovery. Besides the affections above mentioned, the oil may be used in chronic anaemia and chlorosis, in paralysis with debility, and in various nervous affections associated with impoverished blood. It has sometimes proved CUAP. I.] TONICS. COD-LIVER OIL. 211 beneficial in neuralgia, probably from this cause. Amenorrhcea has sometimes yielded to it; probably through its influence over the blood- making function. Contraindications. It is contraindicated in an inflamed and irritable stomach, a plethoric state of the circulation, and active local congestion; and when, in the course of its administration, these conditions may occur, either accidentally, or as a result of its operation, its use should be suspended for a time. This caution it is particularly necessary to observe in phthisis, in which, though it is highly important that the blood should be of good quality, yet in quantity it must bear a due rela- tion to the reduced capacity of the lungs; as otherwise it might endanger inflammation or hemorrhage. Administration. For an adult, a tablespoonful three or four times a day is about the proper dose ; and for an infant, a teaspoonful as often ; and this quantity should always be aimed at. Some can take the oil out of the spoon without inconvenience; but generally it is desirable to obviate the disagreeable taste by some addition. This may often be done sufficiently by taking an aromatic substance into the mouth, im- mediately before and immediately after the medicine. Orange-peel has been particularly recommended for this purpose ; so also has strong coffee, without cream or sugar, in the quantity of a teaspoonful. The addition of ten per cent, of common salt is said to conceal its taste ef- fectually; but so large a proportion as this might sometimes act injuri- ously on the stomach or the blood. The oil may also be taken floating in an aromatic water, as -that of cinnamon, or one of the mints. But probably the best vehicle, on the whole, is a little frothy porter or ale, which covers the taste very well, and is usually not contraindicated. In hectic cases, the dose of oil may sometimes be advantageously ad- ministered in a wineglassful of wild-cherry bark tea. When the stomach is very delicate, it may be given in the form of emulsion, made with an aromatic water; and, when it cannot be otherwise taken, gelatin cap- sules containing it may be resorted to.* * Various preparations of cod-liver oil, in which it holds other medicines in solu- tion, have been recommended and employed. Such are the quinated cod-liver oil, in which it is impregnated with quinia in the alkaline state; l\ie ferruginous oil, in which powdered iron or the recently prepared protoxide are dissolved in the oil ; and the iodized oil, in which it is incorporated with iodine ; but none of these combinations have peculiar virtues; and, when any of the medicines mentioned are indicated in connection with the oil, it ia better to administer the two separately; as the pecu- liar management which each may require cau be thus better regulated. (Note to ttu second edition.) Volatile oil of bitter almonds has been found by M. Jeannel, after numerous ex- periments, entirely to destroy the offensive smell and taste of cod-liver oil. The quantity required for the purpose ia in proportion to the offensiveness of the oil. One grain of the volatile oil will completely disinfect half a troyounce of the moe* 212 GENERAL STIMULANTS. [PART II. It has been recommended to employ the oil externally, by friction, with a view to its constitutional impression; but in this way it would be too offensive for ordinary use, and should be resorted to only when the stomach entirely rejects it. With a view to its local effect, it has been applied to the eye in scrofulous ophthalmia, and to the skin in eruptive complaints. II. TONICS OF VEGETABLE ORIGIN. The vegetable tonics may be subdivided into three sets; namely, 1. the pure bitters, 2. the bitters with peculiar properties, and 3. the aromatics. 1. Pure Bitters, or Simple Bitters. These are characterized by bitterness with little or no intermixture of other taste, and by a purely tonic power, which is identical or nearly so in all. There appears to be a close relation between the bitter and tonic properties; so much so, that the possession of the former may be con- sidered as prima facie evidence of the possession of the latter also. Cullen, indeed, believed this connection to be essential, and taught that it was the tonic power of bodies that gave them bitterness. Bitter sub- stances might have other powers in addition, such as the narcotic and purgative, which might prevent their use in reference to their tonic property, but they still possessed it. He even seems to have thought that the bitterness might reside in a single principle of peculiar compo- sition. This, however, has been shown not to be true. A great number of proximate bitter principles have been discovered, very different in offensive cod-liver oil; but this might injuriously affect the influence of the medi- cine by adding its own sedative action. Not more than one-qunrter or at most one- half of the quantity would be admissible; and the smaller dose would probably be sufficient for any ordinary oil. M. Jeannel, however, thinks thnt the best agent for the purpose is cherry-Inure! water; and it is sufficient to shake the oil with its volume or at most twice its volume of the distilled liquid. The effect is in either case owing to the hydrocyanic acid present; and I have no doubt that the wild- cherry bark tea, referred to in the text, acts in the same way. (Journ dt Fharm. tt de Chim., 3e se>., xxxviii. 360.) In cases in which, though swallowed, the oil is soon afterwards rejected by vomit ing, M. Vigla asserts that he has uniformly found this effect to be obviated by admin- istering to the patient, after he has swallowed the medicine, eight or ten grains of calcined magnesia. (Ibit, 3e s6r , xli. 248.) Extract of Cod-liver. A preparation claiming to be an extract of cod-liver, and which, on chemical examination, has been found to contain all the principles of the oil, excepting oily matter and glycerin, has been brought before the notice of the profession as a substitute for the oil. But too little is yet known of it to justify its adoption among officinnl remedies (Chem. News, Jan. 5, 1866, p. 10.) Notes to the third edition. CHAP. I.] TONICS. SIMPLE BITTERS. 213 composition and chemical relations. Yet I am inclined to think that there is some ground for the opinion of the identity of the two prop- erties. It is easy to conceive that the same arrangement or shape of particles which causes the impression of bitterness on the organs of taste, may give rise to the tonic impression upon the stomach; and that, though all bitters may not seem to be tonic, this may be owing, not to the want of the property, but to the possession of other powers of affecting the system, so influential as completely to overwhelm and con- ceal it. Nux vomica is tonic in small doses ; but, largely given, produces a peculiar effect on the nervous system which quite obscures the tonic. Even quinia, in very large doses, loses apparently all its tonic powers, in its overwhelming influence upon the nervous centres. The same may be the case with other bitters of great medicinal energy, such as colo- cynthin, elaterin, digitalin, morphia, etc. If reduced in their dose so as. to be unable to produce their more powerful and characteristic effect, it is very possible that they might prove tonic to the digestive organs. Effects on the System. The effects of the simple bitters are to increase the appetite, invigorate digestion, and moderately to exalt the nutritive function. They have little direct influence on the circulation, and per- haps none upon the nervous system. The proper cerebral functions do not appear to be affected by them in any degree, unless in so far as these may be influenced by the condition of the others mentioned. Their main operation is directly upon the mucous surface of the alimentary canal ; and their general tonic effects may be ascribed chiefly to the increased quantity, and improved quality of the blood, resulting from the stimu- lated digestion. It is probable that a stimulant effect is extended sympa- thetically from the gastro-intestinal surface to the liver and pancreas, upon the same principle as that by which the presence of chyme in the duodenum excites these organs. It is possible that the bitter principles may be absorbed, and, through the circulation, act on the nutritive func- tion everywhere ; but this has not been proved in relation to the set of substances now under consideration. One evidence that their direct operation is mainly upon the digestive organs is offered by the fact, that, when they are taken largely, so as to prove irritant, their increased effecte are exhibited in those organs, and not directly elsewhere. The simple bitters are apt, in over-doses, to prove laxative, and sometimes nauseate and even vomit; but they do not disturb the heart, nor the cerebro- spinal system, nor any other part of the body, unless in so far as these may feel the condition of the digestive organs. Therapeutic Application. The simple bitters are especially appli- cable to cases in which the indication is to promote the digestive func- tion. In pure dyspepsia, they are, upon the whole, the best tonic reme- dies in our possession. By moderately stimulating the stomach, they probably favour the secretion of a healthy gastric juice, capable of dis- _>14 GENERAL STIMULANTS. [PART II. solving the food, and thus obviate the stomachic uneasiness, flatulence, and sour or acrid eructations, resulting from the irritation of undigested matters, of substances generated by the chemical reaction of these mat- ters, and probably also of the unhealthy secretions of the weakened stomach itself. They extend a similar stimulant influence to the torpid bowels, and probably also to the torpid liver, thus still further favouring the digestive function. Even in deficient action of the bowels and of the liver, unattended with symptoms of proper dyspepsia, they are often use- ful, particularly in combination with remedies more especially addressed to those functions. Hence their use as adjuvants to laxatives in consti- pation, and to cholagogues in jaundice depending on hepatic torpor. From their usefulness in debility of digestion, it follows that good may be expected from them in all those disorders of sensation and function .having their root in this affection. Hence, they are among the most efficacious remedies in headache, vertigo, and other deranged cephalic sensations, connected with excess of acid in the stomabh ; in which cases they should be given combined with an antacid, as magnesia when there is costiveness, chalk when there is diarrhea, the alkaline carbonates or bicarbonates when there is neither, and aromatic spirit of ammonia when there is great gastric insensibility. The simple bitters are also well adapted to the debility of conva- lescence from acute diseases, whether general, as fevers, or local, as cholera, dysentery, and other affections of the alimentary canal. When- ever, under these circumstances, the original disease has been removed, and the appetite remains feeble, and the digestive powers insufficient for the management even of the food that may be taken, the gentle stimula- tion of the simple bitters is indicated, and will often contribute to the restoration of health. In all cases of general debility, and of impaired blood, originating in or connected with simple weakness of the digestive function, these medi- cines may be used with the hope of benefit ; and they are often profitably combined with other to/nics, which exercise a more powerful direct influ- ence over the system at large. They were formerly employed in intermittent and remittent fevers; being administered, in the absence or decline of the fever, as antiperio- dics, and were supposed to be peculiarly applicable to cases in which the apyrexia was not sufficiently complete for the use of Peruvian bark. But, since the discovery of quinia, this use of the simple bitters has been in great measure abandoned. They have been supposed to possess anthelmintic properties; and are no doubt occasionally useful in verminose cases. Some have supposed them to operate by poisoning the worms; and experiment 1ms shown that some of them are noxious to inferior animals; but the probability is, that they do good much more by giving proper tone to the bowels, and CHAP. I.] TONICS. QUASSIA. 215 thus removing the condition favourable to the development of the worms, than by a direct action on the parasites themselves. They are more frequently given as adjuvants of other medicines than by themselves. They are indicated, in this way, whenever weakness of the digestive function is complicated with the special disease prescribed for. Reference has already been made to their combination with laxa- tives in constipation, with the mercurial preparations in jaundice, or other cases of torpid liver, and with other tonics in general debility, as with the chalybeates in anaemia. In the various nervous affections, they are often useful in conjunction with the metallic tonics and the nervous stimulants, in dropsy with diuretics, and in amenorrhoea with emmena- gogucs. The different forms in which they are prepared, as those of powder, extract, infusion, and tincture, afford facilities for these combi- nations, which should not be overlooked in prescription. When given in chief, they are themselves often aided by the addition of aromatics, as of ginger, orange-peel, etc., which render them more stimulant to the stomach when very languid, and more easily retained by it when irritable. The different simple bitters are so similar in their effects, that they may be given indiscriminately; one being preferred to another according to convenience, the choice of the patient, or the existence of some idiosyn- crasy which may render any one or more of them inadmissible. I. QUASSIA. U.S.,Br. Origin. Quassia is the wood of Quassia excelsa (Simaruba excelsa, De Cand.; Picrsena excelsa, Liiidley), a lofty tree growing in Jamaica and other West India islands ; and of Quassia amara, a small tree or shrub inhabiting Surinam. At present, little or none from the latter source is imported. Properties. Quassia is brought to as in billets, with the bark generally attached; but, as kept in the shops, it is in the form of raspings or shav- ings, or split into small pieces. The wood is light, porous, yellowish, inodorous, and of an intense, unmixed, and adhesive bitterness. Active Principle. This is a peculiar, bitter, crystallizable principle, named quassin. Chemical Relations. Quassia yields its virtues to water and alcohol. Its chemical relations are such as not to interfere with the use of any other medicine, with which it may be desirable to associate it in pre- scription. It is asserted to have the property of opposing, in some de- gree, though it will not altogether prevent the putrefaction of animal substances. Therapeutic Application. The use of quassia as a medicine originated 216 GENERAL STIMULANTS. [PART II. in Surinam, in South America. It was introduced into Europe in the year 1756, but was not made generally known until the publication of a dissertation by Linnaeus in 1763, after which it came quickly into gen- eral use. It was at first supposed to have virtues closely analogous to those of Peruvian bark, and was employed in intermittent and remittent fevers, and sometimes also continued fevers, in the low forms of which its antiseptic properties were thought to render it useful. It was con- sidered as especially applicable to cases in which, in consequence of irri- tability of stomach, the more powerful febrifuge could not be retained. But this use of quassia has been abandoned. It is now generally admit- ted to be nothing more than a simple bitter, and to be applicable only to affections in which the tonics belonging to this last subdivision are indi- cated. Quassia is asserted to be noxious to insect life. Employed in cabinet- ware, it is said to afford protection against insects, and the infusion has been used as a fly-poison. A grain of the alcoholic extract, inserted into a wound in the leg of a rabbit, is said to have caused the death of the animal on the third day, without any signs of inflammation ; and from this, and other observations made of its effects on other animals, and on man, it has been supposed to have narcotic properties ; but I have never witnessed any effect of this kind, or anything approaching it; and do not believe that it has the least special influence on the brain. In over- doses, its only known effects are to irritate the stomach and bowels. The uses of quassia are those of the simple bitters generally, of which it is probably the purest and most powerful. For an account of these, the reader is referred to the general remarks on this sot of substances. (See page 213.) It is sufficient here to state that the medicine is applicable to all cases of simple weakness of the digestive organs, being much 1 in dyspepsia, and the debility of convalescence, especially that of febrile diseases and disorders of the alimentary canal, after the entire subsidence of inflammatory action. In consequence of its noxious influence on worms, it has been em- ployed, in the form of enema, in the treatment of ascarides, and with asserted success. A decoction, made by boiling half an ounce of it in a pint of water, has been used for this purpose. Administration. Quassia has been little used in the form of powder. Some dyspeptic patients, who have no objection to its bitterness, carry the wood along with them in small pieces, and chew it habitually with advantage. But care must be taken that this habit do not grow into an abuse. . The Infusion (!NFUSUM QUASSL/E, U. S.) is the preparation in which it is most frequently administered. This is made in the proportion of two drachms to a pint of water. Either cold or hot water may be used, the former making a clearer infusion, the latter acting more rapidly. CHAP. I.] TONICS. SIMARDBA. 217 The officinal Extract (EXTRACTUM QUASSIAS, U. S.) is a very efficient preparation, and is preferable when it is desirajl to administer the med- icine in the form of m|L It is a watery extract, and probably stronger, in a given a weight, tnan any other preparation of the simple bitters. It is very convenient for combination with other medicines in the pilular form ; such as the chalybeates, aloes and rhubarb, myrrh, mercurial pill or calomel, etc. The Tincture (TINCTURA QUASSLJE, U. ) is also officinal, and is re- sorted to, in cases of considerable insensibility of stomach as an addition to the infusion, to other tonic infusions or decoctions, and to liquid pur- gative preparations. The dose of the powder is twenty or thirty grains, of the infusion two fluidounces, of the extract from two to five grains, of the tincture one or two fluidrachins ; each, three or four times a day. II. SIMARUBA. U.S. Origin. This is the bark of the rof Quassia Simaruba (Simaruba officinalis, De Cand.), a tree of considerable size, growing in the West Indies, and in Guiana. Properties. It is in long flat pieces, folded longitudinally, fibrous flexible and tenacious, yellowish internally, inodorous, and very bitter, without admixture of other taste. It yields its taste and medical virtues to water and alcohol. Active Principle. It owes its virtues to the same bitter princ^ile found in quassia. Therapeutic Application. Simaruba was first introduced into Europe from South America in the year 1713, as a remedy in dysentery, diar- rhea, and the hemorrhages; and acquired great reputation in these com- plaints. With our present experience, it can be admitted to have been useful in these affections only when complicated with a debilitated state of the alimentary canal, or of the system, calling for the use of tonics ; and, as there are other remedies more efficient under these circumstances, it has fallen into almost entire neglect. It is in fact a simple bitter, hav- ing nothing peculiar in its action, and so closely analogous in properties to quassia, that it may be looked on as identical with that medicine in its effects and applications. It is usually administered in the form of infu- sion, which may be made in the proportion of two drachms of the bark to a pint of water, hot or cold, and given in the dose of two fluidounces three or four times a day. 218 GENERAL STIMULANTS. [PART II. III. GENTIAN. GENTIANA. U. S., Br. Origin and Sensible Properties. Gentian is the root of Oentiana lutea, and of some other species of Gentiana, herbaceous perennials, growing in the mountainous regions of Europe. It is usually several inches in length, tapering, occasionally branching, sometimes longitudinally sometimes transversely sliced, spongy, wrinkled spirally, grayish-brown externally, yellowish or brownish-yellow internally, of a feeble peculiar odour, and an intensely bitter, slightly sweetish taste. Chief Constituents. The root contains a peculiar bitter principle called gentianin, on which its tonic properties depend; a peculiar organic acid, called gentisic acid or gentisin, which is without effect on the system; a minute proportion of volatile oil, uncrystallizable sugar, gum, pectin, etc. Chemical Relations. Gentian yields its bitterness and medical virtues to water and alcohol. Containing no tannic or gallic acid, it may be asso- ciated in prescription with the salts of iron; but, in consequence of its mucilaginous matter or pectin, it gives precipitates with the acetate and subacetate of lead; and sulphate of zinc occasions a slight flocculent de- posit with the hot infusion. Tannic acid causes a bulky precipitate. Sulphuric, citric, and probably other acids sensibly diminish its bitter- ness. The addition of alkalies does not affect the bitterness; but causes the infusion to gelatinize on standing. (Procter.) In consequence of its saccharine matter, the infusion undergoes the vinous fermentation on the addition of yeast, and by distillation yields a spirituous liquor, said to be used as drink in Switzerland. Effects on the System. Gentian has all the characteristic physiological effects of the simple bitters, being, perhaps, somewhat more excitant to the circulation than most of them. It is said to render the perspiration and urine bitter; and hence its active principle is inferred to undergo absorption. In over-doses it is liable to produce nausea and vomiting, and to act also on the bowels. According to Planche, the djstilled water of gentian occasions violent nausea and a kind of intoxication. Therapeutic Application. Gentian was known by the ancients, and has ranked among standard remedies from a period anterior to the Chris- tian era. It is applicable to all the purposes for which the simple bitters are used, and is among those most employed. (See page 213.) As it is thought to be somewhat more excitant than the others, it should be used more cautiously when there is any suspicion of febrile action or gastric inflammation. Its chief employment is as a stomachic in feeble digestion and defective appetite, either original, or connected wi^i, or consequent upon other diseases. As an ingredient in the Portland powder, it was CHAP. I.] TONICS. GENTIAN. 219 at one time much used in gout; but it is indicated in this complaint only when complicated with dyspeptic symptoms, and even then should be used cautiously, lest it may prove too heating and otherwise excitant. At one time it was thought to be febrifuge; and Dr. Cullen, in his Treatise on Materia Medica, states that, mixed with equal parts of tor- mentil or galls, and given in sufficient quantity, it had not failed in any intermittents of his own country in which he had tried it; but it would command little confidence at present in the treatment of miasmatic in- termittents. Locally, the powder has been used as a gentle stimulant in malignant and sloughing ulcers, and to maintain the discharge from issues ; and the root, from its property of swelling with absorbed moist- ure, has been employed as a tent for enlarging stricturedvpassages. Administration. Gentian is given in powder, infusion, extract, wine, or tincture. The officinal Infusion (!NFUSUM GENTIANS COMPOSITUM, U. ) is made with half an ounce of the root, a drachm of bitter orange-peel, and a drachm of coriander, to a pint of menstruum, containing two fluid- ounces of alcohol and fourteen of water. It is, therefore, a very feeble tincture, and should be used only when, in addition to the effects of a pure bitter, a somewhat more stimulant impression is indicated. The use of the alcohol is to extract the bitterness more thoroughly, and to enable the infusion to keep better. When this is made with water alone, especially with hot water, it spoils readily, in consequence probably of the pectin and mucilage it contains. This disadvantage may be in some degree obviated by the use of cold water, which dissolves less of the principles referred to. The most elegant method of preparing the infu- sion is undoubtedly by percolation with cold water, by which the bitter- ness may be sufficiently extracted ; and the Pharmacopoeia has adopted this plan, using, however, the alcohol with the menstruum. When the infusion is wanted hastily, and is not required to be kept long, it may be most conveniently made with hot water. A combination of senna, gen- tian, and one of the aromatics, in infusion, is well adapted to cases of dyspepsia with constipation. The Watery Extract (EXTRACTUM GENTIANS, U. S.) is a good prepa- ration, and is very much used in the form of pill, either alone, or com- bined with chalybeates, laxatives, etc. Though much weaker than the extract of quassia, it is more convenient for making pills in consequence of its tenacity. The Fluid Extract (EXTRACTUM GENTIANS FLUIDUM, U. ) is a preparation peculiar to our Pharmacopoeia. It is in fact a concentrated tincture, and may be given in the dose of from ten to forty minims. The Compound Tincture (TINCTURA GENTIANS COMPOSITA, U. S.) is prepared with the addition of orange-peel and cardamom. It is an ex- cellent tonic and stomachic tincture, and was formerly much used, not only 220 GENERAL STIMULANTS. [PART II. in debilitated conditions of the stomach, but also in health, as an addition to wine before dinner, under the impression that it promoted digestion, and increased the strength. It was called wine bitters. In the present state of medical knowledge, it will be generally admitted that this prac- tice could do only harm. Indeed, the bitter tinctures generally require to be used with much caution, even in dyspeptic cases, lest incurable habits of intemperance should be formed. Many a drunkard, in former times, could trace his bad habit back to the use of one of these tinctures, originally perhaps prescribed by his physician. The Wine of Gentian (YiNUM GENTIANS), formerly directed by the Edinburgh Pharmacopoeia, has been very properly abandoned in the British, as there is no occasion for it. The dose of the powder is from a scruple to a drachm ; of the infusion one or two fluidounces ; of the extract from ten to thirty grains ; of the tincture one or two fluidrachms; of the wine half a fluidounce to a fluid- ounce. Subordinate to gentian, and closely analogous to it in properties, are several medicines derived from plants belonging to the same natural family of Gentianace, which merit a brief notice. 1. CHIRETTA. U. S. CHIRATA. Br. Chiretta or chirayta consists of the herb and root of Agathotes Chirayta (Don.), an annual plant, growing in Nepaul and other parts of Northern India. It is imported in bundles consisting mainly of the stems, with portions of the root attached. It is inodorous and extremely bitter, and yields its bitterness and medical virtues to water and alcohol. MM. Lassaigne and Boissel have ex- tracted from it a yellow bitter matter, upon which its virtues no doubt depend, but which cannot be considered as a pure proximate principle. The medicine has been long used in Bengal, but has only recently been introduced into Europe and this country. It possesses the properties of the simple bitters, and probably no other; though supposed by some to be more disposed to act on the liver and bowels ; being nauseating and laxative in large doses, and asserted to produce bilious stools. In India it has been employed as a febrifuge in intermittent and remittent fevers, as a cholagogue in torpor of the liver, and as a laxative in habitual con- stipation ; but it probably acts, in all these cases, as gentian and the other simple bitters. Like them, too, it may be used in the anorexia of convalescence, feeble digestion, and general debility connected with inertness of the prima? via. The dose of the powder is twenty irrains; of an infusion made in the proportion of half an ounce of the herb to a pint of hot water, one or two fluidounces; of the tincture (Tinctura Chiratse, Br.), one or two fluidrachms. CHAP. I.] TONICS. AMERICAN COLUMBO. 221 2. AMERICAN CENTAURY. SABBATIA. U. S. This is the herb and root of Sabbafia angularis, an indigenous, annual or biennial plant, growing in the Middle and Southern States, and collected for use when in flower. The leaves are so small, and shrink so much in drying, that the dried herb seems to consist mainly of the stems, with a few shrivelled flowers at the end. American centaury is inodorous and strongly bitter, and yields all its virtues to water and alcohol. It has long been popu- larly used, in this country, as a remedy and prophylactic in intermittent and remittent fevers, and has enjoyed, to a considerable degree, the con- fidence of some practitioners. But it has no special virtues in these affections, in which it acts as a simple bitter, like gentian and quassia, for which it may be substituted in dyspepsia, the debility of convalescence, etc., when on any account more convenient. The dose of the powder is from thirty grains to a drachm. The infusion, which is the most con- venient form, and may be made in the proportion of an ounce to a pint of boiling water, is given in the dose of two fluidounces, which, in the remission or intermission of miasmatic fever, should be repeated every two hours, in other cases three or four times a day. 3. EUROPEAN CENTAURY. CEXTAURIUM. Ed. This is often called lesser centaury (centaurium minus), and consists of the flowering tops of Ery/hrasa Centaurium (Persoon), Chironia Centaurium (Linn.), a small annual plant, growing wild in some parts of Europe. Its medi- cinal virtues are said to have been known to the ancients. They are the same as those of gentian, for which it is sometimes employed as a sub- stitute in its native country. In the United States it is scarcely known ; its place being supplied by our indigenous centaury, which resembles it so closely as to have received the same name from the earlier settlers. The dose and mode of preparation are the same as those of the preceding article. 4. AMERICAN COLUMBO. FRASERA. U. S. This is the root of Frasera Walleri (Michaux), Frasera Carolinensis (Walter), an elegant, indigenous plant, growing profusely in our Western and South- Western States. Its long, spindle-shaped, fleshy root, being cut into transverse slices and dried, bears a slight resemblance in appearance to columbo, whence, and from a supposed resemblance in medical properties, it derived its common name. Sometimes the root is sliced longitudinally, and thus somewhat resembles gentian, to which it is botanically allied, belonging to the same natural family. It has a yellowish colour, and a bitter, sweetish taste, and yields its virtues to water and alcohol. The bitterness is much less intense than that of gentian; and, though similar in properties, the medicine is not so powerful. The fresh root is said to operate as an emetic and cathartic; but this probably happens only when it is largely administered; and the same is to some extent the case with most of the simple bitters It may be used as a mild tonic, '222 GENERAL STIMULANTS. [PART II. either in substance or infusion. The dose of the powder is from half a drachm to a drachm ; of the infusion, made with an ounce of the bruised root to a pint of boiling water, two fluidounces. IV. COLUMBO. CALTJMBA. U. S., Br. Origin and Properties. Columbo is the root of Cocculus palmalus, a climbing plant, growing in the forests of Mozambique, on the south- eastern coast of Africa. As brought into the market, it is in transverse slices, circular or oval, from one to two inches in diameter, usually three or four lines thick, consisting of a thick exterior cortical portion, with a brownish wrinkled epidermis, and of an interior medullary portion, light, spongy, and more or less shrunk. The cut surface is yellowish, with a greenish tinge near the circumference, of a feeble somewhat aro- matic odour, and a very bitter taste, which is strongest in the cortical part. The powder is greenish when fresh. Active Principles. The root contains two bitter principles on which its virtues depend ; one peculiar to it called columbin, the other sup- posed to be identical with berberina, an alkaloid found in Berberis vul- garis. Besides these, there are a peculiar volatile oil, in small propor- tion, albumen and starch in large quantity, and other principles of leas importance. Chemical Relations. The bitterness and medical virtues of columbo are extracted by water and alcohol. The infusion, prepared either with hot or cold water, is precipitated by tincture of galls, and the acetate and subacetate of lead ; but the bitterness is not affected. No precipi- tates are produced by the salts of iron, zinc, or copper, nor by tartar emetic or corrosive sublimate. Tincture of iodine does not affect the infusion prepared with cold water, but gives to the decoction or hot infusion, after cooling, a blue colour. Effects on the System. Columbo has the properties of the simple bit- ters, with the advantage over several of them, that it is less heating and .-tiuiuhuit, and less apt to irritate the stomach. Buchner states that a grain of the ethereal extract, introduced into a wound in the leg of a ral>- bit, caused the death of the animal in ten hours; and hence it has been inferred that the root might possess narcotic properties; but this is much too narrow a basis for the support of such an opinion. I have never seen the slightest appearance; of narcotism from the use of columbo, though I have prescribed it very frequently and freely. It is probably nothing more than a simple bitter, somewhat qualified by the minute pro- portion of volatile oil contained in it, which, however, can scarcely have CHAP. I.] TONICS. COLUMBO. 223 any other effect than possibly to render the medicine more acceptable to the stomach. Therapeutic Application. This root is said to have been long em- ployed, in bowel affections, by the natives of the country where it is produced. The first published notice of it was by Francis Redi in 1685; but it was not until after the publication of Dr. Thomas Perceval's Med- ical Essays, in 1773, that it came into general- use. It may be employed for all the purposes to which the simple bitters generally are applied (see page 213), with this advantage, that, in consequence of its mild- ness and acceptability to the stomach, it may sometimes be advanta- geously given when others prove offensive. The affection to which it is best adapted is probably dyspepsia. I have found few medicines more efficient in this complaint, when complicated with constipation and flatu- lence, than a compound infusion prepared with half an ounce of bruised columbo, half an ounce of ginger, a drachm or two of senna, and a pint of boiling water. A wineglassful should be taken before breakfast; if this do not open the bowels, another before dinner; and if this fail, a third in th<' evening. I have found the combination also promptly successful in severe gastralyic pains attendant on an enfeebled stomach. Even when there is reason to suspect the coexistence of some degree of chronic in- flammation with dyspepsia, columbo is not always contraiudicated; though its use requires more caution. In gastric irritability, uncon- nected with active congestion or inflammation, it is thought by some to have the effect of composing the stomach ; and hence it has been recom- mended in the vomiting of pregnancy or hysteria, bilious vomiting, eic.; but I have no experience with it in these affections. It has also been i -specially recommended in the declining stages, or the imperfect conva- lescence of remittent fevers, and of various affections of the primal viae, as cholera morbus, cholera infantum, diarrhoea, dysentery, etc., under circumstances requiring the use of tonics. Administration. Columbo is sometimes given in the form of powder, which may be combined with ginger, subcarbonate of iron, or rhubarb, when one or more of these medicines is indicated. The infusion, how- ever, is generally preferable. The officinal Infusion (!NFUSUM CALUMB^E, U. 5.) is made with half an ounce of the bruised or coarsely powdered root and a pint of water. The present U. S. Pharmacopoeia prepares it preferably by percolation; and this may be followed by the apothecary; but the old method of maceration is more convenient extemporaneously. It is a question for consideration whether the water should be cold or hot. The infusion is apt to spoil quickly; depositing a considerable quantity of insoluble matter, becoming more or less ropy, and acquiring a disagreeable taste. This tendency has been ascribed to the use of boiling water, by which the starch is di>- jived. Hut it has been found that the infusion made 2'24 GENERAL STIMULANTS. [PART II. with cold water is also liable to change, even more so, according to one observer, than the hot, though this does not exactly accord with my own observation. If cold water does not dissolve the starch, it does dissolve the albumen, which boiling water coagulates and renders insoluble ; and, as albumen undergoes decomposition very readily itself, and promotes the decomposition also of other associated substances, it may be readily understood why the infusion prepared with cold water will not keep well. To obviate both these difficulties, the infusion may first be pre- pared with cold water, by which the starch is left behind, and then quickly raised to the boiling point, so as to coagulate the albumen dis- solved, which may then be separated by nitration. This nicety, how- ever, is necessary only when the infusion is required to be kept for several days. The most convenient method is to prepare it with hot water, and in small quantities at a time, as wanted for use. When cold water is employed, a much greater length of maceration is required, not less than twelve hours, unless the process of percolation be resorted to. The infusion of columbo may be appropriately combined with the solu- ble salts of iron, zinc, or copper, or with corrosive sublimate when in- dicated ; but not with the salts of lead. Free iodine should not be given with the hot infusion. There is an officinal Tincture of Columbo (TmcTURA CALUMB^E, U. S.), which may be used like the other bitter tinctures, and is liable to the same objections. (See Compound Tincture of Gentian, page 219.) The BritiKh Pharmacopoeia directs an extract (EXTRACTUM CALUM- B^E, Br.), which, being prepared with diluted alcohol, is free from the inert starch and albumen, and may be given in the dose of from five to fifteen grains three times a day. The small proportion of volatile oil contained in the root is mainly driven off in the process of evaporation; but the loss of it is probably of little importance. The dose of powdered columbo is from ten to thirty grains ; of the infusion, two fluidounces; of the tincture, from one to four fluidrachms; in each case, to be taken three or four times a day. From the simple bitters above described, all the effects which this subdivision of tonics is capable of producing may be obtained; but there are three others, of indigenous growth, which, though less frequently used, deserve a brief notice, as they are scarcely less efficacious, and may sometimes be found convenient. 1. GOLDTHREAD. Corns. U. S. This is the product of Coptis trifolia, a very small plant, with a per- ennial creeping root, inhabiting low and shaded places in the northern parts of this continent, and of Asia. It is abundant in our own Northern CHAP. I.] TONICS. PECULIAR BITTERS. 225 States. All parts of it have some bitterness, which, however, is strongest in the root; and this is the portion directed by the U. S. Pharmacopoeia, though, as the medicine is kept in the shops, the roots, leaves, and stems are generally intermingled. The root is long, slender, thread-like, of a deep orange-yellow colour, inodorous, and intensely and purely bitter. It yields its bitterness to water and alcohol. The medicine is closely allied to quassia in its properties, and might probably be substituted for it in all cases without disadvantage ; but the smallncss of the product of each plant will always be an obstacle to its general use, unless some superi- ority of virtues can be shown. It is sometimes used, in New England, in aphthous affections of the mouth, as a local application. The dose of the powder is from ten to thirty grains ; of an infusion made with two drachms to a pint of water, one or two fluidounces; of a tincture, con- taining the virtues of an ounce in a pint of diluted alcohol, one or two fluid rachms. 2. YELLOW-ROOT. ZANTHORRHIZA. U. S. By this name is designated, in the secondary list of the U. S. Pharma- copoeia, the root of Xanthorrhiza apiifolia, an indigenous shrub, grow- ing iu the interior of the Southern, and in the Western States. Though the bark of the stem, as well as the root, is bitter, the latter only is officinal. This is cylindrical, from three inches to a foot long, about half an inch thick, yellow, inodorous, and extremely bitter, without astringency. It imparts its colour, bitterness, and medical virtues to water; and the infu- sion is not affected by the salts of iron. It may be employed in the same affections, in the same manner, and in the same dose as quassia. 3. STAR-GRASS. ALETRIS. U. S. This is the root of Aletris farinosa, a small indigenous herbaceous perennial, named from the star-like form assumed by the leaves, which spread out on the ground at the base of the stem. The root is small, branching, crooked, blackish outside, brownish within, and strongly bit- ter. It imparts its bitterness to water and alcohol, but, it is asserted, much more freely to the latter. Little is known of its composition. In small doses it acts as a simple tonic, and may be given for the same pur- poses as the simple bitters. But in large doses, like most of the article* of this class, it is apt to disturb the stomach and bowels, and is said, when taken in great excess, to have acted as a narcotic. The powder may be given in the dose of ten grains for the tonic effect. 2. Peculiar Bitters. These are medicines which, with the simple tonic powers character- istic of the pure bitters, possess others also, which modify the tonic action, and give them an influence on the system more or less peculiar. VOL. i. 15 226 GENERAL STIMULANTS. [PART II. This peculiarity may be owing either to the distinctive character of the bitter principle itself, or to some other principle or principles which may be associated with it. Thus, Peruvian bark owes its characteristic remedial virtues to the peculiarity of its bitter principles ; while serpen- taria and wild-cherry bark have other active constituents besides the bit- ter; the additional constituent being, in the one, hydrocyanic acid which is sedative, and in the other, a stimulating volatile oil. I. PERUVIAN BARK. CINCHONA. Origin. This is the bark of different species of Cinchona, trees grow- ing in South America, along the course of the Andes, extending from the northern coast near Caracas to La Paz in Bolivia, through nine de- grees of latitude, at various elevations on the mountain sides, seldom less than four thousand feet above the level of the sea. The species known to yield bark to commerce are C. Calisaya and C. Boliviano,, growing in Bolivia; C.micrantha,C. nitida, and C. ovata. inhabiting the provinces of Huamilies, Huanuco, etc., in the interior of Peru ; C. Con- daminea, C. scrobiculata, and C. succiruba, of northern Peru and Ecua- dor; and C.lancifolia, (7. cordifolia, and C. Pitayensis, of New Granada ; beside several others less known, or of Jess importance. Classification. The varieties of Peruvian bark may be arranged in two divisions ; 1. the officinal or those recognized in the U. S. Pharma- copoeia, and brought exclusively from the Pacific coast of S. America; and 2. the non-officinal, commonly designated as Carthayena barks, and exported from the northern coast of the continent. The officinal barks are divided by the Pharmacopoeia into the pale, yellow, and red; the non-officinal include the three varieties of hard Carthagena. fibrous Car- thagena, and hard Pitaya bark. Properties. Peruvian bark is in quills or flat pieces, of various dimen- sions, with or without epidermis, of a yellowish-brown, reddish-brown, reddish, or orange-brown colour in the interior, of a feeble somewhat aromatic odour in powder or decoction, and of a bitter taste varying in degree, sometimes nearly pure, but more commonly also nauseous or astringent. It yields its virtues partially to pure water, but completely to alcohol, or to water acidulated with sulphuric or muriatic acid. The several varieties require special notice. CHAP. I.] TONICS. PERUVIAN BARK. 227 1. Classification of Peruvian Barks. a. Officinal Barks. 1. PALE BARK (CINCHONA PALLIDA, U. S., Br.) is in cylindrical pieces, called quills from being rolled, from a few inches to eighteen in length, from two lines to an inch in diameter, and from half a line to two or three lines thick. The colour of the epidermis, which is always ad- herent, is light-gray, brownish-gray, or gra} r ish-fawn ; of the true bark, ^brownish, more or less deep, and inclining to red, yellow, or orange; of *the powder, pale-fawn, and sometimes dusky. The taste is moderately bitter, somewhat astringent, and not nauseous. The commercial varieties belonging to this division are 1. Loxa bark*. usually in smallish quills, derived from C. Condaminea and other species, and named from the town of Loxa, which was formerly the entrepot of the trade in them; 2. Lima or Huanuco barks, usually larger than the . preceding, derived from C. micrantha, and C. nitida, and named from the town of Huanuco in the neighbourhood of which they are gathered, or from Lima, where the trade in them centres ; 3. Jaen or ash-bark, dif- fering little in size from the Loxa Barks, named from the town of Jaen, supposed to be derived from C. ovata, and scarcely known as a distinct variety in the commerce of the United States ; and 4. Huamilies bark, of larger size, in flat pieces and quills, named from the province where it is gathered, conjecturally referred to C. pubescens, and little if at all known in our markets. 2. YELLOW BARK ( CINCHONA FLAVA, U. S., Br.), called in com- merce Calisaya Bark, is in quills and flat pieces; the former from three inches to two feet in length, from a quarter of an inch to two inches in diameter; the latter, quite flat or slightly curved, usually thicker than the quilled, and derived from the larger stems or branches. The epidermis is in general easily separable, and is often separated from the proper bark, especially in the flat pieces, which are almost always quite free from it, and, on their outer surface, show that it was removed without violence, from the mere looseness of adhesion. When present, it is of a brownish colour diversified with whitish lichens, is marked with longitudinal wrinkles and transverse fissures, and is tasteless and inert. Without it, the bark is from one to two lines thick, firm and compact, of a short fibrous fracture with shining points, and, when viewed along its length, exhibiting similar shining points, which are the ends of small transparent spicula. These spicula, when the bark is rubbed, separate from it, and prove highly irritant to the fingers, like cowhage. The colour of the bark is a fine brownish-yellow, usually with a tinge of red ; the taste, intensely bitter without astringency or nauseousness ; the powder, of a bright yellowish-cinnamon hue, often inclining to orange. The officinal 228 GENERAL STIMULANTS. [PART II. yellow or Calisaya bark is the product mainly of Cinchona Calisaya, and is obtained exclusively from Bolivia. 3. RED BARK (CINCHONA RUBRA, U. S., Br.) is, like the preceding, in quills or flat pieces; the former, completely or partially rolled, of various lengths, sometimes exceeding eighteen inches, and from less than half an inch to more than two inches in diameter; the latter, often very large and thick. The epidermis is strongly adherent, of a reddish- brown, gray, or whitish colour, wrinkled longitudinally, and sometimes warty. Beneath the epidermis is a layer, dark-red, compact, brittle, and of feeble taste. The proper bark is woody and fibrous, of a brownish- red colour, passing from deep-red to reddish-yellow, and of a taste very bitter and somewhat astringent. The colour of the powder is a fine brownish-red. The origin of this bark was till recently unknown ; at present, however, through the researches of Mr. Howard, of London, it is referred very confidently to C. succiruba of Pavon (G. ovata, var. erythrodrrma of Weddell), growing in the republic of Ecuador, on the western slope of Chimborazo. b. Non-officinal or Carlhagena Barks. 1. HARD CARTHAGENA BARK comes usually in pieces some- what regular in shape, either completely or partially quilled, or fiat, and frequently warped; the quills being from five inches to a foot long, from three to eight lines in diameter, and from half a line to a line and a half thick ; the flat, somewhat thicker, about the same in length, and from one to two inches broad. But sometimes also it comes in small irregu- larly square or oblong, flattish pieces, variously warped, and mixed with small quills or fragments of quills. The epidermis is often absent, especi- ally from the larger and flatter pieces, having been obviously scraped or pared off with a knife, and not separated, as in the Calisaya bark, by the natural juncture. When present, it is usually soft, whitish or yel- lowish, and of the character which has been called micaceous. The proper bark is of a pale, dull, brownish-yellow colour, often appearing as if rubbed over with the powder. Its texture is firm and compact; its fracture abrupt, though not smooth ; its taste bitter and nauseous. It is derived from Cinchona cordifolia. 2. FIBROUS CARTHAGENA BARK is in quills, half quills, slightly rolled, or flat pieces, of dimensions and shape not materially diU'crent from the preceding, and like that coming generally in somewhat regular forms. but sometimes in small irregular fragments. Some of the largest pieces exceed in thickness and other dimensions any that I have seen of the hard variety. The epidermis when remaining is soft, whitish or yel- lowish, and micaceous; but in the larger and flatter pieces it is gen- erally absent, being artificially removed, as in the preceding. The proper bark differs much in character from the hard variety, being very fibrous, CHAP. I.] TONICS. PERUVIAN BARK. 229 light, loose, soft, and spongy under the teeth. Its colour varies from a light brownish-yellow to an orange or red, the latter existing especially in the largest pieces. The colour of the powder is yellowish, often with an orange tint. The taste is usually bitter, but varies much in degree, being in some specimens strong, in others very feeble. The fibrous Carthagena bark bears considerable resemblance in colour to the Cali- saya, but differs greatly in its soft and spongy consistence, and in the circumstance that its epidermis has been artificially removed by the knife, instead of spontaneously separating at the natural junction. It is the product of Cinchona lancifolia. 3. HARD PITAYA BABK, or Brown Garthayena bark, as it has sometimes been called to distinguish it from the two preceding, which are sometimes designated as yellow Carlhagena bark, is usually, as I have seen it, in small irregular pieces, either quilled or flat, from one to four inches long, and from one to four lines thick. The epidermis is sometimes whitish and soft as in the other Carthagena barks, but some- times also dark brown, with innumerable cracks in different directions, giving the surface a grater-like appearance. Sometimes it is absent. Beneath the epidermis there is often a resinous layer, of a dark reddish- brown colour, and a shining surface when cut; but, though highly char- acteristic when present, it is wanting in some of the pieces. The proper bark is rather hard, compact, and heavy, closely and finely fibrous, and of a dull yellowish-brown colour with a reddish tint. It somewhat re- sembles the hard Cathagena, but differs in the resinous layer, the grater- like epidermis of many of the pieces, and the deeper and redder colour. It has a very bitter taste. It is probably the product of the Cinchona Pitayensis of Weddell. 2. Constituents and Chemical Relations. Constituents.* The most important of these are the alkaloids, quinia, cinchonia, qninidia, cinchonidia, quinicia and cinchonicia. Of these there are two distinct groups, one consisting of quinia, quinidia, and quinicia, all isomeric, and cinchonia, cinchonidia, and cinchonicia, which are also isomeric, but differ in composition from the first group. The last of each group, quinicia, namely, and cinchonicia, appear to result from the influence of heat upon the respective alkaloids with which they are isomeric, and, though they may possibly sometimes pre-exist in the bark, are more frequently the result of the chemical processes employed * Since the publication of the first edition of this work, the subject of the cin- chona alkaloids lias been carefully investigated; and a general view of the results, somewhat different from the account of these alkaloids given in the former edition, is now presented in the text. (Note to the second edition.) :>30 GENERAL STIMULANTS. [PART II. in the extraction of the others. The alkaloids are believed to exist in the bark chiefly in combination with kinic acid, in the form of soluble kinates, but partly also combined with colouring matter or tannic acid, forming compounds insoluble in water, which, therefore, is of itself in- competent to exhaust all the virtues of bark. Other constituents are a bitter substance called kinovic bitter or kinovic acid, tannic acid, a red colouring matter called cinchonic red, a yellow colouring matter, resin, gum, starch, fatly matter, kinate of lime, etc. Properties of the Alkaloids. The alkaloids are the active principles, and exist probably in all the varieties of bark, though in very different proportion. In the pale barks, cinchonia predominates; in the officinal yellow or Calisaya bark, quinia is most abundant; in the red, both these alkaloids are found in considerable proportion ; while in the more active of the Carthagena barks, quinidia exists largely. Quinia, which may be obtained by decomposing the sulphate by means of an alkali, is whitish, flocculent, crystallizable with difficulty, inodorous, and very bitter. It is fusible by heat without chemical change, is very slightly soluble in cold water, somewhat more so in boiling water, and very soluble in alcohol, ether, and the volatile and fixed oils. With the acids it forms crystallizable salts, of which there are two sets, one containing twice as much acid as the other. Different views are enter- tained of the equivalent constitution of these salts; some believing those containing the smaller proportion of acid to be sub-salts (with one eq. of acid and two eqs. of base), and those containing the larger proportion to be neutral (with one eq. of acid and one of base); while others consider the first set to be neutral (with one eq. of acid and one eq. of base), and the second to be super or bi-salts (with two eqs. of acid and one eq. of base). Thus, the two sulphates would be denominated by one party disulphate and sulphate of quinia, by the other sulphate and bisulphate. Of course, the equivalent of the alkaloid is stated differently, according to these different views; being 162 in accordance with the former, and double that number with the latter. Quinia is distinguished from all other substances, with the exception of its isomeric alkaloids, by the emerald-green colour which its solution, or that of its salts assumes, when treated, first with chlorine, and then with ammonia, and which changes to violet upon saturation with a dilute acid. Quinidia, though isomeric with quinia, differs from that alkaloid in crystallizing readily, in being less soluble in ether, and in its influence on polarized light It differs also from this, and all the other cinchona alka- loids, in the circumstance, that a solution of its sulphate yields a white precipitate with solution of iodide of potassium. Its crystals effloresce on exposure to the air. It resembles quinia in its chemical relations with chlorine and ammonia. CI1AP. I.] TONICS. PERUVIAN BARK. 231 Quinicia differs from quinia in being apparently quite uncrystallizable, and in its effects on polarized light; but agrees with it in composition, and iff most of its chemical relations. It is, indeed, in all probability, the result of certain molecular changes produced in quinia by the influ- ence of heat used in its extraction. It is not employed separately in a pure state. Cinchonia may be prepared from the sulphate in the same manner as quinia from its sulphate. It is white, crystallizable, almost insoluble in cold water, very slightly soluble in boiling water, freely soluble in boil- ing alcohol, which deposits it on cooling, scarcely soluble in ether, and but slightly so in volatile or fixed oils. In consequence of its compara- tive insolubility, it is much less bitter than quinia; scarcely having any taste when first applied to the tongue, but becoming bitter in a short time as it dissolves; and its solutions are very bitter. By a moderate heat it melts, but is at the same time decomposed. It forms with the acids crystallizable salts, of which, as in the case of quinia, there are two sets, to which the same remarks are applicable as those made in reference to the salts of the latter alkaloid. Its equivalent is conse- quently given differently, either 154, or double that number. It is dis- tinguished by affording a white precipitate, when its solution, or that of its salts, in chlorine water is treated with ammonia. Cinchonidia bears the same relation to cinchonia that quinidia does to quinia. Like cinchonia it forms anhydrous crystals, which do not like those of quinidia effloresce in a warm air. It also agrees with its iso- meric alkaloid in not producing a green colour with chlorine and ammo- nia; but is more soluble in ether than cinchonia, and differs in its influence on polarized light. Cinchonicia, which is derived from cinchonia, is isomeric with it, and resembles it in chemical relations, but differs in being amorphous or uncrystallizable. Neither this, nor the preceding alkaloid is prepared separately for use, in a pure state, at least in any considerable quantity. Under the name of quinidia or qitinidine, an alkaloid substance was some time since brought into notice, and to some extent introduced into commerce, which Pasteur found to consist usually of the two alkaloids, named respectively quinidia and cinchonidia, but chiefly and sometimes exclusively of the latter. This has led to an unfortunate confusion of nomenclature; but the student should remember that what was com- monly called quinidia in commerce, and still to a certain extent retains that name, is really in great measure cinchonidia. 'The nomenclature adopted here, after Pasteur, is necessary as expressive of the true rela- tions of the several alkaloids. The substance sometimes called quinoidine, which in its pure state is the amorphous quinia of Liebig, and is obtained from the mother waters left after the precipitation of sulphate of quinia, in the process for pre- 232 GENERAL STIMULANTS. [PART II. paring that salt, is usually a mixture of quinicia and cinchonicia, and results from the reactions which take place in the process ; the crystal- lizablc alkaloids having been rendered, by molecular change, amorphous or uucrystallizable. Chemical Relations and Incompatibilities. The alkalies and their carbonates, and the alkaline earths, precipitate the alkaloids from the in- fusion and decoction of bark; tannic acid, and all the astringent sub- stances containing it, precipitate insoluble tannates of the alkaloids. By the reagents mentioned, therefore, the liquid aqueous preparations of bark are deprived of the active principles of that medicine; but, as the precipitated matter is active, the preparations, if the sediment be diffused through them, will still be efficient, though inelegant from their turbid- ness. The same may be said of the slight precipitates produced by the soluble salts of oxalic, tartaric, gallic, and acetic acids, in consequence cf the difficult solubility of the compounds of these acids with the cin- chona alkaloids. These precipitates, moreover, are redissolved by a slight excess of acid. Besides the precipitants mentioned, all of which disturb the relations of the active principles, there are many others, which, through reaction with the tannic acid often found in bark, or with other relatively inert constituents, form insoluble compounds, and occa- sion turbidness or deposition in the infusion. Among these are the solu- ble salts of Ipad, iron, zinc, silver, and mercury, tartar emetic, arsenious acid, and solutions of gelatin. Some of these act on certain varieties of bark, and not on others; as, for example, tartar emetic, which sometimes produces copious precipitates, and sometimes does not disturb the infu- sion. In consequence of the large proportion of kinate of lime in the Calisaya or officinal yellow bark, a strong infusion of this variety is precipitated by sulphate of soda, which does not affect most of the other barks. But the virtues of the infusion are not impaired by these reagents, as the active principles remain undisturbed; so that the incom- patibility has reference, not to the Peruvian bark, but to the substance added. Signs of Value. The taste affords some evidence of the strength of bark, which*as a general rule, may be considered proportionate to the bitterness; but this test cannot be relied on with certainty; as in some inferior barks there is considerable bitterness, in consequence of the presence of kinovic acid, which has not the characteristic virtues of the medicine. The best method of testing any specimen of bark is to determine the percentage of the alkaloids contained in it, which is a pretty accurate measure of its medicinal activity. For the method of doing this, the reader is referred to the U. S. Dispensatory (12//i ed. t p. 295). CHAP. I.] TONICS. PERUVIAN BARK. 233 3. Effects of Peruvian Baric on the System. As the virtues of the bark reside mninlj r in its alkaloids, and these are closely analogous in their effects, it will be most convenient to treat first of quinia, as the one best known and most used ; and afterwards to point out any difference that may exist between its operation and that of the bark itself, or the other alkaloids. The effects of quinia are usually ob- tained from the sulphate; and this may be considered, in the following observations, as representing the alkaloid. When sulphate of quinia is administered to a healthy person, in quan- tities not exceeding six grains daily, in doses of half a grain or a grain, it produces effects very analogous, if not identical with those of the simple bitters. At first no sensible effects whatever may be experienced ; but, after a short time, the appetite is increased, the food appears to be more rapidly digested, the pulse becomes somewhat fuller and stronger, if not accelerated, the temperature of the surface is correspondingly ele- vated, the processes of sanguification and nutrition arc promoted, and other vital functions are moderately stimulated either directly or indi- rectly. In other words, the medicine operates as a pure tonic, accord- ing to the definition of the term given in this work. In irritable states of the digestive organs, or of the system at large, these effects are some- times exalted, by the free use of the medicine, into a moderately febrile state, with anorexia, gastric oppression, thirst, a furred tongue, accelera- ted pulse, heat and dryness of the surface, and headache or other cephalic uneasiness. This condition, however, is probably not the direct result of the action of the medicine upon the system at large, but indirect, and symptomatic of some local irritation produced by it, especially in the stomach or other parts of the digestive apparatus. This state of exces- sive excitement is rarely experienced in health; because, with an inr-rease in the quantity of quiuia administered, other effects are developed, of a contrary tendency, which overcome its general excitant influence. Given to the amount of from six to twelve grains daily, in divided doses, or to a less amount in a single dose, sulphate of quinia evinces a tendency to act specially upon the brain, and often produces very decided effects upon that organ. The quantity, however, necessary to the pro- duction of obvious cerebral symptoms, varies greatly in different indi- viduals; some evincing an extraordinary susceptibility to the influence of even small doses, while others scarcely feel the largest quantity above mentioned. The first cerebral phenomenon usually presented is abnor- mal sound, such as buzzing, roaring like that of a strong wind or of a cataract, singing, hissing, ringing, etc. Along with this there is gen- erally more or less hardness of hearing, which, indeed, is one of the most characteristic effects of quinia. Uneasy sensations in the head are also 234 GENERAL STIMULANTS. [PART II. frequent, as of weight, fulness, tension, and sometimes positive pain, though very seldom severe. The circulation is not much affected; the pulse being sometimes increased sometimes diminished in frequency, but for the most part little altered. When, instead of the quantities above mentioned, from twelve to sixty grains or more are given daily, in divided doses, the effect upon the cerebral functions is increased, and a decided sedative influence upon the circulation produced, as evinced by a diminution of the frequency and force of the pulse, proportionate to the amount of the salt used. Along with the abnormal sounds before referred to, there is now giddiness or dizziness; the individual, if erect, often staggers; occasionally there is irregular muscular movement; the hardness of hearing is not unfre- quently increased to positive deafness, and in a few instances vision is disturbed and blindness induced. At first, if the individual dose is large, there may be flushing of the face, headache, and sometimes epistaxis, indicating decided sanguineous determination to the head; and occa- sionally, though very rarely, active delirium occurs. In experiments upon dogs, even meningitis has in some relatively few instances been brought on by very large doses. (Briquet, Traite Therap. du Quinquina, p. 161.) But these evidences of over-excitement of the brain give way to others indicating a reduction of nervous power, such as diminished hearing and sight, uncontrollable tremblings, depressed spirits, sighing or yawning, and very rarely a kind of mental disorder, compared by Dr. James McCaw of Virginia to delirium tremens. (Stethoscope, ii. 666.) In some instances, a tendency to drowsiness or stupor is evinced; in others, morbid wakefulness; but in the greater number, neither the one nor the other. Though the pulse is at first sometimes temporarily ex- cited by these large doses, probably in sympathy with the excited brain, it in general soon becomes slower, and always feebler. The pulsations of the heart are often reduced ten or twelve in the minute, sometimes as much as twenty or twenty-five; and the whole number in the minute to forty, but seldom if ever lower. In strength, the pulse is diminished very nearly in proportion to the dose, as shown by the experiments of Briquet upon dogs, by means of Poiseuille's haemadynametcr; and, in extreme cases, it may be so much reduced as no longer to be felt at the wrist The skin at the same time becomes cool, pale, and moist, and the face pale or livid, and shrunk. This prostration under the use of quinia may be carried so far as to constitute real poisoning. Death has often been produced in dogs by excessive doses; and in one case, cited by M. Guersent. the same ro.sult is said to have taken place in the human subject.* (jJiacommini, who * In this case, M. Knzire, a practitioner of medicine, in an excited state of imagi- nation bordering on insanity, believing himself to be attacked with pernicious fever, CHAP. I.] TONICS. PERUVIAN BARK. 235 first called attention to the powerful sedative influence of quinia, records the case of an individual, who took by accident about three drachms of the sulphate. Extreme prostration came on, with an almost absent pulse, cold skin, slow respiration, feeble voice, and apparently imminent danger of death, which was, however, averted. In these prostrate cases, the pupil is often dilated, and there is sometimes coma. Hitherto our attention has been directed to the influence of quinia, in large doses, upon the circulation, or the cerebral functions. But it also produces other effects. It has been supposed by some to render the blood more fluid, and to lessen its coagulability by diminishing the proportion of fibrin, or altering its quality ; and in some cases, in which death has occurred during its administration, the blood has been found fluid. But this result was ascribable to the existing disease, and not to quinia; and more numerous experiments and observations have proved that, in any quantity in which it can be introduced into the sys- tem, it docs not impair the coagulability of the blood. Indeed, Briquet found, in his experiments, that it had the opposite effect of increasing the proportion of fibrin. It has been said that quinia has the property of immediately reducing the bulk of the spleen. This view of it was taken by Piorry, but has not been fully sustained by other observers; and the existence of the property must be considered as doubtful. Enlargement of the spleen is undoubtedly often gradually diminished under the use of quinia, espe- cially in miasmatic fevers ; but it is quite as probable that the effect pro- ceeds indirectly from the removal of the cause, as directly from the opera- tion of the remedy on the organ. In the urinary passages quinia occasionally induces irritation, proba- took within a short time 60 grammes (very nearly two ounces Troy) of sulphate of quinia by the mouth and rectum. Symptoms of great prostration, with loss of sight and hearing, came on, which he unfortunately ascribed to the pernicious fever, and hoped to counteract by a continuance of these endrmous doses. In the course of nine or ten days, he took additionally five ounces of the salt. Another physician being then called in, found him covered with cold sweat, completely deaf and blind, with difficult and rattling respiration, profound stupor, and an expression of coun- tenance like that of drunkenness. Though partially roused with much difficulty, so as to give rational answers, he quickly became delirious, and died. (Diet, de Med., 2e ed., xxvi. 570.) A case is recorded in the London Med. Times and Gaz. (April. 1864, p. 461), in which one ounce of sulphate of quinia was given, by mistake, to a soldier affected with ague, with no other unpleasant effect than a kind of stupor and complete deaf- ness, which left him after a time; and at the end of a week he was quite well, hav- ing lost his ague. No antidote was used. From these two cases it may be inferred that, though quinia may sometimes be taken with impunity, by a strong man, in the quantity of an ounce; yet double the quantity may prove fatal; and a legitimate caution would limit the dose far wiihin the smaller amount mentioned. (Note to the third edition.) 236 GENERAL STIMULANTS. [PART II. bly by its direct contact with the mucous membrane of these passages, as it escapes with the urine. Dr. E. Hardy has shown that quinia begins to pass out with the urine in less than seven minutes from its exhibition by the mouth. (Journ. de Pkarm. et de Ghim., 3e s;n\, xliv. lf>0.)* The alkaloid is not generally thought to exercise any special influence on the genital function; though it may no doubt operate beneficially, in certain abnormal states of that function, through its tonic powers. It is, however, believed by Dr. Cochran, on the basis of numerous experi- ments, that it has the property of exciting the menstrual function by a special influence; accelerating and augmenting the menses when it is given a short time before the regular period, and restoring them when arrested by cold or other cause. (Ann. de Therap., A D. I860, p. 194.) Occasional effects are experienced from quinia differing from those which are most common and characteristic. Sometimes it irritates the stomach considerably, causing a sense of weight or oppression, gastric pains, and nausea or vomiting. This is especially the case in febrile diseases, in which the stomach is already not unfrequently in a state of irritation, or strongly disposed to it. Sometimes also it acts similarly on the bowels, causing griping pain, and diarrhoea. It has been accused of producing constipation; but this is doubtful. Its operation, in large doses, is sometimes attended with great oppression of chest and p re- cordial uneasiness, probably dependent upon its irritant influence over the nervous centres. Mr. W. II. Yipan states that, in several cases which have come under his notice, purpura has appeared immediately after the use of quinia. (Lancet, July 8, 1865, p. 37.) The constitutional effects of quinia are essentially the same, by what- ever avenue it enters the system, whether taken by the stomach, injected into the rectum, or introduced into the areolar tissue, the* serous cavities, or directly into the circulation. When applied to the skin denuded of the cuticle, it produces so much irritation as materially to interfere with its absorption. The period, after its administration, at which quinia begins to evince signs of its characteristic action on the nervous system, and the length of time during which these signs persist, vary with the dose and the in- tervals of exhibition. Less than three or four grains, in one dose, rarely * Some experiments have been made to determine the influence of quinia on the excretion of substances with the urine. Dr. Win. A. Hammond, of the U. S. .Army, found, as the result of his investigations in cases of interuiittent fever, that the use of quinia was followed by a diminution of the uricaci'l in the urine, and an increase of the urea (Am. Journ. of Med. Sci., April, 1858, p. 3Uli); and the same result, aa relates to the diminution of uric acid, was obtained by Dr. II. Rankc (Lond. Med. Time* and Gaz., May, 1867, p. 537). But we have, as yet, insufficient facts to jus- tify any positive inference, as to its general physiological action, from its influence on this secretion. (Note to the tecond edition.) CHAP. I.] TONICS. PERUVIAN BARK. 237 produces any sensible effect; six or eight grains usually occasion some cerebral disturbance in half an hour, an hour, or at the latest two hours; while from twelve to sixteen grains, or more, may operate sensibly in so short a time as fifteen minutes. But, when the medicine is given in the dose of a grain or two, repeated at intervals of one or two hours, little or no effect on the nervous system is experienced until nine or ten grains have been taken; and often considerably more is required. The opera- tion of a single dose, just large enough to make itself felt, say five or six grains, continues generally two or three hours ; of double the quantity, given through the day, in divided doses, about eight or ten hours; of larger amounts, given in the same way, up to a drachm daily, from twelve to thirty-six hours. (Briquet.) In animals which have perished under the influence of quinia, no lesion has been discovered, as a general result, sufficient to account for the fatal effect. Almost invariably the pia mater has been found more or less injected; but not to such a degree as to account for the fatal issue, though the appearance may aid in the explanation of its mode of opera- tion. It has already been stated that, in a few instances, traces 'of meningitis have been noticed. The probability is that, if any character- istic lesion be found, it will be in the nervous centres near the base of the brain, upon which the medicine appears mainly to expend its in- fluence, so far as that organ is concerned. Perhaps a careful examina- tion of these parts, by means of the microscope, might reveal some characteristic abnormal condition. In relation to Peruvian bark itself, the effects are essentially the same as those of quinia; but, in consequence of its bulk, or of certain non- alkaline principles contained in it, as the cinchonic red and the yellow colouring ruatte*r, it is much more disposed to irritate the stomach and bowels. It often, therefore, nauseates, and occasionally causes vomiting or purging, especially if the alimentary mucous membrane is in an irri- table state ; and in some instances it cannot be borne on the stomach, in quantities sufficient to produce its characteristic effects on the system. When very largely given, it generally becomes intolerably offensive to the stomach; so that it is difficult to obtain from it the sedative and prostrating effects produced by excessive doses of sulphate of quinia; and, when such effects are observed, it is not always easy to discrimi- nate between them, and the sympathetic effects of the attendant nausea. Hence, the highly important property of diminishing the force and fre- quency of the pulse long escaped attention, and became known only after the discovery of quinia The bark differs also from its alkaloids in another particular; in its occasional tendency, namely, to produce con- stipation, resulting probably from the tannic acid it contains. This effect is of course evinced only in states of the bowels, in which they are not disposed to be irritated by it. 238 GENERAL STIMULANTS. [PART II. Cinchonia has been found to be identical in its effects with quinia, except that it is about one-third weaker; in other words, requires to be given in a quantity about one-third greater to produce the same result. Briquet, in his experiments, never obtained from it the effect upon the vision sometimes produced by quinia; but this was probably owing either to the insufficient number of trials, or to the insufficient amount employed. Quinidia and quinicia appear not to differ from quinia, in their operation on the system, whether physiologically or therapeutically. In relation to cinchonidia and cinchonicia, their effects have not, so far as I know, been separately studied ; but the probability is that they would be found to operate identically with cinchonia, to which they hold so close a chemical relation. 4. Mode and Nature of Operation. It is probable that the tonic operation of quinia upon the digestive organs is chiefly direct; as it certainly possesses the property of local stimulation. This is evinced by the pain and inflammation, often fol- lowed by superficial sloughing, which result from its application, undiluted, to the surface of the skin deprived of the epidermis. The gastric and intestinal irritation, occasionally caused by it, is probably nothing' more than an exaggeration of its legitimate tonic influence upon the alimentary mucous membrane. There is reason to suppose that the febriculous con- dition, sometimes attendant upon its action, is the result of the sympa- thetic extension of this irritation to the system at large. But the con- stitutional impression thus produced is not the normal and characteristic effect of quinia upon the system. The latter arises from the absorption of the medicine, and its direct contact with all parts of the body affected ; and is in fact interfered with by any gastric irritation which may pro- ceed from the quinia, because absorption is thus impeded. Nevertheless, it is not impossible that the tonic effect of the medicine on the digestive organs may depend, in part, upon its entrance, through the circulation, into the interior of their tissues, and the exercise there of an excitant influence upon their nutrition. That the active principles of Peruvian bark enter the circulation run no longer be doubted. Several experimenters have detected quinia in the blood; and it may easily be recognized in the urine, a short time after its administration, by a simple chemical test. A solution of iodide of potassium, in which free iodine has been dissolved, throws down un orange-brown precipitate from the solution of a salt of quinia. In ordi- nary urine no such effect is produced; but, during the use of sulphate of quinia, the application of the reagent is followed by a precipitate as soon CHAP. I.] TONICS. PERUVIAN BARK. 239 as the system becomes affected, and as long as it continues to be so.* The quantity wliich passes by urine is proportionate to that adminis- tered; and, as little or none has been satisfactorily detected in other secretions, it follows that most, if not all of the salt, is eliminated by the kidneys. It is an interesting fact, moreover, that the quinia ceases to appear in the urine soon after its observable effects upon the system have ceased. The inferences deducible from these facts are, in the. first place, that Peruvian bark acts on the system through the medium of the circulation, and, secondly, that its action is dynamic, that is, upon the vital properties of the parts affected, and not through any chemical combination with the tissues, which would otherwise retain the alkaloid. But are the effects of the medicine on the system at large the same as those upon the digestive organs? Is it a general as well as local tonic? Does it stimulate the functions of the brain, heart, and other organs which it roaches by the route of the circulation, as it is admitted to stimulate the stomach? These are questions of great importance, as they are not theoretical merely, but have a strong practical bearing. There are many who agree with the Italian contra-stimulant school, in believing that sulphate of quinia is a powerful direct sedative, especially in large doses, and consequently that it is applicable to cases of high excitement, and even of active inflammation. If, as others suppose, it is essentially stimulant, this application of it is certainly not indicated, and must often be highly injurious. I believe that it is the general impression, and it certainly is my own, that, in small doses, quinia is essentially and universally tonic. Not only upon the digestive organs, but in all the parts to which it is carried by the circulation, its effects thus administered are to excite moderately the nutritive function, and probably in some degree also that of secretion. Through its influence upon the processes by which the blood is formed, * The solution employed by Briquet for this purpose contained 2 parts of iodine, 8 of iodide of potassium, and 2f>0 of water. .He found the action of the test to cor- respond closely with the observable effects of the medicine upon the nervous system. Thus, after the exhibition of 8 grains of sulphate of quinia in one dose, a precipi- tate sometimes appeared in half an hour, though more frequently at the end of two hours; after 4 grains, in two or three hours; after 2.5 grains, if any appeared, it was not till the expiration of five or six hours. The length of time, therefore, before the appearance of quinia is inversely proportionate to the quantity taken; and the same rule holds in relation to the period at which the effects are felt. (Trail. Thf- rap. du Quinquina, p. 220.) Another fact, noticed by the same experimenter, is that the quantity of the salt of quinia eliminated is directly proportionate to that introduced. A third, also highly interesting, is that the elimination always ceases after a short time, generally little exceeding that during which the effects of the quinia persist. Thus, after a single dose of about 3 grains, tlie quinia disappeared from the urine in from 20 to 24 houi ; aftor oO grains taken during 12 hours, in about 40 hours; and after large doses taken tor several days, in from 6U to 80 hours, (fbid., p 230.) 240 GENERAL STIMULANTS. [PART II. it probably tends to augment the quantity of that fluid, and to render it richer. Thus, by its own operation upon the nutrition of the heart, and through the agency of the enriched blood, it gives greater energy to the contractions of that organ; and hence the fuller and stronger pulse, not unfrequcntly resulting from its moderate and continued use. It does not, however, appear, like the arterial stimulants, to excite the heart immediately into increased frequency of pulsation ; and, when this effect is occasionally experienced, it is probably through sympathy with the irritated stomach or brain. In all the points just referred to quinia agrees with the simple bitters. But there is another in which it mate- rially differs from that set of tonics; I refer to its action on the brain. The simple bitters may affect that organ through the enriched blood, or possibly by directly stimulating its nutrition; but its special functions arc not immediately excited, and in no degree observably interfered with. Quinia, on the contrary, acts with a special predilection on the cerebral functions; stimulating them gently, and within the limits of tonic action, when given moderately; but, in excess, producing the effects of over- excitement or irritation proportionate to the quantity used. In small doses, this influence is not evinced by any striking phenomena ; but it is no doubt felt, and contributes to give to Peruvian bark that pre-eminence over other tonics which it has so long enjoyed. But discrimination is neces- sary in order to an accurate understanding of its operation on the brain. Resembling in some respects the stimulant narcotics, it yet differs from them in the special seat of its action. Both obey the general laws of stimulation; that is, they at first increase the normal function of the ex- cited part, then derange it, and finally, by a continuance of their influ- ence, diminish or suppress it. But, while the cerebral stimulants or stimulating narcotics operate more or less upon the whole encephalon, and especially upon the seat of the intellectual and emotional functions in the cerebral lobes; quinia leaves these almost unaffected, and confines its influence more especially to the centres near the base of the brain ; those, namely, of sensation, and those which control the organic func- tions of the system. Hence we seldom see mental exhilaration, delirium, or stupor produced byquiuia; while excitement, disturbance, and de- pression of hearing or sight, and of the reflex muscular movements of circulation and respiration, are its constant results when taken in full doses.* * la reference to the effects of quinia on Bight and hearing, I recently had a patient who, under the full influence of the medicine, was affected with curious hallucinations, not only seeing either strange or familiar faces, but hearing unreal voices, sometimes from visible, sometimes invisible sources; and, as the patient was, on a moment's reflection, conscious that they were illusions, they were often sources of amusement. There was no fever, and no other evidence of cerebral excitement. The hallucinations vanished when sufficient lime had passed for the elimination of the medicine. (Note to the third edition.) CHAP. I.] TONICS. PERUVIAN BARK. 241 Admitting quinia to be moderately stimulant, in small doses, to those cerebral functions which it specially affects, we have next to consider the question, whether the sedative effects undoubtedly produced by it, when largely given, are direct or indirect ; that is, whether they proceed from an immediately depressing influence exerted by the quinia upon the encephalic centres, or are the consequences of a preceding state of exci- tation. To solve this question, it must (irst be determined, what are the immediate effects of a large dose of the medicine, sufficient to induce the ultimate prostration. Close observation upon the human subject and the lower animals has shown, I think, that so far as the brain is con- cerned, these effects are such as characterize excitation. The flushed face, the feeling of tension or fulness in the head, the sensitiveness to light, the buzzing and roaring in the ears, the vertiginous sensations, the involuntary muscular movements, the increased frequency of pulse and heat of skin, and the active delirium and convulsions which occasionally though rarely occur, are all proofs of stimulation and active congestion of the brain ; and these proofs are still further strengthened by the ful- ness of the vessels of the pia mater, uniformly observed on post-mortem examination, and the evidences of positive meningitis which have been observed in a few instances. It is true that these phenomena of excita- tion are much less observable, when the same quantity is administered in small portions, at intervals of an hour or two ; but, in this case, the stimulation from the several portions, not exceeding the degree of tonjc action, is scarcely observable in the pulse, and subsides before being fully reinforced by the succeeding doses ; while the secondary depression of the whole accumulates, and in the end becomes very obvious. The ex- citant effects of the large single dose may continue for two or three hours, when they gradually subside into a contrary condition, proportionate to the quantity taken, and, when this is in great excess, the prostration is in the end extreme. Now this is the ordinary and necessary Ault of over-stimulation ; and it is altogether superogatory to imagine the exist- ence of a directly depressing power in the medicine. The stimulation of an organ first excites its function; if it be continued and increased, the function is disturbed and becomes irregular; if still further increased, the organ is overwhelmed by the congestion induced, and its function is impaired or suppressed. The first excitement is thus followed by de- pression ; and this is deepened through another physiological law, which determines that the excitability of a part i- exhausted by over-exercise. Thus, after the first excitant effects of quiuia above referred to have con- tinued a short time, the cerebral centres become incapacitated for their duties through their congestion, and secondary exhaustion ; and cease to send forth the influence necessary for the support of the functions over which they preside, or which they in any degree control. Hence the diminution or loss of hearing, the occasional loss of sight, the general VOL. i. 16 242 GENERAL STIMULANTS. [PART II. feebleness of the muscular power, the trembling-, the gradually diminish- ing frequency and force of the pulse, the coldness and pallor of the sur- face, and the universal prostration. Now this is a very different condi- tion, in relation to therapeutic indications, from an apparently similar condition produced by a direct sedative to the nervous centres, or to the heart itself; and, though it might prove useful in certain cases if safely induced, yet, in determining upon the propriety of having recourse to it, reference must always be had to the possible danger of the great over- excitement and congestion of the nervous centres involved. This point will again be brought under discussion, when we come to treat of certain therapeutic applications of quinia, proposed on the ground of its sedative properties.* In explaining the effects of quinia on the system, a new path of inves- tigation has been opened by Dr. H. Bence Jones, through the discovery in the animal tissues of a substance strongly resembling quinia in its reagencies; not only exhibiting the same remarkable fluorescence in solu- tion, but responding in like manner to various other tests of quinia. But much further investigation is requisite in order to form a satisfactory opinion of the relation of this new substance with quinia, and how far * Some experiments of Briquet upon dogs would seem to prove a direct sedative influence of quinia upon the motor power of the heart. By injecting quantities of sulphate of quinia in solution, varying from 7.5 to 80 grains, into the external jugular vein of dogs, he found the force of the heart's contractions, as measured by the haemadynameter of Poiseuille, to be diminished in proportion to the quantity used, very slightly by the first quantity, and very greatly by the lust, which caused the speedy death of the animal by syncope. In other experiments, in which similar solutions were made to enter directly the cerebral vessels, the brain was excited, and the force of the heart's pulsation considerably increased. (Traile Therap. du Quinquina.) The inference from these results is that quinia is directly stimulant to the brain, and, through it, is capable of exciting the heart; while, introduced into the hestt it.self, it has a tendency to paralyze that organ. A great objection to these experiments, so far as the heart is concerned, is that, in order to produce the least depressing effect on that organ, the quantity of sulphate of quinia, introduced into the jugular vein, must produce a much stronger impregnation of the blood reaching the heart, than can be produced by any amount of the medicine swallowed, which is eliminated by the kidneys almost as fast as it is absorbed. The inference is, that no direct observable depression of the heart would follow the internal ad- ministration of quinia. But, even though we should admit the entire accuracy and relevancy of these experiments, they do not invalidate 1 the force of the argument in the text, in relation to the use of quinia as a sedative. Whether the depression in the actions of the heart, produced by large doses, depends wholly upon the secondary depression of the brain, as supposed in the text, or partly upon that, and partly upon the direct action of the quinia on the heart, in either case the danger of an over-excitement of the brain, which the same experiments show to result from the medicine, must be encountered, whenever the sedative effect on the circulation is resorted to as a therapeutic agency. CHAP. I.] TONICS. PERUVIAN BARK. 243 any supposed similarity or identity between them can have a bearing on the svstemic influence of the cinchona alkaloid. 5. Injurious Effects and their Treatment. In ordinary doses, quinia is not apt to produce deleterious effects, un- less through want of appropriateness to the pathological condition in which it may be prescribed; but, when very largely administered, it sometimes causes unpleasant symptoms from congestion or over-excite- ment of the brain, among which a greater or less degree of deafness is the most common. Generally this deafness subsides, with the other phe- nomena, in a period of time varying from a few hours to two or three days ; but sometimes it persists much longer, at length gradually yield- ing; and, in very rare instances, has proved permanent and incurable. Cases are on record in which death has occurred from inflammation of the brain, under the excessive use of quinia ; though there is reason to believe that there may have been, in these cases, either a strong predis- position requiring only a special cause to call it into action, or a certain amount of pre-existing inflammation, which was easily aggravated into fatal violence. Still, experiments upon animals have shown that, even in healthy conditions of the brain, encephalitis may possibly result from the abuse of this medicine. In all cases of over-excitement of the brain, the obvious remedies are leeching or cupping behind the ears, cold water to the head, a saline purgative not only to deplete and act revul- sively, but to carry off any unabsorbed portion of the alkaloid, and, lastly, bleeding from the arm, if the symptoms should be urgent, and the pulse permit. The irritation occasionally produced by quinia in the urinary passages, during its elimination, is said, in some instances where large doses have been taken, to have been aggravated into cystitis; and even ret^fcon of urine is asserted to have been produced by it. Another danger from quinia is the great secondary prostration from enormous doses, which, in persons already feeble, may possibly in sonic instances prove fatal.* Experience has shown that, under such circum- stances, stimulants are not only safe, but useful. Carbonate of ammo- nia I should prefer to the alcoholic stimulants, as it excites the heart, with k-ss effect on the brain; but, if this fail, recourse may be had to * It is strange, however, considering the powerful effects often produced by com- paratively moderate doses, how far the quantity may be increased without fatal results. The case of Giacommini has already been referred to (see/jojre 235). An- other is mentioned by Briquet, in which 41 grammes (about ten drachms and a half) were taken in the course of a few days. The patient lost for a time sight, hearing, and speech, and became as cold as a corpse, but nevertheless recovered. (Trait. Tltcrap. du Quinquina, p. 490.) 241 GENERAL STIMULANTS. [p ART IT. wine or other fermented liquor, and even to brandy, should the prostra- tion be alarming. If much nervous disturbance, as tremulousness, con- vulsions, or delirium, attend the prostration, one of the salts of morphia may be employed. Giacommini found coffee useful in cases of cinchonic syncope which came under his notice. In all cases in which the salts of the cinchona alkaloids hdve been given too largely, tanuic acid or an astringent infusion should be administered internally; for, though the tannate is not without effect on the system, it is certainly less rapidly absorbed than the soluble salts. 6. Therapeutic Application. It is an undecided question, whether Peruvian bark was known as a medicine to the aborigines of S. America, before the discovery of the country by Europeans. Both sides of the question have the support of high authority; the affirmative being maintained by Ruiz and Joseph de .Jussieu, and the negative by Humboldt. Leaving aside some absurd stories in reference to the manner in which the remedy was discovered by the natives, and the mysterious secrecy said to have been observed by them in relation to it, the weight of probability appears to me to be in favour of its indigenous employment, long before the invasion of the Spaniards. The traditions in the country were to this effect; and it M-urcely seAis probable that a people, so civilized as the ancient Peru- vians, should have overlooked a remedy so abundant, so easy of access, and so vitally important in the treatment of the fevers which must have prevailed among them. That among the ignorant and degenerate na- tives, at the time of the visit of Humboldt, violent prejudices should have ed against the bark, and an idea been entertained that it was pois- onous instead of remedial, can hardly be admitted as an argument against this view of the subject; as a similar prejudice may be found among the vulgar, even in the most enlightened countries, where the ivmedy is much employed, and highly valued by the intelligent. Peruvian bark, either of itself, or in some one of its preparations, is calculated to meet several distinct therapeutic indications ; 1. as a simple tonic, 2 as an antiperiodic or anti-intermittent, 3. as a supersedent, and 4. in reference to its secondary sedative properties. Of these I shall treat severally, premising that not unfrequently two or more of these indications are presented conjointly in the same disease. 1. As A SIMPLE TONIC. For this purpose, the medicine is employed in small doses, repeated several times a day. Difference of opinion exists as to the preferable form of administration. Some suppose that the tonic property resides mainly, if not exclusively, in the alkaloids ; others, that it belongs essentially to other principles in the bark, the alkaloids having little or none of it; while a third opinion, admitting its existence in quinia, CHAP. I.] TONICS. PERUVIAN BARK. 245 cinchonia, etc., maintains that the colouring matters, tannic acid, etc., associated with them in the bark, so modify their influence as to render the conjoint operation of all considerably more effective than that of the alkaloids alone. My own conviction, derived from no little experience with the different forms of preparation of Peruvian bark, is, that its medicinal powers reside almost exclusively in the alkaloids, and, though the form of combination in which these naturally exist may somewhat modify their effects, by influencing their acceptability to the stomach, or the facility of their absorption or elimination, yet that the bark itself, wholly deprived of them, would be nearly if not quite medicinally inert and useless. The general experience too corresponds, I suspect, with my own; as quinia and its associated alkaloids have to a considerable extent superseded, even in reference to tonic effects, the use of bark, and of the various preparations most completely representing it. The medicine may be used in simple debility of the digestive organs, or dyspepsia. Bark, in substance, is too apt to nauseate and oppress the stomach to be employed advantageously for this purpose; but re- course may be had to the extract, or one of the liquid, preparations, especially the compound infusion of the U. S. Pharmacopoeia, which, in great debility of the stomach or system, may sometimes be usefully combined with the simple or compound tincture. Sulphate of quinia, however, is, upon the whole, the most convenient preparation. Still, it is in no respect superior, in this affection, to the simple bitters ; while it is more apt to oppress the stomach, and is, therefore, comparatively little used. In general debility, however, it stands at the very head of the tonics. It probably owes its superiority, in this condition, over the simple bit- ters, to the greater universality of its action. The latter medicines, though stimulant to the digestive, blood-making, and nutritive functions, have little influence over the nervous centres. Quinia acts energetically upon those centres, and extends, through them, independently of its direct influence upon the tissues, a powerful support to the weakened organic functions. In the debility of convalescence it acts very favourably. In pure anaemia, when the morbid condition exists specially in the blood, with- out obvious deficiency in the digestive or nutritive powers, or in nervous excitability, as often happens in chlorosis, quinia does little good; the appropriate tonic in such cases being iron. But, in that debility of all the functions which is apt to follow the agitations of acute febrile and inflammatory diseases, and from which it often happens that the un- aided system rises slowly and with difficulty, no medicine is probably more efficient; and, if along with this condition there is a relative defi- ciency of the red corpuscles, it adds greatly to the effectiveness of the chalybeates. 246 GENERAL STIMULANTS. [PART II. When debility is associated with any organic mischief, as in the ulcer- ative condition left by inflammation and gangrene, the system is some- times so prostrated as to be unable to carry on the reparative process, and ultimately sinks unless sustained. The tendencies are towards health, but the power to act duly is wanting. Under these circum- stances, the preparations of Peruvian bark, in connection with a nu- tritious diet, are highly important. When debility is produced or maintained by temporary exhausting influences, as by profuse suppuration, excessive secretion, or passive hemorrhage, it is often of the utmost importance to support the strength until the discharge has ceased; and a strong indication is offered, in such cases, for quinia or bark in some other shape, which may often be advantageously combined with opiates and alcoholic stimulants, espe- cially the fermented liquors. Examples of this kind, dependent on pro- fuse suppuration, we have in the advanced stages of extensive inflam- mation of the ordinary character, whether of the internal organs or external parts; in scrofulous abscesses; in erysipelas affecting the subcutaneous tissue ; in metastatic abscess, purulent infection, pyogenic fever, or suppurative phlebitis; and in the last stage of confluent smallpox, in which large portions of the surface are bathed in pus, and subcutaneous purulent deposits sometimes form in enormous quantity. Of exhaustion from excessive secretion we have examples in the effects of colliqualive sweats, diuresis, and diarrhoea, and of copious mucous discharges from the bronchial tubes and urinary passages. In these cases, quinia sometimes acts happily, not only by sustaining the system under the exhaustion, but by correcting the excessive discharge, which itself not unfrequently depends on a pre-existing debility and re- laxation. But astringents are generally still more useful here than quinia, which may often be advantageously associated with them ; and it is probable that the infusion, decoction, tincture, or extract of bark may be more useful than the alkaloids, in consequence of the tannic acid they may contain. The same remark is applicable to passive hemorrhages, which at once depend upon and increase debility, and in which the conjunction of astringents with the preparations of bark is often indicated. Another condition of debility, in which this medicine is highly service- able, is that produced and kept up by some directly depressing agency, independently of any exhausting discharge. Such arc all those condi- tions of the system in which extensive gangrene 1ms taken place, or even a small degree of it, if in one of the internal and vital organ.-. How it is that the connection of a mortified part with living tissue should produce general prostration is not always very evident: but such is certainly the case, even where there has been no preceding debility. When the debility gradually ensues, and is attended with typhoid symp- CHAP. I.] TONICS. PERUVIAN BARK. 247 toms, there has probably been absorption of the deleterious matters resulting from putrefaction, and a consequent contamination of the blood. But frequently the result is too sudden to admit of this explanation. A part dies; and almost instantaneously the pulse becomes feeble, the skin cold, the countenance pale, shrunken, and ghastly; arid, though reaction to a certain extent may take place, yet the energies of the system are still depressed, and continue so more or less until the offending cause is removed. Possibly a depressing effect from the dead matter upon the adjoining nerves may be reflected to the system, through the nervous centres, in the same manner as local irritation. But, however produced, the debility exists, and often requires the interference of tonics and other stimulants to support life, and give the parts power to throw off the offending cause. Certainly, among the tonics there is none so efficient for this purpose as cinchona. So beneficial is it, that an idea formerly prevailed that it possessed a positive and peculiar property of checking or obviating mortification and putrescency. At present, however, this idea is not admitted. All that the bark can do is to sustain the failing energies ; and this it is perhaps better able to do than others, because of its stimulating influence on those very nervous centres through which the depressing impression is propagated. In the gangrenous cases in which a pre-existing condition of system, or depraved state of the blood, has caused the mortification, there is a double indication for the tonic. Hence, the preparations of bark have always been among the most approved remedies in anthrax, gangrsena oris, malignant sore-throat with or without scarlet fever, and erysipelas with sloughing of the subcutaneous tissue. Another large list of diseases, in which debility, depending on a direct sedative influence, indicates the use of bark until the depressing cause shall cease to act, are the typhoid affections. In these, either the mor- bific cause itself, or the depraved state of the blood resulting from it, acts with a special influence on the brain, producing dulness, stupor, low de- lirium, and other evidences of cerebral debility. Cinchona, therefore, is specially called for, both for its excitant action on the nervous centres, and the rapidity with which it acts. Typhus fever, the advanced stages of typhoid or enteric fever, petechial or spotted fever, scarlatina par- ticularly of the anginose and malignant varieties, malignant smallpox and erysipelas, and even the phlegmasite when they assume the typhoid condition, as typhoid pneumonia and dysentery, are often usefully treated with this pervading and powerful tonic. Though of itself insuf- ficient to support life in many of these cases, and therefore requiring the aid of more potent stimulants, as carbonate of ammonia, opium, and the alcoholic liquids, it gives a durability 7 of impression, and power of resist- ance, not equally obtainable from these agents, and, therefore, cannot be fully replaced by any one or all of them. 248 GENERAL STIMULANTS. [PART II. In protracted diseases, particularly those of a febrile character, though perhaps stbenic in the beginning, the vital forces are gradually impaired by their over-exercise, and a state of debility ensues requiring tonic treatment. Here too the preparations of bark are the most efficient. It is highly important to know when exactly the period for this treat- ment has arrived ; for, if prematurely employed, it may injuriously ag- gravate the excitement. I have noticed that the occurrence of night- sweats, under these circumstances, offers one of the best criteria of the new condition. When a patient with a febrile disease, not having been especially affected with diaphoresis, begins to sweat profusely whenever he sleeps, and only then, I consider the symptom as an almost sure sign of debility; and quinia, though previously contraindicated, may now be used with safety and advantage. This condition is quite different from the typhoid. In both there is debility ; but in the latter, it is connected essentially with depravation of the blood ; in the former, it is merely the result of an over-exercise and consequent exhaustion of the vital forces, and the blood is no otherwise diseased than as it may be deficient in quantity, either considered generally, or in relation to the red coqjuscles. My attention has been particularly directed to the condition as it occurs in acute rheumatism, in which it is not very uncommon, though the disease may still be associated with considerable pain and swelling in the joints. Whenever night-sweats take place in that disease, I invaria- bly employ quinia, and almost uniformly with favourable effects, not only checking the excessive sweating, but very much ameliorating if not promptly curing the rheumatism itself. I have been long in the habit of employing and recommending this practice; for many years, indeed, before the recent revival of an old method of treating acute rheumatism by Peruvian bark. Various derangements of health which have been classed together under the designation of cachectic, the only common characters of which are chronic debility, and a not well understood depravity of system, in which the blood is probably always involved, such as syphilis in its ad- vanced stages, scrofula, and various obstinate cutaneous eruptions, in- cluding ecthyma, rupia, and impetigo, are not (infrequently benefited by quinia, in conjunction with certain alterative remedies, as iodine, mercury, and arsenic. Under this head may perhaps also be ranked the use of quinia in enlarged spleen, especially when following miasmatic fevers, or occur- ring in malarious regions. Some ascribe the efficacy of the medicine, in these cases, to a property which they suppose it to possess of directly contracting the spleen. But quite as probably it is ascribable to an alteration, under the tonic influence of the remedy, of that condition of system, and especially perhaps of the blood, which originated and sus- tains the affection. In many instances of enlarged spleen of a different CHAP. I.] TONICS. PERUVIAN BARK. 249 origin, even when there is no reason to suspect cancer, tubercle, or other incurable heterologous formation, quinia proves, as I have often wit- nessed, wholly inoperative. 2. As AN ANTIPEIUODIC, or ANTI-INTERMITTENT. No remedy ap- proaches Peruvian bark in antiperiodic powers. There is scarcely a doubt that, for its peculiar properties in this respect, it is indebted ex- clusively to its alkaloid constituents, and that everything which bark can do, can be effected by quinia. Indeed, in consequence of being less offensive to the stomach, the latter is the more effective of the two, where a strong impression is necessary, or when the affection is complicated with gastric irritability. In all regularly intermittent or periodic dis- eases, quinia may be considered as an almost certain remedy ; at least I do not remember to have met with a case which has not yielded to it, since the management of this medicine has been well understood. But it is not all diseases occurring paroxysm ally that belong to the category here referred to. To come under the head of regular intermittent dis- eases, the affection must occur about the same hour, at the interval of a certain number of days, one, two, or more, without any positive or re- cognizable disease, in the period between the paroxysms, by which they can be reproduced. In other words, the complaint must be at once idiopathic, and regularly periodic. Hectic fever, therefore, though it has paroxysms closely resembling those of intermittent fever, does not belong to the class referred to ; because it depends upon an ever-present organic source of irritation, and its paroxysms are irregular in their recurrence. Epilepsy and hysteria are equally excluded, though both paroxysmal, because often dependent on a constant though perhaps concealed lesion, and almost always more or less irregular. But even these affections, or imitations of them, when purely functional, and occurring at regular periods of one or a few days, will yield for a time to the antiperiodic treatment. Indeed this treatment is, in its nature, essentially temporary; its only effect being to guard the system against the recurring paroxysms, not to secure future immunity, when its direct influence has ceased. If, therefore, there should be some cause in operation capable of inducing a paroxysm of the disease, the patient is still liable to an attack after ap- parent cure, supposing the direct influence of the remedy to have been withdrawn. Hence, even in ordinary intermittent fevers, it very fre- quently happens that the paroxysms recur, at a somewhat varying period, after the suspension of the antiperiodic treatment. All that we can accomplish, then, by this treatment, is to prevent the recurring paroxysms so long as the remedy acts. If, in the mean time, the cause cease to operate, or the susceptibility to its influence no longer exist, when the chain of morbid association, or the force of habit is broken, a permanent cure is effected; if not, the disease is liable to return, and may continue to do so until the cause is at length removed, or the sys- 250 GENERAL STIMULANTS. [PART II. tern becomes insensible to its influence, as it does in time to noxious agencies in general, when not fatal in their effects, or applied in increased quantity or force. Intermittent fever is a disease in which quinia exhibits, probably, its most extraordinary powers. Before the discovery of Peruvian bark, some of the forms of this affection were extremely embarrassing to phy- sicians, and an obstinate quartan was scarcely less dreaded than pul- monary consumption. Afterwards it was found in general to be very manageable under the new remedy ; but cases were now and then met with which resisted its influence, in consequence sometimes of insur- mountable obstacles to its administration in the ordinary quantity, or to its retention when administered, and sometimes of the impossibility of introducing into the system a quantity large enough to meet the requi- sitions of the case. But, since the introduction of quinia into use, the disease may be considered as completely under command, so far at least as regards any single attack. The only requisitions are, that the remedy be administered iu sufficient quantity, and at the proper time. If upon trial a certain amount is not found to answer, it must be increased; and no limitation should be put to this increase, except the production of the desired effect, or a reasonable apprehension of serious mischief to the patient. The general rule is to give enough to affect the cerebral centres decidedly, as indicated by the buzzing or roaring in the ears, or by a greater or less degree of deafness. The question at once presents itself, whether any previous preparation is necessary, and, if any, what? Formerly, it was customary to antici- pate the antiperiodic by an emetic. Experience has shown this to be unnecessary in the vast majority of instances. Should, however, the attack surprise the system with the stomach loaded, and evidences of gastric irritation at the same time exist, it might be advisable to aid na- ture in getting rid of the offending matter, by means of warm water, or warm chamomile tea drank freely, or if necessary by a dose of ipecac- uanha. Ordinarily the only preliminary measure desirable is the evacu- ation of the bowels. In urgent cases, where it is important to produce the antiperiodic impression as soon as possible, even this may be dis- pensed with, and the administration of the quinia commenced at once. I think, however, that it is generally best to begin with a cathartic, in order to remove any possibly offending matter from the bowels, and unload the portal circulation, and thus promote the absorption of the medicine. If the liver is torpid, a portion of calomel or blue mass should be given with the cathartic. Another question to be decided is, how far the treatment is to be in- fluenced by any existing complication of the intermittent fever. Some have supposed that a coexisting inflammation contraindicates the use of quinia, and that the inflammation should be subdued before commencing CHAP. I.] TONICS. PERUVIAN BARK. 251 with the administration of that medicine. I have long been of a con- trary opinion. If the inflammation is insufficient to sustain a febrile excitement between the paroxysms, that is, to convert the intermittent into a remittent, iU'is either periodical itself, and obeys the laws of peri- odical diseases in general, or is insufficient to be materially aggravated by the stimulant properties of sulphate of quinia. Indeed, the general stimulation of the paroxysm is vastly greater than that of the medicine, and consequently much more likely to aggravate the inflammation. It would seem clear, therefore, that by interrupting the paroxysms we must, instead of aggravating, really relieve the inflammation, by removing the most powerful source of excitement, If theory justifies the use of the antiperiodic under these circumstances, experience is no less decidedly in its favour. I have never known the inflammation, attendant on a perfect intermittent, to be increased by the use of quinia; I have not known it to prevent the antiperiodic medicine from having its due effect; while I have observed that the inflammation is mitigated, and indeed often ceases, almost immediately upon the interruption of the paroxysms; and I believe that my experience, upon these points, coincides with that of the great majority of practitioners in the miasmatic districts of the United States. I am, indeed, prepared to go further, and to state that the same thing is true, in a great degree, even when the inflammation is sufficient to maintain some fever between the paroxysms ; but, in such cases, I should premise blood-letting, general or topical, or both, when apparently called for by the severity of the local disease, and permitted by the state of the pulse. The same reasoning applies here as in the former case ; the stimulation of the paroxysm is vastly greater than that of the medicine ; and experience equally confirms its justness by the result. There are only two instances, in which I would admit of an exception to the general rule ; namely, when the cerebral centres, which are espe- cially susceptible to the stimulant influence of quinia, and the mucous membrane of the stomach, which is liable to be irritated by it, are the seat of the inflammation; and, in the latter case, though I might not administer the medicine by the stomach, I should not hesitate to give it freely by the rectum or hypodermically. If inflammatory complication offer no contraindication to the use of quinia in intermittent fever, I know of no other impediment, unless it may be active cerebral conges- tion, which should if possible be removed, prior to its employment. Much has been said of the proper period for the administration of quinia. Some give it indiscriminately at all periods of the disease, without reference to pyrexia or apyrexia; but the great majority confine its employment to the intermission, and, as I tm'nk, correctly, unless in certain cases of pernicious fever, where it is of the utmost importance that the approaching paroxysm should be prevented, and there is reason to apprehend that the intermission may be too short for the purpose. In 252 GENERAL STIMULANTS. [PART II. the first place, there is no necessity for giving the quinia during the paroxysm ; and, secondly, though it may often be given with impunity, yet there is always some risk of aggravating into positive inflammation any pre-existing tendency to it in the brain or the stomach, or of causing effusion of blood in cases of active cerebral congestion. In the true per- nicious variety, in which the great danger arises from defective or per- verted innervation of the vital organs, and there is little tendency to active congestion or inflammation, the risk from quinia in the paroxysm can scarcely be said to exist, while the loss of time in withholding it may be fatal. There is one caution, however, which should be observed in the use of quinia during the pernicious paroxysm ; namely, never to give it so largely, in the cold stage, as to induce its secondary sedative effect, and thus add to the prostration, which is often itself very alarming, and not unfrequently fatal. Admitting then that, as a general rule, the medi- cine should be given only in the intermission, we have still to determine at what time, during this period, we are to begin with it, and when to suspend it. Without referring particularly to the various shades of opinion among authors on this point, I will merely state my own, based upon what is known of the action of quinia, and upon personal observa- tion, that the best plan is to commence immediately after the cessation of the paroxysm, and to continue, with repeated doses, until within about an hour of its expected recurrence, so that, at the time referred to, the system may be under the full influence of the medicine. I prefer the exhibition of the sulphate of quinia in small doses, repeated at intervals of an hour or two, to the use of the full quantity, required for a single intermission, in one or a very few doses. We thus incur less risk of irritating the stomach, or over-exciting the brain, while we have it in our power to modify the dose, if the effects should be unex- pectedly and unnecessarily severe. The absorption is probably also more complete, and the whole amount necessary for the required effect diminished. But there are circumstances which justify, and even demand a departure from the general rule ; as when the intermission is very short, or when it occurs at night, so that a frequent administration might inter- rupt sleep, and in this way injure the patient. In such cases, the whole quantity may be given in one, two, or three doses ; care being taken to throw the medicine mainly into the earlier period of the apyrexia; as, if withheld until immediately before the paroxysm, time is not allowed for its absorption and full operation, while, even if confined entirely to the earlier period, as its action continues for many hours, this may be in full force at the time required. Used in the method above pointed out, sulphate of quinia is capable of interrupting almost any case of intermittent fever, from the mildest to the most violent. But different quantities are required in different varie- ties of the disease. The purely irritative intermittent, occurring inde- CHAP. T.] TONICS. PERUVIAN BARK. 253 pondcntly of miasmatic influence, and sometimes ceasing spontaneously after a few paroxysms, may usually be checked by from six to twelve grains, given in each intermission. The ordinary miasmatic intermittent, though it will sometimes yield to the same quantity, is much more effec- tively treated with from twelve to twenty-four grains in the same time. The pernicious form of the same affection cannot be trusted to less than from twenty to sixty grains. The great rule, in the administration of the medicine, is to give enough to produce an obvious impression on the brain, and to maintain that impression until every vestige of a paroxysm shall have ceased. In many instances, the disease is at once arrested, and there is no return of the paroxysm, especially if the required im- pression has been produced some hours before the period for its recur- rence. More frequently, perhaps, one additional paroxysm occurs, though with mitigated severity, and the succession is arrested at the second. Rarely does the disease pass on to a third. Sometimes, in- stead of having been quite set aside, the paroxysm returns in a very mild or partial form, without a distinct chill, and with very little fever, and altogether so slight that, in itself, it would scarcely attract attention. It is important, however, as indicating that the disease is not yet arrested, and that, unless the impression of the medicine is maintained, the parox- ysms may again assume their original severity. It is not impossible that a quotidian, which has been once interrupted, may return on the follow- ing day as a tertian ; and, in like manner, a broken tertian may assume the quartan type. These results may be guarded against by continuing the quinia beyond the period for the tertian or quartan paroxysm ; though they are so rare that this caution may generally be dispensed with, and the plan only put in force in cases presenting this peculiarity. As a general rule, therefore, the medicine may be omitted immediately after the complete interruption of the paroxysms. It is of no advantage to continue with it regularly afterwards, with a view to prevent the sep- tenary or bi-septenary recurrence of the paroxysms, to which the dis- ease is liable; for a smaller daily amount than that originally necessary for arresting the disease, cannot be depended on for preventing these re- turns; and to persist in the use of so large a quantity may render the system at length insusceptible to its operation. The best plan for check- ing the weekly or bi-weekly returns, the latter of which are by far the most common, is, I think, to ascertain at what period, in any particular case, the paroxysm is disposed to recur, and to anticipate this by giving the patient, during the two days preceding that period, as much as was at first necessary to interrupt the disease ; and to pursue this course every week afterwards for one or two months, or longer if necessary. The interrupted use of the medicine prevents the system from becoming accustomed to it; and, after a time, the disposition of the disease to recur ceases. 254 GENERAL STIMULANTS. [PART II. Writers speak of latent intermittent fever, in which the disease is masked under other forms. Thus, there may be a chill and perspira- tion, without fever, or a headache with loss of appetite, malaise, etc., recurring at the regular day and hour; or the effects of the cause may be shown in an attack -of violent periodical neuralgia, or some special local affection, as diarrhoea or dysentery; and all such cases will yield to the antiperiodic treatment quite as readily as the regular disease. There seems, however, to be no necessity for considering these affec- tions as masked intermittent fever. They are simply different morbid results of the same cause, and, like intermittent fever itself, are not ex- clusively of miasmatic origin, but may result also from other causes. But, whatever may be their source, they are equally amenable to the antiperiodic treatment. Intermittent neuralgia is probably, next to intermittent fever, the most prevalent form of regular periodical disease. It may attack almost any part of the body, internal or external. As I have seen it, however, it is most common in or about the eye. Sometimes there is reason to believe that it is the effect of marsh miasm ; but I have known it much more frequently quite independent of this cause. It is often probably of a rheumatic or gouty character, sometimes apparently the result of debility, occurring in the convalescence from other diseases; but quite as often, its source cannot be satisfactorily traced. I have never witnessed a case of this kind, if unconnected with organic disease, which has not yielded to sulphate of quinia. The ordinary doses of this medicine used in intermittent fever will often cure it; but they will often also fail. Double or even triple the quantity may be necessary to produce the desired effect. Intermittent headache, especially hemicrania, may be considered as closely analogous with neuralgia, and is treated in the same way. But organic lesions of the brain are not unfrequently attended with severe pain in the head, assuming a somewhat regular periodical character, and liable, without caution, to be mistaken for pure functional neuralgia. In these cases, quinia may sometimes afford partial relief; but it is often quite powerless, at least in any quantity in which I have ventured to prescribe it ; and, I believe, may do harm by over-exciting the already irritated nervous centres. Rheumatism and gout are not unfrequently intermittent, in their nervous forms, whether as neuralgia, or painless disorder of function; and sometimes, also, in their inflammatory state. In cither case, they yield in general readily to quinia. The various neuroses occasionally assume the same regularity of recurrence. Epileptic convulsions, in general so intractable, may be treated with quinia with good hope of success, when they occur regu- larly, for any length of time, at the same hour daily, or every other day. CHAP. I.] TONICS. PERUVIAN BARK. 255 The same may be said of hysteria. Cramps, internal spasmodic affec- tions, asthma, nervous cough, and amaurosis, are other complaints occasionally periodical in their character, and, in that state, curable by the great antiperiodic remedy. Hemorrhages are said also to be sometimes regularly intermittent, and remediable in the same way. The fact is undoubtedly true of certain complaints of an apparently inflammatory character. Among these, ophthalmia is mentioned; but, considering the frequency of neuralgia of the eye, I am disposed to think that these cases of apparent inflammation are little more than active congestion, sustained by the extreme nervous irritation, and subsiding when that ceases. I have repeatedly seen diarrhoea periodical, and in that condition yielding to quinia; but it is not always easy to determine whether the affection is inflammatory, or merely irritative. One of the most apparently violent attacks of dysentery which I ever saw proved to be regularly periodical. The case occurred in the Pennsylvania Hospital. At my first visit, the man was seemingly very ill, complained excessively of pain, was constantly going to stool with the characteristic dysenteric discharges, and seemed to me to be in great danger of his life. Next day he was almost well; and I supposed that the disease had yielded to the measures employed. On the following day, however, it returned with all its former violence, and subsided again as before. There were several similar paroxysms. Convinced that it was peri- odical, I gave sulphate of quinia very largely in the intermission, and almost immediately checked the disease. But the probability, I think, is that, in all these regularly intermittent inflammations, the nervous element of the disease is predominant, and that the vascular disturbance is directly dependent upon it. In many cases, however, of apparent intermittent inflammation, especially of the lungs, the local affection is a mere appendage of a miasmatic fever, being lighted up by the general vascular excitement of the paroxysm, acting probably upon a predis- position to inflammation in the organ affected. But, whether its origin be as here supposed or not, it yields with great facility to quinia, when there is proof that the inflammation is quite absent during the period of the apparent intermission. In regular remittent diseases, quinia is scarcely less efficient than in intermittents. In this category, however, are not included all affections having the remittent character. In consequence of the varying excita- bility of the system, almost all complaints, perhaps it may be said all complaints of any considerable duration, are more or less remittent, even though the cause may be constantly operating. But to constitute a reg- ular remittent, in the sense here intended, there must be a paroxysm re- curring daily, or every other day, at regular intervals; and, though the morbid action may continue, in a moderated degree, throughout the inter- vening period, yet it is rather a prolongation of the paroxysm, than a con- 256 GENERAL STIMULANTS. [PART II. tinuous and sustained effect of the canse. It is as if the cause oper- ated only paroxysmally, and the disturbance of system produced by it did not subside completely before the period arrived for the recurrence of its action. These diseases, then, are not continuous affections, undergoing occasional exacerbation and remission ; but consist of successive parox- ysms, more or less intercurrent They are closely analogous to inter- mittent disease, and are submissive to the same antiperiodic treatment. The most important of these diseases is the miasmatic remittent, or common bilious fever. In this complaint, sulphate of quinia is a most efficient remedy. Whenever a decided remission is observed, after due evacuation of the bowels, and of the stomach if necessary, it may be given in quantities similar to those administered in intermittent fever, and will not often fail. In the pernicious variety of remittent fever, or when pernicious symptoms supervene in a case before simple, it is all- important, and, indeed, is the only remedy on which reliance can be placed. As in the pernicious intermittent, the quantity should be double, or even triple that given in the milder form of the disease. In this affection, it is of vast importance that no time should be lost. The next paroxysm may very possibly prove fatal, unless prevented. Nothing, therefore, should be allowed to interfere with the use of sulphate of quinia, upon the first occurrence of signs of remission ; and sometimes it might be advisable not to wait for this period, but, when the nature of the disease is well ascertained, to have recourse to the antiperiodic, by anticipation, even in the paroxysm ; for the tendency here is not to active congestion or inflammation, but rather to nervous prostration and passive congestion, and there is little probability of serious injury to the brain, or other vital organ. In some instances, it is difficult to retain the remedy, on account of great irritability of stomach. It should not be omitted on this account, but given notwithstanding, in the hope that a portion at least may be retained; and its retention may be aided by the simultaneous administration of opiates, and by the application of a sinapism to the epigastrium. The remedy should also, under such cir- cumstances, be additionally employed as an enema with opium, and aa an application to the surface of the body by the endermic method; or, what is still better, by injection into the subcutaneous areolar tissue. In regular remittent neuralgia, also, the best effects may be expected from sulphate of quinia, given in the same manner as in the intermittent form of the disease. Preventive Influence. Upon the same principles as those on which periodical diseases may be cured, they may also be prevented by sul- phate of quinia. There is no prophylactic measure against the miasmatic fevers at all comparable in efficacy to the use of this medicine. It seems reasonable to suppose that an impression on the system, such as pre- vents the return of the paroxysms, would prevent the occurrence of the first. Experience has established the correctness of this inference. All CHAP. I.] TONICS. PERUVIAN BARK. 257 that is necessary is to give, twice every week, in divided doses, a quan- tity equal to that required for the interruption of the disease when formed. From ten to fifteen grains, in doses of two grains every two hours, will probably answer the purpose. I am not sure that the same amount taken weekly will not be sufficient, considering the tendency to septenary periods which characterizes the relapses of the disease. In the irregular intermittent diseases, such as hectic fever, for exam- ple, sulphate of quinia, given in the same manner as in regular intermit- tents, will often check the paroxysms; but cannot be relied on even for this purpose, and is generally quite inadequate to the cure. The cause of these affections is generally continuous in its action, and is always, therefore, lying in wait to renew its assaults, though sometimes tempo- rarily restrained. In hectic fever, the nervous centres, through which the sources of irritation operate in producing the paroxysm, may be rendered insensible for a time to their influence; but, as soon as the pro- tective force is withdrawn, the cause again operates; and, if the quinia be given constantly, the system at length becomes insensible to its effects, and its remedial power ceases. Nature of the Antiperiodic Action. Various theories have been broached to explain the antiperiodic effect of Peruvian bark. Most of them are scarcely deserving of notice. One of the most plausible, in reference to the miasmatic intermittents and remittents, is that the alka- loids have the property of neutralizing the poison in the system. But this is not tenable; as quinia cures the irritative intermittents even more readily than the miasmatic ; and, if there be any disposed to deny the existence of the former affection, the argument will still hold; for in- termittent neuralgia, which often occurs where there can be no possible suspicion of the influence of marsh miasms, even in the midst of cities the air of which serves as a protection against these miasms, will yet almost invariably yield to the same remedy. I know no better explanation of the antiperiodic property, than that which supposes it to depend upon the powerful influence exercised by the remedy upon the nervous centres, through which probably the parox- ysms are produced. Every consideration, in connection with the pecu- liarities of regular intermittent diseases, leads to the conclusion, that the paroxysms are caused by an influence acting through the cerebral cen- tres, without which the result would not take place. Now, if these cere- bral centres can be preoccupied by a strong impression from some other source, they may be rendered insensible to the morbid influence, and the paroxysm, therefore, is set aside. Quinia is characterized by its dispo- sition to act energetically upon certain nervous centres, which are prob- ably the same as those through which the cause of the disease operates. Quinia, therefore, interrupts the succession of the paroxysms; and, as they are probably sustained, in part at least, either by habit, or by some VOL. i. 17 258 r.I'XERAL STIMULANTS. [PART II. chain of morbid action passing insensibly from one paroxysm to the succeeding 1 , the interruption is either permanent, or continuous until the original cause may reassume, in some mysterious way, its original activity, and produce a relapse in the now unguarded system. It is obvious that this explanation of the antiperiodic power of remedies im- plies an identity with that next to be considered; namely, the property of supersession; but, as the explanation is only conjectural, it is deemed best to treat of these two therapeutic agencies distinctly. 3. As A SUPERSEDENT. What has been stated above explains the meaning attached to this term. It simply implies that the medicine so named has the power, by insinuating an action of its own in any part or organ, to displace disease previously existing in that part or organ, or to exclude it if not already established. It is known that quinia acts powerfully on the cerebral centres, especially those of the organic func- tions, and produces in those centres an impression of considerable per- manence. The probable influence of such an impression in preventing the return of regular periodical paroxysms has been referred to. It is evinced also, though much less certainly and strikingly, in the preven- tion of irregular paroxysms of various kinds, and even in the relief of existing disease occupying especially the nervous centres, or acting through them, though not necessarily paroxysmal. Upon this princi- ple, we may explain the occasional efficiency of sulphate of quinia in irregular neuralgia, when given very freely. In chorea, functional /)?/, hysteria, spasmodic asthma, and the advanced stage of per- tussis, it has sometimes been used advantageously; and it is said to have proved efficacious, in large doses, even in tetanus. Associated with in- fusion or oil of valerian, I have been much in the habit of using it in certain forms of nervous headache, imitating an old practice taught me by the late Dr. Jos. Parrish, in which Peruvian bark was used for the same purpose, with the same addition. Much efficacy in the cure of nervous or sick headache is claimed, by MM. Debout and Scrre, for a combination of sulphate of quinia and digitalis; forty-five grains of the former and twenty-two of the latter, being made with syrup into thirty pills, of which one is to be taken every night for at least three months. (Bullet, de Therap., Iviii. p. 311.) 4. As A SEDATIVE. It will be recollected that I consider the sedative effect, produced by large doses of quinia, as essentially secondary ; being always preceded by a longer or shorter period of excitement in certain cerebral centres, and probably dependent, at least in sonn- degree, on this previous excitement, overwhelming, and us it were paralysing these centres, and disabling them from extending their normal influenee to the organic functions generally. In reference to this sedative property of quinia, it would seem to be applicable generally to diseases of over- excitement, not connected with active congestion, inflammation, or pecu- CHAP. I.] TONICS. PERUVIAN BARK. 259 liar excitability of the brain. Some, who believe in the direct sedative power of the medicine, do not admit even this exception. By these it is recommended in all inflammatory affections, even those of the encepha- lon; but experience has shown that it may prove very injurious, and even fatal, in such cases. The quantity requisite for the production of the secondary depression varies from fifteen to sixty grains daily. From a less amount, there might be danger of obtaining the direct stimulating effects of the medicine. The following are the complaints in which quinia has been especially recommended as a sedative. Fevers. There can be no doubt that large doses of quinia will often control febrile phenomena, reducing the frequency and force of the pulse, diminishing the heat and dryness of the surface, and sometimes even relieving headache and delirium. Carried far enough, it will suppress all signs of over-excitement, and may even bring on great prostration. In remittent miasmatic fever it is thus employed, especially in our Southern and South-Western States, very soon after the commence- ment of the disease, before a remission has become decidedly established, and even in the height of the paroxysm. There can be no doubt, from the abundant testimony on the subject, that, thus given, it will often speedily put an end to the febrile phenomena by its sedative operation ; while, through its antiperiodic powers, it prevents a return of the par- oxysms, and thus cures the disease. The effects are, in very numerous cases, so prompt and happy, and the injurious results comparatively so few, that the practice has become very popular, and, in some districts, almost exclusive. But, if my views of the action of quinia in these cases are correct, it is not without its dangers. Should active congestion, or positive inflammation of the brain, complicate the disease, it might be fatally aggravated, especially if it should happen to be seated, not in the lobes, which are comparatively little affected by quinia, but near the base of the brain, in the centres of vision and hearing, and of the great organic functions, which it powerfully excites. Even without the posi- tive existence of high vascular irritation or inflammation, a simple mor- bid tendency to these conditions might be goaded into dangerous action. This is not pure 'theory. One case at least is on record, in which fatal encephalitis, in an attack of miasmatic fever, was ascribed to the exces- sive use of quinia (Baldwin, Am. Journ. of Med. Sci., N. S., xiii. 293); and, were unfavourable results as often noted as the favourable, it is not improbable that others might be adduced. It seems to me, therefore, a safer practice, in these fevers, to wait for a decided remission before pre- scribing quinia. The only exceptions I would make to this rule are cases, either originally pernicious, or becoming so in the course of the disease. In these, the danger of a fatal issue is imminent, and there is little risk of inducing active cerebral congestion or inflammation; as the tendencies are asthenic rather than otherwise, and the disposition much 2GO GENERAL STIMULANTS. [PART II. greater to nervous prostration and passive congestion, than to inflam- matory action. In the pernicious remittent, therefore, or congestive fever of the South, quinia may be given freely after reaction has taken place, and before the occurrence of a distinct remission ; and the main error to be guarded against is the exhibition of the remedy, in over- whelming doses, during the cold stage, or that of prostration, for fear of fatally aggravating the existing depression, by the indirect sedative influence of the qninia. In yellow fever, also, quinia has been largely employed in this country, upon the same principle; that, namely, of suppressing the fever by its sedative influence. Given in doses of fifteen, twenty, or thirty grains, at an early stage of this complaint, it will undoubtedly often relieve and even remove the febrile phenomena; and, if the disease be moderate, and spontaneously curable, the patient will experience little subsequent inconvenience. But experience has shown that, though it may suppress the febrile symptoms, it is incapable of controlling those deeper derangements, and especially that depravation of the blood, in which the chief danger consists ; and, in serious cases, the patient dies with prostration, hemorrhage, black vomit, etc., quite as certainly as though no quinia had been given. There is even reason for believing that the great secondary depression, resulting from the overwhelming doses sometimes used, may, when superadded to the debility of the second stage of the disease, produce a fatal result in cases, which, if otherwise treated, might end in recovery. There is, moreover, the risk of seriously aggravating any inflammatory condition or tendency which may exist in the brain, in the early stage, and of still further irritating the mucous membrane of the stomach, already perhaps the seat of high vascular irritation, if not of inflammation. The reader will perceive, therefore, that the sedative treatment by quinia is not that which I am disposed to recommend in yellow fever; though it is proper to state, that my conclusions have been deduced from d priori reasoning, and the recorded .experience of others, and not from any experience of my own with this mode of treatment. Typhoid or enteric fever is also among the diseases in which this method of treatment has been employed. Some have supposed that, like miasmatic fever, this affection could be promptly arrested, strangled as it were, by large doses of quinia. A knowledge of its pathology, one would imagine, should be sufficient to guard against this error ; for that it is an error has, I think, been abundantly shown by experience. Some- times, it is true, the disease seems to be mixed with remittent fever, having regular paroxysms, recurring at a particular hour every day, probably owing to the simultaneous action of the causes of the two com- plaints. In such cases, as I know from observation, quinia will check CHAP. I.] TONICS. PERUVIAN BARK. 261 the paroxysms, and remove the regular remittent character; but the fe- brile affection will still march on, with its characteristic phenomena, to its regular termination. In France, sulphate of quinia in large doses has been used, not with a view to the prompt suppression of the disease, but in order to diminish the fever, lessen the danger, and lead to a speedier issue. M. Briquet, who employed it largely, states, as the result of his observation, that the pulse is moderated under its influence, the heat of skin diminished, arid the cerebral symptoms very much alle- viated; and on the whole, believes that this treatment will compare very favourably with any other which has been adopted. An appar- ently curious point, in his experience, is the effect of the medicine in diminishing stupor, quieting delirium, and otherwise favourably influ- encing the head affection. But the cerebral symptoms in this complaint are not those of active congestion or inflammation. They have probably a double origin, depending, in part, upon the depressing influence of the cause upon the brain, either immediately, or through the instrumentality of the diseased blood, and partly upon the irritating influence of the dis- eased bowels upon the cerebral centres. Now, quinia is calculated to obviate both these effects. By its excitant influence, it may counteract the operation of the depressing cause, and thus correct in some degree the characteristic stupor; while, in large doses, through an excess of the same influence on the organic centres, it renders them less impressible by the diseased glands of Peyer. We might, therefore, expect some favourable effects from large doses of quinia; but, though I have given the alkaloid often and freely in this complaint, I have never found from it any other advantage than a moderate supporting effect in the low states of the disease ; and have often been compelled to omit it by an aggravation of the symptoms. I have certainly never seen it cure a case of the disease. Nor can the resxilts obtained by M. Briquet be considered remarkably favourable, when judged of by his statistical report. Of forty-three cases of a serious character, including all that came under their notice, treated by himself and M. Blache, either in' part or exclu- sively with sulphate of quinia, eight terminated fatally; and, of these eight, four, on post-mortem examination, exhibited undoubted signs of meningitis. (Trait. Therap. du Quinq., pp. 383 and 385.) Now, the proportion of deaths is here much greater than we habitually meet with in the Pennsylvania Hospital (see my work on the Practice of Medicine, 5th ed., i. 354), even if the serious cases only be taken into account; and the number of cases, four out of eight, in which signs of meningitis were discovered, is far beyond the usual proportion, under any ordinary treat- ment. The inference is fair, that the general result of the heroic treatment with sulphate of quinia is unfavourable, and that it causes death, either by directly inducing meningitis, or by aggravating a tendency to that 262 GENERAL STIMULANTS. [PART II. affection already existing; which is exactly what might have been antici- pated, from the views here inculcated of the action of quinia on the brain.* In typhus fever, the abortive treatment by sulphate of quinia has been recommended strongly by Robert Dundas, of Liverpool ; and has been tried with success by other British practitioners. Among those who report most strongly in its favour is Mr. J. O. Fletcher, who found it very effectual in cases of pure typhus, but not in those complicated with ulcerated bowels, in other words, not in typhoid fever. (Land. Med. Times and Gaz., vi. 422.) As a tonic, Peruvian bark has long been an established remedy in typhus fever; but the idea of employing it in large doses, with the view of speedily arresting the disease, is, so far as I know, of recent origin. Though I have used it much in the former ca- pacity, I have no experience with it in large doses, given at the com- mencement of the fever, with a view to a direct febrifuge effect, and have no right, therefore, to speak decidedly on this point; but, if the humoral views of the pathology of this disease now prevailing are correct, that it depends, namely, on a poison which enters the circulation, and alters the state of the blood, depraving that fluid, and causing the generation within the system, and elimination from it, of a poisonous matter like itself, we know of no properties in quinia which should enable it to cor- rect this condition of things; and, though by its secondary sedative in- fluence it may suppress the febrile phenomena, it would be considered, with these views, as not likely to eradicate the disease. If it has the power of arresting that quasi zymotic action in the blood, which is sup- posed to characterize contagious diseases, it ought to be competent to the interruption of the course of smallpox, measles, and scarlatina; an influence which would scarcely be claimed for it by the most sanguine. PcLechial or spoiled fever, or, as it is frequently called, malignant cerebro- spinal meningitis, is one of the low forms of fever in which quinia appears to act most favourably, if confidence can be placed in testimony. Given freely in the initial stage, it is said often very hap- pily to dissipate the more alarming symptoms, and allow the disease to * A case has fallen under my notice, strongly illu-trative of the dangerous effects which may arise from very large quantities of sulphate of quinia in this lever. 1 was called in consultation to a case of fever, which the attending physician con- sidered, and wus treating as an ordinary bilious remittent. I thought I had con- vinced him that it was euteric or typhoid fever, and we separated after agreeing to a course of treatment consonant with this view. It appeared, however, that he was not really convinced; and, determined apparently to prove me in the wrong, he di- rected between thirty and forty grains of the sulphate of quinia to be administered during the day. Theie had previously been no alarming symptoms in the case; but, on the repetition of my vi.-it next day, I fum.d the patient in violent convul- sions, and within twenty-four hours he died comatose. (Note to the second edition.) CHAP. I.] TONICS. PERUVIAN BARK. 68 be conducted to a favourable issue. My own experience with it is con- 6ned to a single case, in which, in connection with morphia, it appeared to act most happily. In puerperal fever, sulphate of quinia, in large doses, is asserted to have been employed with extraordinary success; and, in epidemics of that affection, it is believed to have been used advantageously as a pre- ventive. M. Beau, of Paris, is among those who strenuously advocate the use of the medicine in this frightful disease. It is given in the quantity of from fifteen to thirty grains in the day, or sufficient to induce the decided effects of quinia on the system. (Ann. de Therap., 1858, p. 178.) Acute Rlieumatism. Peruvian bark was long since employed as a remedy in acute rheumatism in Great Britain ; but the practice had been abandoned, and only came again into general notice after the publica- tion of the results obtained by M. Briquet, and other French physicians, about the year 1842, with large doses of sulphate of quinia in that dis- ease. There can be no doubt that, under the use of this salt, in the quantity of half a drachm, more or less, given daily in divided doses, cases of acute rheumatism have often yielded, and entered into conva- lescence, without any serious inconvenience, at a much earlier period than they ordinarily do if left alone. Very soon after the system has come under the full influence of the remedy, the pains and swelling abate, sleeplessness is relieved, and the pulse is reduced in frequency and force; and the patient, in most instances, when the disease is un- complicated with inflammation of the internal organs, as of the heart, will become convalescent in about ten or twelve days from the com- mencement of treatment. Sometimes, however, as under every other treatment, the complaint is much more prolonged, and, when compli- cated with pcricardial or endocardial inflammation, extends to an aver- age period of sixteen days or more; though it is asserted that these in- flammations, especially if encountered by general or local bleeding, afford no contraindication to the use of quinia. According to Briquet, the cases least benefited by the sulphate of quinia are those of a ple- thoric character, in which the inflammatory fever is intense, and the pulse full, hard, and frequent; while those in which it proves most advantageous are lymphatic subjects, or those weakened by previous disease, or excessive depletion, with pale skin, and a very frequent but not well-developed pulse. This is exactly what might have been ex- pected, from the views of the action of sulphate of quinia here advocated, and quite contradictory to the notion of its direct sedative power. The medicine suppresses the morbid phenomena by an over-excitement, and consequent diminution of the excitability of the nervous centres through which the phenomena are induced, and not by a direct sedative influence on those centres, or on the circulation. But in this very circumstance ex- 264 GENERAL STIMULANTS. [PART II. ists the danger of the practice. Should there happen to exist already in these centres, as now and then happens in acute rheumatism, a vascular irritation or positive inflammation, or a strong tendency to it. then the fear is that quinia may aggravate this condition, and lead to fatal inflam- mation within the eucephalon. This is asserted to have happened in several cases, in consequence of which, the practice has not been gener- ally adopted by the profession ; and I am not inclined to recommend it. The only circumstances under which I should think it advisable to ad- minister quinia, in acute rheumatism, not complicated with miasmatic fever, are those of general debility, and especially as indicated by pro- fuse sweats, occurring during sleep, and not at other times. As before stated, I have for a long time been in the habit of employing, and of recommending, in my lectures, the use of quinia freely in this condition, and have almost always found it promptly effectual in relieving the symp- toms, and generally curative. In chronic rheumatism, the remedy is less efficient than in the acute; but, when carried to the amount of thirty or forty grains daily, it has sometimes proved effectual, especially in cases in which the inflamma- tion has been disposed to change its seat, and thus approach the acute in character. Gout is affected by quinia in a manner very similar to its mode of ac- tion in rheumatism. In the acute form, large doses of it will some- times suppress the local inflammation ; but the disease is not subdued, and there is always danger of its appearance in some other of its numerous shapes. The practice, therefore, is almost never resorted to. But, in debilitated states of the disease, the medicine may be used ad- vantageously, as a tonic, and, in the nervous forms, is not uufrequently useful as an anti periodic or superseding remedy. In the phlegmasise, or local inflammations attended with symptomatic fever, quinia has been thought by some to have a curative effect, in large doses, through its sedative influence. But, for the cure of inflam- mation, something more is necessary than to reduce the force and fre- quency of the pulse. Otherwise digitalis would be among the most efficient remedies in that affection, over which, indeed, it has been found to have little influence. An important indication, in the phlegmasise, is to reduce or alter the quality of the blood, as well as to lessen the quantity, or the force with which it enters the inflamed part. Now quinia has no effect of this kind. As already stated, it has a tendency rather to increase than to diminish the proportion of fibrin in the blood, the augmentation of which is one of the characteristics of severe inflam- mation. It is true that, except in the phlegmasiae of the brain, and the alimentary mucous membrane, and probably the urinary passages, it has little if any direct effect in increasing inflammation ; and the existence, therefore, of this condition does not positively forbid the use of quinia CHAP. I.] TONICS. PERUVIAN BARK. 265 when decidedly indicated on other grounds ; but, in simple inflammation in its active stage, there is no sufficient ground for its use; and, in the large quantities which would be required to suppress the febrile phe- nomena, it might in various ways do harm. But there are states of inflammation in which it is highly useful. As before mentioned, it may be employed, often with the greatest benefit, in miasmatic intermittent and remittent fever complicated with this con- dition ; acting as an antiperiodic in reference to the general disease, and relieving if not curing the local, by removing the injurious influence of the paroxysmal excitement upon it. Moreover, when inflammation is attended with a low, asthenic, or typhoid state of system, this medicine is highly useful as a tonic, aiding in the support of the system until the inflammation has run its course. Upon the same principle, it is useful in the suppurative or gangrenous state of inflammation; and, in these cases, has the additional advantage that, by its tonic powers, it assists in the repair of the local injuries inflicted by the disease, which might not be carried on to completion without this or equivalent aid. 5. LOCAL USE. Peruvian bark is slightly irritant to the parts with which it is brought into contact, and sulphate of quinia more so. Hence, the powdered bark was formerly sprinkled over indolent, flabby, and sloughing ulcers ; and the decoction was employed as a gargle in gan- grenous ulceration of the fauces. The remedy was supposed to be peculiarly useful in mortifying parts, from the fact that bark has some influence in retarding the putrefaction of animal matters ; but it is now well understood that the antiseptic property, though it may tend to pre- vent the decomposition of parts already dead, and, therefore, to correct fetor in sloughing ulcers, has no influence whatever, as such, on the process of mortification; and consequently, if Peruvian bark is useful in such cases, it is by supporting the vital actions through its tonic, and not through its antiseptic powers. The effect of the medicine in giving tone to the stomach may be con- sidered as, in some degree, the direct result of its local application to the gastric mucous membrane ; and, in the same way, it may do good in ulcerative conditions of the bowels, in which a local stimulation is desirable ; as in some cases of chronic diarrhoea and dysentery, and the advanced stages of enteric or typhoid fever. As quinia passes unchanged through the kidneys, and is thus brought into immediate contact with the urinary passages, it must exert upon these its ordinary local stimulation, and may thus prove useful in certain cases of chronic inflammation and ulceration of the pelvis of the kidneys, the ureter, and the bladder, and in retention and incontinence of urine dependent on debility of the bladder or its sphincter. Sulphate of quinia may be used locally for the same purposes as the bark, but, in this case, should be much diluted with some unirritating material. 266 GENERAL STIMULANTS. [PART II. 7. Preparations, and Modes of Administration. Powdered Bark. The powder might be the most efficacious form for administration, could it always be taken in sufficient quantities, and without irritation of the stomach. But its taste is so revolting to most patients, and it is so apt to occasion nausea, if not vomiting, that it is often almost impossible to employ it in quantities sufficiently large to produce the effects required. The taste may, it is true, to a considera- ble extent, be concealed or corrected by appropriate management ; but still the medicine will often offend the stomach by its,directly nauseating properties, and, if in no other way, by its great bulk alone. So much do these disadvantages impair its efficiency, that formerly, when the bark in substance was mainly relied on in the treatment of periodical fevers, it was not unfrequently difficult to break them, and sometimes almost impossible ; and, at all events, the treatment was much more prolonged than at present. Trousseau, indeed, considers the powder preferable to the sulphate of quinia, being, as he thinks, less apt to irritate the stom- ach, and, if properly administered, less offensive to the taste; but it seems to me that this eminent therapeutist must either never have taken the medicine himself, or be misled by personal idiosyncrasy; for certainly the general experience is very much opposed to him. Nevertheless, there may be instances in which, from constitutional peculiarity, sul- phate of quinia may fail of its usual effect ; or may be accidentally un- attainable in due time; and, in either case, recourse may be had to the bark in substance The variety selected for internal use should be one of those richest in alkaloids ; as it is important that as much strength should be concen- trated in as small a bulk as possible. Hence, either the Calisaya bark, or the best red bark, or one of the finest varieties of the Carthagena barks, as the soft or hard Pitaya, should be preferred. (See U. S. Dis- pensatury, 12th ed.) Any bark containing two per cent, of alkaloids may be ranked among the efficient varieties. The dose of powdered bark, as an antiperiodic, is about a drachm, repeated every hour or two, or at such intervals that from one to two ounces may be taken between the paroxysms. In reference merely to the tonic effect, from ten to thirty grains are sufficient to commence with. The powder should be given diffused in water, or other liquid vehicle. It is not the best plan to mix each dose extemporaneously when admin- istered; for the dry powder is not readily diffused in water, and the attempt often results in producing an offensive dose, sufficient, by its very appearance, to produce nausea in one who may have previously taken the medicine. A better method is to introduce a certain quantity of the bark and of the vehicle, say two ounces of the former and two CHAP. I.] TONICS. PERUVIAN BARK. 267 pints of the latter, into a bottle, allow them to stand until the powder has become wet throughout, and then, when the dose is to be taken, to shake them well, and pour out a wineglassful' of the turbid liquid. The addition of a fluidrachm of aromatic sulphuric acid, for each ounce of the bark, will correct in some degree the nauseous taste, and increase its efficiency by rendering soluble the compounds of the alkaloids with the colouring matter. Wine was formerly much employed as the vehicle; but it would be too stimulating for ordinary use. Trousseau strongly recommends hot sweetened coffee, which he says completely corrects the taste. When the bark purges, it should be conjoined with opium, when it constipates, with a little rhubarb. Infusions. The U. S. Pharmacopeia recognizes two infusions, one prepared from the yellow bark (!NFUSUM CINCHONJE FLAV^E), the other from the red (!NFUSUM CINCHONA RUBR^E). These are not simple infu- sions, like those of the preceding Pharmacopoeia; but are made in ac- cordance with the old formula for compound infusion (!NPUSUM CIN- CHONA COMPOSITUM, U.S. 1850), by the addition of a fluidrachm of aromatic sulphuric acid to a troyounce of the powdered bark. The acid is first mixed with a pint of water, and this mixture is then used in per- colation, enough water being poured on, at the end of the process, to make the infusion measure a pint. These are elegant preparations, and afford one of the most efficient methods of administering cinchona. All the virtues of the bark are extracted, and probably in a condition of greater activity than in the powder itself; as, by means of the acid, the whole of the active matter is now dissolved, and therefore readily ab- sorbable. These infusions may be used for all the purposes of the medi- cine. The dose is two fluidounces, to be repeated three or four times a day, as a tonic, in chronic debility ; every two hours in low fevers; and in such a manner as to amount to one or two piuts between the parox- ysms, in periodical diseases. For use in the typhous state of fever, they may be prepared with wine as the menstruum instead of water. The officinal infusions above described are expected to be made in the shop. For a simple extemporaneous infusion, the old method of macerat- ing an ounce of the coarsely powdered or bruised bark in a pint of boiling water, may be resorted to, in accordance with the present British plan. The simple infusion may also be made by treating the coarsely powdered bark by percolation with cold water, which forms a more elegant, and prob- ably stronger preparation. The hot infusion is somewhat turbid ; that made with cold water, perfectly clear. In neither is the bark nearly exhausted ; for water will not dissolve that portion of the alkaloids which is com- bined with the cinchonic red. Pale bark has sometimes been preferred, in consequence of its less disagreeable taste ; but just in the same pro- portion is it less efficient. The preparation is at best feeble, and is used only as a tonic. The dose is two fluidounces, three or four times a day in chronic cases, more frequently in the acute. 268 GENERAL STIMULANT?. [PART II. Decoctiona. The U. S. Pharmacopoeia directs separately the decoction of the yellow bark (DECOCTUM CINCHONA FLAVJE). and of the red (DE- COCTUM CINCHONA RUBR.E). These are made by boiling an ounce of the bruised bark in a pint of water, for fifteen minutes, straining while hot, and adding enough water through the strainer to make the decoction measure a pint. At the end of the boiling, and before the liquid begins to cool, two drachms of orange-peel may be advantageously added. This mode of preparation was formerly much resorted to, when it was deemed desirable to obtain the virtues of the bark speedily in a liquid form. Its disadvantages are that it does not completely exhaust the bark, and that on cooling the decoction becomes turbid, and deposits a precipitate. The turbidness is owing, partly, to the formation of tannate of starch, which, though dissolved by the water when hot, is insoluble in cold water, and therefore subsides on cooling ; and, partly, to the deposition of a com- pound of the alkaloids with the colouring matter, previously existing in the bark, and partially taken up by the water at the boiling temperature. Hence the necessity of straining while hot, so that a portion of the ac- tive matter extracted in the decoction may not be lost. Of course, the precipitated matter should be again mixed with the water by stirring, when the decoction is administered. It would be a great improvement in this preparation to add a little sulphuric, muriatic, or citric acid to the menstruum before boiling. The bark would then be exhausted, and the active matter retained in solution upon the cooling of the decoction. Wine may be advantageously substituted for water in the preparation, when there is an indication at once for alcoholic stimulation and the effects of the bark, as often happens in low levers. Indeed, the decoction of bark in wine was formerly much used in the prostrate state of fevers of a typhoid character, and with great advantage. The dose of the de- coction is two fluidounces, to be repeated in the same manner as the infusion. Tinctures. Two tinctures are directed by our officinal code, one simple, and the other compound. The simple Tincture (TiNCTDBA CINCHONA, U. S.) is ordered to be made with the officinal yellow or Calisaya bark. This is in order to insure efficiency; for this variety of bark is more uniformly strong with alkaloids than most others; but any variety ascertained to be of equal strength may be employed. The bark is probably completely exhausted when the process is properly conducted, especially if percolation is em- ployed. The tincture would, therefore, be very efficient, were it not that the proportion of alcohol to the active matter dissolved by it is so great as to give undue prominence to its effects, and thus often to render im- possible the administration of a sufficient quantity to obtain the desired influence of the bark. Though the tincture is strong, yet a fluidounce of it contains the virtues of only a drachm and a half of the bark. In CHAP. I.] TONICS. PERUVIAN BARK. 269 patients of intemperate habits, or in very prostrate states of fever, this would be an advantage ; and, in such cases, the tincture may be used with propriety. But it is more prescribed as an addition to the infusion or decoction, or in connection with sulphate of quinia, in cases requiring alcoholic stimulation, than by itself. It may be thus employed with propriety in cases of pernicious fever, attended with great prostration, as well as in fevers of the typhous character. In consequence of the resin it contains, it becomes turbid on dilution with water. The dose is from one to four fluidrachms. The Compound Tincture (TmcTURA CINCHONA COMPOSITA, U. .) is the preparation commonly known as Huxhairi's tincture. It differs from the preceding in containing serpentaria and orange-peel with colouring matter, and in being prepared with red instead of yellow bark. It is made with a much smaller proportion of bark than the simple tincture, and is less suitable as an antiperiodic, or in cases requiring a strong im- pression from the medicine. It is, however, an elegant stomachic cor- dial, useful in cases of feeble digestion and general debility. The dose is a fluidrachm. Extracts. An Extract (ExTRACTUM CINCHONA FLAV^E, U. $.)is pre- pared, according to our officinal code, from the yellow bark; but the preparation would be equally effectual made from the red, if carefully selected. In its preparation, the bark is exhausted first by alcohol and afterwards by water; the tincture and infusion are separately evaporated to the consistence of honey ; and the two are then mixed, and the evapo- ration completed. It thus appears that the bark is deprived of all its active matter ; and the extract cannot but be very efficient, if due care is exercised in selecting the bark, and in conducting the evaporation. But, as a large proportion of the matter dissolved by the menstrua is inert, as the gum, resin, and cinchonic red, the preparation is much less efficient than the separated alkaloids, and is now little used. As found in the shops, it is not unfrequently very feeble, from the want of at- tention to the points above referred to. The dose is from ten to thirty grains. The Fluid Extract (EXTRACTUM CINCHONA FLUIDUM, U. S.) is a new officinal of our Pharmacopoeia. It is a highly concentrated tincture, from which a considerable proportion of the alcohol has been driven off, and its place as a preservative agent supplied by sugar. It is much pre- ferable to the Extractum Cinchonse. Flavse Liquidum of the British Pharmacopoeia, which is simply an inspissated infusion, to which spirit is added, partly for its preservation, and partly for the solution of matter deposited during the latter part of the process. This latter preparation is no doubt efficacious, but is liable to the same objection as all others in which water alone is the menstruum ; namely, that the virtues of the bark are not wholly extracted. The dose of the U. S. fluid extract, represent- 270 GENERAL STIMULANTS. [PART II. ing a drachm of the hark, is two fluidrachms. For antiperiodic effect, at least two fluidounccs should be given between the paroxysms. SULPHATE OF QUINIA. QUININE SULPHAS. U. S., Br. Preparation. This is, beyond all comparison, the most important and most extensively used of the preparations of bark, and may be consid- ered as a sufficient representative of its virtues, on all ordinary occasions. For the details of its preparation, the reader is referred to the U. S. Dis- pensatory. For our purposes here, it is sufficient to state that officinal yellow or Calisaya bark, which is usually selected, is exhausted by boil- ing it with water acidulated with muriatic or sulphuric acid; that, from the decoction thus obtained, the quinia and other alkaloids are precipi- tated, together with impurities, by means of lime; that the precipitate is treated with alcohol, which dissolves the alkaloids; that the alcoholic solution is then evaporated ; and, finally, that from the residue, consist- ing mainly of quinia, the sulphate is obtained by treating it with boiling water and sulphuric acid, purifying with animal charcoal, and crystal- lizing. Sensible and Chemical Properties. Sulphate of quinia is in minute, white, silky, flexible, needle-shaped crystals, in tufts or interlaced, in- odorous, intensely bitter, fusible at 240 F., soluble in 740 parts of cold water, 30 of boiling water, and 60 of alcohol, and very slightly soluble in ether. It is, however, very readily dissolved by water acidulated with almost any one of the sour acids. It is also soluble, to a consider- able extent, in glycerin, which, if slightly heated, is said to take up more than one-twelfth of its weight. (Lancet, Am. ed., ii. 262.) Its aqueous solution exhibits a beautiful bluish colour or opalescence on its surface. Two views are taken of its composition; one, that it is a neutral sulphate, containing one eq. of acid and one of base ; the other, that it is a disulpkate, containing one eq. of acid, and two eqs. of base. The former opinion, which was first entertained, subsequently gave way to the latter; but some chemists are disposed to return to it, and the author has always considered it as most probably correct; so that the ordinary designation of the salt should, in his view, be retained. If it be considered a neutral salt, its exact composition will be expressed by the formula; one eq. of sulphuric acid 40, one of quinia 324, and eight eqs. of water 72 = 436. It loses part of its water of crystallization by exposure, or by heat, but always retains about 4 per cent, or two eqs. of water, from which it cannot be separated without decomposition. Bisulphate of Quinia. By an additional equivalent of sulphuric acid, the sulphate is converted into the bisulphate, by some considered as the neutral salt. This is much more soluble in water than the ordinary sul- phate, requiring only 11 parts of cold water for solution, and is freely dissolved by alcohol. It is formed extemporaneously in solution, with the utmost facility, by gradually dropping a little diluted sulphuric acid CHAP. I.] TONICS. SULPHATE OP QUINTA. 271 into a mixture of the ordinary sulphate with water, until the latter is dissolved. Incompatibles. The substances which yield precipitates with solutions of sulphate of quinia, and should, therefore, not be administered, as a general rule, along with it, are the alkalies and their carbonates, the alkaline earths, all astringent solutions containing tannic acid, and the soluble salts of lead and baryta. The soluble salts of oxalic, tartaric, and gallic acids also occasion more or less precipitation with solution of sulphate of quinia, without excess of acid; and the same has been ascer- tained to be the case, by Mr. Maisch, with the soluble acetates (Am. Jo urn. of P/mrm., xxvii. 97); but the precipitates may be redissolved by the addition of an acid. Adulteration. Sulphate of quinia is liable to adulteration; but this can generally be easily detected by referring to its peculiar solubilities. The presence of mineral substances, not easily volatilized by heat, will be evinced by a residue left behind when a small portion of the salt is put upon red-hot iron. (See U. S. Dispensatory, llth ed., p. 1239.) Effects. The properties of sulphate of quinia as a therapeutic agent have already been sufficiently considered. In reference to its antiperi- odic and secondary sedative effects, it has all the power of bark, and more indeed than can always be exerted by the crude medicine. As a mere tonic, it is possible that the compound infusion, or some other pre- paration in which all the active principles of bark are contained, or the bark itself in substance, may be more efficacious; but I do not think that the fact has been rigidly demonstrated. The peculiar advantages of the salt are its convenience of administration, its general acceptability to the stomach, the rapidity with which it is absorbed, the facility of ascer taining its purity and genuineness, and the opportunity which it af- fords, by the smallness of its dose, of obtaining the peculiar effects of bark in a degree greater than can be obtained, as a general rule, from the bark itself. Administration. Sulphate of quinia may be administered in substance or solution. In my own experience, I have been able to discover little difference, in therapeutic results, between these two modes of exhibi- tion ; though it is asserted by M. Briquet, as an inference from his ex- periments, that the solution formed by the addition of a little sulphuric acid, and containing, therefore, the bisulphate, will produce the antiperi- odic effect more quickly, and in considerably smaller doses, than the ordinary sulphate given in substance. There can be no doubt that the salt in solution will be more readily absorbed into the circulation than the undissolvcd salt; but the ordinary sulphate is so readily dissolved by water slightly acidulated with almost any acid, that the instances must be very few, in which there is not sufficient acid in the primaj viae for this purpose. It is, I presume, very seldom that the sulphate of 272 GENERAL STIMULANTS. [PART II. quinia passes undissolved through the stomach, unless secured against the action of the gastric acids by a vicious mode of exhibition. The salt in substance is usually given in pill, or suspended in water; very rarely in the form of powder. The officinal Pilla of Sulphate of Quinia (PILULE QUINIA SUL- PHATIS, U. S. ) are made by the addition of gum and honey, and contain, each, a grain of the salt. They answer very well when made extempo- raneously ; but, if kept very long, there is danger that they may become so hard as to afford a mechanical impediment to solution, and conse- quently to pass through the stomach unchanged. Nevertheless, I have used very old officinal pills, with prompt and powerful effect, as an anti- periodic. A method of preparing them suggested by Mr. Edward Par- rish seems to offer some advantages. This plan is simply to triturate together 20 grains of the salt and 15 drops of aromatic sulphuric acid, until a pilular mass is formed. The pills are thus obtained of smaller bulk and more soluble ; and a pill of five grains is not inconveniently large. The salt, if finely powdered, may be suspended in water by simple agitation ; but the intervention of syrup or mucilage is preferable. M. Trousseau gives it stirred up in hot and sweetened coffee, which seems to correct its taste. The probable conversion of the salt into an insoluble tannate may be urged against this method of exhibition; and the same objection holds against the plan of mixing the salt with tannic acid, as recommended by the late Dr. Thomas, of Baltimore ; but when it is very important, as in some infantile cases, to destroy the taste, either method may be employed ; as, though the tannate may act less rapidly, and re- quire a larger quantity for a given effect, than the sulphate, yet it is in fact dissolved in the stomach whenever acid is present, and experience has proved its efficiency. Dr. W. H. Edwards, of Virginia, has found that, by enveloping sulphate of quinia in a spoonful of thick mucilage of slippery elm, without allowing it to touch the sides of the spoon, it may be taken without the taste being in the least degree observed. (Stetho- scope, iv. 338.) The solution of sulphate of quinia, which, when its bitter taste is not objectionable, is the best form for administration, may be made by adding twelve minims of aromatic sulphuric acid to eight grains of the salt in a fluidounce of water; in other words, a minim and a half for each grain. Twelve grains of the sulphate may be considered as equivalent to one ounce of good bark. The doses proper under different circumstances have been already stated. It may be repeated that, as a tonic, the dose of sulphate of quinia is a grain, to be repeated in chronic cases three or four times a day, in acute cases every two or three hours ; as an antiperiodic, from CHAP. I.] TONICS. SULPHATE OF QUINIA. 273 twelve to twenty -four grains between the paroxysms, in ordinary periodi- cal diseases, which may be increased, in pernicious fever, and very ob- stinate neuralgia, to from thirty to sixty grains, these amounts being, as a general rule, divided into doses of from one to five grains at equal intervals; and, in reference to the secondary sedative effects, not less than fifteen or twenty grains daily, which must sometimes be consider- ably increased. A Tincture of sulphate of quinia is directed in the Br. Pharmacopoeia under the name of TINCTURA QUINIA COMPOSITA, being made by dis- solving sulphate of quinia in tincture of orange-peel. A fluidrachm of it contains a grain of sulphate of quinia. It is a convenient preparation in some cases where the conjoint use of quinia and alcohol is indicated. If the stomach will not retain the salt, it may be given by the rectum ; from six to twelve grains, in ordinary cases, either dissolved by means of a little citric acid, or suspended in two fluidounces of mucilage or solution of starch, and mixed with from twenty to forty drops of lauda- num, being injected into the rectum every six hours. In urgent cases, this quantity may be very greatly increased. The endermic method is sometimes resorted to; but the application of sulphate of quinia, undiluted, upon a surface deprived of the cuticle, is apt to produce superficial sloughs; and its employment in this way should be restricted to cases of emergency. It should also be mixed, before applica- tion, with some unirritating substance, as powdered gum or arrow-root. The epigastrium, and insides of the thighs and arms, are proper positions for its endermic use. The hypodermic method has come into considerable use, and in cer- tain cases may be very advantageously employed. Indeed, sulphate of quinia is peculiarly adapted for subcutaneous injection ; being readily absorbed by the areolar tissue, and producing its effects in quantities not too large for this mode of application ; but it is liable to the ob- jection, that it is not readily dissolved, while the success of the plan depends upon the perfect fluidity of the substance injected. This ob- jection, however, may be obviated by means which will be mentioned directly. The characteristic effects of quinia on the system are more rapidly and more certainly obtained in this than in the ordinary modes of administration ; and, in the same dose, the medicine will produce greater effects. Besides, the patient escapes all those disturbances of the stomach which occasionally follow its use when swallowed. The hypodermic method, however, is liable to some slight inconveniences, which will prevent its general substitution for the usual methods ; but there are circumstances which decidedly indicate, and some which im- peratively call for it. 1. Whenever there is an obvious indication for the use of quinia, and, after a fair trial by the mouth and rectum, it fails to produce the desired effect, there is clearly a call for its subcutaneous VOL. I. 18 274 GENERAL STIMULANTS. [PART II. use. 2. A still stronger demand is made for it in cases where, from an irritable state of the stomach or bowels, from an inability or refusal to swallow it, as in some low cases of disease, and with maniacs or infants, or from idiosyncrasies of the patient, it is either very difficult or alto- gether inexpedient to give it by the mouth. 3. There are, besides, affections so exceedingly painful, and others so imminently dangerous to life, that it is imperatively necessary to have recourse to the most prompt and most effectual means of relief and safety. This condition of things is presented in certain cases of neuralgia, and in all cases of the per- nicious form of miasmatic fever, especially in the latter, when, as often happens, the stomach is excessively irritable. For the method of effecting subcutaneous injection, and the instru- ments employed, the reader is referred to page 81 of this volume. To obtain the salt of quinia in the liquid form, it is necessary either to use the bisulphate, which is much more soluble than the sulphate, or, what is still better, to add just as much of the diluted sulphuric acid, or of one of the vegetable acids, as the acetic, citric, or tartaric, as may be necessary for the solution of the sulphate in the admissible quantity of water, which for one dose should not exceed twenty or thirty minims. It is important not to use more acid for the purpose than is necessary to solution, because in excess it acts as an irritant to the tissues. The dose of the sulphate of quinia may be from one-third to one-half that given by the mouth for the same purpose. For antiperiodic effect, four or five grains may be given two or three hours before the expected paroxysm; and if postponed still later, even to within an hour or three-quarters of the chill, some effect may be expected. The solution may be injected in either of the extremities, or in the trunk along the spine. On the whole the arm is the most convenient. Friction upon the surface with sulphate of quinia, in the form of liniment or ointment, has also been recommended. For this purpose, a drachm of the sulphate, finely powdered, may be incorporated with two drachms of lard; but it would be better that the salt should be preliminarily dissolved, as it is more readily absorbed in this state. The following formula is essentially that of M. Boudin. Dissolve a drachm of sulphate of quinia in the least possible quantity of alcohol, with the aid of a little aromatic sulphuric acid, and incorporate the solu- tion with four drachms of melted lard. The salt being soluble in oleic acid, or pure lard oil, M. Lhermite recommends to dissolve one part of it in ten parts of the oil, with the aid of a gentle heat ; the oil being pre- viously scented with an agreeable volatile oil, as that of bcrgamot, for example. Kit her of these preparations may be rubbed, ad libitum, upon the inside of the upper or lower extremities, or in the axilla. The idea of bringing young infants under the influence of quinia through the milk of the mother, by administering the medicine to the CHAP. I.] TONICS. SULPHATE OF QUINIA. 275 latter, has suggested itself to practitioners; but the alkaloid is probably not thrown off with this secretion; at least numerous attempts to detect. it in the milk of women under its influence have failed. This plan, therefore, should never be relied on, and is the less necessary, as it is very easy to give the remedy to the child directly, by resorting to some expedient for covering the taste. Other Sails of Quinia. Numerous other salts of quinia have been recommended, on various grounds, as substitutes for the sulphate. The acetate, an/imoniate, arsenite, and arseniate, citrate, fcrrocyanate, lac- tate, muriate, tannate, and valerianate, have severally had their peculiar advocates; but the insolubility of most of them is one objection; and. though this may be overcome by the acid of the stomach, or the addition of an acid previously to administration, yet there exists another objec- tion ; that, namely, as they act through the quinia they contain, and all of them have a less proportion of this than the sulphate, in consequence of the higher combining number of their acid, they must be proportiona- bly less efficient, even when dissolved. Besides, experience has failed to establish any superiority of any one of them over the sulphate, except as regards the taste ; and, in relation to the salts with arsenious and arsenic acids, they cannot be given in quantities sufficient to obtain the influence of quinia over the system, without incurring the risk of danger from the arsenical ingredient. Of the above named salts, the valerianate of quinia (QUININE YALERIANAS, U. S.) is officinal; and directions for its preparation are given in the U. S. Pharmacopoeia. It is soluble in 110 parts of cold and 40 of boiling water, in 6 parts of cold and an equal weight of boiling alcohol. It has a strong disagreeable odour of valeri- anic acid. It is peculiarly applicable to debility combined with nervous disorder, and may be found useful in some cases of neuralgia, and hemi- crania. The dose is one or two grains, three or four times a day. CRUDE QUINIA. In the process for preparing sulphate of quinia, after the evaporation of the alcoholic solution, and before the addition of sulphuric acid, a semiliquid -substance is obtained, which, being dried, constitutes the substance here referred to, under the name of crude quinia. It has a resinous aspect, and a brownish-fawn colour more or less deep, is softened by heat so as easily to be formed into pills, is much less bitter than the sulphate, and consists, as procured from Calisaya bark, mainly of quinia, which is mixed with whatever other alkaloids may exist in the bark, and more or less colouring and perhaps resinous matter. It has all the effects of sulphate of quinia, and may be employed for the same purposes. Though but very slightly soluble in water, it is readily dissolved by the addition of an acid, and is consequently soluble in the gastric liquor. From its comparative want of taste, it is applicable to infantile cases. The only objection to it is that, from its want of a pre- cisely definite composition, it cannot be so readily guarded against 276 GENERAL STIMULANTS. [PART II. adulteration. It may be given in the same doses as sulphate of quinia, either in pill, or suspended in water. Dissolved by means of an acid, it acquires the bitter taste of the sulphate. QUINOIDIN. AMORPHOUS QUINIA QUINICIA and CINCHONICIA. After the crystallization of all the sulphate of quinia that can be obtained in that form, in the process for preparing the salt, there is left behind a mother liquor, by the evaporation of which a dark amorphous substance is obtained, which was formerly recognized by our Pharmacopoeia under the name of impure sulphate of quinia. This had been used, before being thus officinally recognized, by the late Dr. Samuel Emlen, of Phila- delphia, and by the author, with all the effects of the pure sulphate in the case of intermittents, though requiring to be given in about double the dose. It was supposed to consist of sulphate of quinia with a little sulphate of cinchonia, and colouring impurities. From the want of pre- cise characters by which it could be recognized, it has been abandoned in the recent revisions of the Pharmacopoeia. Serturner supposed that, in this residuary matter, he had found a new alkaloid, which was named quinoidin from its resemblance to quinia. According to Liebig this new alkaloid has the same composition as quinia, from which it differs only in being uncrystallizable, and impart- ing this same property to its salts. He therefore named it amorphous quinia. Pasteur ascertained that what was called quinoidin by Ser- tiirncr, and amorphous quinia by Liebig, consists usually of two alka- loids, one called by him quinicia, because derived from quinia, the other cinchonicia, from the same relation to cinchonia. They are probably mainly the result of the process for extracting the alkaloids; the heat employed having the effect of modifying the state of quinia and cinchonia, as the same agency converts crystallizable into uncrystallizable sugar. The substance called quinoidin in commerce, containing the amor- phous quinia of Liebig, is obtained by precipitating the mother liquor of sulphate of quinia above referred to, by means of an alkaline car- bonate, which decomposes the sulphates contained in it, and throws down the uncombined alkaloids. By repeated solution and precipita- tion, the alkaline matter may be obtained quite pure, and, in this state, consists of the two alkaloids quinicia and cinchonicia, together with whatever other organic alkali may have existed in the bark, as cin- chonia, and possibly sometimes quinia, quinidia, and cinchonidia. When pure, it is an excellent preparation, and may be employed, in all cases, as a substitute for sulphate of quinia, in about the same dose. SULPHATE OP CINCHONIA. CINCHONAS SULPHAS. U. S. This was first recognized as officinal in the present U. S. Pharmacopoeia. It may be made by directly combining its ingredients, or by crystallization from the mother waters of sulphate of quinia, after this salt has been wholly separated from them. It is in short, oblique, shining, prismatic CHAP. I.] TONICS. SULPHATE OF CINCHONIDIA. 277 crystals, with dihedral summits, which melt at 212 P., are soluble in 54 parts of cold, and a much smaller proportion of boiling water, are readily dissolved by alcohol, and scarcely soluble in ether, and have a very bitter taste. The salt is either a sulphate or disulphate, according to the opinion which may be adopted as to the equivalent of cinchonia; and, like the sulphate of quinia, may be converted into a more soluble salt by combination with an additional equivalent of acid. It has been abundantly proved to have the therapeutic virtues of sulphate of quinia, though somewhat feebler. A general result of observation has been that it is less apt than sulphate of quinia to occasion buzzing in the ears, deafness, and disturbance of vision, at least in the same dose ; though, according to Bouchardat, it produces, even in smaller doses and more certainly than that salt, a peculiar headache, rather severe, which is seated specially in the anterior part of the head, and is attended with a remarkable feeling of compression. (Ann. de Thcrap., 1857, p. 126.) To obtain the same effects from it, the dose should be about one-third, or at least one-quarter, greater than that of the salt of quinia. SULPHATE OF CINCHONIDIA. CINCHONIDIA SULPHAS. This is the salt which a few years since first came into notice under the name of sulphate of quinidia, which name is commercially still applied to it. The fact is that, as sold, it is usually complex, consisting of the two sul- phates of cinchonidia and quinidia, though with a great predominance of the former. It is obtained for use from the barks which most abound in cinchonidia, by the same process as that employed in the preparation of sulphate of quinia from Calisaya bark. Like the analogous salt of quinia, this is considered by some as a neutral, by others as a subsalt, and by the latter would be called a disidphale. It is in long, silky, acicular crystals, soluble in 130 parts of cold and 16 of boiling water, readily soluble in alcohol, but nearly insoluble in ether; and by these properties may be distinguished from the corresponding salt of quinia. It has the same effects as the sulphates of quiiiia and cinchonia, and may be employed in the same doses as the latter salt. That it is little if at all inferior, in the treatment of intermittent fever, has been abundantly proved by the trials made with it by Dr. J. S. Dorsey Cullen, in the Almshouse Hospital of Philadelphia (Am. Journ. of Med. Sci., N. S., xxix. 81); and those of Dr. Geo. L. Upshur, surgeon to the U. S. Ma- rine Hospital at Norfolk (Med. Examiner, N. S., x. 740). From fifteen to thirty grains were employed between the paroxysms. I am not aware that the proper sulphate of quinidia is used as a dis- tinct preparation. It is contained occasionally in the sulphates of the other cinchona alkaloids, and is probably identical in therapeutic influ- ence with sulphate of quinia, or so nearly so as to render its presence, in small proportions, of no practical importance. 278 GENERAL STIMULANTS. [PART II. Peruvian bark owes its special virtues to the peculiarity of its active tonic principles. Besides nectandra or bebeeru bark, recently admitted into the officinal catalogues, there are several substances of minor import- ance, supposed to possess peculiar virtues, which, if the claim be admitted, must rank in the same category. Among these are the dogwood and wil- low barks. It is true that these have a portion of tannic acid associated with the bitter principle; but it is not to this that the remedial effects as- cribed to them, and to which they mainly owe what reputation they possess, can be attributed, any more than the characteristic remedial properties of Peruvian bark can be attributed to the tannic acid which it also contains. If they have special virtues, these reside, in all probability, in their bitter principle; and the medicines, therefore, may be appropriately considered here. 1. NECTANDRA. U. S., Br.Syn. Bebeeru Bark. This bark, which is the product of Nectandra Rodicei, or bebeeru-tree, a lofty tree inhabiting Guiana and neighbouring parts of South America, was introduced into the Pharmacopoeias mainly as the source of a peculiar alkaloid, having virtues analogous to those of the cinchona alkaloids. The bark is in large flat pieces, a foot or two long, from two to six inches broad, and three or four lines in thickness ; grayish-brown on the outer, and deep-cinnamon on the inner surface; of a rough fracture, and of a somewhat astringent, extremely bitter taste. Two alkaloids are said to have been obtained from it, called respectively bebee.rin (bebeeria) and sipeerin (sipeeria) ; but as the two are extracted by the same process, Dr. Maclagan, of Edinburgh, who analyzed the bark, is inclined to believe that the latter is merely the result of an oxidation of the former. Like cinchona, nectandra also contains tannic acid, of the variety which forms a green precipitate with the salts of iron. Bebeeria is amorphous, and forms uncrystallizable salts with the acids. It is pale-yellow, of a resinous appearance, fusible and inflammable, without smell, very bitter, slightly soluble in water, and freely soluble in alcohol and in ether. It consists of carbon, hydrogen, nitrogen, and oxygen; but its formula has not been precisely determined. Sipeeria is also amorphous ; but differs from the preceding alkaloid, in being insoluble in ether; so that, when it is desirable to separate the two, the object may be readily effected by means of ether, which removes the bebecria, leaving the sipeeria behind. Nectandra is tonic and astringent, with febrifuge virtues analogous, though inferior to those of cinchona. It is seldom used in any other form than that of sulphate of bebeeria, either impure, as generally found in commerce, or pure, as directed to be prepared in the British Pharma- copoeia. Sulphate of Bebeeria (BEBEKLE SULPHAS, Br.) is prepared by treating the bark with water diluted with sulphuric acid, adding lime to the infu- sion thus obtained, but so as still to leave an acid reaction, then precipi- CHAP. I.] TOXICS. NKCTANDRA. DOGWOOD. 279 tating with ammonia, treating the precipitate with alcohol so as to dis- solve the alkaloid, concentrating 1 the alcoholic solution, neutralizing with sulphuric acid, and evaporating to dry ness. For the details of the pro- cess, as well as for the method in which the impure sulphate of com- merce is obtained, the reader is referred to U. S. Dispensatory (12th ed., pp. 1023 for the former, and 501 for the latter). The impure sulphate is in thin, shining, brownish scales, becoming yellow when powdered, sparingly soluble in pure, but freely in acidulated water, and freely soluble also in alcohol. It has all the remedial effects of the bark, and may be given either in pill, or dissolved in water by the addition of a drop of diluted or aromatic sulphuric acid for each grain of the impure sulphate. The sulphate of the British Pharmacopffiia has the same sensible prop- erties and probably differs little in any respect. The test of sufficient purity, given in the Pharmacopoeia, is that "it is entirely destructible by heat; water forms with it a clear-brown solution; its watery solution gives with caustic soda a yellowish-white precipitate, which is dissolved by agitating the mixture with twice its volume of ether ; and the ethereal solution separated by a p'pette, and evaporated, leaves a yellow trans- lucent residue, entirely soluble in dilute acids." Anything left undissolved by the ether is probably sipeeria. The medical virtues of ncctandra were first announced so early as 1834, by Dr. Rodie, after whom the specific name of the tree was adopted. But Dr. Douglas Maclagan was still more instrumental in giving it credit. It was for a time supposed that a substitute had been found for quiuia in the alkaloid of this bark ; and there can be no doubt that it will often prove efficacious in remittent and intermittent fevers; but experience has subsequently shown that it cannot be relied on ; and its chief importance at present consists in the fact that, in the absence of the cinchona alkaloids, or where circumstances render their ad- ministration impossible, or when they have failed after trial, recourse may be had to sulphate of bebecria, with good hopes of advantage. The dose is from two to five grains; and from a scruple to a drachm maybe given between the paroxysms of an intermittent. The medicine may be given in pill or in slightly acidulated solution. 2. DOGWOOD. CORNUS FLORIDA. U. 8. This is the bark of Cornus Florida, or common dogwood, a small indigenous tree, remarkable for its conspicuous white flowers, which ren- der it one of the finest ornaments of our forests in the spring, as it.- glossy-red fruit, and leaves beautifully tinted by the frost, do in the au- tumn. The bark is taken indiscriminately from the root, stem, and branches; but that of the root is preferred. It is in pieces of various size, partially or completely rolled, sometimes with and sometimes with- out epidermis, of a reddish-gray colour, a feeble odour, and a bitter, 280 GENERAL STIMULANTS. [PART II. astringent, slightly aromatic taste. It is brittle, and yields a gray, slightly reddish powder. Either water or alcohol will extract its vir- tues. These probably reside in a peculiar bitter principle, which, how- ever, has not yet been isolated ; for neither the cornin of Mr. Carpenter, nor the substance used, under the same name, by the eclectic physicians, so called, can be admitted ta this rank. The bark contains also tannic acid, but not in sufficient proportion to give it any considerable medicinal activity. The effects of dogwood on the system, so far as they can be traced, are those of a mild tonic and feeble astringent. It is said to increase the strength and frequency of the pulse, and the heat of the body; but, so far as known, it produces none of those effects upon the brain which characterize the action of Peruvian bark. In the recent state, it is said to act unkindly on the stomach and bowels ; but, in this respect, it resem- bles most other tonics, when too freely administered. Dogwood has been used almost exclusively, as a substitute for Peru- vian bark, in the treatment of intermittent and remittent fevers ; and, from the amount of testimony in its favour, there can be no doubt that it often has proved efficacious in the former of these complaints. But it has often also failed ; and, since the introduction of sulphate of quinia into use, has been little employed by regular practitioners. It may be used in powder or decoction. The dose of the powder in intermittents is stated at a drachm, so repeated as to amount to one or two ounces between the paroxysms. The U. S. Pharmacopoeia directs a decoction (DECOCTUM CORNUS FLORIDA, U. S.) to be made by boiling an ounce, in a pint of water, for fifteen minutes, then straining, and add- ing enough water, through the strainer, to make the decoction measure a pint. The whole pint may be taken in one intermission, in doses of two fluidounces. An extract, prepared with water or alcohol, might be substituted for either of the above forms with advantage. The profes- sion is indebted chiefly to Dr. John M. Walker, who published a thesis on dogwood, in Philadelphia, in the year 1803, for what is known upon the subject. The bark of two other indigenous species of Cornus, C. circinata or round-leaved dogwood, and C. sericea or swamp dogwood, have similar sensible properties, and are supposed to have the same medical virtues as that of C. Florida. 3. WILLOW BARK. SALIX. U. S. The barks of all the species of willow, possessing a very bitter taste, may be considered as designated by the title above given ; for all proba- bly have identical properties; but only that of Salix alba has been recognized by our national standard. This is the common European or white willow, and has been introduced into this country, where it grows extensively. CHAP. I.] TONICS. WILLOW BARK. 281 When dried, willow bark taken from the branches rolls into close quills, which are fibrous, flexible, and difficult to powder. It has a feeble, some- what aromatic odour, and a peculiar bitter, astringent taste. Water and alcohol extract its virtues. The active ingredients are a peculiar princi- ple called salicin and tannic acid, the latter of which, however, though in considerable proportion, is scarcely sufficient to entitle the medicine to rank among the proper astringents. The effects of willow bark upon the system, so far as they are obvious, are those of a mild tonic and astringent ; but it probably has also an an- tiperiodic action ; as it has been used with some success as a substitute for Peruvian bark in intermittents. This, indeed, has been its chief em- ployment ; though it is not without efficacy in relaxed and debilitated states of the system, as in the weakness of convalescence, certain con- ditions of scrofula, passive hemorrhages, etc., in which a slight astrin- gency is indicated along with a tonic influence. Like many other bitters, it has been used as an anthelmintic. The states of preparation in which it may be used are those of powder, infusion or decoction, and of salicin. The powder is better borne by the stomach than cinchona and many other tonics. The dose of it for other purposes than those of an anti- periodic is half a drachm, repeated three times a day. As a substitute for Peruvian bark, in intermittents, it must be given, during a single in- termission, in the quantity of one or two ounces, which may be distrib- uted into doses of a drachm, repeated as often as may be necessary. The infusion or decoction is made in the proportion of an ounce to the pint of water ; and the dose is one or two fluidounces. From one to two pints must be given between the paroxysms of an intermittent. The decoction has been used as a topical application in indolent, flabby, or foul ulcers. Salicin is by far the most efficient preparation in reference to the anti- periodic effect. Several processes have been suggested for its prepara- tion. Among the best is that of Merck. The boiling concentrated decoction is treated with litharge, in order to precipitate various sub- stances that tend to prevent the crystallization of the salicin. This principle remains in solution, probably holding a portion of the oxide of lead in combination. The lead is thrown down by the addition first of sulphuric acid, and then of sulphuret of barium ; and the remaining liquid, being evaporated and allowed to cool, deposits the salicin, which is purified by repeated solution and crystallization. When pure, it is beautifully white, in minute, soft, shining, slender crystals, inodorous, and very bitter, with the peculiar flavour of the bark. It melts at 230, and is inflammable at a higher temperature. It is soluble in water, much more so in hot than cold, is soluble also in alcohol, but not in ether, or the volatile oils. It is neuter in relation to acids and alkalies, and is not thrown down by any reagent. Sulphuric acid gives it a blood- 282 GENERAL STIMULANTS. [PART II. red colour; but a more certain test is the odour of meadow-sweet (Spiraea ulmoria), which it yields when heated in solution with chromic acid; salicin being resolved by that acid into the oil of meadow-sweet or sali- cylous acid, among other products. Having been employed to adulterate sulphate of quinia, it is important that there should be some method of detecting it. When taken internally, it gives to the urine the odour of salicylous acid, into which it is probably converted in its passage through the system. Since the discovery of salicin, this preparation has been almost ex- clusively used for obtaining the effects of willow bark. At one time, so favourable were the reports of its efficacy in intcrmittents, that the hope was indulged that it might supersede quinia. Hut further experience has shown that, though it will often cure intermittent s, it cannot be relied on with certainty ; and the best that can be said of it is that, when quinia cannot be obtained, it is among the best substitutes of vegetable origin. The dose as an antiperiodic is from two to eight grains, repeated so as to amount to from twenty to forty grains during the intermission. It is less apt to oppress the stomach than quinia. 4. HYDRASTIS. HYDRASTIS. U. S. Yellow-root, oranye-root, and yellow pitccoon are the common names by which this medicine, as well as the plant producing it, have been Jong known in this country, and which have been officinally superseded by the title, both English and Latin, which has been adopted in the U. S. Pharmacopoeia. Already it is probably better known, among the profession, by the name of hydrastis than by any of its vernacular titles. It is the product of Hydrasiis Canadensis, an indigenous plant, widely distributed throughout most of the United States, especially the North and West. It is a perennial herb, with a thick, fleshy, yellow root-stalk, which sends out numerous radical fibres, and from which rises annually an erect pubescent stem, from six to twelve inches high, bearing near the top two unequal, generally five-lobed, pubescent leaves, and a solitary rose coloured or purplish flower. The fruit resembles the raspberry, but should not be eaten. It prefers moist and rich woodlands. The root has long been known as a domestic remedy, and has been much used by irregular practitioners; but did not become officinal untjl the late re- vision of the Pharmacopoeia, when it was introduced ii .to the secondary list of that work. It merits, however, a place in the primary catalogue, and will probably receive it at the next revision. The dried root, which has shrunk much in desiccation, is irregularly contorted, rough and wrinkled, one, two, or three inches long by two or three lines in thickness, with numerous slender rootlets, or the marks where they have been broken off. It is externally of a yellowish colour becoming dark-brown by age, is internally yellow, and yields a yellowish CHAP. I.] TONICS. HYDRASTIS. 283 powder. The odour is strong, sweetish, and somewhat narcotic, the taste peculiar but bitter. Water and alcohol extract its virtues. These prob- ably reside partly in a volatile oil, but much more in two alkaloids, hydraxlia or hydrastin, originally discovered by Mr. Alfred A. B. Du- rand, of Philadelphia, and berberina, a principle long known as existing in the root of Berberis vulgaris, but first recognized by Mr. F. Mahla as being the second alkaloid of hydrastis. This latter alkaloid has since been detected in other vegetable remedies, especially columbo; and the large proportion in which it exists in hydrastis proves that this medicine must have virtues analogous to those of the African root. For the modes of preparing, and for the characteristic properties of these two alkaloids, I must be content with referring to the 12th edi- tion of the U. S. Dispensatory. It is sufficient here to state that hy- drastia crystallizes in shining four- sided prisms, which are white or colourless when pure, inodorous, nearly tasteless in consequence of dif- ficult solubility in the saliva, nearly insoluble in water, but readily dis- solved by alcohol and ether; while berberina is in minute acicular crystals, having in mass a yellow colour, soluble in 100 parts of cold water, less soluble in alcohol, and insoluble in ether, of a decidedly bitter taste, and characterized by the property of forming with muriatic acid a yellow salt, of very difficult solubility. Medical Properties. Hydrastis is decidedly tonic, as might be in- ferred from its partial resemblance to columbo in composition. It is also aperient ; and this property may be ascribed to the berberina, which is the characteristic ingredient of a root long used for its aperient properties, that, namely, of Berberis vulgaris. But it is asserted also to be chola- gogue, deobstruent in its influence on enlarged glands, diuretic, altera- tive, etc. There can, I think, be little doubt .that the alkaloid hydrastia has special remedial powers; and, if further experience should confirm the opinion, that it peculiarly promotes the hepatic secretory function, it will be an invaluable addition to the materia medica, enabling us to dispense in many instances with the use of mercury, otherwise indis- pensable. The affections in which it has been specially employed are dyspepsia, particularly when attended with deficient action of the liver, jaundice and other functional diseases of the liver attended with de- ficient secretion, constipation with or without piles, and generally chronic inflammation of the mucous membranes, in which it is supposed to act as an alterative like the mercurials. But much more experience, and a careful comparison of detailed reports from regular practitioners, above the suspicion of interested motives, are necessary, in order to justify a positive determination as to the merits of this very promising medicine. 284 GENERAL STIMULANTS. [PART II. 5. BARBERRY. BERBERIS. U. S. The bark of the root of Berberis vulgaris is the part designated in the U. S. Pharmacopeia as officinal. The plant is a shrub, sometimes attaining the size of a small tree, indigenous in Europe, but growing wild in various parts of our own country, as in New England and on the banks of the Hudson. A species of the genus, designated by Pursh as Berberis Ganadensis, grows in our country from its northern boundaries to the Carolinas. Hooker, however, considers it as merely a variety of B. vulgaris; and, whatever may be the fact on this point, there can be little doubt that it possesses the same medical virtues. The bark of the root is grayish on the outer, and yellow on the inner surface; is very bitter, staining the saliva yellow when chewed; and yields its virtues and colouring properties to water and alcohol. Long employed in medicine, it never enjoyed a very high reputation, and seems to have fallen into almost entire neglect; but, when it was ascertained to contain a peculiar alkaloid, and that alkaloid found to be diffused among various other medicines, some of them very greatly esteemed, as columbo, xanthorrhiza, xanthoxylum, hydrastis, etc., atten- tion was again forcibly drawn to it, with the result of introducing it into the present edition of our Pharmacopeia, though in the secondary cata- logue. For the method of extracting berberina from the bark, I must refer to the U. S. Dispensatory (12th ed., p. 168). Of the alkaloid itself, the most important and characteristic properties may be given in a few words. When obtained by crystallization from the hot solution, resulting from the decomposition of its sulphate by means of oxide of load, added to a heated solution of that salt, it is in the form of a yellow powder, shown by the microscope to consist of groups of minute acicular crystals. It is inodorous, bitter, soluble in 100 parts of cold water, and requiring still more of cold alcohol, but freely dissolved by both these liquids with the aid of heat, and insoluble in ether. Its most characteristic property is probably that of being copiously precipitated by muriatic acid from its solution in cold water, owing to the very difficult solubility of the result- ing muriate. This property, taken in connection with the bright-yel- low colour of the muriate, is sufficient to distinguish berberina from all other alkaloids. Notwithstanding the very difficult solubility of the muriate in cold water, yet enough is dissolved to produce a deep-yellow colour. Another alkaloid has also been found in the root for which the name of vinelina has been proposed. But little is known of its phys- iological properties. Both alkaloids consist of carbon, hydrogen, nitrogen and oxygen ; but their precise atomic composition can scarcely In- said to have been yet determined, though that of berberina has been given as C^HjjNO,,, of vinetina C M H M NO n . Barberry is tonic, and when freely given, cathartic, with a supposed action on the liver. It has been used in intermittent fever, dyspeptic af- CHAP. I.] TONICS. HOPS. 285 fections with constipation, and in jaundice. Whether it has any real in- fluence on the liver is not yet determined, and would form a good subject for careful inquiry. It was probably first introduced into the treatment of jaundice on the doctrine of signatures, which implies a certain relation between the sensible properties of the medicine and those of the part dis- eased, or some product of the disease ; as, in this case, between the yellow- ness of the bark and that of bile. But, baseless as this principle is, some medicines introduced into use on the grounds of it, have retained their place from their real virtues ; and the same may possibly be the case with barberry. The substances which follow, belonging to the subdivision of bitter tonics of peculiar properties, owe their peculiarity in general to the as- sociation of some other active constituent with their bitter principle. This associated constituent is, with one or two exceptions, a stimulant volatile oil. The most decided exception to this general rule is afforded by the wild-cherry bark, in which, though a somewhat stimulating vola- tile oil is always generated when it is exposed to the action of water, whether within the stomach or out of it, yet, in connection with this oil, a powerful sedative is also produced, hydrocyanic acid, namely, to which the medicine is mainly indebted for its peculiar and characteristic effects. II. HOPS. HUMULTJS. U.S. LUPULUS. Br. Origin. Hops are the fruit or strobiles of Humulus Lupulus, a climb- ing perennial plant, growing wild in Europe and North America, and largely cultivated in both continents. The fruit is picked when ripe, dried by artificial heat, packed in bales, and thus sent into market. Sensible Properties. Each strobile has the shape of a cone flattened by pressure, and consists of a number of thin, translucent, leaf-like scales, one overlapping another, of a pale yellowish-green colour, with two small black seeds near the base of each, and minute yellowish granules upon their surface, easily separable when the fruit is quite dry. Hops are of difficult pulverization, of a strong, peculiar, narcotic, yet fragrant odour, and of an extremely bitter, aromatic, somewhat astringent taste. They impart their sensible and medicinal properties to alcohol and water. Active Constituents. The virtues of hops depend probably, in chief, upon a peculiar bitter principle called lupulite or lupuline, but to which the name of humulin would be more appropriate, as more distinct from lupulin, which had been introduced into use, with another meaning, be- 286 GENERAL STIMULANTS. [PART II. fore the discovery of the principle referred to. They contain also a vol- ntile, oil, which is the source of their aroma, and a small proportion of tannic acid. According to Mr. W. Jauncey, the oil is formed in the hops during desiccation, as he has failed to discover it in fresh stro- biles. (Edin. Med. Joum., iii. (599.) Their other constituents have no special interest for the physician. The active principles of hops are diffused, in some degree, throughout their whole substance, but are mainly concentrated in the yellowish gran- ules upon the surface of the scales. These granules are separated for use, and constitute a distinct medicine, recognized in our Pharmacopoeia by the name of lupulin, proposed for it by the late Dr. A. W. Ivcs, of New York, who first brought it into notice. LUPULIN (Lupulina, U.S.) is prepared by rubbing or threshing the hops, and then sifting the coarse powder obtained. It consists of yel- lowish granules, almost always interspersed with minute fragments of the scales themselves, from which it is impossible entirely to separate them, as ordinarily procured. Lupulin has the odour and taste of hops, and contains the volatile oil and bitter principle above mentioned, with mere traces of the tannic acid. As it possesses all the virtues of hops, in a more concentrated and convenient form, it is generally preferred for internal use. Effects on the System. Notwithstanding the vast consumption of hops in malt liquors, their effects on the system, and mode of operation, have not yet been thoroughly investigated, or satisfactorily determined. That they are tonic to the digestive function is generally admitted, and might be inferred from their intense bitterness. Almost universal experience would seem to have determined that they have the additional property of inducing heaviness, drowsiness, and even sleep ; and by most they are believed to have that also, in some degree, of relieving pain. Never- theless, Magendie was disposed to reject their claim to be considered narcotic, having given lupulin to the lower animals without any such effect; and others are not wanting who maintain the same opinion. Dr. Muton, however, found them to allay pain, produce sleep, and lower the pulse in twenty-four hours from 93 to 60 in the minute. (Pereira, Mat. Med., 3d ed., p. 1247.) Dr. William Byrd Page, of this city, in Feb- ruary, 1849, stated to the College of Physicians of Philadelphia, that he had found lupulin to possess extraordinary powers in allaying irritation of the genital organs, and had been in the habit of using it for that pur- pose for two years. The same fact has since been confirmed, on the con- tinent of Europe, by Xambuco, who was ind'uced to make experiments* with it by an observation of Debout, in relation to its favourable influ- ence in relieving painful erections, lie gave from one to sixteen scruples, without producing disturbance of the nervous system, but with decided effects, of the nature referred to, on the genital organs. (See Lond. Med. CHAP. I.] TONICS. HOPS. 287 Times and Gaz., Feb. 1855, p. 118.) With their tonic, soporific, and anodyne properties, hops may, therefore, be considered antaplirodisiac. That they possess the power of stimulating the cerebral functious is ex- tremely doubtful ; and I am not, therefore, disposed to class them in the same category with opium and alcohol. From the large quantities taken with impunity, it is probable that their influence over the brain is feeble, and. from the symptoms evinced, that it is rather sedative than stimulant. In this uncertainty as to the precise position they ought to occupy, in reference to their influence over the nervous system, 1 have thought it best to rank them with the division of bitter tonics having peculiar prop- erties, to which they undoubtedly belong, whatever claim they may have to a position elsewhere. Opinion is not more settled as to the special influence of the several active principles of hops. It has been a prevalent impression that the odorous and volatile principle is that to which they owe their narcotic properties. The effect of a pillow cf hops in producing sleep may be said to be almost notorious ; and it is asserted that stupor has sometimes occurred in persons who have remained long in warehouses containing hops; but, in the former case, much allowance must be made for the operation of the patient's imagination; and, in the latter, it might be suggested that the experience of such an effect, if real, should be more than occasional, and that there might have been some other cause for the stupor when observed. Besides, Dr. Wagner states that he gave twenty drops of the volatile oil to a rabbit without observable effect. (Chem. Gaz., July 15, 1853.) In reference to the bitter principle, there is little more certainty, except as to its tonic action on the digestive organs. Dr. ChristisoD is disposed to think, that whatever soporific virtues may be possessed by hops reside in the volatile oil, and conse- quently that the bitter principle is destitute entirely of narcotic prop- erties. (Dispensatory.) Mr. Walter Jauncey, as the result of his experi- ments, found the oil to relieve pain, without necessarily producing sleep, and, in large doses, to reduce the frequency of the pulse considerably, and induce headache, anorexia, and nausea; and it acts in this way whether taken into the stomach, or inhaled. He also found it to act as a diu- retic, and to allay the venereal appetite. His general conclusion was, that the oil is sedative and anodyne, and that humulin, or the bitter prin- ciple, is merely tonic. (Ed. Hied. Journ., Feb. 1858, p. 701.) Like all other bitters, hops are ofl'ensive to the stomach in over-doses. Tltt-rapeutic Application. Hops may lie used as a tonic in dyspeptic or debilitated states of the digestive organs, and are specially indicated in cases attended with nervous restlessness and want of sleep. This condition not (infrequently exists in the convalescence from acute dis- eases, and in persons of a nervous temperament, who have been exposed to the influence uf other debilitating causes. On any occasion of obsti- 288 GENERAL STIMULANTS. [PART II. nate wakefulness, dependent on mere nervous disturbance, hops may be tried among other means of relief, and especially when some objection may exist to the use of opiates. They are supposed sometimes to have operated usefully in the morbid vigilance of insanity. In all these ca- a dose of the infusion of hops, of lupulin, or, when stimulation is also indicated, of one of the tinctures, may be given three or four times a day. But the case to which hops are probably most appropriate is that of the inebriate, suffering under the want of his accustomed stimulus. The medicine appears sometimes to operate most happily in such cases, in supporting the digestive function, controlling nervous tremors, obviating hallucinations, and disposing to sleep. Unassisted by stimulants, it is not adequate to supply the want of alcoholic drinks altogether; but, in the form of malt liquors, or that of the tincture of hops or of lupulin, it will, I believe, often enable the patient to escape the horrors of delirium tremens, with a smaller amount of alcoholic stimulus than would other- wise be necessary. In delirium tremens itself, the tincture is often an admirable adjuvant to opium ; and I feel confident that I have seen sleep induced by it, in cases of this kind, which resisted the opiate treatment, without any reason for ascribing the result merely to the alcoholic in- gredient. In convalescence, moreover, from that disease, it is one of our best remedies for sustaining a moderate tonic and soporific influence over the patient, until nature shall have recovered her powers. In these con- ditions, the tincture of lupulin may be given in the dose of half a fluid- ounce every two or three hours in the beginning, to be gradually dimin- ished, and with lengthened intervals, as it may cease to be requisite, either for supporting strength, or producing sleep. Dr. Maton found the medicine useful in allaying the pains of acute rheumatism ; but it is vastly inferior to opium for this purpose. It has occasionally been used in intermittent fever without very en- couraging success; but has recently been recommended in that com- plaint by Dr. W. Y. Godberry, of Benton, Miss., as equal to any other article of the Materia Medica except quinia ; and he has often succeeded in arresting the disease by means of it, after that medicine had failed. He prefers the infusion, which should be made with an ounce to a pint of boiling water; the whole to be taken during the intermission. (Am. Journ. of Med. Sci., N. S., xxvi. 283, from Went. Journ. of Med. and Surg., March, 1853.) From the statements of Dr. Page before referred to, lupulin would ap- pear to be one of the best remedies in our possession for relieving irri- tations of the genital organs in men. In the painful erections occurring in gonorrhoea, he gives it in doses of from five to ten grains, and has never known an instance in which the second dose did not afford relief. He has also found it useful in spermatorrhoea; preventing the discharges while the patient is under its influence, though inadequate to the cure. CHAP. I.] TONICS. WILD-CHERRY BARK. 289 These statements of Dr. Page have been confirmed by subsequent ob- servers. I have myself witnessed, in irritation of the urinary organs, very beneficial effects resulting apparently from the use of lupulin. Administration. Hops are seldom if ever given in substance. The Infusion (!NFUSUM HUMULI, U. S.), which is made in the proportion of half an ounce to a pint of boiling water, may be given in the dose of a wincglassful. Decoction is an unsuitable mode of preparation, as boiling dissipates the volatile principle, on which probably the virtues of the hops partly depend. The Extract (EXTRACTUM LUPULI, Br.) is liable to the same objec- tion as the decoction. It has the bitterness without the aroma of the hops. Nevertheless, it is said to have acted as an anodyne and soporific; but it has been almost entirely superseded by lupulin, which has all its advantages without its defect. The dose of the extract is from ten to thirty grains. A Fluid Extract and an Oleoresin of Lupulin (EXTRACTUM LUPU- LIN^E FLUIDUM, U. S., and OLEORESINA LUPULIN.E, U. S.) were introduced into the present edition of our national code. The former is a very con- centrated tincture of lupulin, the latter a semiliquid ethereal extract. Both of these preparations may be considered as representing the vir- tues of hops. The dose of the former is ten or fifteen minims, of the lat- ter from two to five grains. The oleorcsin is most conveniently given in the form of pill, made up with powdered liquorice root. Lupulin is now probably most used when, the influence of hops is wanted. The dose is from six to twelve grains ; but may be much in- creased, if thought advisable. It is most conveniently given in pill, which may be made by rubbing the powder, in a warm mortar, till it acquires a plastic consistence. The Tincture of Hops (TINCTURA HUMULI, U. S., TINCTURA LUPULI, Br.) is not an eligible preparation, being too feeble and uncertain to be relied on. The usual dose is from one to three fluidrachms. The Tincture of Lupulin (TIVCTURA LUPULIN^E, U.S.) is more effi- cient, and is an excellent preparation when the alcoholic ingredient is not objectionable. The dose for ordinary purposes is one or two flui- drachms. III. WILD-CHERRY BARK. PRUNUS VIRGINIANA. U. S. Origin. This is the inner bark of Cerasus serolina, or wild-cherry, a large indigenous tree, growing abundantly in the Middle and Western States. The officinal name originated in the mistaken supposition, that the Prunus Virginiana of Linnaeus was the tree in question ; whereas, VOL. i. 19 290 GENERAL STIMULANTS. [PART II. according to Torrey and Gray, that title really Jbel on gs to the choke- cherry (Cerasus Virginiana of the N. American Flora), a small tree or shrub, inhabiting the Northern States. The bark is obtaiaed from the root, stem, and branches of the tree ; but that from the root is preferred. It should be collected in the autumn, when it is strongest. The recently dried bark is more efficacious than that which has been long kept. Sensible Properties. Wild-cherry bark, as found in the shops, is usually destitute of epidermis, of a reddish-yellow colour, brittle, and easily pulverized, yielding a fawn-coloured powder. When fresh, or treated with water, it has the odour of peach-leaves. The taste is agree- ably bitter, astringent, and somewhat aromatic. It yields its bitterness to water, to which it imparts a reddish-brown colour like that of Madeira wine. Active Constituents. Among the active principles existing in the bark arc amygdalin and lannic acid. There is probably also some emulsin, a kind of nitrogenous or albuminous matter, found in the bitter almond, where it plays an essential part in changes, analogous if not identical with those which are now to be noticed as occurring in wild-cherry bark. When this bark comes in contact with water, a reaction takes place, under the influence of the emulsin operating as a ferment, between the water and the amygdalin of the bark, whereby the latter is converted into a peculiar volatile oil and hydrocyanic acid, which may be obtained together by distillation, constituting a product which is probably iden- tical with the volatile oil of bitter almonds. When, therefore, wild- cherry bark is used in the form of infusion, it is not merely the amygda- lin and tannic acid which act, but the new product also, which is essentially, in relation to its effects on the system, the hydrocyanic acid ; for the volatile oil which attends it has little effect. When the medicine is taken in the form of powder, it is highly probable that the same change takes place in the stomach, under the reagency of the water there. It is a question whether the bark does or does not contain a bit- ter principle distinct from amygdaliu. I believe that it does so, not only from- its tonic effects, which cannot be ascribed either to the volatile oil or hydrocyanic acid, but from an experiment made at my request by Professor Procter, which appears to determine the question.* Though * A portion of the bark was exhausted by alcohol, and the tincture evaporated to an extract. This contained the amygdalin, and whatever bitter matter and tannic acid existed in the bark. The extract was triturated with water, and with gelatin to remove the tannic acid. The liquor being then filtered, was mixed with an excess of the emulsion of sweet almonds, containing of course the emulsin necessary for causing reaction between the amygdalin and water. A strong odour of hydrocy- anic acid was produced, which had not previously existed in the solution of the alcoholic extract. AH the emulsin was in excess, the whole of the amygdalin must have been destroyed. The liquid was evaporated to a soft extract, and mixed with water. Sweet almond emulsion now added generated no more hydrocyanic acid. CHAP. I.] TONICS. WILD-CHERRY BARK. 291 boiling water will extract the active matters existing in the bark, yet cold water is medicinally the best solvent; for the emulsin is coagulated and rendered inert at a high temperature, and the formation of hydrocy- anic acid consequently prevented. Effects on the System. Wild-cherry bark is, through its bitter princi- ple, a gentle stimulant to the digestive and probably to the nutritive func- tion ; while the hydrocyanic acid, evolved by the reaction of water with the amygdalin, renders it sedative to the nervous system, and, when freely taken, to the general circulation. Dr. Eberle states that, in his own person, he has "several times reduced his pulse from seventy-five to fifty strokes in the minute by copious draughts of the cold infusion, taken several times a day, and continued for twelve or fourteen days." (Mat. Med, and Therap., 4th ed., i. 301.) Therapeutic Application. The joint tonic and. sedative properties of this bark admirably adapt it to the treatment of cases of general debility, with enfeebled digestion, an irritable state of the nervous system, and excessive frequency of pulse. Long before its chemical peculiarities were discovered, experience had established this application of the rem- edy. In the treatment of pulmonary consumption, it has for many years been a favourite in this country, and, before cod-liver oil came into no- tice, was probably more relied on than any other single medicine. It was employed not only in the advanced stages when hectic fever had set in, but from the beginning, and often as a preventive, in cases in which a strong tendency to the disease seemed to be displayed. It was given with the view of imparting tone to the digestive organs and system gen- erally, and thereby modifying the tuberculous diathesis, and was pre- ferred to other tonics, because it was thought to produce these effects with less danger of undue excitement. Now that it is known to be posi- tively sedative to the heart, and to the nervous system, we can better understand its usefulness in that complaint. In other forms of scrofu- lous disease, presenting a similar complication of debility of the digestive and nutritive functions with frequency of the pulse, it is equally indicated. Few remedies are better adapted to hectic fever, from whatever source it may proceed. In the debility of convalescence from fevers, and other severe acute diseases, when attended, as it often is, with night-sweats, a frequent pulse, and sleeplessness, restlessness, or other functional nervous disorder, the wild- cherry bark is also an excellent remedy. Perhaps the tannic acid it contains may contribute to its usefulness in correcting the excessive sweating in these cases; but I am not inclined to attribute much to that principle in estimating the virtues of the bark. It has been recommended also in simple dyspepsia, and as an anti- and there was none of the peculiar odour of that product; yet the taste was decidedly bitter, proving the existence in the bark of a bitter principle distinct from amygdalin. 292 GENERAL STIMULANTS. [PART II. periodic in intermittents : but in the former it is much inferior to the pure bitters, and in the latter, though sometimes successful, it very often also fails, and is not comparable in efficacy with Peruvian bark. It may be emploved, however, in cases of convalescence from miasmatic fevers, in which there is a strong tendency to relapse, and in which a long con- tinuance of the preventive influence may be necessary for the eradication of the predisposition. In such cases, though less effectual than sulphate of quinia, it may perhaps be safer. I have employed the remedy much in functional and organic disease of the heart, attended with a frequent, perhaps irregular, but rather feeble pulse, with an anemic or otherwise debilitated state of system ; and con- sider it one of our best remedies in such cases, combined, if anemia exist, with the use of the chalybeates. As the infusion, however, contains tan- nic acid, it is better not to add the preparation of iron to it, but to ad- minister the two separately. Administration. The bark may be given in the form of powder, infu- sion, or syrup. The powder is seldom used, because less convenient, more apt to oppress the stomach, and less likely to undergo those chemical changes which are essential to the characteristic effects of the remedy. The dose is from thirty grains to a drachm, which may be repeated three or four times daily. The Infusion made with cold water (INFUSUM PRUNI VIRGINIANS, U. S.) is the most appropriate form. It is made in the proportion of half an ounce to the pint of water, and is best prepared by the process of percolation. Any one can perform this process. Introduce an ounce of the bark, in the state of powder, into a common funnel, pack it some- what closely, and pour upon it a quart of cold water; the point of the funnel being inserted into the mouth of a glass decanter. When the water has all passed, pour it back into the funnel, and repeat this measure until the liquid acquires the colour of Madeira wine. Two fluidounces of the infusion, thus prepared, may be given three or four times a day, or more frequently when a strong impression is desired. A Syrup (SYRUPUS PRUNI VIRGINIANS, U. S.) is directed by our Pharmacopeia. It is an elegant preparation, and, where there is no contraindication, from delicacy of stomach or other cause, to the use of so much saccharine matter, may be substituted without disadvantage for the infusion. The dose is half a fluidounce, to be repeated as directed for the other forms. A Fluid Extract (EXTRACTUM PRUNI VIRGINIANS FLUIDUM, U. S.) was introduced into the last edition of the Pharmacopoeia. It is pre- pared ^according to a very ingenious process suggested by Professor Procter, by which the virtues of the bark are obtained in a very con- centrated form. The dose is one or two fluidrachms, equivalent to half a drachm or a drachm of the bark in substance. (See U. S. Dispensatory, llth ed., p. 628.) CHAP. I.] TONICS. CHAMOMILE. 293 Wild-cherry bark should not be prepared in the form of tincture, ex- tract, or decoction. In reference to the two latter, independently of the chemical objection above stated, there is another in the volatile character of the hydrocyanic acid, which, if formed, would be driven off, to a greater or less extent, in the processes for their preparation. IV. CHAMOMILE. ANTHEMIS. U. S., Br. Origin. The chamomile of the shops consists of the flowers of Anthe- mis nobilis, a perennial, herbaceous plant, growing wild in Europe, where it is also cultivated for use. Though it has been introduced into our gardens, none of the chamomile of the shops is produced in this country. All parts of the plant have medicinal properties ; but it is only the flowers that are officinal. They are imported from Germany and England. Varieties. The flowers of chamomile are compound, consisting, in their perfect state, of a central yellow disk, with a circle of white ray florets around it. There are two varieties, distinguished as the single and double ; the former retaining their yellow central disk florets, the latter having had these converted by cultivation into white ray florets. But the distinction is not precise ; for there is a large proportion of the flowers in which this conversion is incomplete ; and, as found in the shops, there is generally a mixture of the single and double flowers, and others in the intermediate state. In most parcels, as brought to this country, the double or white flowers greatly predominate. The single or yellow, how- ever, are more odorous, and more stimulant to the stomach, because the volatile oil, upon which these properties depend, is much more abundant in the central or yellow florets. Sensible Properties. The odour of chamomile is fragrant and peculiar, the taste bitter, warm, and somewhat aromatic. It yields these properties, and its medical virtues, to water and alcohol. Active Constituents. With a minute proportion of tannic acid, which is therapeutically of no account, the flowers contain a bitter principle and volatile oil, upon which their medical virtues depend. It is said that they yield also, on distillation, in very small proportion, a substance resembling valerianic acid. Effects on the System. In small doses frequently repeated, chamomile is a mild tonic, operating like the simple bitters, but with a somewhat more excitant influence on the stomach, owing to its volatile oil. In large doses it is apt to prove emetic, more so probably than the simple bitters, which it resembles in its tonic effects. Therapeutic Application. Chamomile has been employed as a medi- cine from the earliest times. On the continent of Europe, it is distin- 294 GENERAL STIMULANTS. [PART II. guished by the name of Roman chamomile. It is particularly adapted to cases of general debility, in which the stomach participates in a greater degree than other organs. The gentle stimulant influence of its volatile oil on the stomach renders it peculiarly applicable under such circum- stances. Hence, it is much used in the convalescence from acute febrile diseases. In mild d} r spepsia, with defective appetite, flatulent eructa- tions, or slight colicky pains from wind in the stomach or bowels, it may often be given with advantage. Its general mildness and harmlessness adapt it to those slight cases of debility, frequently occurring, especially in sedentary females, in which stronger medicines are scarcely required, and might prove hurtful. By the ancients it was used in the treatment of intermittent fever, and continued to be esteemed among the most valuable remedies in that complaint, down to the period of the discovery of Peruvian bark. Eveii after that period, it long continued to retain some reputation as a febri- fuge, being employed in cases which resisted the bark, and especially in the remission of remittent fevers, before the febrile phenomena of the paroxysms had sufficiently subsided to justify the use of the more pow- erful antiperiodic. But, since the introduction of sulphate of quinia into use, this application of chamomile has been generally abandoned ; as it is now understood that, in miasmatic remittents, when there is a sufficient abatement of the fever to justify a resort to the bitter tonics, quinia may almost always be used, with equal safety, and vastly greater effect. In cases, however, of intermittent and remittent fever, distinctly paroxys- mal, in which circumstances may prevent the employment of cinchona or its preparations, large draughts of warm chamomile tea, given imme- diately before the paroxysm, the patient being kept warm in bed, will sometimes prevent the recurrence of the fever, either by operating as an emetic, or by a joint tonic and diaphoretic action. It has already been stated that, in large doses, chamomile is apt to vomit. To produce this effect, however, it should be given in the form of warm infusion, and in large draughts, so as to aid the medicine by the nauseating effects of tepid water. It may frequently be employed with advantage, in this way, incases of gastric spasm arising from undigested food or other irritating matters in the stomach, and attended with sensa- tions of nausea, or ineffectual efforts to vomit. Indeed, in any case of irritable stomach, when that organ seems unable wholly to free itself from its contents, it may very properly be aided by large draughts of warm chamomile tea. In febrile and bilious diseases, there is often a good deal of retching from the presence of acrid bile in the stomach, which may thus be promptly relieved. The tea is often also adminis- tered along with other emetics, or shortly afterwards when they are tardy, in order to promote their action, or to render it more easy to the patient, by giving the stomach a greater bulk to act upon. CHAP. I.] TONICS. CHAMOMILE. 295 The flowers were formerly much used externally with hot water, in the way of fomentation, or as a sort of cataplasm inclosed in a flannel bag. They add nothing to the virtues of the hot water; but, in the latter case, may be useful by absorbing the liquid. Administration. Chamomile is given in powder, infusion, or extract ; and the volatile oil is sometimes separately administered. The powder was formerly given occasionally, with the view to the an- tiperiodic effect, in doses of from half a drachm to a drachm, repeated three or four times a day, or oftener if required. As a mere tonic, its dose may be stated at from ten to thirty grains ; but it is almost never admin- istered in this way. The flowers themselves are sometimes chewed by dyspeptic persons, and by those who wish to break themselves of the habit of chewing tobacco, by substituting a more innocent substance. The Infusion (!NFUSUM ANTHEMIDIS, U.S.) is made in the proportion of half an ounce to a pint of water. When time is allowed for a suffi- cient maceration, cold water is preferable to hot as the menstruum, as it yields an infusion more acceptable at once to the palate and the stomach ; but in case of haste, boiling water maybe used ; and, with a view to its emetic operation, the latter is decidedly preferable, and the infusion should be taken warm. The dose as a tonic is a vvineglassful, three or four times a day. When given to aid emetics, a small bowlful, containing from six to twelve fluidounces, may be given at once, and repeated if required. The Extract (EXTRACTUM ANTHEMIDIS, Br.), directed by the British Pharmacopoeia, is not an ineligible preparation ; as the volatile oil, which was driven off in the old Edinburgh process during the evaporation, or rather an equivalent quantity of it, is added at the close of the concentra- tion. As now prepared, the extract represents the virtues of the flowers, and may be given whenever these are indicated. It is occasionally used as an addition to laxatives or metallic tonics, and as a vehicle for other med- icines, given in the pilular form. The dose is from five to thirty grains, the strength being about double that of the flowers. The decoction was formerly used as an external fomentation, as an enema, or as a local application to flabby or indolent ulcers; but has been abandoned, because in no respect preferable to the infusion, and inferior from the circumstance, that a portion of the volatile oil must be driven off in its preparation. The Volatile Oil (OLEUM ANTHEMIDIS, Br.) is occasionally prescribed. It is obtained by distillation with water from the flowers. As first pro- cured, it has a sky-blue colour, which is changed by time to yellow or brown. Its odour is that of chamomile, its taste pungent and aromatic. It is stimulant to the stomach, and may be given in gastric pains of a purely functional character, and in flatulence, in the dose of five or six drops. It is sometimes associated with purgatives to prevent griping. 296 GENERAL STIMULANTS. [PART II. Other species of Anthemis have been used. A. Cotula, may-weed, or wild chamomile, which grows abundantly in this country, and is one of the most common weeds in our public roads, has virtues analogous to those of A. nobilis, but, in consequence of its very unpleasant odour, is little if at all used with us. In Europe it is said to be occasionally em- ployed as an antispasrnodic and emmenagogue. Our national Pharma- copoeia recognizes it, in the secondary list, under the name of Cotula. GERMAN CHAMOMILE. MATRIOARIA. U. S. This medicine is considered here in a subordinate position to Anthe- mis, because, though closely similar to the common or Roman chamomile, and largely used on the continent of Europe, and especially in Germany, for the same purposes, it is probably inferior in strength, and is little used in this country unless among German practitioners. The plant is an annual syngenesious herb, of which the flowers only are officinal. As found in our shops they are imported from Germany. They are smaller than the common chamomile, and the yellow disk or central florets, which are deep-yellow, are proportionably more numerous than those of the ray. They owe their virtues to a volatile oil and bitter principle, both of which are readily imparted to water and alcohol. Their effects are essentially the same as those of common chamomile, and they are given for the same purposes, and in the same way. V. THOROUGHWORT, OR BONESET. EUPATORIUM. U. S. Origin. This consists of the leaves and flowering tops of Eupalorium perfolialum, an indigenous, perennial, herbaceous plant, growing abund- antly, usually in clusters, in low moist grounds, in most parts of the United States. All portions of the plant are medicinal. It is in flower from July to October, and should be collected during that period. Sensible Properties. Boneset is sometimes kept in the shops in bunches, sometimes in small oblong packages, in which it is much broken up. In the former state, it may be known by its perfoliate and decussating leaves, and by its flattish, dense summit of white, almost feathery flowers. The leaves may be considered as consisting of two, join id at their base, where they are perforated by the stem. Each leaf is broadest at the base, long, narrow, and gradually tapering to a point, serrate on the edges, wrinkled, whitish below and green above, and hairy. The pairs are so placed on the stem, that each one is at right angles with the one above and below it. The odour is feeble, yet dis- tinct, and the taste strongly bitter and peculiar. It yields its sensible and medicinal properties to water and alcohol. CHAP. I.] TONICS. EUPATORIUM. 297 Active Constituents. Little is known, positively, on this point. There is little doubt that the bitterness resides in one or more proximate principles; but they have not yet been satisfactorily isolated. From the smell, it may be inferred to contain a small proportion of volatile oil, and the fact seems to have been established by the examination of Mr. Bickley. (Am. Journ. of Pharm., xxvi. 495.) The medicine is placed next to chamomile, more from its analogy to that medicine in effects, than from any known resemblance in composition. Effects on the System. Eupatorium, in moderate doses, produces on the system effects like those of the simple bitters ; but superadds to these, especially when taken in warm infusion, and somewhat freely, a decided diaphoretic action. It is said, also, sometimes to be diuretic, and, in large doses, proves emetic and laxative. It is among the remedies de- rived from the aborigines, from whom it passed into popular use, and thence into the hands of the profession. Therapeutic Application. Eupatorium may be given, like the simple bitters, in pure dyspepsia or general debility; but, being more liable than they to irritate the stomach, and probably less efficient as a mere tonic, should not be allowed to supersede them, unless under peculiar circumstances of idiosyncrasy or prejudice. Dr. Burgon, of Bucks County, Pennsylvania, preferred it to all other tonics, in the loss of ap- petite incident to the abuse of alcoholic drinks. (Am. Med. Record., iii. 331.) Dr. Eborle found it peculiarly useful in the indigestion of old people, in whom, while it restored tone to the stomach, it rendered the skin soft and comfortable. (Mat. Med. and Therap., 4th ed., ii. 219.) But its highest reputation has been as a febrifuge. From the inau- gural dissertation of Dr. Anderson (New York, 1813), it would appear to have been employed with very great success, in the treatment of in- termittents, in one of the New York hospitals. Subsequen/ observation of its effects has proved less favourable ; and, employed as a mere anti- periodic, in the ordinary mode of prescribing bark or quinia in the inter- missions, it cannot be relied on. But I have known it to supersede the paroxysms of intermittent fever, when given in emetic doses, in the state of strong tepid infusion, shortly before the period for the return of the chills ; and if, jointly with this method of exhibition, it be administered in moderate doses, at short intervals, during the apyrexia, there is little doubt that it will often prove successful. Still, it is greatly inferior to sulphate of quinia in certainty, while, in its effects as thus used, it is much more disagreeable. It may be very appropriately tried in obsti- nate and frequently recurring attacks of intermittent fever, in which quinia has become offensive to the patient, or inoperative from repetition. The same remarks are applicable to its comparative efficacy in remittents; in which, however, its tendency to produce perspiration is somewhat in its favour. 298 GENERAL STIMULANTS. [PART II. It was recommended, by Drs. Bard and Hosack, in yellow fever (Eb- erle, loc. cit.); and has been used as a tonic and diaphoretic in low fevers, and typhoid pneumonia; but its special merits iu these affections are at best equivocal, and it is now seldom employed. Perhaps its best application is to the treatment of catarrahal affec- tions, more particularly the epidemic catarrh or influenza, which is fre- quently attended with an asthenic state of system, calling for supporting measures. The most effectual method of employing it, in these cases, is, very soon after the attack of the disease, to administer it freely at bedtime, in the form of hot infusion, the patient being well covered, so as to provoke copious and lasting perspiration; and if vomiting should take place the effect would be more certain. In the morning, the disease will often be found to have been arrested, or very much moderated ; and afterwards the medicine may be given in small and repeated doses, so as not to nauseate. Dr. Chapman, in his Therapeutics (2d ed., i. 388), speak- ing of its employment in a species of influenza which had prevailed many years previously in the United States, and which, in consequence of the pain attending it, was commonly denominated break-bone fever, states that, from its prompt success in relieving this symptom, it acquired the popular name of boneset, by which it is still known. The probability is, that the epidemic alluded to by Dr. Chapman was that described by Dr. Rush as having occurred in Philadelphia, in the summer and autumn of 1780, called break-bone fever, from the violence of its pains, but which, there is every reason to suppose, was the disease since better known under the name of dengue. This fact would suggest a trial of eupatorium in that very painful epidemic disease. In acute rheumatism, the medicine is said to have proved useful ; and, in the atonic variety, occurring in feeble constitutions, without plethora, it might !>< very properly tried, with a view to its conjoined tonic and diaphoretic effects. Though said to have been advantageously employed in obstinate cuta- neous diseases, I have no faith whatever in its efficacy, except in so far as it may operate, like any other tonic, in promoting the general health. The same may be said of its remedial powers in dropsy, in which it has been recommended. Administration. As an antiperiodic or tonic, the medicine m;iy he given in powder, in doses of twenty or thirty grains, or more; but it is very little used in this form. The Infusion (!NFUSUM EUPATORII, U. /S.) is a more eligible prepara- tion. It is made in the proportion of an ounce to a pint of water, and given in the dose of one or two fluidounces, repeated more or less frequently, according to circumstances; three or four times a day, as a tonic, in chronic cases; and every hour, two, or three hours, as an antiperiodic, or joint tonic and diaphoretic, in those more acute. When its emetic CHAP. I.] TONICS. SERPENTARIA. 299 effect is wanted, six or eight ounces of the hot infusion may be given at a draught. A watery extract has been used in the dose of four or five grains. Several other species of Eupatorium have been employed. Among our indigenous species, E. purpureum, or gravel root, has tonic and astringent properties, and is said to be diuretic. E. teucrifolium, or wild horehound, corresponds with the officinal species in properties, though less powerful ; and E. aromaticum is considered, among the so- called eclectic physicians, as a valuable remedy in a number of diseases. The root of E. Cannabinum was formerly used in Europe as a purga- tive ; and E. Aya-pana, of Brazil, resembles the boneset, but is weaker. VI. SERPENTARIA. U.S. SERPENTARIA. U.S., Br. Syn. Virginia Snakeroot. Origin. This consists of the roots of Aristolochia Serpentaria, Aris- tolochia reticulata, and probably several other analogous species of the same genus, all of them small, indigenous, herbaceous perennials, grow- ing in the woods in the Middle, Southern, and Western States; A. Serpentaria abounding in western Pennsylvania, Virginia, Ohio, Ken- tucky, etc.; A. reticulata in Louisiana, Arkansas, and the neighbouring regions. Sensible Properties. The root consists of a short, contorted, knotty head, with numerous long, slender fibres or rootlets proceeding from it, which are often more or less interlaced, as the medicine is found in the shops. The roots of A. reticulata are straighter, thicker, and less flexible than the others, and consequently much less interlaced. The colour is at first yellowish, but becomes brownish by time ; the odour is strong, aromatic, and agreeable ; the taste very bitter, aromatic, and somewhat camphorous. The root yields its sensible properties and medical virtues to water and alcohol. Active Constituents. These are a peculiar bitter principle, and a pecu- liar volatile oil, which may be separated by distillation. Adulterations. Occasionally the roots of Spigelia Marilandica, and the young roots of Polygala Senega, are mixed with serpentaria, but probably not by design. They are distinguishable by the total want of the odour and taste of the genuine root. Effects on the System. Serpentaria is a stimulating, diaphoretic tonic; owing its tonic properties, which are probably identical with those of the simple bitters, to its bitter principle, and its stimulant and diaphoretic in- fluence mainly to its volatile oil. Taken internally, it sharpens the appe- tite, hastens the digestive process, increases the frequency of pulse and 300 GENERAL STIMULANTS. [PART II. warmth of skin, and occasions, not unfrequently, either diaphoresis or diuresis ; being disposed to produce the former effect, if given in warm infusion while the patient is well covered in bed, and the latter, if in powder, or cold infusion, while he is walking about and exposed to the air. When taken in over-doses, it may produce nausea, griping pain in the bowels, even vomiting or tenesmus, and will sometimes cause pain or a sense of weight in the head, with disturbed sleep. Therapeutic Application. Virginia snakeroot has been known as a medicine from an early period of the settlement of this country. Like others of our valuable indigenous remedies, it originally attracted notice as an antidote to the bite of serpents; and, as such, is alluded to in a work by Dr. J. Cornutus, published at Paris in 1635 (W. P. C. Bar- ton, Veg. Mat. Med. of the U. S., ii. 48) ; but the first known mention of it was by Thomas Johnson, an apothecary of London, in an edition of Gerarde's Herbal, published in 1633 (Pereira, Mat. Med., ii. 1299). Its supposed efficacy in the poison of serpents led naturally to its use in low and malignant febrile diseases, in which the blood was believed to be poisoned ; and, by an easy transition, it came to be employed in other fevers, in which this malignant type was not presented. Sydenham re- commended it in vernal intermittents (Sydenham's Works, edited by Dr. Rush, p. 460); and it is favourably spoken of by many of the medical writers of the last century. Its real value is now probably better known than formerly. It is simply tonic and stimulant to the circulation, with a tendency to produce perspiration, generally acceptable to the stomach in moderate doses, and probably without special influence on the brain or nervous system. It may be employed in pure dyspepsia, attended with a degree of de- bility calling for something more stimulating than the simple bitters, and especially wl^ere there is a disposition to dryness of the surface ; but its most appropriate application continues to be that for which it was early recommended, to the treatment, namely, of fevers of a low or typhoid character, or disposed to take on that character. Whenever any febrile disease begins to exhibit this tendency, and stimulation is demanded, serpentaria is one of the first medicines to which we may have recourse, provided the stomach be wholly free from inflammation, or vascular irri- tation. It may be used, therefore, with the condition of stomach men- tioned, in typhus or typhoid fever when passing from the first stage of excitement into that of debility, in protracted remittent fever a.-suminga low character, in typhoid pneumonia, and in smallpox, scarlatina, malig- nant sore-throat, and erysipelas, under similar circumstances. But it should be understood that, in none of these affections, does it possess any specific curative powers, that it can act merely as a tonic and gentle stimulant, and that it should be used only as an adjuvant in very serious cases, being alone wholly incompetent to the support of the system under CHAP. I.] TONICS. ARNICA. 301 powerful depressing influences. In many of these cases, it may be very properly associated with Peruvian bark or quinia. From my own observation, I should infer that serpentaria possesses no peculiar antiperiodic power, and that it cannot, therefore, be relied on for breaking the course of an intermittent or remittent fever; but in either, it may be conjoined with sulphate of quinia when the system is feeble, and the stomach somewhat insusceptible. The association of ser- pentaria with Peruvian bark has long- been a habit among practitioners. It exists in the compound tincture of Peruvian bark of the British and American Pharmacopoeias, better known under the name of Huxham's tincture of bark. Dr. Chapman says of serpentaria "that it is admirably suited to check vomiting, and to tranquilize the stomach, especially in bilious cases." (Elem. of Therap., etc., 2d cd., ii. 434.) Administration. The medicine is sometimes, but rarely, given in pow- der. The Infusion (!NFUSUM SERPENTARIA, U.S.), made in the pro- portion of half an ounce to a pint of boiling Avater, is the preparation ordinarily used. In the present Pharmacopcoia the infusion, though prepared also in this way, is preferably made by percolation with cold water, essentially the same proportions being used. There is an officinal Tincture (TINCTURA SERPENTARIA, U. S.), which is rendered turbid by water. The dose of the powder is from ten to thirty grains ; that of the infu- sion, one or two fluidounces, to be repeated three or four times a day in chronic cases, every hour, two, or three hours, in acute. Of the tincture, which is employed chiefly as a stimulant and stomachic addition to other medicines, the dose is one or two fluidrachms. A Fluid Extract (EXTRACTUM SERPENTARIA FLUIDUM, U. S.) is directed in the present Pharmacopoeia, and is a good preparation, con- taining all the virtues of the root in a very small space. It is, indeed, a concentrated tincture ; but the proportion of alcohol is almost insig- nificant, and, in view of the stimulant effect the fluid extract is intended to produce, wholly so. The dose is twenty or thirty minims, to be fre- quently repeated. ARNICA. U. S., Br. On comparing arnica with other medicines, I find none to which it appears to me to approach more closely than serpentaria; though it must be acknowledged that there is considerable difference between them. I have accordingly concluded to give it this subordinate position to serpentaria provisionally, until a better place can be found for it in the classification. The name of arnica is given, in the U. S. Pharmacopoeia, to the flowers, in the British, to the root of Arnica montana or Leopard 1 s-bane, 302 GENERAL STIMULANTS. [PART II. a perennial herbaceous plant, growing in the mountainous regions of Europe and Siberia, and, according to Nuttall, in the North-western parts of this continent. The entire plant has, when fresh, a strong dis- agreeable odour, which diminishes in drying, and an acrid, bitter, last- ing taste. The flowers are most used in this country. Among other ingredients they were found by MM. Chevallier and Lassaigne to contain a peculiar principle, analogous if not identical with cytisin, previously discovered in the laburnum-tree. This is a powerful agent, acting ener- getically in the dose of five grains as an emeto-cathartic, and probably capable in excessive doses of producing poisonous effects. It is no doubt one of the active ingredients of the flowers ; but certainly not the only one ; as, besides a small proportion of volatile oil and acrid resin, a peculiar alkaloid has been obtained from them, which is not without influence upon the system. Our information, however, as to the relation between these two substances, the cytisiu and arnicina (or preferably arnicia) as the alkaloid has been named, and as to the effects of both on the system, is yet too indefinite to admit of positive conclusions. It seems certain, however, that they are not identical ; for, according to its discoverers, cytisin is readily dissolved by water, with difficulty by strong alcohol, and not at all by ether; while arnicia is but slightly soluble in water, and freely soluble in alcohol and ether. The root probably has essentially the same virtues as the flowers. As a medicine, arnica has long been used on the continent of Europe, particularly in Germany, where it is highly esteemed. In the United States, it was almost unknown as a remedy until of late ; but within a few years it has risen greatly in reputation, probably in part through the many German practitioners who are pursuing their profession in this country. So decided is the change in this respect that, in the present edition of the U. S. Pharmacopeia, it takes a place in the primary cata- logue, having been transferred from the secondary, where it previously held a somewhat doubtful place. Arnica appears to be a general stimu- lant and tonic, analogous in this respect to serpentaria, but directed espe- cially to the nervous system, and acting as a diaphoretic, diuretic, and emmenagogue. It is apt to nauseate, and in large doses operates as an emetic and cathartic. Very freely taken, it causes burning in the stom- ach, violent abdominal pain, excessive headache, muscular spasms, and other evidence of nervous disturbance. It is no doubt capable of acting as a poison. A case is recorded in the London Lancet (Nov. 18, 1864, p. 571), in which the patient was apparently saved only by the use of remedies from threatened death, consequent on the swallowing by mis- take of an ounce of tincture of arnica. When first seen by the physician, he was in a state of approaching collapse, with sunken and glassy eyes, dilated pupils unaffected by light, voice low and muttering, pulse over a hundred, feeble and fluttering, great pain in the epigastrium, and a cold, CHAP. I.] TONICS. ARNICA. 303 dry skin. Intelligence, however, was not lost ; and, from his account of himself, it appeared that little effect had been experienced for the first eight hours after the swallowing of the poison, except dryness of the mouth, that at the end of that time he was awakened from sleep by vio- lent pain in the stomach, and that on rising he felt sick and feeble. The treatment consisted in the exhibition of an ounce of brandy and twenty minims of laudanum, which were repeated in two hours, and the exter- nal application of heat. He gradually recovered. An emetic would have been the appropriate remedy at an earlier stage, but was out of the question under the circumstances of the present case. Arnica appears to be adapted to febrile diseases with a low or typhoid tendency, also to various phlegmasiae offering a similar condition. It has been used in rheumatism and gout, diarrhoea and dysentery, chronic catarrh and nephritis, passive hemorrhage, dropsy, and amenorrhoea, and certain paralytic affections, especially amaurosis. Having been found useful in the nervous disturbance following accidents of various kinds, it got a reputation as a special cure for wounds, sprains, bruises, and the swellings consequent on dislocation, and is much employed in domestic practice as a local application in these affections, for which the tincture is deemed especially useful. The powder is sometimes used to excite sneezing. Arnica may be given in powder or infusion ; the dose of the former being from five to twenty grains ; of the latter, made in the proportion of an ounce to the pint, half a fluidounce to a fluidounce every two hours. A Tincture of the Flowers (TINCTURA ARNIOE, U. S.) and a Tincture of the 'Root (TINCTURA ARNICA, Br.) are officinal, the former in the U. S., the latter in the Br. Pharmacopoeia. It is this preparation either undiluted, or mixed with water or soap liniment, that is so much used in the local affections above referred to. From some observations made by Dr. Garrod, of London, there is reason to believe that the effects of the tincture in these cases is little more than that of the alcoholic menstruum. The dose for internal use is from thirty minims to two fluidrachins. An Extract (EXTRACTUM ARNICA ALCOHOLICUM, U. S.) is prepared from the flowers by percolation with alcohol and subsequent evaporation. The dose is from five to ten grains. But is more used in the prepara- tion of the plaster than for any other purpose. The Plaster of Arnica (EMPLASTRUM ARNICA, U. S.) is made by in- corporating the extract with the melted resin plaster. This is another preparation very popular, outside of the profession, as a remedy for sprains, bruises, etc. 304 GENERAL STIMULANTS. [PART II. VII. MYRRH. MYRRHA. U. S., Br. Origin. Myrrh is a concrete exudation from Balsamodendron Myrrha, a shrub or small tree, growing in the deserts of Arabia and North-eastern Africa, Two commercial varieties were formerly brought into market, one from the ports of Egypt in the Mediterranean, the other from the ports of India; both, however, being originally obtained from the same neighbourhood. They were distinguished by the names of Turkey and India myrrh. The former was much purer and finer than the latter, because selected with greater care, in reference to its more expensive carriage. At present both kinds are imported from India, whither they are taken by Arab vessels from the Red Sea. Sensible Properties. Myrrh is in small fragments, irregular or rounded, like tears, or in larger masses, as if consisting of the smaller agglutinated together. The best specimens, formerly called Turkey myrrh, are of a pale reddish-yellow, or reddish-brown colour, often powdery on the sur- face, and translucent. The larger agglutinated pieces exhibit various shades of colour. The inferior kinds, formerly known as India rnyrrh, are in very irregular lumps, of a dark colour, opaque, and full of im- purities. Myrrh is brittle, with a shining fracture. The powder of the best kinds is whitish or yellowish-white, of the inferior darker, with a somewhat reddish hue. It is not fusible by heat, but is inflammable. The odour is strong, peculiar, and fragrant; the taste bitter, somewhat acrid or pungent, and aromatic. Composition, and Relation to Solvents. The active principles of myrrh are & peculiar bitter resin, which has been called myrrhin, and a volatile oil. In composition it is a gum-resin, containing volatile oil, and other ingredients of little or no practical importance. Water dis- solves the gum and a very small proportion of the volatile oil ; alcohol the resin and the whole of the oil ; and, as these two are the active principles, alcohol would seem to be the best menstruum. But when the gum-resin is rubbed with water, it readily forms a white or yellowish- white opaque emulsion, in which the resin and oil are held in suspension by the gummy matter dissolved in the water; and, though a portion of the resin soon subsides, the mixture is sufficiently permanent, or so easily rendered uniform by shaking, that this form is usually preferred for the administration of the medicine. Alkalies unite with the resin, and ren- der it much more soluble in water; so that, by the addition of a portion of an alkaline carbonate in forming the emulsion, this is rendered of easier preparation, and more permanent. The volatile oil may be separated from the gum-resin by distillation. CHAP. I.] TONICS. MYRRH. 305 Effects on the System. Myrrh acts on the system probably as a simple bitter tonic through its resin, and as a stimulant to the circulation through its volatile oil. It has no special influence on the brain or nervous system generally; but is supposed to have a peculiar tendency to the lungs and uterus, stimulating their functions respectively, and consequently acting as an expectorant and emmenagogue. When swal- lowed in small doses, it increases the appetite, produces a feeling of warmth in the stomach, and invigorates digestion, as well probably as the vital functions generally. In larger quantities, it increases the pulse, produces a glow over the system, and operates generally as a mild arterial stimulant. In over-doses, it irritates, or may even inflame the stomach, and gives rise to general febrile phenomena. Therapeutic Application. Myrrh has been known as a medicine from the earliest records of our science. It is now probably less esteemed than formerly, but is still much employed, and is not without valuable powers. As a tonic simply, it is not often used; being too stimulating, and too apt to irritate the stomach, if this be at all disposed to be so affected, or to augment any existing irritation or inflammation. But in a perfectly sound, though weakened state of the stomach, with a languid condition of the functions generally, it may be given advantageously; and especially when, with this debilitated state of the system, there coexists either arnenorrhcea, or a chronic bronchial inflammation, with profuse expectoration, or both these conditions jointly. The particular affections, therefore, to which it is best adapted, are chlorosis in females with amenorrhoea, and chronic bronchitis in the old or debilitated, with or without hectic fever, but with copious and especially puruloid expecto- ration ; and, when these affections are associated, the indications for its use are still stronger. But particular care must be taken that the stom- ach is in no degree phlogosed when it is administered. It has been much used in phthisis ; but I cannot say that I have known it to be of material service in that complaint; while it has often done harm by dis- turbing the stomach. It is seldom given alone. In anemic states of the system with amenorrhoea, it is often combined with one of the pre- parations of iron, and, if there be constipation at the same time, or a tendency to it, with aloes or rhubarb. Being a local stimulant, myrrh has been much used externally in foul, flabby, or indolent ulcers, as a mouth-wash in spongy or ulcerated gums, and as a gargle in ulcerous affections of the fauces. For these purposes, the powder is, in external ulcers, simply sprinkled on the diseased sur- face, or applied in the form of an ointment; in affections of the mouth and fauces, it is employed rubbed up with water. Administration. Myrrh may be administered in powder, pill, or emul- sion, in the dose of from ten to thirty grains. In the simple form of powder, it is little used. VOL. i. 20 306 GENERAL STIMULANTS. [PART II. Nor is it often given, uncombined, in the form of pill; but it enters into several officinal combinations in this form. Such are the Pilulse Aloes el Myrrhse, formerly called Rufus's pills, Pilulae Ferri Comp., Pil. Galbani Comp., and Pil. Rhei Comp., of the U. S. Pharmacopoeia. To these the reader is referred, under the heads of their prominent in- gredients respectively. Emulsion is the form of administration most frequently used. It should be made by selecting the finest pieces, powdering them, and rub- bing the powder up thoroughly with such a proportion of water, that a tablespoonful of the mixture shall contain the dose of the gum-resin which it may be desired to exhibit. If an alkaline carbonate be indi- cated at the same time, its addition will tend to facilitate the prepara- tion. The noted anti-hectic mixture of Dr Griffiths, formerly very popular, and still considerably used in chlorosis, amenorrhcea, hysteria, and the hectic fever of pulmonary complaints, is made of these ingre- dients, with the addition of sulphate of iron, which is converted into the carbonate through reaction with the carbonate of potassa used. The Mistura Ferri Composita of the Pharmacopoeias is an imitation of this preparation. Decoction is not an appropriate mode of preparing myrrh, as the whole of its active properties are not extracted by water. The gum- resin, however, is an ingredient in the Compound Decoction of Aloes of the British Pharmacopoeia, in which the resin is dissolved by means of the alkaline carbonate used. Tincture of Myrrh (TiNCTURA MYRRHS, U. S.), though little used internally, is often employed locally as a stimulant to indolent and foul ulcers, to promote the exfoliation of bones, and, diluted with water, as a mouth-wash or gargle, in spongy gums, aphthous sore mouth, and ulcer- ation of the mouth and fauces. When mixed with water, it becomes turbid by the separation of the resin. The dose is from thirty minims to a fluidrachm. There are several other stimulant tonics, which owe their virtues to bitter principles and volatile oils, but having little to recommend them in preference to those in more general use, and not being at present much employed, will be more appropriately considered in a subordinate position. Such are angustura, cascarilla, contrayerva, wormwood, tansy, and horehound. A brief notice will suffice for each of these. 1. ANGUSTURA BARK ANGUSTURA. U. S. CUSPARIA. Br. is the bark of the Galipea officinalis of Hancock, a small tree in the interior of South America, on the banks of the Orinoco. It is taken first to the town of Angustura upon the Orinoco, and thence to the West Indies, whence it enters into general commerce. CHAP. I.] TONICS. ANGUSTURA BARK. 307 Properties. It is in pieces of various length, usually short, slightly rolled or nearly flat, thin, with edges pared obliquely, externally covered with a soft, yellowish-gray or whitish epidermis, internally yellowish, and when pulverized yielding a pale-yellow powder. It has a peculiar odour becoming fainter with age, and a bitter, slightly aromatic, and ad- hesive taste, leaving a sense of pungency on the end of the tongue. Active Constituents. These appear to be a peculiar bitter principle soluble in water and alcohol, called angusturin or cusparin, a hard bit- ter resin, a soft acrid resin, and a volatile oil; but it may be questioned whether the bitter resin referred to may not owe its taste to an unsepa- rated portion of the proper bitter principle. The soft resin is probably the oxidized volatile oil. Medical Properties and Uses. Angustura was employed by the abo- rigines, who appear to have made it known to the early settlers. From the continent it passed to the West Indies ; and was not introduced into Europe till about ninety years since. Its effects on the system are those of a stimulant tonic, in small doses acceptable to the stomach, but in larger apt to vomit and purge. Its tonic property depends probably on the bitter principle, the stimulant on the volatile oil. It has no special influence on the brain or nervous system. In South America and the West Indies, it has been used as a substitute for cinchona in intermittent and remittent fevers, and is said to have proved very efficacious in the malignant bilious fevers of those latitudes. Experience in Europe and this country has not proved favourable to its claims as an antiperiodic. and it probably possesses no peculiar property of this kind. Though it has succeeded in arresting some slight cases of ague and fever, which almost anything capable of impressing the system at all will occasionally do, yet in the more obstinate kinds it has failed, and can be certainly relied upon in none. Another application made of it has been to the treatment of bilious diarrhcoa and dysentery, as they occur in tropical countries ; and it may have been useful as a tonic and stimulant in some of those cases: but, in the diseases as they occur with us, it would in general probably do more harm than good. It is little used in this country. Administration. It may be given in powder, in the dose of from ten to thirty grains. The Infusion (!NFUSUM ANGUSTUR^E, U. S.) is, how- ever, preferred. It is made by macerating half an ounce with a pint of boiling water; or, in essentially the same proportions, by percolation with cold water; and given in the dose of two fluidounces, three or four times a day. The Tincture is no longer officinal. The dose of it, as formerly prepared, was one or two fluidrachms. FALSE ANGUSTURA BARK. Under this name, a bark, now believed to be the product of Strychnoa Nux Vomica, has sometimes been sold for genuine Angustura bark, with fatal consequences. This could happen 308 GENERAL STIMULANTS. [PART II. only before attention had been called to the subject. Such a mistake would be unpardonable now ; for there is little real resemblance between the two barks, and it is only necessary that the slightest caution should be observed. In this country, I do not think that the substitution has ever taken place. I have never seen false Angustura bark in the United States, except parcels which have been sent hither as specimens. It is not used in medicine, but, containing a large proportion of brucia, and probably also strychnia, it might be employed for the extraction of those principles. 2. CASCARILLA. U.S.,Sr. Cascarilla is the bark of Croton Eleuteria, a small "West India shrub, inhabiting especially the Bahamas, and abundant in the little island of Eleuteria, from which it derived its name. Properties. It is in small quills or pieces of quills, from three or four inches long and half an inch in diameter, down to the smallest fragment. Sometimes it is in pieces curved longitudinally, and appearing as if shaved from the stem, having now and then portions of the wood attached to their inner surface. Externally the bark is invested with a whitish or grayish-white epidermis, which, however, is sometimes want- ing, in which case the surface of the proper bark presents a dark-brown colour. The inner surface is of a chocolate colour, and the fracture, which is short and abrupt, is reddish-brown. The odour is agreeably aromatic, and increased by friction ; the taste, warm, spicy, and bitter. When burnt, the bark emits an odour, resembling that of musk, though not so strong, and more agreeable. On this account, it is used for fumi- gation ; and smokers sometimes add it to their tobacco. It yields its vir- tues to water or alcohol, but more completely, it is said, to a mixture of the two. Active Constituents. These are a peculiar bitter principle, called cas- carillin, and a volatile oil, which is abundant, and may be obtained by distillation. Medical Properties and Uses. The first account of the use of casca- rilla dates as far back as about the year 1690. It was for a time a very popular remedy in Europe, having been seized upon, as a substitute for bark, by many who were prejudiced against that medicine; and its febri- virtues were for some time in high esteem. It came, however, at to be estimated at its true value; and at present is considered nothing more than a mild aromatic tonic, usually acceptable to the stom- ach, and, in consequence of the predominance of its aromatic properties, deserving perhaps better to rank in that division of the tonics, than among the bitters. When smoked in connection with tobacco, it is said to have induced vertigo and intoxication; but, admitting this effect, which, however, is doubtful, it must be ascribed, not to the cascarilla itself, but to its empyreumatic product. The strong resemblance of its CHAP. I.] TONICS. CASCARILLA. CONTRAYERVA. 309 odour, when burned, to that of musk, would justify an attempt to collect the volatile products resulting from its combustion, and to ascertain whether they might not also imitate that powerful antispasmodic in its effects on the system. The bark is used chiefly in debilitated states of the stomach and bow- els, as in dyspepsia, flatulence, and diarrhoea and dysentery connected with weakness or relaxation of the bowels, or in the convalescence from these affections. It is a good addition to more powerful tonics. M. Follemberg, a European veterinary surgeon, has found cascarilla to exercise a powerful influence, in the lower animals, in promoting a flow of milk after the birth of their first young. He gives to a mare, in twenty-four hours, about two ounces of the powder incorporated with meal. In greatly reduced doses, it may possibly prove equally useful in the puerperal woman whose milk is retained. (Ann. de Therap., A.D. 1863, p. 84.) The dose of the powder is from ten to thirty grains. The Infusion (INFTJSUM CASCARILL^E, U. S.) is made by macerating an ounce of the coarsely powdered root in a pint of boiling water, or by percolation in similar proportions with cold water; and is given in doses of two fluid- ounces, repeated as customary with tonic medicines. A Tincture (TiNC- TURA CASCARILLA, Br.) is directed by the British Pharmacopeia, and may be added to stomachic or purgative infusions in the quantity of one or two fluidrachms. 3. CONTRAYERVA. U. S. 1850. Contrayerva has been omitted in the present Pharmacopoeia. It is the root or rhizome of Dorstenia Conirayerva, a small perennial plant, growing in the West Indies, Mexico, and Peru. As in the shops, it is of a somewhat oblong shape, an inch or two in length, rough, very hard, reddish -brown externally, pale internally, and furnished with numerous long, slender, yellowish radicles, attached to the lower part. The odour is aromatic; the taste warm, pungent, and bitter. Boiling water or alcohol extracts its virtues, which probably depend on a volatile oil, and a bitter principle, though the latter has not been isolated. In its effects on the system, it is gently tonic, aromatic, stimulant, and diaphoretic, bearing some resemblance to serpentaria, but less powerful as a tonic. It was formerly used in low febrile diseases disposed to as- sume a typhous or malignant character, in dysentery and diarrhoea with debility, and in other conditions supposed to call for stimulation ; but it has given place to more convenient or efficient remedies, and is now scarcely used. The dose of the powder is from twenty to thirty grains. An infusion, made in the proportion of an ounce of the bruised root to a pint of boiling water, may be given in doses of one or two fluid- ounces. 310 GENERAL STIMULANT?. [PART II. 4. WORMWOOD. ABSINTHIUM. U.S. Wormwood, as a medicine, consists of the leaves and flowering tops of Artemisia Absinthium, the common wormwood of our gardens, but a native of Europe. It has a strong, peculiar odour, and an extremely bitter, disagreeable, nauseous taste. These properties, as well as its medical virtues, it imparts to water and alcohol. They reside chiefly, if not exclusively, in a bitter principle called absinthin, and a peculiar vol- atile oil, which, when separated by distillation with water, has a deep- green, brown, or yellowish colour, an acrid, bitter taste, and a strong odour of the plant. The herb may contain a little tannic acid, but not enough sensibly to modify its effects. Wormwood is a stimulating tonic, resembling chamomile in its effects, but stronger and more disagreeable. In small doses, it operates like the simple bitters ; in larger, excites the pulse, increases the heat of the skin, produces headache, and is said sometimes to have exhibited nar- cotic effects. Its active principles are no doubt absorbed, as it renders the flesh and milk of animals fed with it bitter. In very large doses it is apt to vomit. It is among the medicines used by the ancients, and, before the discovery of Peruvian bark, was much relied on in the treatr ment of intermittent Though greatly inferior in antiperiodic power to cinchona, it has some efficacy in arresting intermittent fevers, and is particularly recommended as a preventive. It has been used also as an anthelmintic and emmenagogue, and probably has some efficiency in these respects. It is probably not without a stimulant influence over the ner- vous system, such as characterizes the antispasmodics, or nervous stimu- lants of the classification adopted in this work; and hence may be used, with hope of benefit, in hysterical cases attended with feeble digestion, and defective menstruation. The dose of the powder is one or two scruples; that of the infusion, made in the proportion of an ounce to the pint, is two fluidounccs. The herb has been used externally with hot water as a fomentation, but prob- ably with little other benefit than such as may be ascribed to the heat and moisture. A cordial is much used in France under the name of absinthe. It is said to be prepared by mixing about five drachms of the volatile oil of wormwood (essence d'absinlhe) with 100 quarts of alcohol. It might be supposed that, in so small a proportion, the oil could produce no se- riously injurious effects; but M. E. Descaine has satisfied himself that the cordial is much more marked in its effects, and much more injurious than the spirit contained in it can be ; intoxication being more rapidly produced; the phenomena included under the name of alcoholism, both acute and chronic, more quickly developed ; and the effects on the nervous system more marked, resembling those of the acrid narcotic poisons. (Complex Rendus, A out, 1864.) In confirmation of the statements of M. Descaine, M. Marce made various experiments with the lower ani- CHAP. I.] TONICS. TANSY. HOREHOUND. 311 mals, from the result of which it appears that the oil of wormwood is in large doses a violent narcotic poison. In the dog two or three grammes (30 to 45 grains) caused trembling, stupor, and insensibility; three or four grammes, epileptic convulsions, involuntary evacuations, foaming at the mouth, and stertor. But these symptoms were tran- sient, and death did not result. (Bullet. Gen. de Therap., Mai 15, 1864.) 5. TANSY. TANACETUM. U. S. The tansy, or Tanacetum vulgare, is an herbaceous perennial, indige- nous in Europe, but introduced into the United States, where it grows wild, and is cultivated in gardens. The whole herbaceous part is used. It has a strong, peculiar odour, which is much diminished by drying, and a warm, bitter, sub-acrid, aromatic taste. Its activity, which is im- parted to water and alcohol, depends on a bitter ingredient, and a vola- tile oil. There is also a little tannic acid, but insufficient materially to influence the operation of the medicine. The oil is greenish-yellow, and has the characteristic odour of the plant. Tansy has been known as a medicine for at least one thousand years. It is a stimulating tonic, and supposed also to possess anthelmintic and emmenagogue properties. In large quantities, it is probably somewhat narcotic ; at least, so we may infer from the operation of the volatile oil. From its supposed possession of the power of causing abortion, this oil has been repeatedly taken in large doses ; and three cases of death from it, in this country, have been recorded; one resulting from a single fluidrachm of the oil, a second from half a fluidounce, and the third from an ounce. The symptoms were violent convulsions, coma, and great prostration, which speedily ended in death. The fatal issue was too rapid to be owing to any irritant operation on the stomach, and in one case, which was examined after death, no inflammation was found. The medicine has been given in dyspeptic affections-, intermittent fever, to prevent the paroxysms of gout, in hysteria, amenorrhoea, and worms in the bowels. At present, its use is confined mainly to the two latter affections, and in these it is employed much more in popular than regular practice. The seeds are thought to be more powerful, as a vermifuge, than the oil. The dose of the powder is from thirty grains to a drachm ; that of an infusion, made with an ounce of the herb to a pint of water, two or three fluidounccs, two or three times a day. A drop or two of the oil may be added to each dose of the infusion. 6. HOREHOUND. MARRUBIUM. U.S. Common horehound, or Marrubium vulgare, is a perennial herba- ceous plant, a native of Europe, but introduced into the United States, where it grows abundantly along the roadsides. The whole herbaceous 312 GENERAL STIMULANTS. [PART II. part is used. This has, when fresh, a strong, rather agreeable odour, which is diminished by drying, and lost by long keeping. The taste is bitter and lasting. The herb yields its sensible properties and medical virtues to water and alcohol. These depend on a bitter constituent and a volatile oil. It contains also a little tannic acid. Horehound has been known as a medicine from the times of Charle- magne. In reference to its effects on the system, it is mildly tonic and gently stimulant, and is thought also to be somewhat diaphoretic, diu- retic, and laxative. If we may judge of the opinion entertained of its action by the use made of it, we must add to the properties just men- tioned those also of an expectorant. The complaints in which it has been given are dyspepsia, chronic hepatitis, jaundice, amenorrhcea, vari- ous cachectic affections, chronic bronchitis, pulmonary consumption, and ordinary catarrh. What good can be effected,, in these and other com- plaints, from a mild tonic, which, when taken in warm infusion, may gently promote the cutaneous and bronchial secretions, and perhaps the uterine, may be expected from horehound, but nothing more. It is at present seldom used by regular practitioners, and, even as a domestic medicine, is chiefly employed in catarrhal affections of the air-passages. The dose of the powder is from thirty grains to a drachm. The infusion is made in the proportion of an ounce to a pint of hot water, and given in wineglassful doses. A syrup is often prepared from it, and a candy impregnated with its taste is sold in the shops; both being used for ordinary colds. 7. CATNEP. CATARIA. U.S. This well-known plant, sometimes called catmint (Nepeta Gataria), is a very old medicine, at present more employed in domestic than in regular practice. The whole herb is efficacious ; but the leaves only are recognized in our Pharmacopeia. They have a strong peculiar odour, and a pungent, bitterish, somewhat aromatic taste ; but both the smell and taste are disagreeable rather than otherwise. Their virtues, so far as known, depend on their peculiar volatile oil, tannic acid, and a bitter principle, which, however, has not been isolated. They impart their virtues to water and alcohol. In its effects on the system, catnep is a moderately stimulant tonic, with antispasmodic and emmenagogue prop- erties. In cats it is said to act as an aphrodisiac. Certainly these animals exhibit a great fondness for it ; and it owes its name to this cause. It is generally used in the form of infusion, which may be made in the proportion of an ounce to the pint, and given, in the dose of one or two fluidounces, in flatulent colic, amenorrhcea, and the different forms of hysteria. The fresh leaves are said to relieve toothache, if chewed, and kept for a few minutes in contact with the diseased tooth. CHAP. I.] TONICS. AROMATICS. 313 8. YARROW. ACHILLEA. U.S. This was introduced into the secondary catalogue of the U. S. Phar- macopoeia at the recent revision. The whole herb is used. It is the product of Achillea Millefolium, often called milfoil, from the great number and minuteness of the divisions of the leaves. Though a native of Europe, it is now abundant in this country, in which it has become completely naturalized. The herb has a feeble though rather agreeable odour, which is retained after drying, and a bitterish, pungent, some- what astringent taste. The aromatic properties are somewhat stronger in the flowers than the leaves. In the latter the astringency and tonic property predominate. The active principles are volatile oil, tannic acid, and a bitter substance which has not been isolated. There is also a peculiar acid, called the achilleic ; but how far this possesses any thera- peutic properties has not been ascertained. The volatile oil, separated by distillation, has a beautiful blue colour, and the odour of milfoil. The virtues are extracted by water and alcohol. Yarrow is a mild aromatic tonic and astringent. It has been used in intermittent fever, flatulent colic, and hysterical disorders. M. Richard, of Soissons, in France, finds it efficacious in low conditions of the ex- anthematous fevers with imperfect eruption, in colic, infantile convulsions and dysmenorrhcea, using it at the same time as a drink in the form of infusion, as an injection in the same form, and in fomentation. Dr. B. H. Coates, of Philadelphia, confirms the old opinion as to its efficiency in hemorrhages. (Trans, of College of Phys. of Philadelphia, N. S., ii. 334.) Dr. Joly, of France, considers it an excellent emmenagogue, and has obtained advantageous results from it in suppression of the lochia. (Bullet. Gen. de Therap., Mars, 1857.) The most convenient form of administration is uiat of infusion, which may be made in the proportion of an ounce to the pint, and given in the dose of a wineglassful. The dose of the volatile oil is twenty drops. 3. dramatics. This subdivision of medicines is characterized by an agreeable odour and taste, dependent on the presence of volatile oil. They do not cor- respond exactly with the tonics, being more excitant, though less so than the class of circulatory stimulants. They do not eq\ial the bitter tonics in the property of promoting the digestive and nutritive functions. Their action, moreover, is more speedy, and less durable. Yet they approach more closely to these medicines than to any other division in the classification I have adopted, and are often used, in conjunction with tonics, to increase then: stimulant influence, or in other ways modify 314 GENERAL STIMULANTS. [PART II. their action. I have, therefore, thoughl it best to follow the example of Dr. J. Murray, of Edinburgh, in his excellent system of Materia Medica, in arranging them in the position they here hold; guarding the student, however, against the mistake of supposing them identical, or even very analogous, in their operation, with the bitters. Effects on the System. When taken internally, the aromatics occasion generally an agreeable feeling of warmth in the stomach, moderately increase the frequency of pulse and heat of the surface, and often diffuse a pleasant glow over the system, without exhibiting any special tendency towards the brain or nervous system generally, or any particular in- fluence over the secretions. They resemble, in their direction to the cir- culatory function, the medicines hereafter to be described under the name of arterial stimulants; but they differ, in being much more powerful, relatively, in their local than their general excitant effect. Thus, to whatever surface they are directly applied, whether the skin, the mouth and fauces, or the mucous membrane of the stomach, they stimulate actively the blood-vessels of the part, and, largely used, cause high vascular irritation, or even inflammation ; while upon the heart and gen- eral circulation they produce little greater effect than might be ascribed to sympathy with the local excitement. This disproportion in their local stimulation may be ascribed to the difficult, absorption of the vola- tile oils, to which they owe their powers. There is a great difference in the absorbability of the different volatile oils. Some, as those of tur- pentine, copaiba, garlic, etc., enter the circulation with great facility, and hence display considerable energy in their action upon the system generally, or on organs remote from the point of their application. The aromatic oils, as those of cinnamon, cloves, ginger^ peppermint, etc., have, in general, much less of this facility; and, though they may act locally with equal power, are much less diffusible in their effects. In their operation specially upon the stomach and other portions of the alimentary canal, they do not so much invigorate the particular function of digestion, as produce a general vascular excitement of the parts, attended with a comfortable or pleasurable sensation, comparable to that of a genial glow on the surface of the body. In the accompany- ing plentiful, but not excessive supply of blood, which is the proper material for all the functions, that of the stomach is in a state to respond to its special stimulants ; and tonics, therefore, will often operate with greater energy, in connection with aromatics, than when administered alone. The muscular tissue, too, without being stimulated, as by purga- tives, to an increase of its regular peristaltic action, is yet put into a condition of greater power, and will contract with increased energy under the special stimulus of distension, or with a better regulated move- ment under that of cathartic medicine. Upon these principles may be ex- plained all the peculiar therapeutic uses of the aromatics. CIIAP. I.] TONICS. AROMATICS. 315 Ther-apeutic Application. They are much used as cordial stimulants to the stomach and bowels, in debility of these organs; and have the great advantage over the more diffusible stimulants, such as alcohol in its different forms, that their operation is limited mainly to the part. Given in connection with food, particularly with such as may be of diffi- cult digestion, they favour its solution in the stomach, by enabling this organ both to secrete the solvent juice more vigorously, and the muscular coat of the stomach to perform its office more efficiently, under the stim- ulus of the nutriment. Hence their use as condiments in all times, and in all parts of the world. They are given also to relieve nervous uneasiness and spasmodic pain of the stomach, to aid in the expulsion of flatus, and to correct nausea. All these offices they perform upon the principle above stated. The nervous tissue, duly supplied with blood, is relieved of those irregular sensations and actions to which it is so liable when debilitated, and can better resist the disturbing influence of substances calculated to produce nausea or griping pain. The muscular coat, in the same state of its sup- ply, feels duly the presence of the distending flatus, which it now expels by a vigorous contraction, instead of being thrown by it into- those irregular and vain contractions called spasms. In reference to this operation of aromatics, they are called carminatives, a word handed down from the ancients, who were familiar with this effect, but could not so satisfactorily explain it, and therefore referred it to the mysterious influence of charms, and believed it to be much promoted by singing verses (carmina), during the administration of^e medicine. To sum up, in a few words, the therapeutic applications of aromatics; they are used to relieve the nervous pains, spasms, disordered sensations, and languor of stomach, attendant on dyspepsia or other debilitated states of the organ ; to correct flatulence and pains arising from it, whether in the stomach or bowels; as anti-emetics to obviate nausea or gastric irri- tability when purely nervous; and, lastly, to aid or correct the operation of other medicines, or facilitate their administration by concealing or modifying their disagreeable taste. They are given with substances disposed to nauseate, whether by their taste, or their direct influence on the stomach, in order to obviate this effect. With cathartics they are very often exhibited, not only in reference to the influence just mentioned, but also to correct or obviate their griping tendency. With tonics they are habitually administered, to cover their taste, to render them more acceptable to the stomach, to give them greater effi- ciency in the promotion of digestion, and to increase their stimulant effect, when such an increase is indicated. They are contraindicated by existing vascular irritation or inflamma- 316 GENERAL STIMULANTS. [PART II. tion of the stomach, and by any considerable febrile excitement, in a sthenic state of the system. In very large quantities, some of them, and all in the concentrated form of their volatile oil, are capable of inducing inflammation of the stomach, and thus proving dangerous if not fatal. When abused as condiments, they may cause the following evil effects. In the first place, they may give rise to chronic inflammation of the stomach, by sustaining a constant vascular irritation of that organ; secondly, they may debilitate the stomach by wearing out its excita- bility through over-excitement; and thirdly, by increasing the amount of food digested, they may lead to an excess in the supply of blood, a con- sequent plethoric state of system, and, in conjunction with other influ- ences, to the generation of a gouty diathesis. They are not unfrequently used externally, either alone, or in con- junction with other medicines, as irritants to the skin, or rubefacients. (See Rubefacienls.) As they depend mainly for their efficiency upon the volatile oils they contain, these are often separated by distillation with water, and very advantageously used as substitutes for the aromatics themselves. Their effects are the same ; but they require to be administered with more caution, as they are more liable to produce serious effects, if taken in over-closes. As to the modes of preparing the aromatic volatile oils, their chemical composition and reactions, the tests of their purity, and the general rules regulating their pharmaceutical management, the reader is referred to the U. ^Dispensatory. Administration. Tl^iromatics may be given in substance, or in the forms of infusion, tincture, fluid extract, and volatile oil. The form of infusion is much used, and generally very suitable ; but it should be re- membered that water will dissolve but a small proportion of volatile oil, and, in the case of those particular aromatics which depend for their in- fluence exclusively on the oil, the proportion of the medicine to the men- struum should be small, to avoid waste. Decoction and dry extract are inappropriate forms ; as the volatile oil on which their virtues depend is more or less driven off during their preparation. In the fluid extract, if properly made, the oil may be retained ; and this is often a very con- venient form for use. Tincture is a very appropriate form, whenever the necessary amount of alcohol, used in the preparation, may not be objectionable. The aromatic oils are frequently preferred, in consequence of their less bulk, their greater power, and their greater convenience of admin- istration. Some of them may be given undiluted, simply dropped on sugar; but most of them are too pungent and powerful to be exhibited in that way. They are, however, often and very conveniently exhibited by dropping them on sugar, and then mixing this thoroughly with water. CHAP. I.] TONICS. AROMATICS. 317 The sugar enables the water to hold the oil suspended sufficiently long for use. A common method of exhibiting the oil is in alcoholic solution, in the shape of spirits or essences. The name spirit, in relation to the aromatic oils, was formerly used to designate preparations made by exposing a mixture of the aromatic and alcohol to distillation; the oil coming over dissolved in the alcohol. It is now also applied to similar preparations, made either by directly dissolving the oil in alcohol, or by distilling the oil and alcohol together. Such is the meaning of the term spirit as employed in the present U. S. Pharmacopoeia, though it is ex- tended so as to embrace spirituous solutions of aeriform or volatile sub- stances in general. But, in former editions of the Pharmacopoeia, to entitle an alcoholic solution of one of the volatile oils to the officinal title of spirit, it was required to be of a strength approaching that of the spirits made in the original method. The name of essences has been popularly appropriated to stronger solutions of the oil in alcohol ; generally of such a strength as to permit the preparation to be taken on sugar without further dilution. These were designated iu the Pharma- copoeia of 1850 as tinctures of the respective oils. Thus, we had tinc- tures of the oil of peppermint, and oil of spearmint; but this nomen- clature has been abandoned. Another very common and useful form of exhibition is that of the aromatic waters. These were originally made by distilling water from the aromatic in substance; but this method of preparation has, in the United States, been almost entirely abandoned^ar the much more con- venient method of simply dissolving the oil in ^tter. When the oil and water are merely shaken together, they unite but sparingly, and the resulting solution is very feeble. But, by the intervention of some body which, without being itself soluble, may, by trituration with the oil, so divide its particles as to bring them into intimate contact with the par- ticles of water, when the two are shaken or rubbed together, a consider- able proportion of the oil is taken up; enough to give a decided odour and taste, and some medicinal activity to the solution. The substance preferred for this purpose is usually carbonate of magnesia; and the aromatic waters of our national standard are prepared in this way; care being always taken to separate the insoluble matter by filtration. The aromatic waters may sometimes be advantageously given with a view simply to the medicinal effect of the oil; but much more frequently they are used as menstrua or vehicles for other substances, the taste of which they cover, while they often render them more acceptable to the stomach. 318 GENERAL STIMULANTS. [PART II. I. ORANGE-PEEL. 1. BITTER ORANGE-PEEL. AURANTII AMARI CORTEX. V. S. AURANTII CORTEX. Br. 2. SWEET ORANGE-PEEL. AURANTII DULCIS CORTEX. U.S. Origin. This is the rind of the orange, of which there are two kinds, derived from different species or varieties of Citrus; the one, Citrus vul- garis, the bitter, or Seville Orange; the other, Citrus Auranlium, or common sweet orange. Both are natives of India and China, but culti- vated generally in tropical latitudes. Sensible and Chemical Properties. The rind consists of two parts, the outer, which is coloured, and the inner, white and spongy. In the former exclusively reside the virtues of the medicine; and sometimes it is only the outer coating that is kept in the shops. The bitter orange-peel, which is imported into the United States, is generally, as found in the shops, in vertical slices, though sometimes in thin parings, as if cut off from the orange with a knife, like the paring of an apple. In the former, the white inner portion is retained, in the lat- ter is wanting. The peel has an agreeable characteristic odour, and a bitter aromatic taste. The sweet orange-peel is also in vertical slices, usually thinner than the other variety, with the same characteristic odour, and warm, aro- matic taste, but withouLbitterness. In both, there is a p^Riliar volatile oil, which resides in distinct cells in the rind, and may be obtained by pressure when the rind is fresh. In addition to this, there is, in the bitter orange-peel, a principle to which it owes its bitterness, but which has not been fully investigated. Water and alcohol extract all the virtues of the peel. Kept in moist places, orange-peel is apt to spoil, in consequence of the attraction of the inner spongy portion for moisture. The parings keep better. Medical Effects and Uses. Bitter orange-peel has the virtues of the aromatics combined with those of the simple bitters; the sweet variety is simply aromatic. Both are mild, and the tonic powers of the bitter are feeble. They are used almost exclusively in connection with other medicines, to render them less disagreeable to the taste, and more accept- able to the stomach. It is usually with tonics that they arc associated, as with Peruvian bark, gentian, etc. ; or with purgatives, as rhubarb. When with the former, the bitter variety should be preferred; when with the latter, the sweet. Orange-peel is not altogether without danger if abused. I knew of a case in which death occurred, in an infant, from swallowing considera- CHAP. I.] TONICS. AROMATICS. ORANGE-PEEL. LEMON-PEEL. 319 ble quantities of the fresh rind. The child died with symptoms of ob- struction of the bowels; and, on examination after death, the rind was found impacted in the intestines. But I am by no means certain that the oil contained in the rind may not have acted injuriously. In Buch- ner's Neues Repertorium (ii. 440-5) are given the results of numerous observations, by Dr. A. Imbert-Gourbeyre, of the effects of the oil of bitter orange, among which are mentioned headache, painful vision, buzzing in the ears, oppression of chest, loss of sleep, and phenomena similar to those of epileptic spasms. (Cent. Blalt, 15 Feb. 1854, s. 128.) Administration. The peel is rarely given in substance. The dose of the powder might be from ten grains to a drachm. The infusion is generally preferred. When used as an adjuvant or corrective of other medicines, the peel is most commonly employed in this form; half an ounce of it, well bruised, being added to a pint of the liquid. When the other ingredients are prepared in decoction, the peel should not be added till the end of the boiling. The British Pharmaco- poeia directs an Infusion (!NFUSUM AURANTII, Br.), prepared with half an ounce of orange-peel, and an imperial half-pint or ten fluidounces of water. This may be used for the general purposes of the aromatics (see page 315), in wineglassful doses. A Tincture (TINCTURA AURANTII, Br.) is directed by the British Pharmacopoeia to be prepared from bitter orange-peel, and may be used to qualify the taste and action of various liquid preparations. A Syrup (SYRUPUS AURANTII CORTICIS, U. S.; SYRUPUS AURANTII, Br.\ prepared by the U. S. Pharmacopoeia from the sweet peel, by the British from a tincture of the bitter, is a very grateful addition to other medicines. The U. S. preparation is much to be preferred. A Confection (CONFECTIO AURANTII CORTICIS, U. S.) is prepared by separating the rind by a grater, and incorporating the coarse powder thus made with sugar. It is used chiefly as a vehicle for tonic and pur- gative medicines in powder. An Aromatic Water (AURANTII FLORUM AQUA, U. S.; AURANTII AQUA, Br.), made by distilling water from the fresh flowers, is occasion- ally used as a perfume in the sick room. Other products of the genus Citrus are occasionally used in medicine for their aromatic properties. Among these are the following. 1. LEMON-PEEL. LIMONIS CORTEX. U. S., Br. This is the rind of the lemon, which is the fruit of a variety of Citrus medica, a native of Asia, but now cultivated throughout the civilized world, either in the open air, or in conservatories. It has the same aro- matic properties no orange-peel, though less agreeable, and is employed for the same purposes. 320 GENERAL STIMULANTS. [PART II. The Volatile Oil of Lemons (OLEUM LIMONIS, U. S., Br.) is often ob- tained from the fresh rind, either by distillation or pressure ; that pro- cured in the latter method having more exaetly the odour of the rind, though the former is more clear. It is used to impart an agreeable flavour to other medicines, for which purpose a drop or two may be added to a fluidounce of a liquid for internal use, and ten drops to an ounce of unctuous matter for outward application. It has been em- ployed, undiluted, as a local application to the conjunctiva, in affections requiring stimulation; being pressed from the fresh peel directly into the eye. It produces, however, excessive pain, and should be used with caution. A Spirit- of Lemons (SPIRITUS LIMONIS, U. S.), prepared by the TJ. S. Pharmacopoeia from lemon-peel, with the addition of the volatile oil of lemons, by maceration in alcohol, and a Tincture (TINCTURA LTMONIS, J5r.), prepared in the same manner from the fresh peel, may be used as grateful additions to bitter and laxative infusions and mixtures. 2. OIL OF BERGAMOT. OLEUM BERGAMII. U.S. BERGAMOTJE OLEUM. Ed. This oil is obtained by expression, or distillation, from the fresh rind of the fruit of Citrus Limetta. It is employed chiefly, if not exclusively, for the sake of its very agreeable odour; being mixed with substances used as liniment or ointment, in the same manner as oil of lemons. It has been asserted, however, to be of itself very efficacious in the itch. (Med. andSurg. Reporter, Oct. 1, 1864, p. 112.) II. CINNAMON. CINNAMOMUM. U.S.,Br. Under the above name, the U. S. Pharmacopeia recognizes two pro- ducts, the proper cinnamon gathered in Ceylon, and another kind brought from China, and known in commerce by the name of cassia. These may be conveniently distinguished, in reference to their commercial origin, as Ceylon cinnamon and Chinese cinnamon. It is the latter which is most commonly found in our shops, being brought to this country directly from Canton. The former is used only in small proportion, and generally comes to us by special order from England. It is the only variety recognized in the British Pharmacopoeia. Cinnamon was known to the ancients. Origin. Ceylon cinnamon is the prepared inner bark of Cinnamomum Zeylanicum, a tree growing wild in the East India island of Ceylon, where it is largely cultivated. The tree has been introduced into other CHAP. I.] TONICS. AROMATICS. CINNAMON. 321 tropical countries, and is cultivated to a considerable extent in the French province of Cayenne in South America. When the tree has attained a proper age, the stems arc cut and decorticated ; and the bark, deprived of its epidermis, is allowed to roll into quills, which are inserted one within another, so as to form a solid cylinder. Chinese cinnamon or cassia is the inner bark of a species of Cinna- momum growing in China, which is believed to be the G. aromalicum, though certain knowledge upon this point is wanting. Sensible Properties. Ceylon cinnamon is in cylindrical fasciculi, each consisting of a congeries of quills, inserted one into another, and, when unbroken, several feet in length ; distinct fasciculi being neatly joined end to end, so as to appear as if of one piece. This variety is of a yellowish- brown colour, almost as thin as paper, smooth, somewhat shining, pliable, and of a splintery fracture. Its odour is very fragrant, and its taste warm, pungent, sweetish, slightly astringent, and exquisitely grateful. The Chinese variety is in single tubes, of which the finest differ little in appearance from the cinnamon of Ceylon, but by far the greater pro- portion are larger, thicker, deeper-coloured, rougher, denser, and of a shorter fracture. The pieces are often much rolled upon themselves, but sometimes not completely quilled. The odour and taste are of the same general character ; but the former is less agreeably fragrant, and the lat- ter less sweet and grateful, though equally or more pungent, and more astringent. In both varieties, the powder is of a yellowish-brown colour, so char- acteristic that, when met with in other bodies, it is distinguished by the name of cinnamon colour. Active Constituents. These are a peculiar volatile oil, and tannic acid, the latter of which is not in large proportion. The oil is separated by distillation with water; being generally prepared in the East, probably from the broken fragments and refuse barks. There are two kinds of oil, distinguished as oil of cinnamon and oil of cassia, the former ob- tained from the Ceylon, the latter from the Chinese bark. Both oils, as first procured, are of a fine yellow colour; and both become red by age. The flavour of the proper cinnamon oil, however, is sweeter and finer than that of the oil of cassia. Both, when oxidized by exposure to the air. yield cinnamic acid. Cinnamon yields its virtues in small proportion to water, and much more freely to alcohol. Medical Properties and Uses. This bark has in a very high degree the general properties of the aromatics, with some astringency, dependent on the tannic acid. It is among those most employed. It is used for all the purposes of the aromatics (see page 3 15), but most frequently in con- junction with other medicines, to qualify their taste, and render them more acceptable to the stomach. One of its most appropriate applica- VOL. i. 21 322 GENERAL STIMULANTS. [PART II. tions is to the treatment of diarrhoea, in association with other astringents and with chalk; a purpose to which the tannic acid it contains especially adapts it. It has also been highly recommended in uterine hemorrhage. In consequence of its peculiarly agreeable flavour, it is used as a con- stituent of a great number of officinal preparations. Administration. Cinnamon is sometimes administered in powder, in the dose of from ten to twenty grains. It is often, in this state, associated with other medicines given in the same form. The Aromatic Powder of the Pharmacopoeias (PULVIS AROMATICUS, U. ) consists of cinnamon, ginger, cardamom, and nutmeg; a very fine combination of spices. From ten to thirty grains of this may be given for a dose. It is occasionally applied externally in the form of cataplasm, which may be prepared by adding a little heated spirit so as to bring the oil into activity, and rendering the mixture adhesive by honey or other viscid substance. Such a cataplasm may be advantageously applied to the epigastrium in vomiting, and over the whole abdomen in the cholera of children. An officinal Confection (CONFECTIO AROMATICA, U. S.) is prepared by incorporating the aromatic powder above referred to with clarified honey. It may be used for the general purpjoses of the aromatics, in the dose of from ten grains to a drachm. An infusion of cinnamon may be made by macerating two drachms in a pint of boiling water, and given in the dose of one or two fluidounces ; and the bark may be added to other substances in infusion in the same proportion. When added to decoctions, it should be introduced at the end of the boiling, but while the liquid is still boiling hot. The Oil of Cinnamon (OLEUM CINNAMOMI, U. S.) is never used alone, in an undiluted state ; as, independently of its extreme pungency, it might endanger serious irritation, if not inflammation of the stomach. In over- doses it may prove fatal. Mitscherlich killed a dog in forty hours wit^r two drachms, and in five hours with six drachms. But, made into emul- sion with gum arabic, loaf sugar, and water, it will produce all the effects of cinnamon except those dependent on its astringency; and may often be administered advantageously as a stomachic and carminative. It is, however, more frequently employed in solution, in one of the following forms. The dose of it is one or two drops. Cinnamon Water (AQUA CINNAMOMI, U. ) was formerly made by dis- tilling water from cinnamon, and this is recognized in the U. S. Pharma- copoeia as an alternative process ; but it is now much more generally and conveniently prepared by dissolving the oil in water, through the inter- vention of carbonate of magnesia, as described under the general head of aromatics (see page 317). Although only thirty minims are employed to two pints of water, the. resulting solution is too strong for ordinary pur- poses, unless diluted. It is chiefly employed as a menstruum or vehicle CHAP. I.] TONICS. AROMATICS. CANELLA. 323 for other medicines, given in liquid mixture or solution; but, when used for this purpose, it should generally be diluted with an equal measure or double its measure of water. The dose of this aromatic water is from half a fluidounce to a fluidounce. Spirit of Cinnamon (SriRrrus CINNAMOMI, U. S.) is prepared by dis- solving a fluidounce of the oil in fifteen fluidounces of stronger alcohol. The dose is from ten to twenty drops. A Tincture of Cinnamon (TIXCTURA CIXNAMOMI, U. S., Br.\ prepared, according to their ordinary method, both by the U. S. and British Phar- macopoeias, affords an agreeable mode of obtaining the effects of the aromatics, with the astringency of the cinnamon, when alcohol is not contraindicated. The dose is from one to four fluidrachms. The two following barks, though little used, are noticed in most works on Materia Medica, and, as appears to me, can be nowhere more appro- priately considered than as subordinates to cinnamon. 1. CANELLA. U. S. This is the bark of Canella alba, ajarge tree growing in Jamaica and other West India islands. The bark is stripped from the branches, de- prived of its epidermis, and dried. Sensible Properties. It is in pieces of various size, usually thicker and larger than the coarsest cinnamon, either completely or partially quilled, often twisted, of a pale-orange or light reddish-yellow colour on the outer surface, nearly white on the inner, brittle with a short fracture, and yielding a yellowish-white powder. Its odour is aromatic, its taste warm, bitterish, and very pungent. Active Constituents. A peculiar volatile oil is the main active ingre- 4i* nt; but there is also a bitter substance, and an aromatic resin, which are probably not without influence. The bark yields its virtues imper- fectly to water, but readily and wholly to alcohol. Medical Properties and Uses. Canella has the properties of the aro- matics generally, with a greater degree of pungency than most of them, and some tonic power. It is well adapted to atonic states of the stom- ach and bowels ; but is seldom used except in conjunction with other medicines, of which it may cover the taste, and correct any nauseating or griping property. The dose of the powder is from ten to thirty grains. Associated with aloes, it forms the Powder of Aloes and Ca- nella (PULVIS ALOES ET CANELLA, U. S.), which was formerly so much esteemed as to have received the name of hiera picra, or sacred bitter, though now comparatively little used. Whatever its virtues may be, they must be ascribed almost exclusively to the aloes, of which the ca- nella is merely a corrective. Canella is also an ingredient in the Wine of Rhubarb (ViNUM RHKI, U. S.}. 324 GENERAL STIMULANTS. [PART II. 2. WINTER'S BARK. WINTERA. This has been of late rejected from the Pharmacopoeia, and owes what little attention is now paid to it to old associations. It is the bark of Drimys Winteri {Winter a aromatica, Willd.), an evergreen tree, grow- ing in the southern extremity of the American continent, along the straits of Magellan, and thence northward to Chili and Brazil. As found in commerce, the bark is in quills about a foot long by an inch in di- ameter, or in larger flat pieces. On the outside it appears as if it had been scraped or rubbed, and has a pale-yellowish or reddish-gray colour, with red elliptical spots; the inner surface is reddish-brown or cinnamon coloured. Its powder resembles that of Peruvian bark. Its smell is fragrant, its taste hot, pungent, and spicy. Its chief active constituent is a peculiar volatile oil, with which there is also a somewhat acrid resin. and sufficient tannic acid to cause the infusion to be darkened by the salts of iron. Winter's bark was first made known by Captain Winter, who com- manded one of the vessels in Drake's famous expedition, and, on his return to England, in 1579, brought some of the bark with him. It has often been confounded with canella, which it resembles in appearance; but it may be distinguished by its dark inner surface, while that of canella is white, and by affording with reagents evidence of containing tannic acid, which canella does not. Its medical properties are essentially the same as those of canella, and it may be used for the general purposes of the aromatics ; but it is sel- dom to be found in the markets of the United States, and is little em- ployed. The dose of the powder is about half a drachm. III. CLOVES. CARYOPHYLLUS. U. S. CARYOPHYLLUM. Br. Origin. Cloves are the dried unexpanded flower-buds of Caryophyllus aromaticus, a small and beautiful tree, inhabiting the Molucca Islands, in the East Indies, whence it has been successfully transplanted to va- rious parts of the world, as the Isle of France, Singapore, Sumatra, and Cayenne in South America, in which places it is now cultivated to a considerable extent Sensible Properties. Cloves have the form of a small nail, being on the average somewhat more than half an inch long, with a round head, having four spreading points beneath it. When pressed with the finger- nail, if of good quality, they exude oil. Their colour is dark-browii, their odour strong and fragrant, and their taste hot, pungent, aromatic, and lasting. The powder is dark and oily. CHAP. I.] TONICS. AROMATICS. CLOVES. NUTMEG. 325 Chief Constituents. The active principle of cloves is a volatile oil, which may be separated by distillation. When first procured, it is colourless, but gradually becomes yellowish by time, and ultimately reddish-brown. It has the odour and taste of the cloves; but is rela- tively less pungent. It is heavier than water. Besides the oil, there are two crystalline principles, called respectively caryophyllin and eu- genin, and a little tannic acid ; but the first two are insipid, and the last is of no practical importance. Cloves yield their active matter only in small proportion to water, but freely and entirely to alcohol. The alcoholic extract is excessively fiery, but becomes insipid when distilled, while the oil which comes over is relatively mild. Distillation would appear, then, to have produced some change in the oil, which renders it less active. Medical Properties and Uses. Cloves were made known to Europe by the Arabians, but were not largely used until after the discovery of the passage to India by the Cape of Good Hope. They possess, in a high degree, the characteristic properties of the aromatics, and may be used for all the purposes mentioned in the general observations on this subdivision of the tonics. They are, however, much more employed as a condiment in cookery, than as a medicine. Occasionally they are given to correct nausea, relieve flatulent pains, and stimulate the languid digestion; but their chief medicinal employment is as an adjuvant to other medicines, and they form a subordinate ingredient in several offici- nal preparations. The dose of the powder is from five to twenty grains. The officinal Infusion (!NFUSUM CARYOPHYLLI, U. S.) is made with two drachms of the cloves to a pint of boiling water, and given in the dose of two fluid- ounces. The French Codex directs a tincture, of which the dose is a fluidrachm. The Oil of Cloves (OLEUM CARYOPHYLLI, U. S.), prepared by distillation from cloves, is occasionally employed either alone, in the dose of from two to six drops, properly diluted, or as an ingredient in purgative pills, to prevent nausea or griping. It is also used to relieve toothache, by being introduced, upon cotton, into the carious hollow. It relieves the pain by blunting the sensibility of the part through ex- cessive irritation. IV. NUTMEG. MYRISTICA. U.S.,Br. Origin. Nutmeg is the kernel of the fruit of Myristica moschata, a handsome middle-sized tree, originally confined to the Moluccas, but now cultivated in Sumatra, Java, Singapore, Cayenne, Brazil, and other 326 GENERAL STIMULANTS. [PART II. intertropical countries. The product, however, is said nowhere to attain such perfection as in its native islands. The fruit, about the size of a small peach, has an outer covering or hull; and within this is a red membrane with slits, through which is seen a chestnut-coloured nut The shell of the nut being broken, the kernel is obtained, and, having been steeped in a mixture of lime and water, and afterwards cleaned, is prepared for market. Sensible Properties. The appearance of the nutmeg is too well known to require description. When broken, or cut through, it presents a yel- lowish surface, with dark, branching veins, in which volatile oil abounds. It is not very easily pulverized by pounding, and is reduced to powder by grating or grinding. It has a fragrant odour, and a warm, spicy taste, and is among the most grateful of the aromatics. It yields its virtues much more readily, and in larger proportion, to alcohol than to water. Chief Constituents. The most interesting constituents of nutmeg arc a volatile and fixed oil, the former of which is obtained by distillation with water, the latter by expression with heat. The volatile oil is lighter than water, colourless or of a pale straw colour, with the odour of nutmeg, and a pungent, aromatic taste. It is the active principle of the medicine. The faced oil, often though erroneously called oil of mace, concretes, after expression, into a soft unctuous solid, of a yellowish or orange-yellow colour, often more or less mottled, and of the smell and taste of the nutmeg, owing to a proportion of the volatile oil contained in it. Medical Properties and Uses. Nutmeg seems not to have been known to the ancients. The Arabians were acquainted with it; but it was little employed in Europe until after the discovery of the maritime passage to India. It has the ordinary properties of the aromatics, and, in large doses, is somewhat narcotic. In the quantity of two or three drachms, it has produced delirium and stupor; but no danger need be appre- hended from it in the ordinary medicinal doses. It is more used as a condiment, or to give flavour to ordinary drinks, than as a medicine; and, in the latter capacity, it is chiefly employed to cover the taste and qualify the action of other substances. It is an excellent addition to farinaceous drinks used as a diet by the sick. The dose of the powder is from five to twenty grains. The Volatile Oil (OLEUM MYRISTIC^, U.S.) may be used, for any of the purposes of the aromatics, in the dose of two or three drops. There is an officinal Spirit (SpiRixus MYRISTIC^G, U.S.), prepared by distilling proof spirit from bruised nutmeg. In the quantity of from one to four fluidrachms, it forms an elegant addition to tonic and purgative infusions, when the stimulus of alcohol is not forbidden. The expressed oil is sometimes CHAP. I.] TONICS. AROMATICS. BLACK PEPPER. 327 used as a gentle rubefacient in local rheumatism and palsy, and is an in- gredient in Emplastrum Picis of the British Pharmacopoeia. Mace (MACIS, U. matic8. In pure dyspepsia it is often used with much benefit, either alone or in combination; and, when added to tonics, in this affection, it rcndeiv them 111 once more acceptable and efficient. In the feeble condition of the digestive organs attendant on atonic gout, it is also an excellent ad- juvant to other measures. It is one of the best carminatives; and. in the form of hot infusion, is much employed in simple spasmodic or flatulent colic, especially in children. As a preventive of cholera, its cordial influence upon the digestive organs renders it piTiiliarly appro- priate; and, in the epidemics of this complaint, it has been among the prophylactic medicines most relied on. It is very frequently used in connection with tonics and purgatives; with the former, to inch their stimulant effect; with the latter, to obviate griping; and with both, to cover their taste, and mitigate or prevent their nauseating effects. It is also much employed as a condiment in cookery. Locally, ginger is actively irritant. When chewed, it produces a burning and painful sensation in the month, and increases the flow of saliva. Jlence it is -nnetimes employed as a masticatory in toothache, rheumatic affections of the jaws or neighbouring parts, relaxation of the uvula, and palsy of the tongue, or other part of the mouth or fauces. CHAP. I.] TONICS. AROMATICS. GINGER. 351 Snuffed up the nostrils, it produces sneezing, and increases the secretion of mucus, and is, therefore, occasionally used as an errhine. Upon the skin it acts as a rubefacient ; and the powder, formed into a cataplasm with warm water, may often be advantageously applied to the cheeks in toothache, the forehead in headache, and over the stomach in irritable states of that organ. Administration. Ginger is given internally, in the forms of powder, infusion, tincture, and syrup. The dose of the powder is from ten to thirty grains. In this state it is often combined with powdered columbo, and subcarbonate of iron, and is an ingredient in the Pulvis Aromalicus of the Pharmacopoeias. The Infusion (!NFUSUM ZINGIBERIS, U. S.~) is made in the proportion of half an ounce of the bruised or powdered root to a pint of boiling water. The dose is one or two fluidounces; but it may be given more freely in urgent cases, especially of flatulent colic. In that affection, a small bowlful, sweetened, may sometimes be drank with advantage. In this form, ginger is much used in connection with the simple bitters, as gentian, quassia, and columbo, and with cathartics, especially senna and rhubarb. The Tincture (TINCTURA ZINGIBERIS, U. S.), according to the direc- tions of our national code, is made very strong, to fit it for the prepara- tion of the syrup; and this concentration has also the advantage of in- creasing the proportion of the aromatic, and diminishing that of alcohol. This is the more necessary, as it is officinal alcohol and not diluted alcohol or proof spirit, that is used as the menstruum ; the latter causing 1 lie tincture to become turbid, in consequence of the quantity of mucilage dissolved. Under the name of essence of ginger, a still more concentrated pre- paration is made, either by employing a larger proportion of ginger, or preferably by evaporating a portion of the alcohol of the tincture, and filtering. Either of these preparations may be given as a carminative and stomachic stimulant, or added to tonic and purgative infusions, tinc- tures, and mixtures, in debilitated states of the alimentary canal. The dose of the tincture is from forty minims to a fluidrachm, that of the essence, according to the degree of its concentration, from twenty to forty minims. The Syrup (SYRUPUS ZINUIBERIS, U. S.) is prepared from the tincture, because, by this method, the starch and gummy matter of the root are avoided, which, if present in the syrup, would dispose it to spoil. The alcohol is driven off during the process. Syrup of ginger is an excellent addition to tonic and purgative infusions, and to other liquids used for drink, especially to carbonic acid water, when one of the alkaline car- bonates or bicar 1 .nates is exhibited with it in solution, as these are in- 352 GENERAL STIMULANTS. [PART II. compatible with most of tho ordinary syrups, in consequence of the acid they contain. It is also a good vehicle for substances in powder, the taste of which it covers, while it gives them a suitable consistence for exhibition. Rubbed up with magnesia or its carbonate, it enables that medicine to be readily and uniformly suspended in water; at the same time covering its taste, and obviating its nauseating effect. A fluidrachni of it may be added to every fluidounce dr two of the liquid with which it is administered. Ginger Troches or Lozenges (TROCHISCI ZINGIBERIS, U. S. ) are pre- pared in our Pharmacopeia by incorporating tincture of ginger with powdered tragacanth and syrup of ginger. They often answer a good purpose in relieving gastric uneasiness and flatulence, on being taken into the mouth and allowed slowly to dissolve. Those prepared by the confectioners may often be substituted without disadvantage. Ginger beer is one of the most wholesome of its class of bevn;; In its various forms, ginger is employed, as an adjuvant or corrigent, in a considerable number of officinal preparations. The four following roots appear to me worthy of a brief notice, either for their former reputation, or present use, however limited the latter may be. 1. ZEDOARY. ZEDOARIA. Two kinds of zedoary are noticed by authors, the round and the long; but the former only is now to be found in the shops. The round zedoary is the root of Curcuma Zedoaria, growing in the East Indies, win-re it is cultivated. It is usually in slices, which are the halves or quarters of a roundish root, ending in a point. These are marked, on their convex surface, with the sections of circular rings, which in the whole root sur- round it horizontally, and with small projecting points, which are the remains of the radical fibres. The root is grayish-white on the outside, yellowish-brown and somewhat marbled on the freshly cut surface, hard, and compact. Its odour is :i'_-n 'i-altly aromatic, and its taste bitterish, pungent, and camphorous. Its activity resides mainly in a volatile oil; but the bitterness is probably dependent on a distinct principle, whieh may add a slight tonic influence to the aromatic qualities of the root. Its medical properties and effects are essentially the same as those of ginger, though weaker. It is at present seldom if ever u-nl in this country. The dose is from ten to thirty grains. 2. TURMERIC. CURCUMA. U.S. This is the root of Curcuma longa, a small perennial plant, indigenous in tin- East Indies and Cochin China, and abundantly cultivated in va- CHAP. I.] TONICS. TURMERIC. CALAMUS. 353 rious parts of Southern Asia. There are two varieties, both produced by the same species of Curcuma, but distinguished by their shape, one being- long, and the other round, and therefore named curcuma longa and curcuma rotunda. The former, or long turmeric, is much more abundant in the market than the latter. It is cylindrical, about as thick, but generally not quite so long, as the little finger, tuberculated, and somewhat contorted. The latter, or round turmeric, is round or oval, about the size of a pigeon's egg, or somewhat larger, and marked ex- ternally with numerous annular wrinkles. Both are yellowish on the out- side, and of a deep orange-yellow within, compact, hard, exhibiting when broken a wax-like fracture, and yielding a yellow or orange-yellow pow- der. Turmeric has a peculiar aromatic odour, and a warm, bitterish, somewhat aromatic taste, and tinges the saliva yellow when chewed. Its medical properties probably reside exclusively in a volatile oil, which is yellow and acrid. It contains, however, another interesting principle, denominated curcumin, on which its colouring properties, and its use as a chemical test, depend. (See U. S. Dispensatory.) It formerly had some reputation as an aromatic, resembling ginger in its action on the system, though less efficient, and also less agreeable. It was also supposed to have a special influence upon the biliary organs, probably from its yel- low colour, and was used in jaundice and visceral disease. At present, it is scarceh r used as a medicine, and probably never in this country. As a condiment, however, it is largely consumed in the East, entering into the composition of most of the curries so much in favour there. Its chief use here is as a test for alkalies, which change its yellow colour to brown. For this purpose it is employed in the form of tincture, or of turmeric paper. The powder might be exhibited in the dose of from ten to thirty grains. 3. CALAMUS. U. S. This is the root (rhizome) of Acorus Calamus or sweet flag, an in- digenous plant growing also in Europe and Western Asia, and, in this country, abounding in low, meadowy grounds, too wet for the culture of the useful grasses. The plant may be distinguished, by those not ac- quainted with its botanical character, from the young cat-tails, and coarse grasses with which it is frequently associated, by the aromatic odour of the leaves when bruised, and their aromatic taste. The root is horizon- tal, jointed, somewhat flattened above and below, often several feet long, from half an inch to an inch thick, with numerous fibres or radicles pro- ceeding from its under surface, which are cut off when it is dried, leav- ing little, round, permanent spots. When dried, it shrinks much. As kept in the shops, it is in pieces of various lengths, wrinkled, yellowish- brown externally, and whitish or yellowish-white internally. In some pieces the exterior cortical part has been removed, leaving the inner por- VOL. i. 23 354 GENERAL STIMULANTS. [PART II. tion, the surface of which acquires a grayish-white colour. The odour is strong and fragrant ; the taste warm, bitterish, pungent, and aromatic. It yields its virtues to boiling water. These may be considered as re- siding exclusively in a volatile oil, which is occasionally separated by distillation, is yellow, and has an odour and taste analogous to those of the root. There is said also to be an acrid extractive matter; but too little is known of it to justify the ascribing to it of any of the virtues of the medicine. Starch is another ingredient. Calamus has been known from ancient times. It has medical virtues closely analogous to those of ginger, for which it might be substituted in most cases, though it is generally much less acceptable to the palate. There is one use of it which I would recommend from experience. Hav- ing some tenacity, though sufficiently brittle to be easily broken by the teeth, it may be carried in the pocket, and a little of it chewed as wanted. In this way it will often afford great relief to the gastric uneusim-. spasmodic pains, and flatulence so frequently attendant on dyspesia, ner- vous gout, and hysterical affections. The dose of it is from twenty grains to a drachm. An infusion, made with half an ounce or an ounce to a pint of boiling water, may be taken in the dose of two fluidounces or more. In the form of powder, calamus is said to have a strong preservative influence against the attacks of insects, if sprinkled over the object to be preserved. (Med. and S. Reporter, Sept. 24, 1864, p. 107.) 4. WILD GINGER. ASARUM. U.S. Canada Snakeroot. Wild ginger is the root (rhizome) of Asarutn Canadense, a very small, perennial indigenous plant, growing in wooded grounds, from Canada to Georgia. All parts of the plant have an agreeable aromatic odour, which is strongest in the root. This is in long, somewhat contorted pieces, of the medium thickness of a crowquill, hard and brittle, exter- nally wrinkled and brownish, internally whitish, and often furnished with short radicles. Its taste is aromatic, bitterish, and grateful, bearing some resemblance to that of cardamom. The active principles are a volatile oil, and a bitter acrid resin. Water extracts them partially, alcohol completely. Wild ginger is a stimulant aromatic, with tonic and diaphoretic prop- erties, somewhat analogous to serpentaria in its operation, but with less of the characteristic effects of the simple bitters, and approaching more nearly the subdivision of tonics in which it is here placed. It may be used as a gentle stimulant and diaphoretic in low fevers ; but I should be more disposed to employ it for the same purposes as ginger, for which the country people are said occasionally to substitute it, and its affinity for which is indicated by one of its common names. It might be ap- propriately used as an adjuvant of tonic and purgative infusions, in debil- itated states of the alimentary canal. The dose of the powder is twenty CHAP. I.] VANILLA. MINERAL TONICS. 355 or thirty grains. It may be given also in infusion, made with half an ounce of the root and a pint of boiling water, in the dose of two fluid- ounces. It would form an elegant tincture, which might be made by macerating four ounces in two pints of diluted alcohol, and used, as an addition to tonic infusions, in the quantity of one or two fluidrachms for each dose. 5. VANILLA. U. S. Vanilla is one of the most agreeable of the aromatics ; and it is sin- gular that it should not have been sooner adopted by the Pharmaco- poeias. It is now recognized only in our own. It is the fruit of the Vanilla aromatica and probably other species of the same genus, climb- ing plants, indigenous in Mexico, the West Indies, and South America. The fruit is a long slender pod, which is collected before maturity, dried in the shade, then covered with a coating of oil, wrapped, several pods together, in sheet lead, and enclosed in metallic boxes. The prepared fruit has an exquisite odour and taste, dependent on a volatile oil, which is said to be generated in the drying process, and cannot be obtained separate by distillation with water. Vanilla, besides being aromatic, is probably somewhat stimulant to the nervous system. It is very much employed by confectioners for its agreeable flavour ; but has not been much used in medicine. It has been recommended in low fevers, and in hysterical affections, usually in the form of infusion, made in the proportion of half an ounce to a pint of boiling water, and given in the dose of half a fluidounce. It should be employed, more frequently than it is, to flavour medicine and food for convalescents. Nothing so agreeably flavours chocolate, ice-cream, and liquid custard. The only preparation in which it is officinally employed are the Troches of Subcarbonate of Iron (TaocHisci FERRI SUBCARBO- NATIS, U. S.). III. TONICS OF MINERAL ORIGIN. There is sufficient ground, in the different properties exercised by the different mineral tonics, for arranging them in three subdivisions ; one, including those which, so far as their pure and direct tonic action is con- cerned, operate exclusively on the mucous membrane of the alimentary canal ; a second, those which act on the system at large, and produce their effects by a direct influence upon the vital properties of the tissues, without entering necessarily into their composition ; and a third, those which, though they may possibly operate in the mode just mentioned, are nevertheless peculiarly characterized by forming an essential element of some constituent of the body, and produce their remedial effects. 356 GENERAL STIMULANTS. [PART II. either by increasing the amount of this constituent, or restoring it when diseased to its normal state by supplying a wanting ingredient. In the first subdivision may be ranked the mineral acids, as the sulphuric, nitric, muriatic, and phosphoric ; in the second, the preparations of silver, cop- per, zinc, and bismuth ; and in the third, the preparations of iron. 1. Mineral Tonics Acting on the Stomach and Bowels. Mineral Acids. The peculiarity of this subdivision is owing simply to the circumstance that, in consequence of their strong chemical affinities, they seem to be incapable of absorption into the circulation unchanged. Either their dis- position to combine with saliiiable bases causes them to be neutralized in the alimentary canal, and thus to lose their acid character; or a similar change in their nature takes place by union with one or more of the or- ganic principles they meet with, as albumen for example, with which they readily unite; or they undergo decomposition; or lastly, they re- main unchanged in the primae via; till expelled with the feces. Indeed, this incapability of absorption unchanged, is probably essential to the prevention of poisonous effects from them; as they might very danger- ously react on the blood itself through their chemical affinities. Their direct effects, therefore, as mineral acids, arc confined to the alimentary canal. Various secondary effects result, to which it will bo necessary to call attention in considering them severally. These may even be of a tonic character; but the acids are, nevertheless, not less distinctly char- acterized, as a subdivision, by the peculiarity referred to. I. SULPHURIC ACID. ACIDUM SULPHURICUM. U. S., Br. Sulphuric acid was known as early as the seventh century. As found in commerce, it is often called oil of vitriol, and is more or less impure, containing, among other foreign bodies, a small proportion of sulphate of lead, which, however, is thrown down when the acid is diluted with water; so that practically its presence is of less importance than might have been supposed. For an account of the chemical properties and characteristics of this acid, the reader is referred to the U. S. Dispensa- tory. I shall here treat of its relations to the human system, and after- wards of its preparations; premising that the strong acid, though much employed as a pharmaceutical agent, and sometimes as a caustic, is never directly prescribed for internal use. CHAP. I.] MINERAL TONICS. SULPHURIC ACID. 357 Effects on the System. When taken in very small doses, sufficiently diluted with water, sulphuric acid produces at first no other observable effect than to increase the appetite. 13ut, after a short time, digestion and secondarily nutrition are found to have been promoted; and a tend- ency to constipation is sometimes evinced. It is said also somewhat to reduce the frequency and fulness of the pulse, and to diminish the temper- ature of the body, especially if previously elevated; though I cannot say that I have myself ever noticed these effects. Dr. Christison, in his Dispensatory, states that it is also diuretic, and that it sometimes suc- ceeds in producing an increased secretion of urine in dropsical effusions, when other powerful diuretics have failed. With these properties, sul- phuric acid must be considered as tonic, astringent, refrigerant, and diuretic. If given too freely, it produces uneasiness in the stomach, disturbance of digestion, griping pains in the bowels, and often purging; and the same effects may result from its too long continuance in proper medicinal doses. They are the direct consequence of its irritant action on the ali- mentary mucous membrane. In large quantities, and even in smaller if taken in the concentrated state, as not very unfrequently happens by mistake, in consequence of the extensive use of the acid in the arts, it very quickly produces burn- ing pain in the mouth, fauces, and stomach, with nausea and generally vomiting of bloody or dark coloured liquids, followed by excruciating pains in the bowels, sometimes attended with constipation, sometimes with purging and bloody stools. Occasionally there are spasms of the muscles of the face, back, and upper extremities, arising no doubt sym- pathetically, through irritation of the nervous centres. The voice often becomes hoarse from inflammation of the glottis ; the breath sometimes fetid from the decomposition of the destroyed tissues; and generally, when a corrosive effect lias been produced, great prostration comes on, with a cold surface, feeble and irregular pulse, intense anxiety, and in- cessant jactitation, which soon end in death; the mind remaining unclouded not unfrequently even to the very last. The fatal result sometimes takes place in a few hours, but more frequently at a period varying from twelve hours to two or three days, and occasionally is much longer protracted. When the quantity has not been sufficient to cause immediate death, the case may run on for weeks or months, with frequent vomiting of membranous flakes, fetid breath, great disturbance of the general system, and gradual emaciation, under which the patient at length sinks. Sometimes the effects are confined to the mouth and fauces; complete deglutition having been prevented by the excessive irritation, or other cause ; and great destruction or inflammation of these parts may ensue, from which the patient may or may not recover. The appearances after death are those indicative of inflammation and disor- 358 GENERAL STIMULANTS. [PART II. ganization of the mucous membrane. In some places, the surface is reddened by congestion ; in others, whitened from a combination of the acid with the albumen of the tissue; and in others again, blackened by its decomposing effect, the blood being coagulated in the surrounding vessels Death results from the direct action of the acid on the alimen- tary mucous membrane, and probably in no degree through its absorp- tion into the blood-vessels. Dr. Christison states that the smallest fatal dose of sulphuric acid which he had found recorded was a drachm, or somewhat more than half a teaspoonful. Patients, however, not unfre- quently survive the effects of much larger quantities. A case of recovery IB recorded after six drachms had been swallowed; but such a result must be very rare, and could probably occur only in consequence of a prompt evacuation or neutralization of the poison. From a few drachms of the dilute officinal preparation of the acid, recovery may be reasonably hoped for, if prompt measures of relief are applied, or the immediate occurrence of vomiting has caused nearly all the poison to be thrown off. A patient got well after taking ten drachms of the aromatic sul- phuric acid, or elixir of vitriol, which had brought on vomiting and purging of blood. (Lond. Med. Gaz., xxv. 944.) The treatment of poisoning by sulphuric acid consists in the prompt exhibition of substances fitted to neutralize the acid, with diluent drinks to favour the complete washing out of the stomach, and afterwards in the use of measures calculated to allay the inflammation, and support the patient, if necessary, until the recuperative processes shall have been . c6mpleted. The best antidotes are magnesia, chalk, and the hiearbonates of potassa and soda; but, in the absence of these, any salifiable base which may happen to be nearest should be at once resorted to, as soap, whiting, or even wood ashes mixed with water. The inflammation may be treated with demulcent drinks, and the ordinary antiphlogistic meas- ures, carefully graduated to the amount of reaction, and the probable future strength of the patient. Where the stomach rejects everything, attempts should be made to support the system by animal broths in- jected into the rectum. Mode of Operating. The first effect of the acid, given medicinally, is to stimulate the function of digestion. It probably enables the stomach to secrete the gastric juice more freely, upon the application of its proper stimulus, the food; and there is reason to think that it directly aids tin- solvent power of the juice itself, especially when, from a debilitated con- dition of the organ, that fluid may have been produced without the pro- portion of acid requisite for the due performance of this function. The phenomena which follow its more free exhibition are those purely of irri- tation of the mucous membrane, or of chemical corrosion. The astrin- gency which it often exhibits, in its action on the alimentary canal, probably results chiefly from its direct influence on the vital property of CHAP. I.] MINERAL TONICS. SULPHURIC ACID. 359 contractility in the tissues, or from a similar influence of the salts which it forms with salifiable bases, present in the contents of the stomach and bowels. It has long been noticed that this acid is peculiarly apt to give astringency to its salts, more so, indeed, than any other mineral acid, as evinced in the effects of alum and sulphate of iron. Perhaps another mode in which it proves astringent is by a chemical combination between the acid and the albuminous constituent of the superficial epithelial layers, causing a contraction of the tissue beneath. Something of this kind may occur when it is taken very largely ; but, as ordinarily given for medical purposes, in small doses and very much diluted, it is extremely improbable that it produces any such effect. In the prefatory remarks on the mineral acids, I have expressed my opinion very decidedly that they never enter the circulation as such. In fact, should they be absorbed, they could ex- ist there only an instant uncombined ; for they would immediately be neutralized by the alkalies or albumen of the circulating fluid. Orfila in- jected a little diluted sulphuric acid into the veins of a dog, and caused its almost immediate death, with coagulation of the blood. But though, in the uncombined state, it cannot enter the circulation, it is undoubtedly, I think, often absorbed in the state of saline combination ; and, as its salts prove astringent in the stomach and bowels, they may exercise a similar influence on the tissues generally, through the blood. Hence we may account for the supposed efficacy of the acid in the relief of hemor- rhages, to the seat of which it can have no direct access. Being, how- ever, offensive to the system, when thus in excess in the blood, the salts are thrown off with the urine ; and, in order that this elimination may - be effected, it is probable that they have the property of stimulating the kidneys, and thus produce the diuresis, which has been noticed as an occasional result of the exhibition of sulphuric acid. It is not probable that the acid exerts any tonic influence on the tissues generally, other than the indirect promotion of sanguification and nutrition, by the in- vigoration of the digestive process. None of the salts of the acid, ex- cepting those with a tonic base, as the sulphates of iron and zinc, act as tonics ; and these metals produce their effects as well without as with the sulphuric acid. The absorption, therefore, of the salts it may form in the bowels, will not be followed by a tonic operation on the system. This is a point of more than merely speculative interest. If the opinion thus given be well founded, it would be useless to prescribe sulphuric acid with the view to a tonic effect, except in so far as it may be desira- ble to invigorate digestion. Tlierapeulic Application. Sulphuric acid is admirably adapted by its local tonic powers to cases in which, without organic disease or vascular irritation of stomach, there is loss of appetite, with languid or inefficient digestion, general debility, and especially night-sweats. These conditions are often presented in the convalescence from acute diseases, particu- 360 GENERAL STIMULANTS. [PART II. larly fevers, in which this acid, given alone, or in connection with the simple bitters, or some preparation of Peruvian bark, produces the hap- piest effects. The hectic fever of scrofula and consumption, and the advanced stage of suppurative inflammation, often afford similar indi- cations. In pure dyspepsia the medicine is little used; as, though it would seem to be indicated by the state of the digestive process, experience has not pronounced in its favour. To be curative in this affection, a remedy must be continued for a considerable time; and sulphuric acid, when its use is long persisted in, is apt to become irritant to the stomach, though well borne at first The acid has also been recommended as a tonic in low typhoid and malignant fevers; but I believe, that it is of little advantage, and may often prove hurtful in these affections, by a too irritant action on the stomach, and through it indirectly on the system. It is only upon the alimentary canal, as before explained, that it acts directly as a tonic; and a mere gastric stimulant is not what is wanted in these ca- With a view to its conjoint tonic and astringent effect, sulphuric acid has been employed in diaiThoea, cholera, hemorrhage, and colliquative sweats. In diarrhoea, connected with a relaxed state of the bowels, or in that complaint in its chronic form, and with a suspicion of ulccration of the mucous membrane, it has long been occasionally employed as an astringent or alterative; but it is only of late that it has been intro- duced, as the main remedial agent, into the treatment of acute diarrhoeas in their earlier stages, and of epidemic cholera. In the London Medical Times and Gazette for January, 1852 (page 31), is a communication from Dr. H. W. Fuller, of London, strongly recommending the use of the acid in this affection, and ascribing the first public notice of the remedy to a letter of Mr. Griffiths, which appeared in the Lancet three months pre- viously. In a subsequent communication to the same journal (Oct. 1853, p. 344), Dr. Fuller reiterates his recommendation, based now upon a very large experience of the remedy. lie had found it especially adapted to "acute autumnal" or epidemic diarrhoea, and to that form of the dis- ease which precedes cholera; and in all such cases, amounting to up- wards of ninety, it had proved invariably successful. In many of the cases there were cold extremities, severe cramps, vomiting and purging, and sometimes even rice-water discharges. He found it of little use in bilious diarrhoeas, and certain chronic cases of the disease. In choleraic diarrhoea, and in cholera itself, in its earlier stages, no remedy is. lie thinks, equally efficient. These statements have been confirmed by re- ports from other practitioners, which have appeared in the London journals; though, in the hands of some, the remedy has proved of no avail, and has occasionally seemed to be injurious. The mode of exhib- iting the acid is to give from twenty to thirty minims of the diluted sul- CHAP. I.] MINERAL TONICS. SULPHURIC ACID. 361 phuric acid of the Pharmacopoeias, with sufficient cold water to render it palatable, every hour until its beneficial effects are experienced. In some cases, Dr. Fuller recommends that the dose should be repeated every twenty minutes, or even more frequently, during the first hour. "Sometimes after the second dose," says Dr. Fuller, "more commonly after the third, and almost always after the fourth, the patient expe- riences a grateful sense of warmth at the epigastrium, heat returns to the extremities, the nausea and vomiting cease, the purging is stayed, the cramps subside, and the countenance reassumes its natural appear- ance." The patient goes on amending, and, after a few hours, the remedy may be suspended. If the acid be exhibited at intervals of six or eight, or even three or four hours, the same happy effects are not obtained. Should the liver not act properly after the cessation of the characteristic symptoms, a little blue mass may be exhibited. Some administer aromatic tinctures, opiates, or other adjuvants in conjunction with the acid; but Dr. Fuller prefers it simply diluted with water. In relation to the treatment of cholera itself, in its different stages, it w r ould appear, from the statements in the return of the English Board of Health, that sulphuric acid can, at the best, boast of no superiority over other reme- dies. (B. and F. Medico-cliirurg. Rev., July, 1855, Am. ed., p. 103.) In the hemorrhages, sulphuric acid is occasionally useful ; but it does not stand among the most efficient remedies. In hemorrhage from the stomach and bowels it may do good by a direct action on the bleeding surface; but even here it has found no great favour with the profession generally. In that from surfaces which it cannot directly reach, as in haemoptysis, hsematuria, mcnorrhagia, etc., its efficacy has been doubted, upon the ground that it does not come in contact with the bleeding ves- sels ; but it is probable, as before explained, that the saline compounds which it forms in the alimentary canal may enter the circulation, and those salts may be as styptic as the acid itself. Nevertheless, sulphuric acid has no sufficient haemostatic power to be relied on exclusively in the treatment of the hemorrhages, and, for the most part, is employed merely as an adjuvant. The incompatibility between it and acetate of lead would forbid its use, in any case, in conjunction with the latter remedy. In colliqualive sweaty, there are few remedies more efficacious than sulphuric acid. Its use in cases of this kind attending convalescence, the hectic of phthisis and scrofula, and the suppurative stage of inflam- mation, has been already referred to. But whenever excessive sweating occurs, especially if during sleep, and with general debility, as happens sometimes idiopathically, and often in connection with other diseases, the remedy may be resorted to with a reasonable hope of benefit. Gen- erally, in such cases, it may be advantageously associated with sulphate of quinia. It probably acts either througlL the astringency of such of its salts as enter the circulation, or, what seems to me more probable, by a rns 362 GENERAL STIMULANTS. [PART II. sympathetic propagation of its action on the bowels, through the nerve centres, to the surface of the body. From its supposed possession of refrigerant properties, it has been recommended in fevers generally ; but I have never seen it useful in cases where the prominent indication was to reduce the pulse and heat of the body; and I have, therefore, much doubt as to the existence of any property of this kind, at least in a sufficient degree to justify its use upon that ground alone. The saline compounds which it forms in the prima? via? may, when absorbed, prove somewhat refrigerant, as the neu- tral alkaline salts generally are known to do ; but if such an effect is produced in fevers, it is more than counterbalanced by the tendency of the acid to disturb the stomach, already but too prone to irritation. The phoaphatic lithiasis, or that condition of the system, and of the urinary organs, in which there is a disposition to an excessive formation and deposition in the urine of the earthy phosphates, is often treated with the mineral acids ; and, among them, with the sulphuric. One ob- ject in the treatment of this affection is to maintain a due acidity of the urine, by which the phosphates are held in solution ; and another, to give tone to the digestive organs, which are often in fault. Now, it was sup- posed that these objects would be accomplished by acid medicines, pos- sessing, like the one in question, tonic powers; the supposition being entertained that the acid would pass out through the kidneys, and thus impregnate the urine. But the mineral acids are not absorbed as such ; neither are they thrown off as such by the emunctories. As before stated, it is in the form of salts that they enter the circulation, and are eliminated. Nevertheless, experience has proved them to be among our best remedies, if not the best, in this affection ; and, though they do not directly acidify the urine, it is very possible that they may do so indi- rectly. In the contents of the bowels, and in the blood, are salts, from which the acid matter normally contained in the urine is probably sepa- rated. The sulphuric acid introduced into the stomach must, in order to form salts, decompose some saline substance which it meets with in the primse via? : and the liberated acid may either be absorbed, and escape with the urine, or, in its turn, disengage from some one of the salts of the blood an acid to be thrown off by the kidneys. Sulphuric acid had at one time some reputation as a remedy in colica pictonum, and is still considered a good prophylactic against that com- plaint, under certain circumstances. It was supposed to act by forming an insoluble and inert salt with the lead, and thus to remove the cause of the disease. But the preparations of lead do not produce colica picto- num, while lying loose in the alimentary canal, or even precipitated upon its surface. They must enter the circulation, and come into direct con- tact with the nervous tissue which they affect. Now, sulphuric acid cannot follow them into the circulation and the tissues; and, even if, in CHAP. I.] MINERAL TONICS. SULPHURIC ACID. 363 the form of soluble sulphates, it should do so, the formation of an insol- uble compound of lead in these situations, from which it could not be readily removed, would not, it appears to me, be the best method of ex- pelling the poison. So far as the acid can do good by combining with any lead in the stomach and bowels, thus far it may be useful in colica picto- num, by preventing the further absorption of the poison. It may, there- fore, prove prophylactic, if habitually used as a drink by those who are exposed to the necessity of swallowing small quantities of lead with their saliva, or antidotal in those who may accidentally take the poison into the stomach in larger quantities ; but all that it could do chemically in such cases, could be as well done, and with less liability to injury, by the use of one of the soluble sulphates. It must, therefore, act by some other than its mere chemical properties, if it has any special use- fulness in the poison of lead ; but that it has such usefulness, remains yet to be satisfactorily proved. Dr. D. Darrach, of Quincy, Illinois, has found this acid, in several cases, very efficient in the expulsion of tape-worm. He used it in the form of the aromatic sulphuric acid or elixir of vitriol, of which he gave a drachm, diluted with several ounces of water, in the course of three or four hours. (Am. J. of Med. Sci., Oct. 1860, p. 378.) The acid has been used externally in eruptive affections, as lichen, prurigo, obstinate urticaria, and psora, and in indolent or ill-condi- tioned ulcers. It is also employed as a gargle in ulcerated sore-throat, and the anginose affection of scarlatina, and as a caustic application to diphtheric exudation in the mouth and fauces. But for all these pur- poses, its place has been supplied by more efficient or more convenient remedies; and it is now little employed. When used, it should be much diluted. The precise strength will be mentioned under the preparations. Incompatible s. If the special action of sulphuric acid is wanted, it should not be given with metallic iron ; with salifiable bases, with which it forms salts; with the carbonates, or salts of vegetable acids; with sol- uble nitrates, chlorides, iodides, or sulphurets; or with the soluble salts of lime, baryta, and lead, which it decomposes, forming insoluble or nearly insoluble sulphates of these bases respectively. Sometimes, pos- sibly, it may be appropriately administered in connection with one or more of these substances; but this should never be done, unless with a view to the reactions which must follow. Preparations of Sulphuric Acid. As kept for internal use, sulphuric acid is always in one of the follow- ing forms. In relation to its external use as a caustic, it will be treated of under the escharotics. 364 GENERAL STIMULANTS. [PART II. 1. DILUTED SULPHURIC ACID. ACIDUM SULPHURICUM Di- LUTUM. U. S., Br. This is prepared by the U. S. Pharmacopoeia, by mixing two troy- ounces of concentrated sulphuric acid, with fourteen fluidounces of dis- tilled water, then filtering, and passing through the filter as much more of the water, as may be necessary to make the diluted acid measure a pint. After the mixture, a white insoluble substance gradually separates, if the commercial acid is used in the preparation. It is the sulphate of lead previously contained in the strong acid, which would subside if the mixture were allowed to stand, and might be got rid of by decanting the clear liquid. In the U. S. process, it is separated by filtering. The British preparation is somewhat stronger, but not materially so. Even in this state of dilution, the "acid is still corrosive, and requires to be much more diluted before it can be borne by the palate. The officinal preparation is intensely sour, and will set the teeth on edge, if it come in contact with them. When taken, therefore, it should either be sucked through a quill, or other tube introduced far into the mouth ; or, what I think is ordinarily a better plan, it should be swallowed rapidly, and the mouth, immediately afterwards, well and repeatedly washed out with water, or a weak solution of one of the alkaline carbonates. Without some precaution of this kind, the teeth may be seriously injured. The done of the diluted acid is from ten to thirty drops, to be repeated, for ordinary purposes, three times a day, or more frequently. To be efficient in hemorrhages, it must be given every two hours. The dose should be taken in one or two wineglassfuls of water, sweetened or not, as the patient may prefer. When used as a drink in hemorrhages or fevers, the same quantity may be added to half a pint or a pint of water. For a gargle, in ulcerative affections of the throat, a fluidrachm may be added 1o a pint of water; for application to the skin, double the quan- tity. When intended for pseudomembranous patches in the mouth or fauces, this preparation may be used undiluted, and should be applied by a brush directly to the affected part, and no other. Compound Infusion of Roses (!NFUSUM ROS^E COMPOSITUM, U. S.) is an infusion of red roses, containing about three fluidrachms of the diluted sulphuric acid in two and a half pints. The preparation acquires a slight astringency and a red colour from the roses; but its efficacy depends altogether on the acid. It is considerably used in Great Britain, as a drink in hemorrhages and colliquativc sweats, and as a vehicle fur saline medicines, especially sulphate of magnesia, the taste of which it in some measure conceals. The dose is from two to four fluidounces. It is also used as u gargle. 2. AROMATIC SULPHURIC ACID. ACIDUM SULPHURICUM AROMATICUM. U. S., Br. Elixir of Vitriol. This preparation, which is very generally known under the name of CHAP. I.] MINERAL TONICS. NITRIC ACID. 365 elixir of vitriol, is a simplification of Mynsichfs acid elixir. It is pre- pared, according to the present U. S. process, by obtaining a tincture of ginger and cinnamon by percolation with alcohol, and then adding the tincture to a mixture of sulphuric acid and alcohol previously prepared. It may be considered as a tincture of the aromatics mentioned mixed with the acid; though some chemical reaction has no doubt taken place between the several ingredients. It contains one part of the acid to about nine parts by measure of alcohol, and is therefore considerably stronger than the preceding preparation. As the drop, however, is smaller, the dose is about the same as given in drops. The U. S. prepa- ration is about one-third stronger than the British. It is a reddish-brown liquid, of a peculiar agreeable odour, and, when diluted, of an acid not unpleasant taste. In this country, it is the form generally preferred for the internal administration of sulphuric acid. The dose of it is from ten to thirty drops, given in one or two wineglassfuls of water. It is very often used as an addition to sulphate of quinia to render it soluble in water; and is an ingredient in the two Infusions of Peruvian Bark of the U. S. Pharmacopoeia, in the preparation of which it enables the water to extract all the virtues of the bark, while it agreeably qualifies the taste of the infusion. 3. OINTMENT OP SULPHURIC ACID. This ointment was until recently an officinal of the Dublin College. It was made by rubbing together a drachm of the acid and an ounce of lard. Reaction took place, which altered the colour of the ointment; but it was still merely a dilute preparation of sulphuric acid for external use. Mixed with an equal quantity of lard, it was employed as a remedy for scabies, lichenous ringworms, prurigo, and other obstinate cutaneous eruptions, and, still further diluted, as a rubcfacient in paralysis, chronic inflammation of the joints, rheumatism, etc. II. NITRIC ACID. ACIDUM NITRICUM. U. S., Br. Origin. This acid, according to Dr. Percira, was known to Geber in the seventh century. In commerce it is usually denominated aquafortis, and in technical language sometimes azotic acid. It is prepared by heating together a mixture of nitrate of potassa and sulphuric acid, and condensing in a receiver the vapours which are given off. For an ac- count of its composition, chemical relations, the tests of its purity, etc., the reader is referred to the U. S. Dispensatory. It is here to be con- sidered mainly in its direct medical relations. 366 .. GENERAL STIMULANTS. [PART II. Properties. Two forms of the acid are kept in the shops, distinguished as the nitrous and nitric acids. Nitrous acid of the shops is characterized by its orange colour, which is sometimes very deep, and by the orange-coloured fumes which it gives off. This peculiarity is owing to its impregnation with nitric oxide or deutoxide of nitrogen, by reaction between which and a portion of the nitric acid, the proper chemical nitrous acid is generated, which imparts its colour to the mixture. But, when the liquid acid is diluted with water, the orange-coloured nitrous acid is decomposed again into nitric acid and nitric oxide, the latter of which escapes, assuming an orange colour when in contact with the air, and leaving a colourless diluted nitric acid; and, as the medicine must be diluted before being adminis- tered, it follows that the nitrous acid of the shops has nothing to dis- tinguish it, in relation to medical effect, from the purer form. This ob- servation is necessary, as peculiar virtues have been ascribed to it. Nitric acid, when quite pure, is a colourless liquid, but, as often kept, is slightly yellowish. If duly concentrated, it gives out white fumes. As directed by the U. S. Pharmacopoeia, it has the sp. gr. 1.42; but it is of variable strength as found in the shops. It has a peculiar odour, and, when so far diluted as to be borne in the mouth, an intensely sour taste. When in contact with the skin, it stains the cuticle yellow ; and the colour remains until the cuticle itself is gradually removed, a prop- erty which serves to distinguish the stain from that produced by iodine and bromine. The colour, moreover, may be distinguished by becoming brighter under the application of ammonia or soap. Effects on the System. Nitric acid, in the smallest medicinal doses, excites the appetite, promotes digestion, and secondarily invigorates the general nutritive process. It is, therefore, a tonic, acting specially on the stomach and bowels, and in this respect resembles sulphuric acid, from which, however, it differs in being without astringency. It is said also to be refrigerant, and to have alterative properties which render it useful in peculiar morbid states of the system. On these points more will be said directly. It is thought to have sometimes induced ptyalism ; but, at best, this result is very rare. Too largely taken, and in the ordinary medicinal doses if continued too long, it is apt to cause disturbance of the stomach, gastric pain or spasm, and sometimes severe attacks of intestinal colic. S wallowed very copiously, and even in smaller quantities if concentrated, it pro- duces poisonous effects so much like those resulting from sulphuric acid that it is unnecessary to repeat an account of them. (See page 357.) With the nitric acid, however, the inside of the mouth is stained yellow- ish instead of whitish; and yellow stains on the skin of the face will often serve to distinguish the poison. Two instances have recently oc- curred of fatal poisoning from inhalation of the fumes of nitric acid, CHAP. I.] MINERAL TONICS. NITRIC ACID. 367 arising from the fall and breaking of a jar containing the acid, as it was carried across a room. Timely efforts to save the patients were made but unavailingly. (Pharm. Journ. and Trans., A.D. 1863, iv. 475.) The antidotes and remedial treatment are absolutely the same as in the case of poisoning from sulphuric acid. When poisoning results from inha- lation, as in the cases just referred to, the use of the recently invented atomizer obviously suggests itself. By means of it, a perfectly safe solu- tion of one of the bicarbonated alkalies might be thrown, in the form of spray, into the upper passages, and thus made to neutralize any acid there present, leaving only inflammation to be combated, which would require the copious use of leeches preceded by the lancet. Gaseous ammonia is itself so irritating, that there might be fear of aggravated inflammation from its use. Mode of Operating. Nitric acid is a direct stimulant to the alimentary mucous membrane, becoming irritant in over-doses. It is probably never absorbed in the acid state; but combines in the stomach and bowels with the albumen, and the salifiable bases which it always encounters there, and in this state of combination may enter the circulation, in order to be thrown off immediately by the kidneys. Now the alkaline salts of nitric acid are remarkably refrigerant and sedative to the circulation when absorbed, especially the nitrates of potassa and soda; so that, as one of these salts will be likely to be formed by the nitric acid in the bowels, we may readily account for the refrigerant effect asserted to be produced by the acid. As to its supposed alterative action, so far as such an effect has been experienced, it may be explained in a somewhat similar manner. Muriatic acid frequently exists in the stomach. It is possible that, by reaction with this, the nitric acid may sometimes gen- erate that peculiar combination called nitromuriatic acid, which undoubt- edly has an important alterative action on the system. This view is rendered the more probable, as it is only occasionally that nitric acid is found to exercise the alterative influence ascribed to it ; and it is only occasionally that the reactions can occur which produce nitromuriatic acid. We may explain in the same way the reported occurrence of pty- alism in some instances; as one of the admitted characteristic properties of nitromuriatic acid is frequently to act on the gums. In the concentrated state, nitric acid decomposes the tissues through its chemical affinities, and thus causes the death of the part, acting as an escharotic. Therapeutic Application. The use of nitric acid as a tonic is very nearly the same as that of sulphuric acid. Like that, it is peculiarly applicable to the debility of convalescence, with want of appetite, and a disposition to sweat at nights; though not perhaps equally efficient in correcting excessive perspiration. I have occasionally met with cases of fever, from, which the recovery seemed very slow ; the pulse remaining 368 GENERAL STIMULANTS. [PART II. rather frequent, especially in the latter part of the day, the tongue some- what furred, and the appetite feeble or wanting; and this state of things continuing for days with little or no change. Under such circumstances, nitric acid, given in small doses every two or three hours, has seemed to answer an excellent purpose in hastening and confirming the conva- lescence. It has also been used with asserted advantage in fevers generally, being prescribed partly as a tonic, and partly as a refrigerant in those of feeble action, and as a refrigerant alone, in such as require no sup- porting treatment; but, in cases of this kind, having had little faith in its peculiar efficacy, I have not been in the habit of using it; and can, therefore, say nothing from experience of its, virtues. I have already explained how it is possible that it may produce a refrigerant effect. Dr. Bedford Brown, of Yanceyville, N. C., has found it highly advantageous in the adynamic state of remittent fever, in connection with sulphate of quinia, to which, he thinks, it "certainly added efficacy." He began with three drops every six hours, and gradually increased even to ten drops in cases of peculiar intensity. (Am. J. of Med. Sci., Jan. 1860, p. 49.) Dr. Win. A. Hammond states, as the result of his treatment of 41 cases of intermittent, 32 by nitric acid, and 9 by sulphate of quinia, that the former was equally successful w r ith the latter. He gave ten drops of the acid three times a day. (Ibid., April, 1861, p. 606.) It had pre- viously been used as an antiperiodic by Drs. E. T. Bailey and Geo. Men- denhall, of Indiana. (U. S. Dispensatory, 12th ed.) Some have supposed it to have an alterative influence on the liver, and to be useful in chronic inflammation of that organ. Generally it has altogether failed of making any useful impression in such cases, and certainly cannot be relied on. Nevertheless, it may occasionally do good, through the generation of nitromuriatic acid in the prima3 viaj. Of its asserted specific virtues in secondary syphilis, scrofula, and various eruptive affections characterized by a depraved blood, as im- petigo, eclhyma, rupia, etc., I have seen nothing which might not be ascribed to its simple tonic action upon the digestive organs, and to the consequent improvement in sanguification and nutrition. Nevertheless, there may possibly result from its chemical reactions within the system, substances having in some degree the peculiar virtues referred to; and the statements as to its efficiency made by respectable practitioners would tend to confirm this view. It is, however, acknowledged to be inferior to other medicines in the cure of the affections mentioned, and, if used at all, should be so as an adjuvant merely. In diarrhoea, and dysentery, and the ordinary forms of cholera, it ha? been highly recommended ; and, in the form of what is called Hope's mixture, was at one time in great repute. This consisted of nitrous acid, camphor water, and laudanum. Much stress was laid upon the CHAP. I.] MINERAL TONICS. NITRIC ACID. choice of nitrous preferably to nitric acid. I have already shown that this preference was unfounded. I have employed this mixture in the affections above referred to, but generally with little greater effect than could be ascribed to the laudanum and camphor water. The acid often provoked irritation and pain in the stomach or bowels. Nevertheless, there are cases of bowel affections in which the acid appears to do good. I consider it wholly inapplicable to acute cases, with severe pain in the bowels, and febrile symptoms. The circumstances under which it has appeared to me useful, are a certain degree of general debility, without heat of skin, with no considerable pain, and evidences of a feeble or re- laxed condition of the mucous membrane, which disables it from re- suming its healthful functions. In such a condition, whether the affec- tion be in the early or advanced stage, and whether it have the form of diarrhoea or of dysentery, the combination above referred to may prove useful ; but it is, I think, in cases of diarrhoea following cholera infantum that it has proved most beneficial in my hands. In ordinary cholera morbus, other methods are so uniformly successful, that I have never considered myself justified in omitting them in order to try nitric acid. Epidemic cholera has also been treated by nitric acid, but I believe with no peculiar success. In hooping-cough it was recommended by Dr. Arnoldi ; and Dr. Geo. D. Gibbs considers it as a most efficient remedy. In a treatise by the latter, published in London, A.D. 1854, he states that "it not only arrests the paroxysms, and removes the hoop, but shortens the disease almost as effectually as quinine does intermittent fever." (Lond. Med. Times and Gaz., July, 1854, p. 118.) Dr. Arnoldi adds as much of the acid to water, sweetened with sugar almost to the consistence of syrup, as will give it the sourness of pure lemon-juice. Of this preparation he gives to a child one year old a dessertspoonful every hour, to an adult a tum- blerful during the day. It is useless to speculate upon the mode of action of the remedy, till further experience shall have established its efficacy. Hooping-cough is sometimes protracted in consequence of a state of debility into which the patient is apt to fall, and which is re- lieved by tonics. Thus far nitric acid may no doubt prove useful ; but much more is claimed for it by the practitioners above referred to. Several cases of spasmodic asthma very promptly yielded to the use of the acid, in the practice of Dr. T. S. Hopkins, of Bethel, Georgia. Most if not all of the cases were of young children. He gave from three to five drops of the acid three times daily. (Am. Journ. of Med. Sci., N. S., xx. 549.) As an antililhic, Ike remarks made upon sulphuric acid are precisely applicable to the nitric. It will be remembered that it is in the phos- phatic diathesis that the remedy is specially indicated. VOL. i. 24 370 GENERAL STIMULANTS. [PART II. As a local remedy, nitric acid has been used to stimulate feeble ulcers, to remove the callous edges of the obstinate, and to correct the morbid action of the ill-conditioned and phagedenic. It has also been recently employed, with great asserted advantage, as an application to prolapsed anus and piles.* Sir B. Brodie succeeded in dissolving a phosphatic calculus, by injecting into the bladder, every two or three days, for a time varying from fifteen to thirty minutes, water acidulated with nitric acid, in the proportion of two and a half minims to a fluidounce. Administration. The dose of the officinal acid is from three to seven drops; but, as kept in the shops, it is often of less than the officinal strength ; and no precise rule can be given under the circumstances. I have found, however, that the above quantity of the officinal acid makes a large wineglassful of water rather disagreeably sour; and enough, therefore, of any specimen employed should be added to water to pro- duce this effect. In the uncertainty as to the strength of the acid, a small dose should be given at first, to be gradually increased until it produces some sensible effect upon the stomach, a little pain for example, and then to be somewhat diminished. The water may be sweetened, if so preferred by the patient. Special care should betaken to avoid injury to the teeth. (See Diluted Sulphuric Acid, page 364.) As a wash for ulcers, from twenty to forty minims of the strong acid may be added to a pint or a quart of water. Incompatibles. The acid should not be administered with uncombined inetals, alkalies, alkaline earths, or their carbonates, nor with soaps or sulphurets. Caution should always be observed not to drop it into a silver spoon, as it would thus form nitrate of silver, or lunar caustic. It should be administered from a glass or porcelain vessel. Diluted Nitric Acid (ACIDUM Nmiicot DILUTUM. ('. &,, Br.} is an officinal preparation. The present Pharmacopoeia directs three troy- ounces of the officinal acid (sp. gr. 1.4-2) to be mixed with sufficient dis- tilled water to make the Diluted Acid measure a pint ; but, in order that the preparation may be of uniform strength, the apothecary, if unable to obtain a strong acid of the officinal specific gravity, should make the re- quisite allowance, and increase the proportion of the acid sufficiently to compensate for its feebleness. This he will be enabled to do by consult- ing the table of Dr. lire (see U. S. Dispensatory), from which he can learn the quantity of strong acid in any specimen of a given specific gravity. The dose of the diluted acid is from twenty to forty drops, which should be taken in a large proportion of water. The preparation may be applied ^diluted, by means of a camel's-hair pencil, to pseudo- * In reference to the surgical use of nitric acid, as an escharotic in piles and prolapsed rectum, see the Lond. Med. Timtt and Gaz., April, 1853, p. 343; Aug. 1854, p. 184; and Dec. 1865, p. 560. CHAP. I.] MINERAL TONICS. MURIATIC ACID. 371 membranous exudations, and certain indolent and insusceptible ulcers ; care being taken not to allow the application to extend beyond the sur- face affected. An ointment of nitric acid was formerly officinal ; but has been omitted in recent editions of the pharmacopeias. It was made, according to the Dublin process, by melting together a pound of olive oil and four ounces of lard, and adding, upon the commencement of concretion, five and a half drachms of the acid. The resulting ointment, which was yellow and of a firm consistence, was used in cutaneous affections, more espe- cially porrigo and impetigo. III. MURIATIC ACID. ACIDUM MURIATICUM. U. S. ACIDUM HYDROCHLORICUM. Br. Syn. Hydrochloric Acid. Chlorohydric Acid. Origin. Muriatic acid was described by Basil Valentine in the fifteenth century. To the older chemists it was known by the name of spirit of sea salt; when better understood, but before its composition had been discovered, it was called muriatic acid; at present, chemists usually denominate it hydrochloric or chlorohydric acid. In the U. S. Pharma- copoeia the name of muriatic acid has been retained as sufficiently ex- pressive, and best adapted for a medical and pharmaceutical title, until chemists shall adopt one upon which all can unite. The term is applied to the liquid acid obtained by acting upon chloride of sodium with sul- phuric acid and a little water, and receiving the hydrochloric acid gas given off in distilled water, which condenses it. The U. S. Pharmacopoeia directs that it should have the sp. gr. 1.16. Properties. Muriatic acid when pure is a colourless liquid, but is often somewhat yellowish as in the shops. It emits a vapour which forms a white cloud in contact with the air. Its smell is strong, pungent, and peculiar; its taste, when diluted, extremely sour. It yields with nitrate of silver a white precipitate, insoluble in nitric acid, but readily dissolved by solution of ammonia. Undiluted, it is corrosive or escharotic. Effects on the System. So far as regards its action upon the digestive function, it closely resembles sulphuric and nitric acids. Like them, too, when given largely, it produces heat and pain in the stomach, and occa- sionally disturbs the bowels. In very large quantity, or in a concen- trated state, it operates as a corrosive poison, with symptoms similar to those produced by the acids just named; but distinguishable, it is said, by the emission of its peculiar odour from the mouth. At least this effect 372 GENERAL STIMULANTS. [PART IT. has been observed, when it has been given in poisonous quantities to the lower animals. The treatment of its poisonous effects is the same as that indicated for the other mineral acids. (See page 358.) Therapeutic Application. Muriatic acid may be used as a tonic to the digestive organs, and indirectly to the system, under the same circum- stances as the sulphuric and nitric. From the fact that, mixed with gas- tric mucus, it will dissolve food, and from the supposition, at one time entertained, that it was an essential agent in the solution of the food in the stomach, the inference seemed reasonable, that it would prove pecu- liarly useful in facilitating digestion when impaired. It certainly has this effect occasionally ; but experience has not proved it to possess any superiority over the other mineral acids. Dr. Paris considers it, when taken in connection with strong infusion of quassia, as one of the best preventives of the reproduction of worms, after they have been ex- pelled from the bowels. The acid has been much used in typhus, malig- nant scarlatina, and other fevers of a malignant character, partly under an impression of its antiseptic qualities; and much has been said of its efficiency in these affections. It has also been considered specially use- ful in scrofulous and syphilitic complaints and cutaneous eruptions. But there may be some doubt whether it acts in all these cases by any other than its tonic powers. It has been used, like the other mineral acids, to correct the phosphatic urinary deposits, and probably acts in a similar manner. Administration. The dose of the undiluted acid is from five to twenty drops, which may be given in half a tumblerful of sweetened water, and repeated more or less frequently according to the nature of the case ; every two or three hours, for example, in acute cases, and two or three times a day in chronic. The same caution should be observed us with the other acids, to prevent injury to the teeth. (See page 364.) To the incompatibles, mentioned under nitric acid, may be added, for the muriatic, the soluble salts of silver and lead. The acid is sometimes used locally. Applied carefully, without dilu- tion, to diphtheritic or pseudomcmbranous surfaces, it will effectually change the morbid action ; but, though strongly recommended for this purpose by Bretonneau, it is probably in no respect superior to the nitrate of silver, while it is less convenient. In ulceration of the mouth and fauces, it has been used, largely diluted, as a mouth-wash or gargle. For this purpose, from one to two fluidrachms may be added to eight fluid- ounces of water. There is an officinal Diluted Muriatic Acid (AciDUM MURIATICUM DILUTUM, U. &), containing, according to the directions of the present U. S. Pharmacopoeia, four troyounces in a pint of the diluted acid, the remainder being distilled water. The dose is from fifteen to sixty droj. CHAP. I.] MINERAL TONICS. NITROMURIATIC ACID. 373 IV. NITROMURIATIC ACID. ACIDUM NITROMURIATICUM. U. S. Origin, etc. This combination first attracted notice as a solvent for gold, whence it received the name of aqua regia. It is said to have been known to Geber, who lived in the seventh century; but its intro- duction into medicine dates only from the early part of the present. According- to the strict chemical nomenclature of the day, it is named nitro-chlorohydric, or nitro-hydrochloric acid. It is prepared, accord- ing to the present Pharmacopoeia, by mixing three troyounces of nitric acid with five troyounces of muriatic acid. When the acids are of suffi- cient strength, a reaction takes place, which Davy supposed to result in the production of nitrous acid, water, and chlorine. But M. Baudri- mont found, upon collecting the vapours rising from the mixture, that they did not consist of chlorine, but of a combination of this element with hyponitrous acid, in the proportion of two equivalents of the former to one of the latter; and he gave the name of chlorazotic gas (chloro- nitric gas) to the new compound. Gay-Lussac afterwards investigated the subject, and states as the result of his examination, that two new products are formed, consisting of nitric oxide and chlorine, which may be deemed to have been produced, the one from hyponitrous acid by re- placing one equivalent of its oxygen with one of chlorine, the other from nitrous acid by a similar substitution of two equivalents of chlorine for two of oxygen ; but Gay-Lussac admits also the evolution of free chlo- rine. It is seen, therefore, that the compound is no longer a mixture of the nitric and muriatic acids, but of certain new substances, having dis- tinct chemical properties, and probably an entirely different physiological action. As the medicine is officinally prepared, it contains a considera- ble excess of nitric acid ; so that its effects must be those conjointly of that acid and the new products. It is a fact worthy of particular attention, that nitric and muriatic acids will not react on each other so as to produce the changes above referred to, which are essential to the distinctive medicinal character of the compound, unless in a certain degree of concentration. If the acids employed be weak, they wilLstill remain nitric and muriatic acids in the mixture, and will exercise on the system only the effects of these acids. It is probably from this cause, in part at least, that the disappointment in the effects of nitromuriatic acid has proceeded, which has led to its aban- donment by many practitioners, and to the slighting notices of it given by some of the recent English writers. I have used it much, have taken care to guard against this source of failure, and have had every reason to 374 GENERAL STIMULANTS. [PART II. be satisfied of its great efficiency. Indeed, I consider nitroruuriatic acid as among our most valuable remedies. When the strong acids cannot be obtained, reaction may be speedily brought about by the addition of a little sulphuric acid, which probably operates by concentrating the weak acids through its affinity for water. At present there is little occasion for this expedient, as the acids are gen- erally to be found of sufficient strength ; but it was not always so ; and I have repeatedly made this addition with satisfactory results. Properties. When reaction has but partially taken place between the constituents, the colour of the mixture is yellow ; but it deepens as the changes go on ; and at length, when they are completed, is reddish or orange. The odour closely resembles that of chlorine, but is somewhat different. The taste, upon dilution so as to render the medicine support- able in the mouth, is intensely sour, and somewhat peculiar. Care should be taken that the preparation is kept in a cool place, and excluded from the light. Effects on the System. Nitromuriatic acid promotes the appetite, and in other respects operates as a tonic to the digestive function, in the same manner as nitric acid. Like that acid, too, it is irritant to the ali- mentary mucous membrane in over-doses ; and, when swallowed in great excess, or in a concentrated state, apts as a corrosive poison, with the same phenomena as those already described as the result of poison- ing by the mineral acids. The antidotes and remedies are also the same. (See pages 357-8.) But this medicine produces other and very important effects upon the system. It is certainly not absorbed precisely as administered; for the nitric acid, which, as before stated, is contained in it in excess, probably never enters the circulation unchanged. There can hardly, however, be a doubt that one or more of the new bodies, resulting from the reaction of the ingredients, is really absorbed. This can scarcely be the chlorine; for the chemical affinities of that element are so powerful, that it could not remain long enough in the primse vise, or in contact with the tissues through which it must pass, without satisfying those affinities by union with some other body elementary or compound. May it not be, that the new compound noticed by M. Baudrimont, or one or both of those which offered themselves to Gay-Lussac's research, are capable of absorption, and of producing all the peculiar effects of the medicine upon the blood, and upon the tissues to winch they are conveyed by the blood? An evidence of this action through the circulation is presented in the increased secretion of bile, causing not unfrequently bilious evacuations from the bowels, and in the fact that this occurrence takes plaed advan- tageously in depraved states. of health, attended with ul<:erative affec- tions of the skin, or certain eruptions, as ecthyma, rupia, porrigo, etc.; in the purulent infection consequent on the absorption of degraded and disintegrated pus, and in the .somewhat similar condition of the system CHAP. I.] MINERAL TONICS. NITROMURIATIC ACID. 377 in gangrene. In all these cases, it probably acts jointly by the tonic influence of its acid ingredient on digestion, and the general alterative influence of the portion absorbed. In the oxalic lilhiaxis it is certainly an admirable remedy. Suggested first, I believe, by the late Dr. Bird, of London, instead of the nitric acid recommended by Dr. Prout, it has come into general use, and often pro- duces the happiest results. I have repeatedly used it in cases char- acterized by an abundance of oxalate of lime in the urine ; and, I believe, in no instance have known it to fail in correcting, or much diminishing that symptom; while, at the same time, the constitutional symptoms have often undergone a similar amelioration. There is a special morbid condition, which I have occasionally met with, and have for many years been in the habit of combating, by means of this remedy, with the happiest success. I do not know that I can convey an accurate idea of this condition to the reader, but it is suffi- ciently well characterized to my own observation. There is a failure of the appetite, a slight fur upon the tongue, which, however, remains moist, a tendency to constipation, a cool, moist, and relaxed surface, and a pulse rather feebler, perhaps, than in health, sometimes a little accel- erated, but not strikingly abnormal in any way. With these symptoms are frequently conjoined an offensive breath, general languor, and a re- markable and apparently causeless depression of spirits, with perverted feeling, sometimes almost approaching insanity. I have attributed this condition to a depraved state of the blood, dependent probably on de- fective digestion and assimilation. It may continue for weeks without abatement; but, under the use of nitromuriatic acid, begins to improve in a few days, and, in a period of time varying from two or three weeks to some months, often yields entirely. Since the practice of chemical and microscopical investigation of the urine has come into vogue, circum- stances have prevented me from investigating the state of the secretion in this affection unless in a few instances ; and, in all of these, oxalate of lime was noticed in the urine. Administration. The dose of the acid is from two to ten drops, accord- ing to its strength. About five drops is a medium dose, which may be given in from two to four fluidounces of sweetened water, and repeated two, three, or four times in twenty- four hours. As the medicine, in large doses, is apt to induce colicky pains, it is best to begin with a small dose, and increase till it evinces some sign of acting. The same caution should be observed as with the other acids, to guard the teeth against injury. Care should be taken, in opening the bottle in which the acid may be contained, to avoid exposing the face to the jet of gaseous vapour, which sometimes suddenly escapes, especially when the bottle has been kept in a warm place, and which may endanger the eyes, if not guarded. When the patient, or a nurse, mixes the acids, particular 378 GENERAL STIMULANTS. [PART II. direction should be given that they should not be dropped into water before they have been mingled, and full time has been allowed for mu- tual reaction. In fact, it is best that the mixture should be made by the apothecary, and, after sufficient reaction has taken place, should be di- luted before being dispensed. I frequently thus prescribe the remedy, directing it to be diluted with camphor water, in such proportion that a tablespoonful of the preparation shall constitute a dose, to be afterwards further diluted by the patient. To this mixture a portion of laudanum may be added, whenever indicated. The incompatibleK are so numerous, that the safest plan is to give the acid without other accompaniments than those just mentioned. It should be administered from a wineglass, or by means of some other glass or porcelain instrument, and never from a metallic spoon, especially one of silver. So far as concerns the effects of the medicine on the liver, it has been thought that its external use is scarcely less efficient than the internal. At least, the two methods may often be advantageously conjoined; or the outward application may be resorted to when the medicine operates offensively on the alimentary canal. It may be employed externally in the form of lotion, footbath, or full bath. For the purpose first men- tioned, it may be added to water, in the proportion of two fluidrachms to a pint, and applied by means of a sponge. For a footbath, from one to two fluidounces may be used to the gallon of water; for a bath, about one fluidounce to the same quantity. Both the bath and footbath should be at the temperature of about 96 F., and should be prepared in wooden vessels. The application may be continued from ten to thirty minutes, or till a tingling or pricking sensation begins to be felt in the skin. It may be repeated daily, or twice a day. V. PHOSPHORIC ACID. ACIDUM PHOSPHORICUM. There are three isomeric conditions of phosphoric acid, identical in composition, but differing in their relation to bases, of which one unites with one equivalent, the second with two eqs., and the third with three; and hence they are distinguished by the names of monobasic, bibasic, and tnbasic phosphoric acid; water when combined with these being considered in the state of a base. With these preliminary remarks, I must be content with referring to the U. S. Dispensatory (12th ed., p. 51), for the chemistry of this acid. Two forms of phosphoric acid are now officinal, the glacial, namely, and the diluted, both of which were intro- duced into the U. S. Pharmacopeia, for the first time, at its late revision. CHAP. I.] MINERAL TONICS. PHOSPHORIC ACID. 379 1. GLACIAL PHOSPHORIC ACID. ACIBUM PHOSPHORIC UM GLA- CFALE. U. S. Syn. Monobasic Phosphoric Acid. Meta phosphoric Acid. Phosphate of Water. This is the first of the three varieties just named, being always combined with one cq. of water, and represented by the formula HO,P0 5 ; the anhydrous acid consisting of one eq. of phos- phorus and five eqs. of oxygen. It results when the product of the combustion of phosphorus is introduced into water; but is commonly obtained from calcined bones, by treating them with sulphuric acid, which produces a superphosphate of lime, dissolving this out by water, adding carbonate of ammonia, and exposing the resulting phosphate of ammo- nia first to an evaporating heat, and then to calcination, by which the ammonia is driven off, and the glacial acid is left. (See U. S. D.) This variety, however, of phosphoric acid is generally imported, being seldom made in our chemical laboratories. The glacial phosphoric acid is a transparent, white or colourless, fusible solid, inodorous, sour to the taste, slowly deliquescent, and soluble in water and alcohol. It is chemically characterized by producing precipi- tates with soluble salts of lime, baryta, and silver; the precipitate with chloride of barium being redissolved by an excess of the acid ; and is distinguished from the other states of the acid by coagulating albumen. Though capable of producing all the effects of phosphoric acid upon the system, this variety is seldom prescribed, being always first brought to the state of the officinal diluted acid. Indeed, it was introduced into the Pharmacopoeia, as affording a ready means of preparing that officinal. 2. DILUTED PHOSPHORIC ACID. ACIDUM PHOSPIIORICUM Di- LUTUM. U.S., Br. This is prepared, according to both the United States and British Pharmacopoeias, by carefully heating together phosphorus, nitric acid, and water. The phosphorus is oxidized and converted into phosphoric acid at the expense of the nitric acid; and, having been obtained in a somewhat concentrated liquid form, is afterwards diluted with water to the officinal strength. Our Pharmacopoeia also permits it to be prepared by dissolving a troyounce of the glacial acid in three fluidounces of distilled water, adding a little nitric acid, boiling until the whole of the- latter acid is driven off, and then adding distilled water till the diluted acid measures twelve fluidounces and a half. The object of boiling with the nitric acid is to convert the glacial or monobasic into the tribasic, which is the proper officinal ac.id ; the nitric acid appearing to act, in facilitating the change, simply by its presence; as no decompo- sition takes place. The strength was intended to be as nearly as pos- sible the same as that of the diluted acid, prepared according to the other formula. The sp. gr. of the U. S. diluted acid is 1.056, that of the British officinal preparation 1.08; the latter, therefore, being considera- bly stronger. This should be recollected in estimating the value of the doses of this acid given by British writers. 380 GENERAL STIMULANTS. [PART II. Properties. Diluted phosphoric acid is a colourless liquid, without smell, extremely sour, and possessed of strong acid properties. Though much less corrosive, even in a concentrated state, than sulphuric acid, it is yet capable in that state of destroying life. Orfila has seen fatal gastritis produced in a dog by thirty grains of it dissolved in a very little water. Medical Uses. As a medicine, it has been more used, till of late, on the continent of Europe, particularly Germany, than either in Great Britain or this country. Having never prescribed it, or seen it prescribed, I am not entitled to give an authoritative opinion upon its properties or value as a medicine ; but, from all that has been written upon the sub- ject, though some writers claim for it special and extraordinary virtues, there seems to be good reason to believe that it resembles the other acids in its effects, and can do little more than they. It is thought espe- cially to resemble sulphuric acid in tonic virtues, and, though not so energetic, has the advantage that its taste is somewhat more agreeable, and its tendency to produce gastric and intestinal irritation less. It may, therefore, be employed to promote the appetite and invigorate digestion in debilitated states of the system. Scrofulous affections, passive hemorrhages, colliquative sweats, excessive suppuration, low febrile diseases, caries of the bones, ulcerous and eruptive affections with depraved blood, are complaints in which it has been recommended, and in which its tonic properties may have rendered it useful. Its property of dissolving phosphate of lime out of the body has led to its employ- ment in ossification of the heart and blood-vessels, and in cases of phos- phatic deposits in the urine, in the hope that it might dissolve the abnor- mal bony matter, and calculous formations within the tody. In the urinary affection, it may operate beneficially in the same manner as sulphuric acid. It has been supposed to possess the power of greatly reducing vital irritability, and has been employed, in reference to this property, in hysteria and convulsive disorders. On the contrary, from an imagined excitant influence over the generative organs, it has been used in impotence in males. As a local application, it has been espe- cially recommended in caries, in which it corrects the fetor, dissolves and aids in the separation of the dead portions of bone, and otherwise favours the healing process. It is said also to have proved beneficial in offensive cancerous ulcers. It might be supposed that phosphoric acid would occasionally prove useful by supplying a deficiency of phosphorus or the phosphates in the tissues. There can be no doubt that it forms \vitli tin- saliliable bases it meets with in the alimentary canal, as lime, soda, etc., salts which may enter the circulation, and thus produce all the effects which it has of late been somewhat fashionable to ascribe to the phosphates. But when it is considered that there is always more or less, of the phosphates in the CHAP. I.] MINERAL TONICS. CARBONIC ACID WATER. 381 blood and in the urine, resulting probably from the disintegration of the tissues, and in part, possibly, from the food taken, it is obvious that it is not the presence of the phosphates that is wanted, but the due power of appropriating them. I have never, therefore, been disposed to ascribe much virtue to the phosphates used in medicine, merely with the object of supplying a supposed deficiency of phosphorus in the nervous tissue, or of phosphate of lime in the bones. The dose for internal use is from ten minims to a fluidrachm, which should be given largely diluted. For external use, the officinal acid may be diluted with nine or ten times its bulk of water. VI. CARBONIC ACID WATER. AQUA ACIDI CARBONIC!. U. S. Syn. Artificial Seltzer Water. Artificial Mineral Water. Preparation. Carbonic acid water is prepared, according to the U. S. Pharmacopoeia, by forcing into water five times its bulk of carbonic acid gas, obtained by the reaction between marble and dilute sulphuric acid. Water, under the ordinary atmospheric pressure, and at ordinary tem- peratures, absorbs about its own volume of carbonic acid gas, and may be made to take up any additional quantity that may be required by increasing the pressure; the quantity absorbed being directly propor- tionate to the augmentation of the pressure. Thus, if with the pressure of the atmosphere it will absorb its own volume, with a pressure double that of the air it will absorb two volumes, with triple the pressure three volumes, etc. As kept in the shops, the solution has not always the officinal strength; being sometimes stronger and sometimes weaker. I am told that the preparation generally kept by the druggists of Phila- delphia contains about seven or eight times its bulk of the acid gas. This statement, however, applies only to the water first drawn from the fountains; as. being driven out by the pressure of its own escaped air, it gradually becomes weaker as the fountain is exhausted, and towards the close must be much more so than at first. The colder it is, the more gas it is capable of containing. To maintain its proper strength, it must be kept under steady pressure; and hence the best plan is to have it bot- tled by the manufacturer ; in which case, it retains an equable strength for an indefinite length of time, if well secured. Properties and Im}>ri(ii>s. Carbonic acid water is an effervescing, sparkling, colourless liquid, of an acidulous, pungent, agreeable taste; often producing, when swallowed, considerable irritation in the fauces. It reddens litmus paper, and precipitates lime-water. 332 GENERAL STIMULANTS. [PART II. From the mode in which it is prepared and kept, it is liable to two impurities, which very much interfere with its beneficial operation. Not unfrequently the fountains or reservoirs containing it are furnished with a leaden tube of exit, so that a portion of the water, drawn at any one time, must have been for a longer or shorter period in contact with lead, and is liable to be more or less impregnated with the carbonate of that metal. Should it be frequently drawn, there will be no appreciable quantity of the salt of lead; but if not, the impregnation may be con- siderable. The water which has remained over night in the exit pipe often contains it; and I have known of two instances of colicapictonum, induced by the habit of drinking every morning the first draught of the water from the fountain. Another impregnation is copper, derived from the fountain, which is usually made of that metal. The copper fountains are, it is true, tinned in the interior ; but the process is not always well performed, or the tin coating is worn off in spots; and thus it very frequently happens that more or less copper is dissolved. Sometimes the solution is so strong as to be obvious to the taste. It is highly important, for medical purposes, that the water should be quite free from these impurities. Their presence may easily be detected. If lead is contained in the preparation, it will be evinced by the pro- duction of a dark discoloration on the addition of hydrosulphatc of am- monia ; if copper, by a brown precipitate with ferrocyanide of potassium. This latter test is so delicate, that one part of copper, dissolved in 56,000 parts of the water, may be detected by the reddish tinge it produces. Medical Effects and Uses. Carbonic acid is at first locally irritant. This is perceived on attempting to inspire the pure gas, when a strong irritant impression is felt in the throat and air-passages, so strong, indeed, that the glottis closes spasmodically, and refuses to admit it unless diluted. Applied to the skin for a short time, it produces a feeling of warmth and tingling or prickling, which is said to be sometimes posi- tively painful. When the strongly impregnated liquid is swallowed, it is often so irritant to the fauces, us \vitli some persons to render it almost impossible to take a large draught of it without interruption. It exer- cises a similar excitant influence on the stomach itself, and this is proba- bly one cause of its medicinal effects. In other words, it is a gentle gas- tric stimulant, operating in a manner more analogous to that of the milder aromatics than of any other medicines. It is said to be refrig- erant, and to excite perspiration and diuresis. But I I it-Hove it owes these effects to the water with which it is taken; and one of its advant- ages is that, by the gentle stimulation of the acid, it prevents injurious effects from tin- lanr< i draughts of very cold water swallowed with it. I do not think that of itself it is stimulant to the secretions. It is probably not absorbed into the circulation as carbonic acid from the alimentary CHAP. I.] MINERAL TONICS. CARBONIC ACID WATER. 383 canal, for the tendencies of the blood are everywhere to give out rather than to take in that substance. Its first stimulant impression appears to be followed, as is known to be the case with the gas locally applied, by a sedative influence on the nervous tissue. The gently stimulant action of carbonic acid water renders it useful as a tonic in dyspepsia and other states of gastric debility, if not used so largely and so frequently, as on the one hand to produce inflammation of the stomach, and on the other to exhaust its excitability. The dys- peptic patient will find advantage in taking a moderate draught of it twice a day. Another great advantage is the one, already referred to, of obviating too great a depressing effect from cold water, and of ren- dering it acceptable to the stomach, when it might otherwise prove op- pressive, possibly excite gastric spasm, or be rejected. Hence, when heated and perspiring, we may much more safely take a draught of cold carbonic acid water, than an equal amount of equally cold water not similarly protected. Hence, too, in febrile diseases, carbonic acid water very cold may be given happily as a refreshing and refrigerating drink, when cold water in the same quantity might oppress the stomach. It thus, too, enables the liquid to act as a diluent, and, by entrance into the circulation, and passing off with the secretions, to relieve febrile excitement. But the most useful remedial effect of carbonic acid is the relief of nausea and vomiting. There are few means more efficient for this purpose, when th'e nausea is not dependent on positive inflammation of the stomach. It is one of our very best resources in the irritable stomach of fevers. Most frequently, perhaps, the effect of carbonic acid, under these circumstances, is obtained through the medium of the effervescing draught ; because there is usually, at the same time, an in- dication for the diaphoretic and refrigerant influence of the citrate of potassa. But the carbonic acid water is also much used, and is very efficient. The best method of employing it is to have a number of small bottles, each containing about two fluidounces, filled with the liquid, then well closed, and kept in ice-cold water. The contents of one of these may be taken, as wanted, every half hour, every hour, or less frequently; and the preparation remains unimpaired ; whereas, if the liquid is used in successive draughts from one large bottle, the strength of it becomes exhausted before the bottle is emptied. It is not only the nausea of febrile disease that may be thus treated ; but that also of cholera morbus, cholera infantum, and all other disorders in which the affection is prop- erly gastric, and not positively inflammatory. As a vehicle for laxative, diuretic, and diaphoretic medicines, in order to obviate any nauseating effect from them, and to render them accepta- ble to the stomach, carbonic acid water is much used. It is an excellent menstruum for su'^hato of magnesia, citrate of magnesia, or any other 384 GENERAL STIMULANTS. [PART II. of the more soluble saline cathartics, of the citrates of potassa and am- monia as diaphoretics, and of the alkaline carbonates as diuretics and antilithics. It is also sometimes useful as a solvent for substances not soluble in water alone. The carbonate of iron and carbonate of mag- nesia are soluble to a certain extent in carbonic acid water, which thus offers the means of agreeably administering these substances in solution. The dose of the preparation is not precise. The patient may, in gen- eral, be left to his own discretion ; but it is best on the whole to give it in small quantities, as of a wineglassful, repeated frequently, than very largely at once. Seldom more than from four to eight fluidounces should be taken at one draught. It is often advisable to flavour it with some agreeable syrup ; as, in febrile cases, with lemon syrup, and in dyspep- sia with ginger syrup ; but in nausea and vomiting, it is usually more effective when taken alone. Considerable use has been made of carbonic acid water topically, as a gently stimulant agent. Applied by means of cloths, it has been em- ployed advantageously in cancerous, sloughing, and other ill-conditioned ulcers, of which it relieves the pain, improves the secretions, and checks the gangrenous tendency. Fermenting poultices have been used for the same purpose. They owe their efficacy to the carbonic acid evolved. Many natural mineral waters contain carbonic acid gas, which adds greatly to their usefulness, by rendering them more palatable and more acceptable to the stomach. CARBONIC ACID GAS. Much attention has been recently bestowed on the medical properties and uses of carbonic acid in its pure gaseous form. Towards the close of the last century, it was brought into notice, as an anaesthetic agent, by an experiment of Ingenhousz, who found that a finger, deprived of its cuticle, and introduced into oxygen gas. became more painful; whereas, by immersion in carbonic acid gas, the pain was relieved. Acting upon this hint, several English physicians employed it remedially, injecting it into the rectum in dysentery, and applying it to painful and ill-condi- tioned ulcers on the surface; and Mr. 10 wart, a surgeon of Bath, obtained great benefit from it in cancer of the breast. The direet application, however, of the pure gas seems to have fallen into entire neglect; though it has ever since continued to be employed, in the form of effervescing draughts, for the relief of irritable stomach, and in that of fermenting poultices, for gangrenous ulcers. In 1834, M. Mojon, of Genoa, recom- mended the injection of the gas into the vagina in dysmeborrhoBa, and other painful affections of the uterus; and the practice seems to have been imitated by other Italian physicians. About the same time, it was employed at certain mineral springs in Germany and France, in the CHAP. I.] CARBONIC ACID GAS. 385 form of air-bath and of the air-douche, for rheumatic pains and various other affections ; the gas being used as it issued from the natural fount- ains. But it is to Sir J. Y. Simpson, of Edinburgh, that we are mainly indebted for the revival of this remedy, and the much more extended use now made of it, Having seen a notice of its efficacy in a case of uterine disease, under the care of Dr. Rossi, of Italy, he was induced to give it a trial, and made his experience with it public, in an essay upon the subject, written, in 1856, for the New York Academy of Medicine. Properties. When a stream of carbonic acid gas is directed upon a sensitive surface, as of the mucous membranes, or the skin denuded of the cuticle, it produces at first an irritation, variable in degree according to the sensitiveness of the surface, and sometimes very painful, especially in the conjunctiva, which, it is said, cannot support the application longer than 4 or 5 seconds. In the nasal passages it produces an effect analogous to that of ammonia, and, when the attempt is made to inhale it, either unmixed, or diluted with 50 per cent, or less of atmospheric air, it causes so much irritation in the larynx that the glottis closes spasmodically, and its entrance into the lungs is prevented. (Herpin, Ann.de Therap., 1859, p. 60.) This property of carbonic acid gas has been long known ; and I once convinced myself of its reality by cautiously attempting to inhale the air over the surface of the fermenting liquid, in a large brewers' vat. It has been denied by Sir J. Y. Simpson, probably from the circumstance that, in the cases in which he applied the gas to the air-passages, it was much diluted with atmospherffc air. (See Brailhwaite's Retrospect, xxxviii. p. 260.) When mixed with 80or 90 per cent, of atmospheric air, it is in- haled readily, and without inconvenience. Its first irritant impression on the part to which it is applied is soon followed by a sedative effect upon the nervous tissue, by which pain, if present, is often entirely re- lieved. Even ordinary sensation is after a time much diminished, as shown by an experiment of Dr. T. A. Demme, of Philadelphia, who im- mersed his naked arm in the gas, and, after ten minutes, found the skin so much benumbed that it could be violently pinched without causing pain. (Med. and Surg. Reporter, Feb. 26, 1859, p. 380.) When inhaled, in the diluted, state, the gas is said to accelerate the circulation, though acting as a sedative to the nerves. After a short continuance of inhala- tion, it causes a state of somnolence and anaesthesia, which, according to Messrs. Faure and Ozanan, who experimented with it on the lower ani- mals, may be kept up, without danger to life, for 10, 20, or even 30 minutes, so as to give ample time for the performance of any ordinary surgical operation. Though, in its concentrated state, it causes speedy suffocation by excluding air from the lungs, yet, when mixed with so large a proportion of common air as to be readily inhaled, it is said not to occasion sudden death, but to induce insensibility gradually, and with- out any violent symptoms (Herpin, Ann. de Therap., he. cit.) If these VOL. i. 25 386 GENERAL STIMULANTS. [PART II. results should be satisfactorily confirmed by experiment, carbonic acid gas would be a safer surgical anaesthetic than chloroform. Dr. Cl. Bernard, of Paris, has observed that the injection of carbonic acid into the vagina is not unfrequently attended with constitutional effects, similar to those produced by its inhalation. The symptoms are headache, giddiness, abnormal sounds in the ear, nausea, somnolence, languor and prostration, and even involuntary discharges of urine; and he has sometimes found them so threatening as to preclude the use of the remedy. He noticed the effect as well in cases in which the surface of the vagina retained its integrity, as in those in which there was ulcer- ation. Prom a series of experiments by MM. Ch. Leconte and J. Dcmarquay, of Paris, on the effect of gases injected into the subcutaneous cellular or areolar tissue, or cavity of the peritoneum, it has been satisfactorily de- termined that carbonic acid thus injected produces no injurious effect ; being absorbed in forty-five minutes ; and that, consequently, no hesita- tion need be felt in applying it in this way, when from any cause indicated. (Arch. Gen., Oct. 1859, p. 568.) Now, as carbonic acid gas has pro\ed anaesthetic under various circumstances of application, it would probably be found so if injected into the areolar tissue. At least it might be worth the trial, in cases of obstinate local pains which have resisted other anes- thetics, or in which there may be some objection to their use. MM. Leconte and Demarquay also ascertained that this gas, brought into contact with divided tendons, facilitated their union. Uses. The affections in which the gas has been found most useful, when topically applied, are painful states of the uterus and vagina, with or without ulceration. Great relief is afforded in cancerous cases; and sometimes ulcers of this character, at the neck of the womb, are said to have been much benefited, and even healed under its influence. (Cl. Bernard, loc. cit.) The anodyne influence of the gas is sometimes pre- ceded by severe burning pain, which is diffused through the pelvis; and this is said occasionally to be so inconvenient as to prevent the use of the remedy. But in general the uneasiness, if produced, soon subsides, and is followed by the anaesthetic effect. The application may be re- peated twice or three times daily; and each time may continue fifteen minutes or longer; but should always lie suspended on the occiirrenee of constitutional symptoms. .Much relief is also asserted to have been obtained from the remedy in irritable stales of the bladder, with painful micturition. It is injected through the urethra, by means of a double catheter, by which injurious accumulation and distension of the vi.-eus are prevented. Sometimes, as from injections into the vagina, the pain is very severe. According to Dr. Robert Johns, of Ireland, who has had considerable experience with the remedy, it should not be repeated, as a general rule, oftener CHAP. I.] CARBONIC ACID GAS. 387 than once daily, and the bladder should be well washed out with warm water before the application. (See Am. Journ. of Med. Sci., N. S., xxxvi. 561.) In the tenesmus of dysentery relief may be expected from the injec- tion of carbonic acid gas into the bowels ; and it has been already stated that this use of the remedy was made before the commencement of the present century. The same is true of its employment in external cancer and other ill- conditioned ulcers; and Sir J. Y. Simpson recommends it in wound? and burns. It is said not only to relieve the pain of these ulcers, but to promote their cure. In the photophobia attendant upon scrofulous disease of the conjunc- tiva, a stream of the gas properly diluted has been found useful ; but its intensely irritating effect, when too concentrated, must be borne in mind. Good might be expected from it in that not uncommon, and very painful affection, in which exposure to light produces great suffering, from an over-sensitive state of the retina. In a case of severe earache, Dr. Demme obtained very favourable effects from the introduction of the gae into the external meatus. (Med. and Surg. Reporter, loc. cit.) Employed, in a much diluted state, by inhalation, it is said to have proved useful in chronic bronchitis, laryngitis, and pharyngitis, and in asthma and irritable cough. In this way it has been employed, to a considerable extent, by Bischoff and others in Germany; and, as as- serted, without unpleasant effects. It is not, however, considered appli- cable to acute inflammation of the air-passages, or to phthisis. (See Am. Journ. of Med. Sci., April, 1859, p. 543.) Should the remedy be used by inhalation, its application should be watched by skilful persons, and the danger of fatal asphyxia be most carefully guarded against. The physician could not be held unaccountable, should serious consequences occur, either through his own carelessness, or the ignorance of those to whom he may entrust the use of the remedy. Mode of Application. The most convenient method of applying the gas, is by means of a flexible caoutchouc or gutta percha tube, proceed- ing from a bottle in which it is generated. A Wolfe's bottle may be used having three tubulures, into one of which the exit tube is inserted, in another a safety tube with its lower end beneath the surface of liquid in the bottle, and in the third a stopper removable at pleasure. A mixture of five drachms of bicarbonate of soda and four of bisulphate of potassa, in the form of powder, is first introduced, and, when the instrument is to be used, water is poured in sufficient to cover them. Sir J. Y. Simpson uses eight drachms of crystallized bicarbonate of soda, six drachms of crystallized tartaric acid, and four or five ounces of water. When the evolution of the gas begins to slacken, it may be increased by shaking the bottle. 388 GENERAL STIMULANTS. [PART II. 2. Mineral Tonics Acting on the System generally, through Us Vital Properties. It is at present no longer doubted that the medicines belonging to this subdivision enter the circulation, and thus come into contact with all the tissues. They operate primarily on the alimentary mucous membrane, in a manner closely analogous to that of the mineral acids ; that is, they moderately stimulate or excite the function of the membrane, or, in other words, act as tonics. But they are all, moreover, somewhat astringent, causing a contraction of the tissues, like alum or acetate of lead, though in a less degree ; for a very energetic contraction would interfere \vith the functions of the membrane, and thus prevent the proper tonic effect Jt is highly probable that they operate, in a manner precisely analogous, upon the various tissues of the body which they reach through the blood. Producing a slight increase of the vital cohesion of the molecules of the tissues, they give them a greater power, while, by a gentle excitation, they call this power into a somewhat higher exercise. But, while thus generally tonic and astringent, they are disposed to act more especially upon the nervous centres ; or, to speak more precisely, the organized nervous substance of these centres seems to be peculiarly susceptible to be impressed by them, and to take on, under their influence, a condition of greater firmness or compactness, which enables them, if previously weakened, to perform their proper function more efficiently. Here we have the secret of one of the most important therapeutic effects of this set of tonics; that, namely, of controlling the irritability of the nervous centres, and thus obviating various nervous disorders, and especially muscular spasm. From their influence in this way, they have not unfre- quently been considered as antispasmodic, and been so denominated. Spasm, as well as most other irregular nervous phenomena, depends upon a disturbance in the nervous centres, produced generally from some source extraneous to themselves. The more movable or excitable these centres are, the more liable will they be to give rise to these irregular phenomena under irritating influence. Now the tonics here referred to, by increasing the vital cohesion of their molecules, and rendering their structure firmer, enable them better to resist disturbing causes; at the same time supporting due action in them by a gentle stimulation. The disordered phenomena cease ; and, by a sufficient persistence in the use of the remedy, the centres may acquire a permanent capacity of resist- ance, which may lead to a permanent cure. Hence, it is in the various nervous diseases, such as hysteria, chorea, and epilepsy, that these tonics have acquired the highest reputation, and are most extensively used. CHAP. I.] MINERAL TONICS. SILVER. 389 Some suppose that they act by entering into chemical combination with the constituents of the tissue, and thus forming a part of the organiza- tion itself; and that their effects are to be explained by the new qualities which the tissues acquire through this change of structure. They sup- port this opinion by the fact, that the metallic ingredient of these medi- cines is found in the very substance of the organs, from which it can be separated after death, supposing the patient to have died while under their influence. But this is no proof whatever, and scarcely even in any degree confirmatory of the notion of a chemical union. The metal may be in the capillaries of the organ ; it may be deposited in the very sub- stance of the tissue ; it may even be there combined with some organic principle derived from the blood or from the tissue; but even admitting all this, it does not follow that it is chemically combined with the con- stituents of the tissue in their organized state; and it is not easy to con- ceive how a foreign body, thus thrust into the constitution of the nucleus or cell, which performs the office of the tissue, would enable it to perform that office more effectively. We may conceive that a metallic substance may possibly enter into such a union ; but it would be to impair, not to improve the function ; it would be to produce the effects of a poison, and not those of a remedy. Indeed, it is not improbable that some metallic poisons operate in this way ; but more positive proof must be adduced, before we can admit that medicines produce their curative effect through such a combination, and especially medicines whose immediate opera- tion is to improve and to invigorate. I. SILVER, ARGENTUM. U. S. REFINED SILVER. Br. Appendix. Metallic silver is quite inert, and may lie for a long time in the ali- mentary canal without sensible effect. It is only in chemical combina- tion that it becomes efficient. As all the constitutional effects of its pre- parations can be obtained by the exhibition of the nitrate, and as this is generally preferred in practice, it may conveniently represent the metal in its relations to the system at large ; and all that it is necessary to say, in reference to the operation and uses of silver as a medicine, may be included in our consideration of that salt. Afterwards, nothing need be noticed, in relation to the other preparations, except what may be pecu- liar to them severally. 390 GENERAL STIMULANTS. [PART II. NITRATE OF SILVER. ARQENTI NITRAS. U. S., Br. Lunar Caustic. Origin. This salt has been known since the times of Gebev, who de- scribed the mode of preparing it. I propose to treat of it, in this place, solely in reference to its internal use. As an external remedy, it is among the most valuable; but the consideration of it, in this capacity, belongs to another part of the work. (See Escharotics and Protectives.) It is kept in two forms; one, that of cylindrical sticks, adapted for topi- cal use, and frequently called lunar caustic; the second, that of crystals, which are preferred when the medicine is to be given internally. It is to the latter that the following remarks apply. The crystals of nitrate of silver are prepared by dissolving silver in nitric acid with a little water, and then evaporating,, so that crystalliza- tion may take place upon the cooling of the liquid. They should be kept in well-stopped bottles, from the interior of which everything or- ganic should be excluded. Composition. Crystallized nitrate of silver consists of one equivalent of nitric acid and one of protoxide of silver, without water of crystal- lization. Properties. The crystals are colourless, transparent, and in the form of rhomboidal plates. They are inodorous, but of a strong, bitter, metallic, peculiar, extremely disagreeable, and adhesive taste. Water and alcohol dissolve them freely, especially the former, which takes up its own weight of the salt. At a moderate heat they melt, and at a strong heat are decomposed. In contact with the smallest portion of organic matter, they blacken on exposure to light; but they remain un- changed, even by the sun's rays, in the entire absence of such matter. Their solution in pure distilled water is similarly unaffected by sunlight, unless organic matter is present, in which case it is darkened. The change of colour is owing to a partial reduction of the silver. Incompalibles. Nitrate of silver is decomposed, with the formation of insoluble products, or such as are but slightly soluble, by the alkalies, alkaline earths, their carbonates, and soap ; by sulphuric, muriatic, hy- driodic, phosphoric, hydrosulphuric, and tartaric acids, and all the soluble salts formed by the reaction of these acids with sail liable bases, conse- quently by the soluble sulphates, muriates, phosphates, tartratcs, chlo- rides, iodides, and sulphurets; and by astringent vegetable infusions, in consequence of their tannic acid. With albumen and fibrin it unites, forming compounds insoluble in water; but it is a fact of sonic import- ance, in explanation of the operation of the salt on the system, that the albuminate of the nitrate of silver thus formed is soluble in an excess of albumen. Of like significance is also the fact, that the insoluble chloride of silver, which is formed whenever the nitrate comes into contact with CHAP. I.] MINERAL TONICS. NITRATE OF SILVER. 391 muriatic acid or a soluble chloride, is rendered soluble by an excess of chloride of sodium or potassium.* In consequence of the great number of substances which decompose the nitrate, or combine with it, and the constant presence in the stomach of one or more of these substances, especially albumen, muriatic acid, or a chloride, it is scarcely possible that it can long retain its integrity after having been swallowed ; though it may do so sufficiently long to exert a direct influence on the mucous coat. That it should enter the small intestines as nitrate of silver, appears to me to be clearly impossible, unless swallowed in quantities so large as to be poisonous, or unless so incorporated with other substances in the form of pill, that, in this shape, it may pass through the stomach before the pill is broken up, and its interior exposed to the reagents there existing. Effects on the System. Locally, nitrate of silver is powerfully irritant, and, in a concentrated state, acts as an escharotic by combining with the albuminous matter of the tissues, and thus disorganizing them. When in contact with the mucous membranes, with ulcers, or with the skin deprived of the cuticle, it combines with the albumen of the secreted matters, and often with that of the tissue itself, forming a white and insol- uble compound, which covers the surface ; and this happens as well in the gastric and intestinal mucous membranes, as in those visible from without. Applied to the skin, it soon produces a black stain, in conse- quence of the partial reduction of the silver by reaction with the cuticle. This black stain usually remains until the cuticle separates, either grad- ually, or at once completely, as in vesication. It may be removed, however, by applying to the spot the tincture of iodine, and following this with a solution of hyposulphite of soda; or by the similar applica- tion of a solution of cyanide or of iodo- cyanide of potassium. (Journ. de Pharm., Nov. 1865, p. 414.) These remarks, in reference to the local effects of nitrate of silver, will be extended in a subsequent account of the escharotic and protective operation of the salt. At present, they seemed necessary to explain the effects of the medicine upon the stomach. In very small doses, repeated two or three times a day, nitrate of silver produces no other observable effects than those of a gentle tonic and astringent; as improved appetite, invigorated digestion, and per- haps a tendency to costiveness. Taken more largely, it causes warmth of stomach, and some gastric uneasiness, indicating an irritant action, * Some doubt is thrown upon the uniform occurrence of the chemical reaction here referred to, by an experiment of Professor Procter, performed at my request. A drop of solution of nitrate of silver was made to fall into a solution of chloride of sodium, and produced a precipitate; yet, after long contact of this precipitate with the supernatant solution, the latter, when filtered off. gave no evidence of the pres- ence of silver when applied to bright copper, and touched with bright iron; and the taste was purely saline. 392 GENERAL STIMULANTS. [PART II. which, upon a still further increase of the quantity, is evinced by gastric pains, sometimes nausea and vomiting, and occasionally also by griping pains in the bowels, with either diarrhoea or constipation. As to the degree of irritant effect, much depends on the mode of administration, and the condition of the stomach at the time. It has been repeatedly observed that, in the form of pill, large doses produce little irritation; while a smaller quantity will violently irritate, if given in solution. Dr. Powell found that he could sometimes give fifteen grains in pill, while five grains in solution could rarely be borne by the stomach, (llfed.-chir. Trans., ix. 238.) The result is obviously owing, in the instance of the solution, to the whole quantity being brought at once into contact with the surface of the stomach, before time has been allowed for decompo- sition ; while, in the pilular form, dissolving gradually, it acts also grad- ually, and is more liable to decomposition before it can act at all. When the stomach is full of food, the medicine would be much more exposed to decomposing reagencies than when it is empty, and would con- sequently be less likely to irritate; for all the insoluble substances re- sulting from the chemical changes of the nitrate in the stomach arc much less irritant than the salt itself. Thus, the chloride of silver, which must be among the most common products, may be given in large doses, without observable effect. How far nitrate of silver would operate as a deadly poison, in exces- sive amount in the human subject, is left very much to inference; for few cases of acute and fatal poisoning from this substance have been re- corded. Boerhaavc mentions the case of a pharmaceutical student, who, having swallowed a portion of lunar caustic, died from gangrene of the first passages. But this is the only case of the kind that 1 have met with in the books. In the Bulletin Generale de Therap. (Sept. 1839), the case of a young man is related, who, after having taken a large quantity of the salt in solution, an ounce, according to his own account after recovery, was carried to the Hospital St. Louis, in Paris, quite in- sensible in all parts of the body, with convulsive movements of the face and upper limbs, jaws firmly closed, eyes rolled up, and pupils dilated and insensible to light. Common salt was li'iven freely, and afterwards emollient drink.-!. When sensibility began to return, the patient suffered from violent epigastric pains. He ultimately recovered without serious consequences. The effects upon the nervous system may have been sympathetic with those upon the stomach, which was, no doubt, in- tensely irritated. (See Am. Journ. of Med. Sci., N. S., xxvi. 239.) Orfila found that from twenty to thirty-six grains, introduced into the stomach of a dog, caused death with I lie phenomena of corrosive poisoning, and that ulceration in the alimentary canal was produced. The fact proba- bly is, that large doses may be borne without immediately fatal conse- quences, partly from the rapid chemical change which the salt under- CHAP. I.] MINERAL TONICS. NITRATE OF SILVER. 393 goes, and partly from its superficial caustic operation, by which an extremely thin layer of epithelium is disorganized, and, forming with it an impermeable film, protects the deeper and more vital parts of the membrane from destruction. But, admitting this, it must be allowed that a frequent repetition of these large doses might gradually corrode into the deeper structure, and death ensue at last from the slow and continued operation of the poison. Esquirol mentions a case, in which nitrate of silver was given freely during a period of eighteen months, at the end of which time the patient died, and the stomach was found des- titute of the mucous coat over one-half of the inner surface, with several points of corrosion to the peritoneal coat. Nitrate of silver, therefore, must be ranked among the corrosive pois- ons. In acute cases of its poisonous operation, the treatment should consist in the use of common salt, or, if this is wanting, of the white of eggs, and a thorough washing out of the stomach by diluent drinks, or other means if necessary. Opiates should afterwards be administered, in the form of enema, to quiet irritation ; and the resulting inflammation must be treated on general principles; care being taken not to exhaust the patient by too copious depletion. Hitherto I have considered only the local operation of the medicine on the alimentary canal. It acts also on the system at large, through the circulation. Of its absorption, or rather of the absorption of the metal in one form or another, there can be no reasonable doubt. Leaving out of view the statements made as to the discovery of metallic silver in the pancreas after death, w r e have Orfila's declaration that he has found it in the liver of animals to which the nitrate has been adminis- tered for some time (see Lond. Med. Times and Gaz., March, 1852, p. 279); and, in addition to this, the indisputable evidence of the discol- oration of skin produced by it. In any dose in which it is ordinarily given, its physiological influence upon the general functions is not strik- ing. There may possibly be some increase in the frequency or force of the pulse, and the general temperature; but these results are much less observable than from the more powerful of the vegetable tonics. Sali- vation is said to have been sometimes produced, and writers speak of an eruption upon the skin; but I am not certain that I have witnessed either. One effect, however, is very striking. When the medicine is given in large doses, and long persevered with, a darkening of the skin is sometimes produced, which gradually deepens, till the whole surface of the body assumes a bluish-slate colour, extremely disagreeable to the eye, as totally differing from any natural tint. The discoloration is deepest in the parts exposed to light; but is said also to have been ob- served in the interior tissues, and in one instance to have pervaded the whole body; though this last statement may be considered as wanting confirmation. It is asserted that, in many instances, it does not occur 394 GENERAL STIMULANTS. [PART II. uutil months after the medicine has been discontinued, and its favourable effects experienced. (Sigmund, London Lancet. March 31, 1838.) In con- nection with this fact, may be mentioned the detection by Orfila of silver in the liver of animals, to which the nitrate had been given, six months after its administration, showing that it is apt to become fixed in the tissues. In seven months, however, it had disappeared, and he could find no evi- dence of its existence in any part of the body. (Lond Jled. Times and Gaz , March. 1852, p. 279.) So far as any inference can be drawn from this fact, it is that a patient cannot be considered free from the danger of discoloration in less than seven months after the omission of the medi- cine. The discoloration is generally permanent ; but is said to have m siimc instances diminished with time, or under the operation of certain remedial measures. The seat of it is the true skin ; for it remains unaf- fected when the cuticle is removed by a blister. The obvious explanation of the phenomenon is, that the preparation of silver circulating with the blood, when it enters the tissue of the true skin, and is thus exposed more or less to exterior influences, as of light and the air, undergoes decomposi- tion, with the deposition of the partially reduced metal, probably in the state of a suboxide. This being insoluble in the blood, or in any liquid which the parts can generate, remains unabsorbed in the tissue. Happily, before the skin begins to exhibit this hue, a similar dark discoloration usu- ally appears upon the gums and tongue and in the fauces, and serves, if observed, to put the practitioner upon his guard. It is said that the dis- coloration has disappeared under a steady course of cream of tartar. Dr. Pereira states, in his work on Materia Medica (3d ed., page 886), that he has been informed of a case in which washes of dilute nitric acid diminished it. Iodide of potassium has been proposed as a remedy; but has proved ineii'ectiuil. From what has been already said of the facility with which nitrate of silver is either decomposed, or otherwise rendered insoluble by chemical reaction, it is highly improbable that it ever enters the circulation with- out change. There are, however, two known states of combination, in which the metal may possibly be absorbed when the nitrate is adminis- tered. One of these is in the compound of nitrate of silver with albumen, which is soluble in an excess of albumen, and consequently in the blood, and the other in the double compound of chloride of silver and sodium, which is said to be soluble in water. (See pages o'JO-1.) As the albu- minate undergoes the darkening process out of the body on exposure, it is highly probable that it undergoes the same change in the tissue of the skin, with a less degree of the same exposure. Therapeutic Application. Besides the uses of the nitrate as an ex- ternal remedy, which will be noticed elsewhere, it is employed for two distinct purposes; the one, for its direct influence on the alimentary CHAP. I.] MINERAL TONICS. NITRATE OF SILVER. 395 mucous membrane, the other, for its effects upon the system at large through the circulation. 1. For its influence on the stomach and bowels, it might be employed, in minute doses, as a tonic, in debilitated states of their functions; but other remedies answer the indications so much more conveniently and effectively, that it is very seldom used for this special purpose. Still, as it has been supposed to exercise a peculiar influence over the nervous tissue, it has been recommended in certain painful affections sometimes dependent on dyspepsia, as gastrodynia and pyrosis; and it has been found useful in morbid sensitiveness of the stomach. But it is vastly more beneficial, given rather freely, through its alterative action upon the mucous membrane in a state of chronic inflammation or ulceration; and has been strenuously recommended even in active irritation or acute inflammation of the same tissue. In chronic gastritis of the worst kind, I know of no remedy so effectual as nitrate of silver. Recommended originally, so far as I am aware, by Dr. Hudson, of Dublin, in this affection, it has been employed by me habitually since the first published notice, and with the happiest effects in most obstinate cases. I have not been in the habit of using it in mild cases, which yield readily to a regulated diet, with other suitable hygienic measures, and with little aid from medicine ; but, in those severe and obstinate forms of the affection, which have set all ordinary means at defiance, I have found it a most valuable resource. The cases in which it has appeared to me to do most good are those attended with incessant vomiting of food, and often with a smooth dryish tongue, apparently destitute of the papillary structure. I have used it, too, whenever I sus- pected the existence of ulcers in the stomach. One case of yeasty vomit- ing, of a most obstinate character, and probably dependent on an ulcer near the pylorus, yielded in the course of two or three months to this remedy. One most striking instance, in which I have little doubt that it was the means of saving life, was that of a female patient in the Pennsylvania Hospital, who had been reduced^to the last degree of emaciation and debility, and whose death I was looking for from hour to hour. The stomach had long refused to retain food, and the slightest nutriment induced vomiting. I directed that nothing whatever should be taken into the stomach, except a little cold water, and pills of nitrate of silver with opium, repeated three or four times a day; life being sus- tained by the injection of rich soups with laudanum into the bowels. The vomiting ceased under this treatment; in a few days a disposition for food returned, which was very cautiously indulged ; and the patient went on gradually improving, until her health was perfectly re-estab- lished after many months of illness. I believe the remedy acts, in these cases, very much as it does upon the visible mucous surfaces when in- flamed. Combining with the outer layer of the epithelium, or of the 396 GENERAL STIMULANTS. [PART II. ulcerated surface, it forms a thin coating, which protects the diseased tissue beneath from irritating matters in the stomach, whether derived from its own secretion or from without, and at the same time, by its astringent and tonic properties, imparts a healthy contraction and tone to the expanded vessels. To produce this effect, it must be in the state of the nitrate. The oxide or the chloride will not at all answer as a sub- stitute. Hence the importance of giving the medicine upon an empty stomach, when it will be less likely to encounter decomposing substances, and will thus be enabled to exert its full influence on the diseased mem- brane. In these cases, I have never administered large doses of the salt Beginning with one-quarter or one-third of a grain, combined with from an eighth to half of a grain of opium, repeated three or four times a day, I have very gradually increased, if the symptoms otherwise refused to yield, up to one grain at each dose; but have never exceeded that quantity. In chronic enteritis, also, great benefit is said to have accrued from the nitrate of silver; though, in the trials I have made with it, the results have been much less favourable than in the gastric cases. It probably seldom enters the small intestines, or at least penetrates far into them, without being decomposed, and thus rendered unable to act on the sur- face of the bowel in the method above referred to. In ulcerative affections and chronic inflammation of the small intestines, it has appeared to me less effective than sulphate of copper. Nevertheless, much testimony might be adduced in its favour, not only in chronic, but even in acute inflammation of the alimentary mucous membrane. Trousseau strongly commends its use in acute dysentery, giving half a grain of the nitrate of silver, and the same quantity of nitre, made into a pill with starch, repeated every half hour till it begins to purge; at the same time administering, twice a day, an enema composed of a pint of distilled water holding from three to ten grains of the salt of silver in solution. (Trousseau et Pidoux, Traite de Therap., 4e ed., i. 354.) The latter part of the treatment, that, namely, by injection into the rectum, has been imitated with great asserted success in some severe cases of the disease; though the measure has failed in many others. Of the uso of nitrate of silver by the mouth, in this complaint, I have had no experience. The same practitioner has found the medicine very useful in infantile diarrhoea. In cases attended with tormina, and glairy or bloody stools, he gives, morning and evening, an enema consisting of eight ounces of distilled water with one or two grains of the nitrate, according to the age; in other cases, characterized by nausea, and serous, green, or lien- teric passages, he administers by the mouth from the twentieth to tin- fifth of a grain dissolved in sweetened water. (Ibid., p. 355 ) The same practice has been employed with success in our indigenous cholera in- CHAP. I.] MINERAL TONICS. NITRATE OF SILVER. 397 fanlum, when there was good reason to suspect the existence of ulcera- tion of the bowels; and it is certainly among the measures to which the prudent practitioner would be justified in resorting, in obstinate cases of the disease. By M. Boudin, of Marseilles, the nitrate was recommended so long since as the year 183(5 (Gazette Med., No. 51, 1836), in enteric or typhoid fever, with a view to its curative influence upon the intestinal ulceration of that affection. He gave it either by the mouth or by the rectum, ac- cording as the disease appeared to be seated higher or lower in the ali- mentary canal ; and sometimes he united both methods. He adminis- tered from a quarter to half a grain by the mouth, in the form of pill, and three or four grains, by enema, night and morning, dissolved in six fluid- ounces of water. This practice has been imitated by other physicians, but has not been generally adopted. I entertain strong doubts of its efficacy ; as I do not believe that the nitrate, when swallowed, will reach the seat of the local disease unchanged ; and they who are familiar with the position of the ulcerated surfaces, extending often throughout the whole length of the ileum, would scarcely admit that six ounces of fluid, thrown into the rectum of an adult, would come in contact with them. In the diarrhoea of phlhiais the medicine has been used with supposed advanUitiv; but experience has not proved it to be more efficacious in this affection than other medicines habitually employed. The late Dr. J. F. Peebles, of Virginia, found it remarkably efficient in certain cases of jaundice connected with an irritated condition of the stomach and small intestines. He gave from three-quarters, of a grain to a grain twice a day, on an empty stomach. (Am. Journ. of Med. Sci., N. S., xviii. 59.) In reference to the cathartic effect which the nitrate of silver some- times produces, it was recommended by Boerhaave in dropsy ; and the medicine is said to have been used advantageously in worms; but these applications of it are now seldom or never made. 2. For its effects upon the system at large, njgpte of silver has been employed chiefly in nervous affections. In some of these it has been carried to an enormous extent, with the effect probably sometimes of seriously injuring the coats of the stomach, and, in not a few instances, three of which at least have come under my own observation, of produc- ing the indelible discoloration of the skin already described. Nor does this excessive use of the medicine, probably, contribute to the end in view. When given largely, the very irritation of the mucous membrane induced must interfere to some extent with its absorption ; and by far the largest proportion is converted into chloride of silver, and passes out with the feces in this state, as proved by the experiments of Dr. Heller. In one instance, a boy aged thirteen took twelve grains daily for three months, without any effect on the system, or discoloration of GENERAL STIMULANTS. [PART II. the skin ; and no trace of silver could be discovered in the blood or the urine; while the whole amount of the metal was found in the evacua- tions from the bowels. (See Am. Journ. of Hed. Sci., N. S., xii. 476.) Nevertheless, that the silver does occasionally enter the circulation is, I think, certain ; and it may be presumed to do so generally, though in minute quantities. As the absorption depends upon the solubility of the compound of silver formed in the bowels, and as this probably depends on the presence of an excess of albumen or an alkaline chloride in the alimentary canal, the less the amount of the nitrate given, the greater will be the excess of the solvent agents, and the consequent probability of its absorption. The practical inference from these views, is. that the physician should limit himself to moderate doses of the medicine, as being at once safer, and likely to prove not less effectual. I have before endeavoured to explain the nature of the action, by which this medicine, and others belonging to the same subdivision, prove useful in nervous diseases. (Seepage 388.) It will be sufficient to repeat, in this place, that the silver probably acts by increasing the vital power of resistance of the nervous centres to irritant influences, and thus preventing the effects of their irritation, as exhibited in spasms and other irregular movements, and in neuralgic pain. The long period during which, according to the experiments of Orfila before referred to, silver continues to adhere to the tissues after its administration has been omitted, may serve in some measure to explain the permanency of its effects in nerv- ous diseases. Epilepsy is that one of the nervous affections in which the nitrate of silver has been given most frequently, and in the treatment of which it has the highest reputation. It is certainly among the remedies which have proved most effectual, so far as testimony can avail to decide the question. Every one knows that epilepsy, from the very nature of its sustaining cause, is often quite incurable. That the nitrate of silver, therefore, should very frequently fail, is nothing more than might be ex- pected. The great olptacle to its general use is its liability to cause discoloration of the skin, which is even more objectionable to most per- sons than the disease itself. The physician, dreading the responsibility of such a result, if he employ the remedy at all, is apt to do so inefli- cientlv; either using it in too small a quantity, or not continuing it suffi- ciently long. Upon this point, however, he should always guard him- self, by informing the patient or his friends of the possible result, and leaving the decision with them. The risk of the discoloration may be, con- sidered as extremely small, when proper precautions are taken. These will be mentioned. Other nervous affections, in the treatment of which nitrate of silver has enjoyed considerable reputation, are chorea and angina pectoris. The former disease, however, is so readily curable by other less objec- CHAP. I.] MINERAL TONICS. NITRATE OF SILVER. 399 tionable remedies, that it would not be justifiable to expose the patient to the risk, however small, of the cutaneous discoloration. But in angina pectoris, as in the cases of epilepsy, the choice may well be left to the patient; though the chances of a cure from the remedy are so slight, that little encouragement should be offered. To its use in hysteria, asthma, and pertussis, in which it might be considered as indicated by its influence on the nervous centres, the liability above alluded to should be deemed an all-sufficient objection. A few years since it was employed by Wunderlich, with remarkable success, in a disease now known as locomotor- ataxy ; and MM. Vulpian and Charcot have subsequently ascertained that, given in small doses, rarely exceeding half a grain in the day, it exercises a most favourable influence over this exceedingly intractable disease. The great drawback, in this, as in all the other nervous diseases requiring a long continuance of the remedy, is the liability of the patient to the very repulsive discol- oration of the surface. It would be an unspeakable benefit to humanity, could means be found of preventing or removing this effect of nitrate of silver, without impairing its therapeutic- virtues. The remedy has been used by M. Buchut, with entire success, in a case of idiopathic infantile paraplegia (Ann. de Therap., 18(U, p. 225); and the same physician asserts that general progressive palsy, whether of the insane, or not thus complicated, sometimes gets well under the use of this remedy, in the dose of from one-third of a grain to about a grain daily. (Ibid., 1866, p. 2H.) Administration. When the effects of nitrate of silver upon the system generally are desired, it should be given preferably in the form of pill; as a larger dose can thus be taken, without irritating the stomach, than in solution. The same form is also preferable when it is given by the mouth for intestinal affections; as there may be some hope that it may thus, in part at least, escape decomposition by the gastric contents. For its alterative influence on the stomach, it may be given in either form ; but the solution would probably be most effective if well borne. When taken in pill, it should be mixed up with flour, starch, or pow- dered gum, with syrup. The crumb of bread, often used, is objectiona- ble on account of the common salt it contains. If given in solution, distilled water should be employed as the menstruum ; the taste being covered, if deemed advisable, by a little oil of mint or peppermint. In either case, the preparation should not be long kept before being used. The dose to begin with, at least in delicate states of the stomach, should not exceed one-quarter or one-third of a grain, three times a day, which may be gradually increased to one, two, or even three grains, should no irritant effect be experienced. Some have pushed the medi- cine much further, even so far as fifteen or twenty grains, and with im- punity ; for there are generally in the stomach substances, especially the chloride of sodium, which render it inert by decomposition; and it might 400 GENERAL STIMULANTS. [PART II. unite with the albumen of the mucus, or even superficially with that of the epithelium itself, without serious injury. But these decomposing substances might be wanting, or the mucous coat might be unprotected by its ordinary secretion, and the medicine come into contact with some exposed point with too great intensity; in short, experience has shown that the salt may prove highly irritant, and even poisonous; and there is no occasion to incur any risk, for, as before stated, these large doses are almost wholly decomposed, and pass out of the bowels; a very small portion only being absorbed; so that, when not mischievouspthey will probably be useless. The great point will be to guard against the discoloration of the skin. For this purpose, the mouth should be carefully and frequently observed, and the least appearance of a dark blueness in the gums should be con- sidered as a signal for discontinuing the medicine until this has disap- peared. As the nitrate in solution might have the effect of darkening the surface of the mouth by its direct contact, the discoloration thus pro- duced must not be mistaken for that resulting from the absorption of the medicine. Dr. James Johnson states that no case of discoloration is on record, in which the use of the medicine has not been continued beyond three months.* It would, therefore, be a good rule, after having em- ployed it continuously for that length of time, to suspend it for a period, say one or two months ; and there is some ground for this suspension in the long retention of the medicine in the tissues, as shown by the exper- iments of Orfila; so that, though it should be omitted, that already taken and absorbed might still be acting. The medicine should be taken on an empty stomach, and the caution should be observed that nothing containing common salt, or any other substance having the property of decomposing the nitrate, should be swallowed within a short time, either antecedent or subsequent to its administration. The following are preparations of silver derived from the nitrate. 1. OXIDE OP SIBVER. ARGENTI OXIDUM. U. S., Br. This is prepared by adding solution of potassa to a solution of nitrate of silver, the oxide being precipitated. It is an olive-brown powder, in- odorous, nearly tasteless, and very slightly soluble in water; and consists of one equivalent of silver and one of oxygen. Though used as a med- icine, on the continent of Europe, during the last century, it attracted little notice until proposed by Dr. Butler Lane, as a substitute for the nitrate, in the various diseases in which that remedy has been used. Oxide of silver acts locally as a slight irritant and astringent, but is * A case is recorded in which the daily use of half a grain, for eight months con- secutively, produced a striking and universal discoloration of the surface. ( Archive* Glntrale*, 5e ser., ix. 358.) CHAP. I.] MINERAL TONICS. CHLORIDE OF SILVER. 401 wholly destitute of the property, which renders the nitrate so valuable, of combining with the tissues. Taken into the stomach, it is either ab- sorbed, or forms soluble compounds which are absorbed; for it produces occasional soreness of the gums and salivation, and has even caused dis- coloration of the skin. It was substituted for the nitrate as a milder remedy, and capable of producing its constitutional impression, with less danger of affecting the skin ; but the want of the property of combining with the superficial part of the tissues, incapacitates it for those local alterative effects on diseased surfaces which give its highest value to the nitrate; and, in proportion as it may be less liable to discolour the skin, it will probably prove less efficacious as a medicine ; the liability to produce that effect being incidental to the absorption of the silver, no matter in what form it may be taken up, and consequently in some degree a test of its con- stitutional influence. It seems to me, therefore, that little is gained by the substitution. Nevertheless, the oxide has been found useful, by Dr. Lane and others, in gastralgia, pyrosis, gnteralgia, dysentery, diar- rhoea, idiopathic night-sweats, dysmenorrhcea, leucorrhcea, and uterine hemorrhage. In the last-mentioned affection, the favourable report of Dr. Lane is supported by the experience of Dr. Golding Bird ; and Dr. Thweatt, of Petersburg, Va., published several cases of menorrhagia, in which the medicine appeared to have proved efficacious. (Am. Journ. of Med. Sci., X. S., xviii. 69.) The oxide would seem to promise most fairly as a substitute for the nitrate in epilepsy, and other spasmodic complaints; but, though it may probably be given with less risk in large doses, experience has not proved that it possesses superior advantages as a remedy. It is said to have been used successfully in trenia. The dose is a grain, repeated twice or three times a day, which may be gradually increased to two grains. In the larger quantity, it some- times occasions a little griping and tenesmus, which may be checked by an anodyne enema. (Thweatt, Ibid.) The same caution is requisite, in relation to the continuance of the dose, as when the nitrate is employed. It may be given in powder or pill. The oxide has been used also externally, in powder or ointment, in ophthalmia, excoriated nipples, irritable ulcers, and venereal sores ; and, smeared on a bougie, has been employed in gonorrhoea. The oint- ment may be prepared with a drachm of the powder and an ounce of lard. 2. CHLORIDE OF SILVER. ARGENTI CHLORIDUM. This is made by adding muriatic acid, or a solution of chloride of so- dium, to a solution of nitrate of silver. The chloride of silver is pre- cipitated as a white curdy substance, which, when washed and dried, is ready for use. Though white at first, it soon begins to darken on expo- sure. It is insoluble in water. The circumstance that nitrate of silver YOL. i. 26 402 GENERAL STIMULANTS. [PART II. is often converted into the chloride in the stomach, has led to the em- ployment of the latter, as likely to produce the same effects on the sys- tem, while much less irritant. Many years since, I was induced myself, by this consideration, to try it in epilepsy; but, meeting with no en- couraging success, I soon abandoned it. Dr. Perry used it in the Blockley Hospital of Philadelphia, and obtained advantage from it in chronic dysentery. It has been employed also in syphilis, and in other diseases in which the nitrate is recommended ; but it has not come into general use. The dose is from one to three grains, or more, three or four times a day. Twelve grains have been given daily for three months, without unpleasant symptoms. A dose of thirty grains has produced vomiting. 3. IODIDE OF SILVER. ARGENTI IODITHM. This may be prepared by mixing solutions of nitrate of silver aud iodide of potassium ; the iodide of silver being thrown down as an insol- uble, greenish-yellow powder. Dr. Charles Patterson, of Dublin, having convinced himself, by experiment, that this preparation does not change colour on exposure to the liglit, even in contact with organized matter, conceived that it might be advantageously substituted for nitrate of sil- ver, on the ground that it would not be liable to cause discoloration of the skin. In order to determine how far it might possess the therapeutic virtues of the nitrate, he tried the medicine in various diseases; and, though he succeeded in curing a gastric affection of the Irish peasantry, in which the nitrate had been found useful, in ameliorating pertussis, and in relieving a case of dysmenorrhoea, his experience \v;vs certainly not, upon the whole, very satisfactory; and a much more extensive sc- ries of observations would be necessary, to establish the claim of the iodide of silver to be used as a substitute for the nitrate. Nor is it by any means certain that it might not cause discoloration of the skin; for though, if absorbed unchanged, it might not thus act, the probability is that, before entering the circulation, it would be chemically altered, and that the compound of silver really absorbed would be liable to the same changes in the system, as that which enters the blood-vessels when the nitrate is administered. Nevertheless, the iodide is perhaps worthy of further trial; as, if found to be possessed of the virtues of the nitrate, without its disadvantages, it would be a most valuable addition to the Materia Medica. From one to three grains may be given three times a day, and gradually increased till some disagreeable effect upon the stom- ach or bowels is produced. CHAP. I.] MINERAL TOXICS. COPPER. 403 II. COPPER. CUPRUM. In the metallic state, copper is quite inert. Instances are on record in which copper coins have remained long in the stomach without any observable effect; and animals which have been made to swallow filings of the metal, to the amount even of an ounce, have in no degree sensibly suffered from them. Yet other cases have occurred, in which local injury to the stomach, or some derangement of the system has followed, under similar circumstances. The result in these instances has, no doubt, depended on chemical changes, by which the metal has been oxi- dized, and converted into a salt through the agency of the gastric acids; so that it was not the copper itself, but one of its soluble compounds, probably the chloride, that acted. Copper may generally be detected in minute quantities in the blood of persons in health, and has been repeatedly found in the tissues, when no preparation of the metal was known to have been taken. It has hence been inferred that, like iron, it forms an essential constituent of the blood; and Millon supposed it to enter into the normal constitution of the red corpuscles. But so much copper is taken into the system in various ways with our food, that the exceedingly minute portion which a delicate chemical analysis can detect, has its origin probably in this source, and is only accidentally present in the blood, which would in no degree suffer from the want 'of it, as it does from the want of iron. Wackenroder has confirmed this view by showing that the blood of domestic animals, living on pure vegetable food, is quite destitute of it : while it may readily be discovered in the blood of the same animals and of man, when fed on a mixed diet. (Chem. Gaz., May 1, 1854, p. 175.) It may be inferred, however, from these facts, that a proportion of cop- per large enough to be sensible to chemical research, may exist in our economy without impairing health. Effects on the System. The preparations of copper are locally irritant, and most of them, in a concentrated state, corrosive. Taken internally, in moderate doses, they operate as gentle excitants to the mucous sur- face of the stomach, increasing the appetite, and producing other effect* characteristic of tonic medicines. In over-doses they become irritant ; but happily provoke vomiting very promptly; so that, being discharged from the stomach, they have not time allowed them to produce serious and permanent effects, unless taken very largely. In this latter event, as will be seen directly, they are capable of producing fatal inflammation and corrosion of the alimentary mucous membrane. Like nitrate of sil- ver, they decompose the superficial parts of the tissue, forming com- pounds with albumen, which are of a greenish-blue colour, and, accord- 404 GENERAL STIMULANTS. [PART II. ing to Mialhe, soluble in an excess of the salt, when its acid is of vege- table origin, but not when it is mineral. But the preparations of copper also act on' the system generally. This they are enabled to do by the facility with which they enter the circulation. They appear, indeed, to be among the metallic substances most easily absorbed. After one of the salts of copper has been taken for a short time, the metal may be sought for in vain in the alimentary canal, but will be found in the blood, the substance of the liver, and other tissues. When absorbed, moreover, it holds its place in the organism with great tenacity. Orfila states that it may be detected in the liver, in- testinal coats, and bones, eight months after having been taken into the stomach. (Lond. Med. Times and Gaz., March, 1852, p. 279.) No observable effects upon the system, in health, are produced by small medicinal doses of the salts of copper; but the results of their use in disease prove that, even in these quantities, they are not without efficiency. Their action appears to be that of a tonic, especially on the nervous centres, which they strengthen against irritating influences, as explained in the general observations on this subdivision of mineral tonics. (See page 388.) When taken too largely, or too long, they give unmistakable evidence of their effects, which may even be poisonous, independently of their direct action on the alimentary mucous membrane. The poisonous operation of the salts of copper is of two kinds, either rapid from a large quantity given at once, or slow from too long a con- tinuance of relatively small quantities. In both of these modes of action, moreover, there appears to be a union o/ a local influence on the mentary mucous membrane, with a general influence dependent on ab- sorption. 1. Acute poisoning from a large quantity is attended with a coppery taste in the mouth, nausea, ineessant vomiting, violent pains in the stom- ach and bowels, purging sometimes profuse, severe headache, cramps in the lower extremities, and, in fatal cases, convulsions, palsy of the limbs, and coma. In the lower animals, Orlila noticed, among the last phe- nomena before death, rigidity of the museles, and even tetanus. Occa- sional salivation is also mentioned; and jaundice is not uncommon, gen- erally appearing during life, but sometimes not until after death. The first series of the symptoms here detailed arc evidently tin- direct result of the irritant action on the stomach and bowels; those which succeed depend on a systemic influence directed more especially to the nervous centres, but sometimes exerted on the salivary glands, and not unfre- (juently upon the blood, as evinced by the jaundice, which probably arises from the destruction of the red corpuscles, and the alteration of their colouring matter. That the nervous symptoms are not merely sympathetic with the gastric disorder is proved by the facts, first, that after death the mucous membrane of the stomach and bowels is, in some CHAP. I.] MINERAL TONICS. COPPER. 405 instances, found to all appearance quite healthy, especially after speedy death; secondly, that the nervous symptoms sometimes precede the gas- tric and intestinal, and thirdly, that similar phenomena have resulted from the poison injected into the veins, or applied to awoumlod surface. The ordinary post-mortem phenomena are signs of severe inflammation in the stomach and bowels, gangrenous patches here and there, corrosion and sometimes even perforation of the intestinal mucous membrane, and green discoloration of the tissue to a greater or less extent. The lungs are said also to have been seen inflamed; but this may have been an accidental coincidence. 2. The slow poisoning, according to Dr. Corrigan, of Dublin, who has drawn up his summary from an observation of several cases, is attended with emaciation, a cachectic appearance, muscular weakness, colicky pains, cough without discoverable pectoral disease, "and a peculiar characteristic retraction of the gums, with a purple, not a blue edge;" without the severe colic, constipation, and local palsy, which result from lead. (Braithwaite, xxx. 303, from Dub. Hosp. Gaz., Sept. 1853, p. 232.)* Besides these phenomena, loss of appetite and diarrhoea are mentioned * In July, 1855, Dr. Pietra-Santa, who had been favourably situated for observ- ing the effects of copper on the system, read a memoir before the Academy of Medi- cine of Paris, in which he stated that, after three years of observation, he had come to the following conclusions; "1. that a person may live in an atmosphere loaded with the dust of copper, without any appreciable alteration of health; 2. that the introduction of powder of copper into the stomach occasions only some slight dis- turbances of health; 3. that the colic of copper, as previously described by authors, does not exist; 4. that the phenomena described by authors must be attributed to other contemporaneous causes ; and 5. that the purple edging of the gums, mentioned by Dr. Corrigan as characteristic of copper poisoning, is not so constant or general as he supposes." (Arch. Gen., 5e s6r., vi. 354; and Journ. dePharm. et de Chim., Avril, 1858, p. 313.) Note to the second edition. A case of copper-colic, with the stain on the gums as described by Dr. Corrigan, is reported by Dr. Harley, whose patient was a copper-plate printer, and had on one occasion been peculiai-ly exposed to the inhalation of one of the salts of copper, while cleaning some old plates, from which a dust arose like verdigris. He had suffered twice before in the same way. The symptoms were a sudden and violent pain in the abdomen as if from a blow, somewhat abating and increasing, aug- mented by pressure rather than diminished, no diarrhoea, and no constipation. There was a sallow, almost clay-coloured complexion, with anxious expression, livid lips, and sunken eyes. He rapidly recovered under the use of spirit of nitric ether, and dilute sulphuric acid, with a little sulphate of magnesia and laudanum, taken in camphor mixture. (Med T. and Gaz., Aug. 18G3, p. 129.) It is difficult to recon- cile these opposite observations of Drs. Pietra-Santa and Harley, unless upon the supposition, that the "dust of the copper" of the former was the metal itself in a state of minute division ; while the powder, which was the poisonous agent in the case described by the latter, consisted of a salt of the metal. The uncombined metal is innoxious, while its saline compounds may be extremely poisonous. (Note to the third edition.) 406 GENERAL STIMULANTS. [PART II. by other observers. I have seen no account of death from this slow poisoning. The symptoms are probably due partly to a chronic irritation of the alimentary canal, partly to a direct action upon the system. Poisoning by copper sometimes results from the accidental swallowing of one of its preparations used in medicine or the arts, but more fre- quently from food or drink prepared or kept in copper vessels, which, even though protected by tinning, are nevertheless apt to lose this pro- tection, and to communicate deleterious properties to substances con- tained in them, especially when these substances are in any degree acid. There is reason to believe that much injury has thus been produced in the digestive organs, if not in the general system, by the habitual use of carbonic acid water, prepared and long kept in copper fountains. The treatment of the acute poisoning consists mainly in the free use of the white of egg mixed with water, which forms an insoluble com- pound with the poison, and at the same time facilitates the cleansing of the stomach. Should this not be at hand, recourse may be had to milk, or even wheat flour mixed with water. Ferrocyanide of potassium ha* also been recommended as an antidote ; but, according to results obtained by Dr. Scharder, of Gottingen, it must be considered of doubtful efficacy. Hydrated protosulphuret of iron, recommended by Mialhe, hydrate of magnesia, and sugar, proved inefficacious in the hands of the same ex- perimenter. (Deutsche Klinik, 1855, No. 4.) Should free emesis not take place, the stomach should be thoroughly washed out by the stomach- pump. Afterwards the antidote should be administered with a cathartic, in order that it may reach any portion of the poison that may have entered the bowels. The irritation of the stomach and bowels may then be quieted by opiates; and the case otherwise treated on general prin- ciples. The therapeutic applications of copper will be most conveniently treated of, under the heads of its several preparations. I. SULPHATE OF COPPER. CUPRI SULPHAS. U. S.,Br. Blue Vitriol. Origin. Sulphate of copper exists in solution in the water running from copper mines, from which it is obtained by evaporation and crys- tallization. But it is more frequently prepared artificially; and the method usually employed in this country is by the direct action of sul- phuric acid on copper or its oxide. Composition. It consists of one equivalent of oxide of copper, one of sulphuric acid, and five of water of crystallization. Properties. Sulphate of .copper is in fine, large, deep-bint!, transparent crystals, inodorous, of a strong, harsh, .styptic, metallic, and very dis- agreeable taste, very soluble in water, and insoluble in alcohol. It i slightly efflorescent on exposure. By heat it melts, and loses its water CHAP. I.] MINERAL TONICS. SULPHATE OF COPPER. 407 of crystallization, becoming white and opaque ; and by an intense heat is decomposed. On the addition of ammonia to its solution, a precipi- tate is first thrown down, which is dissolved by a further addition of the ammonia, with the production of a beautiful deep azure-blue colour. Incompatibles. The fixed alkalies and their carbonates, the alkaline earths, the soluble salts of lead, lime, and baryta, acetate of iron, bichlo- ride of mercury, nitrate of silver, borax, tannic acid, and the astringent vegetable substances containing it, yield precipitates with the solution of sulphate of copper, and are therefore incompatible in prescription. Effects on the System. The effects of this salt are those already de- scribed of the preparations of copper in general, with the addition of astringency, in which it much exceeds the others. In short terms, it may be said, in relation to its action on the alimentary canal, to be tonic, as- tringent, powerfully emetic, highly irritant, and corrosive, according to the quantity swallowed ; in relation to its effects upon the system, to be in medicinal doses tonic to the nervous centres, and in excessive doses poisonous by an overwhelming influence upon those centres. Death, with coma and convulsions, has resulted from two drachms of ;t swal- lowed. Besides albumen, magnesia has been recommended as specially useful in poisoning by the sulphate. Therapeutic Application. Sulphate of copper is thought to have been employed as a medicine by the ancients. In regard to its emetic opera- tion, I shall treat of it under the emetics, and as an external remedy, in which capacity it is much used, under the escharotics. It is here con- sidered solely in reference to its tonic, astringent, and alterative action on the stomach and bowels, and its general influence on the system. 1. It is seldom employed for its tonic action on the stomach ; but has been highly recommended in chronic diarrhoea and dysentery from a supposed astringent effect. In certain cases of this kind, it is certainly an admirable remedy. No doubt its astringency renders it useful in some of these cases; but I ascribe its efficacy chiefly to a stimulant and alterative influence upon the ulcerated surfaces, similar to that which it exerts upon old and indolent ulcers externally. It has the great advantage, in intes- tinal affections of this kind, over nitrate of silver, that it may pass un- decomposed through the stomach into the bowels, and thus come into contact with the ulcei'S. The particular condition in which I have found it specially useful, and in which, so far as my experience has gone, it is equalled by no other remedy, is a kind of chronic enteritis, attended with diarrhoea, distressing pains in a particular part of the abdomen, with or without tenderness on pressure, emaciation, great depression of spir- its, a pulse often, though not necessarily frequent, and a moist tongue. In such cases, I have been disposed to ascribe the obstinacy which they often exhibit, and sometimes in an extraordinary degree, to the existence, within a comparatively small extent of the bowels, of a chronic, indolent 408 GENERAL STIMULANTS. [PART II. ulceration, which requires a strongly excitant and alterative impression to enable it to take on a healing tendency. I have seen them, after being treated by a diversity of remedies, opiates, astringents, etc., and linger- ing month after month, without permanent relief, yield most happily to the persevering use of this remedy, combined with a little opium to ren- der it less offensive to the stomach. A beneficial change is usually ex- perienced in a few days, and afterwards regularly advances to a cure. The only adjuvants which have seemed to me advisable, besides the small proportion of opium, are a diet exclusively of milk and farinaceous substances, and the daily use of the hot salt bath. In somewhat larger doses than an- necessary in the affection just mentioned, I have no doubt that the remedy would prove highly useful also in certain obstinate cases of chronic dysentery, with ulceration of the large intestines. In the former affection, one-quarter of a grain of the sulphate, with the same quantity of opium, or even less, may be given four times a day, and gradually increased, if necessary, till the stomach is disturbed; in the latter, one-half a grain may form the commencing dose, to be similarly increased. The necessity of the larger dose in the dysenteric affection is that, the seat of ulceration being lower in the bowels, the medicine will have been to a greater degree diminished by absorption before reach- ing it. Dr. Pereira states that he has, in an old dysenteric case, increased the dose to six grains three times a day, and continued this for several weeks, with no other obvious effect than slight nausea, and amelioration of the disease. ( Mat. Med., 3d ed., p. 802.) 2. For its effects on the nervous system, sulphate of copper has been employed in epilepsy, hysteria, and other spasmodic, convulsive, or ner- vous affections ; but for these purposes it is generally less esteemed than the ammoniated copper, to which the reader is referred. It has also been recommended in intermiltents, and might a priori be deemed useful in these complaints, from its corroborative influence upon the nervous cen- tres, rendering them, like quinia. insensible to the irritant impressions which give rise to the paroxysms. Though much less efficient than quinia, it might be used as a substitute for that remedy when circum- stances prevent or forbid its use ; and I have occasionally employed it as an adjuvant in obstinate cases.* Besides the diseases mentioned, sulphate of copper has been recom- mended in dropsy, worms, chronic catarrh with excessive secretion of mucus, and catarrh of the bladder; but I have had no experience with it in these affections, and should have little faith in its efficacy. * The prescription I have employed is as follows. Take of sulphate of copper one grain, sulphate of quinia eight grains, opium one grain. Form with syrup of gum arabic into a mass, to be divided into four pills. One to be taken four times a day. CHAP. I.] MINERAL TONICS. AMMONIATED COPPER. 409 Administration. The dose of sulphate of copper, to begin with, is one-quarter of a grain, three or four times a day, which may be gradu- ally increased, if the stomach will bear it well, to two grains. In doses of from three to five grains, it would be apt to vomit. It is most con- veniently given in the form of pill, which may be made with crumb of bread, or with a mixture of gum and syrup. II. AMMONIATED COPPER. CUPRUM AMMONIATUM. U.S. Origin. This is made by rubbing together carbonate of ammonia and sulphate of copper. A reaction takes place, attended with the escape of carbonic acid, and resulting in the formation of a moist deep-blue mass, which, when dried, constitutes the preparation in question. Composition. Different opinions have been held as to the precise com- position of this salt. The most probable is that which considers it a compound of one equivalent of sulphate of ammonia, and one of cuprate of ammonia, the oxide of copper performing the part of an acid in the latter salt. Properties. It is in the form of a coarse powder, having a beautiful deep azure-blue colour, the smell of ammonia, and an astringent metal- lic taste. It is readily soluble in water. On exposure to the air, it is gradually decomposed, giving out ammonia, and assuming a greenish colour. It should, therefore, be kept in well-stopped bottles. Incompatibles. These are the same as in the case of the sulphate, with the addition of the acids. Effects on the System. Ammoniated copper has the physiological properties of the preparations of copper in general; being less astringent and irritant than the sulphate, but supposed to act more energetically on the nervous centres. In over-doses, it is capable of producing poisonous eifects. Therapeutic Application. This preparation has been chiefly used, in reference to its cllVcts upon the nervous system, in various spasmodic convulsive, and neuralgic affections. In epilepsy, it has been consider- ably employed, and is among the remedies which have been most effect- ual, and are at present most relied on. In these respects, it probably stands next to nitrate of silver, over which it has the great advantage of not discolouring the skin. To sulphate of copper it is preferable, from being somewhat less disposed to irritate the stomach, and perhaps some- what more effective as an antispasmodic. It should be persevered in for a long time, care being taken to guard against any obvious injurious effects on the system. In chorea, hysteria, pertussis, spasmodic asthma, and neuralgia, it has been recommended, and may be resorted to upon failure with other less irritant substances. It has been used also in in- termittent fever, in dropsy, and against worms in the bowels. Administration. The dose is half a grain, three or four times a day, 410 GENERAL STIMULANTS. [PART II. to be increased, if necessary to obtain its curative effects, to four or five grains, unless it should prove irritant to the stomach. It is most con- veniently given in pills, made like those of the sulphate, and may often be usefully associated with assafetida. A solution of it in water has been used as an injection in gonorrhoea and leucorrhcea, a collyrium in opacity of the cornea, a wash in pru- rigo, and a stimulant application to indolent ulcers. According to the effect desired, the strength of the solution may vary from one to thirty grains to the fluidounce of water. III. ZINC. ZINCTJM. U.S. Metallic zinc is without influence on the system; and it is only in chemical combination that it becomes active. The effects of its prepa- rations are closely analogous to those of the preparations of copper, though less energetic. In relation to their visible topical effects, they are, according to their degree of solubility and concentration, either mildly excitant and astringent, or actively irritant, or escharotic. Taken internally, they operate directly on the alimentary mucous membrane, and, through absorption, on the system at large. In reference to the former of these seats of their action, they are, in small doses, simply tonic and astringent; in larger, promptly and powerfully emetic; in still larger, highly irritant, and even escharotic, sometimes causing death by inflammation or destruction of the mucous membrane. This higher grade of action is exercised only by the soluble preparations. TJpon the system at large, when given in small and repeated doses, they produce no sensible effect in health; and it is only by the reliefer cure of certain morbid conditions, that they are inferred to exercise a tonic or corrobo- rant influence on the nervous centres, analogous to that of silver and copper. That they are absorbed has been proved beyond question. After having been swallowed, they have been found in the secretions and the solid tissues. Dr. Michaelis, in his experiments on the lower animals, noticed that, though zinc was found in the urine, after the in- ternal exhibition of the oxide, it was more largely eliminated with the bile (Arch. Oen., 4e ser., xxx. 481.) Taken in poisonous doses, together with the local injury of the primaj vise, the preparations of zinc some- times occasion symptoms evincive also of an action on the nervous centres, as coma, convulsions, and paralysis. It has been a question, the decision of which is of considerable im- portance, whether the slow and continued introduction of zinc into the system is capable of materially deteriorating the health ; in other words, CHAP. I.] MINERAL TONICS. ZINC. 411 of inducing a state of chronic poisoning, as the preparations of lead and some other metals are known to do. The general impunity under the long use of zinc as a medicine, and the comparatively little inconvenience experienced by. those engaged in the various manufactures or applica- tions of the metal, would seem to determine this question in the nega- tive ; but facts have been brought forward, which appear to me to place beyond doubt the occasional action of the preparations of zinc in the way referred to. Thus, a patient who took twenty grains daily, for several months, of the oxide of zinc, for the cure of epilepsy, became pale, ema- ciated, and almost idiotic, with a furred tongue, constipated bowels, tumid abdomen, cold extremities, oedema of the lower limbs, dry, shriv- elled skin, like parchment, and a slow, small, very feeble pulse; symp- toms, however, which quickly disappeared upon the omission of the medicine, and the use of cathartics, with a tonic and supporting treat- ment. (Brit, and For. Med. Rev., July, 1838, p. 221.) Several men employed in barrelling oxide of zinc, and exposed for some days to an atmosphere loaded with the powder, experienced, from the beginning, loss of appetite, clammy taste in their mouths, and colic; and, after ten days, were attacked with vomiting, constipation, and violent colic, not unlike the a flection produced by lead, and which, as that usually does, yielded to purging and opiates. (See Chem. Gfaz., viii. 362.) In another instance, workmen exposed to the powder arising from beaten zinc, were affected with general depression, sore-throat, angina, ulceration of the tonsils, white pellicles on the gums, salivation, fetid breath, nausea, colic, and diarrhoea. The symptoms subsided, upon the abandonment of the occupation, in less than a week. (Ibid.) In these instances, it is obvious that large quantities of the powdered oxide must have been swallowed; and it was probably from this source that the symptoms proceeded. They were mainly such as result from a direct irritation of the aliment- ary canal ; and, though it is probable that some of them arose from the absorption of the metal, they were of little importance. They moreover disappeared rapidly, on the removal of the cause, leaving no permanent effect behind. It is satisfactory that the evil from this cause seems so trivial, when compared with that from exposure to the influence of lead, for which zinc is in a course of rapid substitution as a material for painting. Abundant confirmation has recently been obtained of the morbid influ- ence of zinc, largely introduced into the system, from observations made both in France and England, upon the effects of exposure to the fumes of the metal by the brass-founders. Workmen thus exposed, and especially those who have inhaled freely the fumes of oxide of zinc, arising from the combustion of this metal when heated in contact with the air, suffer much and often from a certain complication of symptoms, which, from an imperfect resemblance to intermittent fever, has received among them the name of brass-founders' ague. This subject has been carefully in- 412 GENERAL STIMULANTS. [PART II. \vstigated by Dr. E. H. Greenhow, of London; and an essay containing the results has been published in the Medico-chirurgical Transactions (A.D. 1862, vol. xlv., p. ITT). As stated by him, there is at first a sense of uneasiness or weariness, and of constriction of the chest, followed near bedtime by shivering and coldness, which ends in a hot stage, often attended with headache and vomiting, and invariably succeeded by pro- fuse sweating. The patient is better the next day, but on fresh exposure is liable to fresh attacks, which, however, are quite irregular in their recur- rence, and thus differ essentially from the genuine ague. Indeed, a fe- brile paroxysm, with its precursory nervous disorder, its cold, hot, and sweating stages, seems to have been developed by the presence in the blood of an absorbed poison, acting especially on the nervous centres. It is said that men engaged in this business are seldom long-lived, and are carried off in the end by the development of a pectoral disease called asthma, which, however, according to Dr. Greenhow, is chronic bron- ehitis. The symptoms might also be ascribed to the vapours of the cop- per employed ; but, independently of the fact that the copper gives off vapours with much greater difficulty, this metal does not cause the phe- nomena in the absence of zinc. In poisoning from large quantities of the soluble salts of zinc, the treat- ment should consist of the use of magnesia or one of the alkalies as an antidote, of free dilution with demulcent drinks, of opium to quiet irrita- tion of the stomach and bowels, and of measures to combat inflammation corresponding with the exigencies of each particular case. Of the therapeutic application of zinc it will be sufficient to treat under its several preparations. Of these, I would here observe, that, for inter- ual use, all might well be spared except the sulphate and oxide, from which every curative eil'ect can probably be obtained which the others are capable of producing. I. SULPHATE OF ZINC. ZlNCI SULPHAS. U. S., Br. - White Vitriol. Origin. This was known so early as the middle of the sixteenth cen- tury. It is prepared by acting upon metallic zinc with dilute sulphuric acid. The metal is oxidized at the expense of the water, the liberated hydrogen escapes, and the oxide of zinc formed unites with the acid, to produce the sulphate, which is then obtained by evaporation and crystal- lization. Composition. The crystallized salt, which should always be selected for use, consists of one equivalent of sulphuric acid, one of oxide of zinc, and seven of water. On exposure, it partially effloresces, and loses much of its water. Properties. The crystals are small, slender, transparent, four-sided prisms, and in mass very closely resemble those of Epsom salt, for which CHAP. I.] MINERAL TONICS. SULPHATE OF ZINC. 413 they have sometimes been mistaken. They are inodorous, of a styptic, metallic, disagreeable taste, very soluble in water cold or hot, and insol- uble in alcohol. By heat they are dissolved in their own water of crys- tallization, which gradually escapes, leaving the salt in the form of a white opaque powder. By an intense heat they are decomposed. Incompatibles. Sulphate of zinc is decomposed, with insoluble precip- itates, by the alkalies and alkaline earths and their carbonates, by the soluble salts of lead, of lime or calcium, and of baryta or barium, by sul- phuretted hydrogen and the soluble sulphurets, and by astringent vege- table infusions through their tannic acid. Effects on the System. These are such as have been described in the general remarks on zinc, and do not require to be repeated particularly here. It is sufficient to state that this is the most astringent of the salts of zinc, and one of the most energetic in its effects on the system, whether medicinal or poisonous. It has been frequently taken, by mistake for sulphate of magnesia, in doses of an ounce or more, and sometimes, though very rarely, with fatal results. Happily, the powerful emetic properties of the salt usually cause the whole of it to be rejected, before it has had the opportunity to produce a caustic effect upon the coats of the stomach. In a case of the kind which fell under my kno\vledge, one of the severest symptoms was a feeling of excessive constriction of the mouth, throat, and oesophagus; but the patient, who was a young woman, recovered without any serious consequences. Generally, along with in- cessant vomiting and retching, there is violent gastric and intestinal pain ; and, in the fatal cases, there hare been observed, in addition, purging, anxiety, restlessness, great prostration, and ultimately convul- sions. The treatment required in such cases has been already stated. Therapeutic Application. As an emetic, sulphate of zinc will be con- sidered particularly with the class of emetics. First, I shall treat of its internal, and afterwards of its external use. 1. For its direct effects on the alimentary canal, the salt has been used in dyspepsia, diarrhoea, dysentery, and colica pictonum. As a gentle tonic, in very small doses, it is sometimes beneficial in simple indiges- tion ; but it is seldom used in that affection. To diarrhoea it is adapted by its strong astringency ; but it is too irritant for the disease in its acute form, unless associated with great intestinal relaxation. It is to chronic diarrhoea that it is best adapted, and especially to those cases in which there may be a suspicion of ulcers in the small intestines. In these cases, associated with opium in small doses, it is sometimes very useful, though less effective, I think, than the corresponding salt of copper. In acute dysentery it should not be used by the mouth, except, sometimes, in the very advanced stages; but it may at any time be tried in the chronic form of the disease, when the tongue remains moist, and the ordinary measures have been employed in vain. There is a condition of dysen- 414 GENERAL STIMULANTS. [PART II. lery in which it may often be used with very great benefit, I allude to - in which the rectum is the part mainly affected, whether the case be subacute or chronic. In instances of the latter kind, the patient will often suffer long with the most harassing tencsmus; and though, from the want of constitutional sympathy, his general health may suitor less than when the higher portions of the large intestines are inflamed or ulcerated, yet the local distress and inconvenience are so great that life is rendered burdensome. The remedy should here be used by injection, .<> as to bring it into direct contact with the ulcerated surface. I have been for many years in the habit of resorting to this measure in the class of cases mentioned ; and, though the disease may have been of several months' duration, and, in one instance which I remember, had continued a year, they have speedily begun to improve, and generally marched on steadily to convalescence. I usually direct from four to eight fluidouncee of water, holding two grains of the sulphate in solution for each fluid- ounce, with the addition of thirty or forty drops of laudanum, to be thrown up the bowel twice a day. With the use of the salt in colica pictonum I have no experience; and I should not be disposed to rely on it, while medicines known to be efficient are at command. 2. In reference to its tonic effects upon the system generally, and on the nervous centres more especially, the medicine has been given in most of the chronic nervous diseases to which the metallic tonics are thought to be peculiarly applicable. Epilepsy, hysteria, hooping-cou'jh , and asthma are among these complaints; but the one in which ii has the highest reputation, and in which experience has shown it to be most efficacious is chorea, or St. Vitus's dance. It is certainly among the remedies which I have found most effectual in that complaint, especially when used in connection with occasional purging. Upon the same principle, it will sometimes succeed in interrupting the paroxysms of intermittent fever , though probably less efficacious in this affection than sulphate of copper, and incomparably less so than sulphate of quinia, or the arsenical preparations. It is asserted to have proved useful in ob- stinate chronic gleet and leucorrhoea; and Dr. Christison, in his Dis- pensatory, states that, in the dose of from three to six grains twice or thrice daily, he had frequently been successful with it in such cases. It would appear to operate by something more than a mere a.-tringency. It may possibly exert an alterative influence over the mucous mem- branes, and thus prove useful also in chronic bronchitis with profuse expectoration, in which it has been recommended. Administration. The dose, to begin with, is one or two grains, twice or three times a day, which may be gradually increased, if requisite, as the stomach is found to tolerate it without inconvenience. Dr. Uabing- ton has increased to thirty-six grains three times a day; but this can rarely be necessary; and it is probable that all that the medicine can CHAP. I.] MINERAL TONICS. SULPHATE OF ZINC. 415 effect may be obtained from much smaller quantities. It may be given in pill or solution. External Use. There arc few more valuable medicines for external use than sulphate of zinc. Being at once excitant and decidedly astrin- gent, it serves to stimulate enfeebled surfaces, and, by contracting their blood-vessels, to obviate inflammation in them. But there is something, also, in its mode of operation, which we do not exactly understand, by which it changes the condition of parts even specifically diseased, and disposes them to take on a healthy action, to which otherwise they would have no tendency. In other words, it is alterative, as well as tonic and astringent, in its local influence. It has been used as a simple styptic to bleeding surfaces, though probably inferior in this respect to some other astringents, such as alum and acetate of lead. As a collyrium in the very commencement of inflammation of the conjunctiva, in slight affections of the kind at any stage, in chronic cases or the declining stages of the acute, and whenever the blood-vessels appear to be merely passively dilated, it is among the safest and most efficient remedies. For this purpose, it may be dissolved in rose-water, or in pure distilled water, in the proportion of one grain to the fluid- ounce, or even less when the eye is very sensitive. The solution may be applied twice a day, and gradually strengthened, if requisite. In very slight cases, which, however, are sometimes troublesome by inter- fering with the use of the eyes, a single application often proves sufficient. In gonorrhoea, in any stage, unless when the inflammation is very high, and involves more than the mucous membrane, it is a very efficient remedy, if properly used. At the very commencement of an attack, it will sometimes almost immediately arrest the affection. The strength of the solution should not at first exceed tw r o grains to the fluidounce of water, and it may be even weaker in very sensitive conditions of the urethra. To be successful, the injection must be very frequently re- peated, so as not to allow the impression to subside before it is renewed; every three or four hours for example, or six or eight times in the twenty- four hours. In leucorrhosa the same injection will often prove highly useful, em- ployed two, three, or four times in the twenty-four hours; but little good can be expected from it when the discharge is sustained, as it too fre- quently is, by organic disease. In chronic injlammation of the rectum, with mucous discharges, it is an invaluable remedy; whether this condition be original, or a mere accompaniment or consequence of dysentery. The method of adminis- tration has been mentioned in the remarks made on the use of the remedy in that affection. Chronic purulent discharges from the ears, and the same affection 416 GENERAL STIMULANTS. [PART II. of the nostrils known under the name of ozxna, are other complaints in which sulphate of zinc is often extremely useful. In these cases, the strength of the solution, at first only two or three grains to the fluid- ounce, should be increased, as the parts will bear it, to five or even ten grains. Whenever the immediate seat of the discharge can be seen, as sometimes when an ulcer exists, even a stronger solution than the strong- est mentioned, may be directly applied to the diseased surface by means of a camel's-hair pencil, leaving the sound parts untouched. But perhaps the local affections most amenable to the remedy, are ulcers and pseudomembranous patches in the mouth and fauces. Whenever the surface of the ulcers, in these positions, is covered with a whitish exudation, whatever may be their duration or size, from the small superficial aphthous ulceration to the obstinate and destructive cancrum oris, the solution of sulphate of zinc will, according to my observation, effect a cure. I do not include in this category the gan- grsena oris, which I believe to be a different affection, and which is more effectively treated by more active escharotics. as nitrate of silver or sul- phate of copper, nor syphilitic ulcers, in which corrosive chloride of mercury is more effectual. The solution should have the strength of fifteen or twenty grains to the fluidounce of water, and should be applied daily or twice a day, by means of a brush or hair-pencil, exclusively to the diseased surface, and continued until the whitish exudation, before alluded to, gives way to a red surface, after which it should be omitted. As soon as this change takes place, the ulcer speedily heals. A much weaker solution, say of two or three grains to the fluidounce, may sometimes be used in obstinate cases of the infantile thrush or mug net of the French, with great benefit. The same remedy is applicable to all ulcers, wherever seated, which, in consequence of a loose, flabby, debilitated state of the old tissue, or of the new granulations, refuse to take on the healing process; and espe- cially when the ulcers are attended with a copious purulent discharge. The strength of the solution mu*t, in these cases, vary so much that no precise rule can be given. It may contain from two to twenty Drains to the fluidounce. Dr. F. L. Keyes, of Jerseyville, W. Canada, strongly recommends a solution containing three grains of the sulphate to a fluidounce of water, as a dressing for burns and scalds, of all kinds, except those pro- duced by gunpowder, and containing grains of the powder in the wound. (Pharm. Journ. and Trans., Dec. 1865, p. 338.) Certain cutaneous eruptions yield to the local use of this solution. I have found it specially beneficial in that brownish superficial discolora- tion, which sometimes spreads over large portions of the surface, to the great anxiety of the patient, and which is now, under the name of pity- riasis versicolor, recognized as a parasitic affection. Made in the pro- CHAP. I.] MINERAL TONICS. ACETATE OF ZINC. 417 portion of from two to five grains to the fluidounce, and thoroughly ap- plied morning and evening, the solution has, I believe, invariably within my recollection, effected cures. Sometimes a mixture of acetate of lead and sulphate of zinc in solution, has been employed as a collyrium, and an an injection in gonorrhoea, preferably to the sulphate alone In this case, a double decomposition takes place, with the production of sulphate of lead, which is precip- itated, and of acetate of zinc, which remains dissolved. If the liquid, therefore, be employed clear, it is the latter salt which is the real agent ; if it be agitated, the insoluble sulphate of lead is applied at the same time. It is possible that this salt may add something to the curative effect by affording a sort of protective covering to the mucous surface. When it is the effect of the acetate of zinc alone that is wanted, recourse should be had preferably to a solution of the pure salt. The proportion of the two salts employed is usually three grains of the acetate of lead to two of sulphate of zinc, in a fluidounce of water. II. ACETATE OF ZINC. ZlNCI AcETAS. U.S.,Br. This is prepared by exposing metallic zinc to the action of a solution of acetate of lead. The zinc takes the place of the lead in the solution, while the latter metal is deposited in the pure state. The liquid being now evaporated, and allowed to stand, yields acetate of zinc in crys- tals. The salt consists of one equivalent of acetic acid, one of oxide of zinc, and seven of water. It is in soft, white, shining, micaceous crys- tals, which effloresce in a dry air, are inodorous and of an astringent metallic taste, and are very soluble in water, and soluble also in alcohol. The effects of this salt are essentially the same as those of the pre- ceding, but milder, and less astringent. Though capable of doing injury in excessive doses, it is much less poisonous than the sulphate. It may be given internally for the same purposes, but is seldom used in that way. It is chiefly employed in the form of solution, as a collyrium in ophthalmia, or an injection in gonorrhoea. The dose for internal use would be one or two grains. The solution for topical application may contain from one to three grains to a fluidounce of water. III. YALERIAXATE OF ZINC. ZlNCI VALERIANAS. U.S., Br. This may be made by double decomposition between valerianate of soda and sulphate of zinc, dissolved separately in boiling water, and then mixed. Upon evaporation, the valerianate of zinc is formed, being less soluble than either of the other salts, and is separated in the shape of crystals, which float on the surface, and are removed as they appear. The salt is in white, pearly, scale-like crystals, which have a feeble odour of valerianic acid, and a styptic, metallic taste. It is of difficult solubility, requiring 160 parts of cold water, and 60 of alcohol. VOL. i. 27 418 GENERAL STIMULANTS. [PART II. Its effects on the system tire essentially the same as those of the sul- phate, though less astringent. It was introduced into use under the im- pression that valeriauic acid might impart to it greater antispasmodic efficiency than belongs to the preparations of zinc generally. It has proved useful in various nervous diseases, such as those for which the other preparations of zinc are employed; but experience has not satisfactorily shown that it has any superiority over them. The dose is one or two grains, several times a day. It is usually administered in the pilular form.* IV. PRECIPITATED OARBOXATE OF ZIX(\ ZlNCI CAR- BON AS PRJSCIPITATA. U.S. ZINCI CARBONAS. Br. Carbo- nate of Zinc. The U. S. Pharmacopoeia directs this to be made by double decompo- sition between sulphate of zinc and carbonate of soda, mixed in boiling hot solution. It has been introduced among the officinal preparations as a substitute for calamine, or impure carbonate of zinc, which, us found in the shops, is often a wholly surreptitious substance, containing no zinc whatever, and therefore not to be relied on. The officinal car- bonate of zinc is really a subcarbonate ; the oxide of zinc being in con- siderable excess, in consequence of the escape of carbonic acid during the reaction of the two salts used in its preparation. Precipitated carbonate of zinc is a soft, light, white powder, insoluble in water, and without smell or taste. It is, however, soluble in most acids; and, when applied locally to a secreting surface, may be consid- ered as undergoing solution in very small proportion in the extravasatcd liquid, through the instrumentality of an acid contained in it, or some other chemical reagency. Therapeutic Application. This is exclusively topical and external. Probably in consequence of the slight solution, just referred to, which it may be supposed to undergo in the moisture of the surface to which it is applied, it may acquire a very moderate degree of the excitant and astringent properties which characterise the soluble preparations of zinc, and thus produce a positive impression, such as it could not produce in a perfectly insoluble state. But it probably also acts, when in the form of powder, by absorbing the irritating secretions of the diseased surface, and thus in some degree correcting their influence; and. whether in powder or ointment, it has some effect by the exclusion of atmospheric * In the case of a girl of fourteen, troubled with an almost incessant barking cough, no doubt of an hysterical character, a cure was effected, under the care of Dr. Harley, by the use of valerianate of zinc, assafetida, and camphor, aided by a cold douche, with frictions to the spine, night and morning; but it is impossible t<> say what share the valerinnatc had in the cure. (Med. T. and Gm.. Aug. 186:?, p. 116.) Note to the third edition. CHAP. I.] MINERAL TONICS. OXIDE OF ZINC. 419 air. It is used in excoriations, whether from the chafing of opposed surfaces, as in fat persons and particularly children; from acrid secretions, as of the upper lip in coryza, or from superficial injuries; also in chapped hands and sore nipples, and sometimes in scalds and blisters. It is applied in the form of powder dusted on the part, or in that of a cerate (CERATUM ZINCI CARBONATIS, U. S.), made by incorporating two parts of the powder with ten of simple ointment. This has been substituted for the old Turner's cerate, which was prepared from calamine. CALAMINE CALAMINA. U.S. 1850. This, when genuine, is an ore of zinc consisting chiefly of the carbo- nate of that metal. It is in hard masses, which are first heated, then pulverized, and afterwards submitted to the processes of levigation and elutriation, in order to reduce them to the state of fine impalpable pow- der, in which state it constitutes prepared calamine. Both the crude calamine and the prepared, though formerly recognized in our own and all the British Pharmacopoeias, have been entirely dis- carded, in consequence of uncertainty as to its genuineness; substances having been substituted for it, which often do not contain a particle of zinc. Prepared Calamine (CALAMINA PR^EPARATA, U. S. 1850) is in the form of a powder of various colours, according to the particular specimen of ore from which it may have been obtained, either pinkish, yellowish, or brownish. It is inodorous and tasteless, and quite insoluble in water. Sometimes it is in small pulverulent lumps. The sophisticated article often found in the shops is generally of a pink colour. Calamine has the same properties, and is used for the same purposes, and in the same manner as the precipitated carbonate. There was formerly an officinal cerate called Calamine Cerate (CERATUM CALAMINE, U. S. 1850), or Turner's cerate, which was made by mixing prepared calamine with yellow wax and lard melted together. It has Been superseded by the aerate of carbonate of zinc, mentioned above. V. OXIDE OF ZIXC ZINCI OxiDUM. U. S., Br. Origin and Properties. The oxide of zinc is prepared either by burn- ing the metal, and condensing the vapours, or by heating the carbonate of zinc strongly, and thus driving off the carbonic acid. Procured by the former method, it has been called floivers of zinc. In composition it is a protoxide, consisting of one equivalent of each of its ingredients. It is a white powder, without smell or taste, unalterable in the air, insol- uble in water, but readily dissolved by most of the acids. Effects on the System. Oxide of zinc is probably inert in its uncoin- bined state; but, as there is very often free acid in the alimentary canal, with which it may react so aa to form soluble salts, it is capable of pro- ducing the characteristic effects of the preparations of zinc on the sys- 420 GENERAL STIMULANTS. [PART II. tern. The experiment of Orfila, who gave to a small dog from three to six drachms, without producing any other observable effect than vomit- ing, is not to be received as a sufficient proof of the inactivity of the oxide; for there may have been no acid present in the stomach, or too little to generate any considerable proportion of soluble salt. Given largely to men, it is said sometimes to have produced vomiting and purging; and even giddiness and intoxication have been mentioned among its effects. As already stated, in the general remarks on the metal, it is capable of acting injuriously when used freely and for a long time. Having recently been largely employed as a substitute for white lead in painting, in consequence of retaining its white colour when exposed to the action of sulphuretted hydrogen, it is a very happy circumstance that, if not absolutely innoxious, it should have proved so much less in- jurious than that paint. Its general effects on the system, so far as it acts at all, may be considered as identical with those of the preparations of zinc already described. Therapeutic Application. This medicine has been used in all the ner- vous affections to which the preparations of zinc are deemed applicable; namely, epilepsy, catalepsy, chorea, hysteria, hooping-cough, neuralyia, and gastric spasm; but it is in the treatment of epilepsy that it has enjoyed the highest reputation. If some accounts which have been published of its efficacy are to be relied on, it is capable of curing a very considerable proportion of cases; but they who are familiar with this disease, and know how obstinately, when once established, it n every variety of treatment, are prepared when they read such rep to make many allowances for failure in diagnosis, for the deceiving el: of preconception, and for the fact, almost universally noticed, that the paroxysms of epilepsy are often suspended, and sometimes kept long at bay, by anything calculated to excite the hopes and occupy the attention of the sufferers. NYh'-u the disease is purely functional, it may often, no doubt, be cured, if submitted to treatment at an early stage ; and there is as little doubt that it has not unfrcquently given way under the use of oxide of zinc; but the number of failures, taking all the cases into con- sideration, will probably greatly exceed the cures effected by this remedy. It has the advantage over the sulphate, that it is less disposed to irritate the stomach and bowels; and it may, therefore, be used preferably when these organs are peculiarly delicate. Since the publication of the first edition of this work, the oxide of zinc has acquired some reputation in the treatment of the night-sweats of phthisis. My own trials with it have not been so satisfactory as to in- duce me to join in its recommendation from personal observation. The dose is from two to eight grains or more, given three times daily. It should not be indefinitely increased; as conditions of the alimentary canal, in which it may be innocent at one time, may be so changed that CHAP. I.] MINERAL TONICS. CHLORIDE OF ZINC. 421 it shall prove highly irritant at another. I do not think that the dose of twenty grains should be exceeded; and, should irritant effects be experi- enced, the smaller doses mentioned should be diminished, or withheld for a time. It may be given in pill, or in powder mixed with syrup. External Use. As in the case of the carbonate, this preparation may possibly be dissolved, in minute quantities, in the liquid secretion pro- ceeding from diseased surfaces, and thus rendered positively efficient in its action on such surfaces. In the form of powder or ointment, the oxide has been much used as an absorbent, desiccant, and alterative, in cutaneous eruptions characterized by copious liquid extravasation, as in eczema and impetigo, in excoriations of all kinds, superficial burns, blisters, chapped hands, lips, and nipples, and profusely secreting ulcers. In chronic ophthalmia, it has been recommended in the form of a collyrium, made by diffusing a drachm of the powder equably in three or four fluidounces of mucilaginous liquid ; and the same method of pre- paration has been recommended in cutaneous affections, and for injec- tions in gonorrhoea and leucorrhosa. Ointment of Oxide of Zinc (UNGUENTUM ZINCI OXIDI, U. S.) is made by mixing one part of the oxide with six parts of lard. It was intended as a substitute for the old iutly ointment (unguentum tutiae) prepared in the same manner from tufty, which is an impure oxide of zinc, of uncer- tain strength, formerly much used, but now nearly abandoned. VI. CHLORIDE OF ZINC. ZlNCI CnLORIDUM. U.S.,Br. The mode of preparing, and the properties of this compound, will be considered under the head of escharotics, to which it belongs by its most important application. It is sufficient here to state that it is a soft. uTi-enish-white, translucent substance, deliquescent on exposure, and sol- uble in water, alcohol, and ether. Its consistence has gained for it the name of butter of zinc. It is locally irritant and caustic, and, in its effects upon the system, corresponds with the soluble salts of zinc already mentioned. In over- doses, it is an irritant poison, producing constriction of the throat, nausea, vomiting, gastric and intestinal pains, cramps in the limbs, and great prostration, with paralysis of the extremities, convulsions, and coma. Several cases of death from it are on record. The indications of treatment are thoroughly to wash out the stomach, to administer albumen freely which is coagulated by it, and afterwards to treat the case with opiates, and such antiphlogistic measures as may seem to be required. Introduced by Papenguth into medicine, it has been occasionally used by other practitioners, particularly on the continent of Europe, in scrof- ula, epilepsy, chorea, and neuralgia. It has no advantage, that I can appreciate, over the sulphate or oxide, while it is more likely to injure 422 GENERAL STIMULANTS. [PART II. the stomach and bowels. The dose is from half to three-quarters of a grain, to begin with. Its local uses will be more conveniently detailed under the escharot- ics ; and, among them, the disinfectant property.* IV. BISMUTH. BISMUTHUM. U. S., Br. The only preparation of bismuth used in medicine was for a long time the subnitrate ; but the subcarbonate has been of late introduced as a sub- stitute, and is now recognized in the U. S. Pharmacopeia; and a prepa- ration containing the citrate of the metal with ammonia has recently been introduced, with the advantage that it may be used in the liquid form ; the others being insoluble. These three preparations will be treated of under the present heading. I. SUBNITRATE OF BISMUTH. BlSMUTHI SuBNlTRAS. U.S. BISMUTHUM ALBUM. Br. White Oxide of Bismuth. Magistery of Bismuth. Origin. Subnitrate of bismuth is prepared by dissolving the metal in nitric acid, and pouring the resulting solution into water. Two salts are formed ; one a supernitrate, with great excess of acid, which remains dis- solved, the other a subnitrate, which is thrown down. The latter is the preparation in question. Properties. It is a heavy, white powder, without smell or taste, very slightly soluble in water, but readily dissolved by nitric acid. It be- comes grayish on exposure to the air, and blackens under the influence of sulphuretted hydrogen. It has been ascertained by Prof. R. E. Rogers, of Philadelphia, that subnitrate of bismuth, as found in the shops, often contains arsenic; and, though this is in small proportion, the fact is sufficient to put the physician upon his guard against pre- * Besides the preparations above mentioned, several others have been employed. Iodide of Zinc has been recommended as peculiarly useful in cases of chorea, con- nected with a scrofulous taint. From two to five grains may be given three times a day; but, as the salt is deliquescent, it is best kept and administered in the form of syrup. Lactate of Zinc has been recommended by M. Herpin in epilepsy, as a substitute for the oxide, to which it is preferable on account of its solubility, more ready entrance into the circulation, and greater uniformity of action. The dose is two grains thrice daily, to be increased as the stomach is found to bear it. Phosphate of Zinc has been used in epilepsy, by Dr. Barnes, of London, under the impression that in this disease, which especially affects the brain, there might be a demand for phosphorus to supply the cerebral waste. lie has employed it, with CHAP. I.] MINERAL TONICS. BISMUTH. 423 scribing large doses of the medicine, unless assured of its perfect freedom from that poisonous ingredient.* Effects on' the System. Ordinarily, when given internally, the oxide produces little observable effect; and very large quantities have been exhibited with perfect impunity. These facts might lead to the sus- picion that former observers were mistaken in ascribing active irritant properties to the medicine. But the apparent discrepancy is explained by reference to the very feeble solubility of the salt in water, and to its ready solubility in some of the acids. Whether, therefore, it shall prove nearly inert, or powerfully irritant, may depend on the absence or pres- ence of an acid in the primae vise, capable of dissolving it. An instance of death is recorded, which resulted from swallowing two drachms of the subnitrate with a little cream of tartar. It produced the ordinary symp- toms of inflammation of the mucous membrane of the stomach and bow- els, as pain, vomiting, purging, swollen abdomen, hiccough, etc.; and, besides these, cramps and coldness in the limbs, intermittent pulse, laborious breathing, swelling of the hands and face, suppression of urine, salivation, and delirium. Some of these symptoms were clearly the result of the absorption of the medicine. The patient, who was a man, died on the ninth day. Dissection showed marks of inflammation and gangrene throughout the alimentary canal. (Chrislison on Poisons.) It is quite possible that the accompaniment of bitartrate of potassa may have had some influence in the result, by rendering the salt of bismuth more soluble. Bismuth has not been detected in the urine of persons using it. The effects of the medicine on the system are quite equivocal ; but it may probably be ranked with the metallic tonics of the present section more safely than elsewhere. Therapeutic Application. Subnitrate of bismuth was introduced into medicine by Dr. Odier, of Geneva. It has been supposed to have a pe- culiar influence over painful affections of the stomach, either directly blunting the sensibility of the nervous tissue of the organ, or operating through the nervous centres. It has been more especially recommended in gastralgia, gastric spasm, cardialgia, and pyrosis; and has been found also to allay nausea and vomiting. At a comparatively recent the like object, in other affections attended with exhaustion of the brain. He directs four grains, three times a day, to be given with dilute phosphoric acid, which is its proper solvent. For further particulars in reference to the iodide and lactate of zinc, see the U. 8. Dispensatory, and, in reference to the phosphate, the London Lancet, Am. ed., i. 343. (Note to the second edition.) * The presence of arsenic may be detected by treating, by means of Marsh's ap- paratus, a solution made by boiling the subnitrate with an equal weight of potassa in five times its weight of water, filtering, and saturating with sulphuric acid. (Note to the second edition.) 424 GENERAL STIMULANTS. [PART II. period, it has been very much employed in different forms of diarrhoea, with groat asserted advantage. It is not impossible that the small por- tion dissolved may operate as an astringent; but it is not in this way that the extraordinary effects claimed for it can be explained. Perhaps, as suggested by M. Monneret, it may act by deposition upon the inner surface of the membrane, and the protection thus given against the irritant action of the contents of the primae vise. Hence, it is recom- mended by that practitioner in very large quantities, not less than two or three drachms in a day. It has been special!}' recommended as ex- traordinarily efficient in the diarrhoea of phthisis, that of enteric or typhoid fever, and the chronic diarrhoea of children. I can say little of the remedy from my own experience. Having almost constantly failed with it in the gastric affections in which it was originally recom- mended, I have long ceased to employ it. The dose, as formerly given, was too small. From five to twenty grains may probably be adminis- tered with safety, under any ordinary circumstances, to the adult. Cream is said to be an excellent excipient. The caution should be strictly ob- served, not to accompany its use with that of nitric acid, or indeed any other acid. Dr. Rodolfo Rodolfi, of Brescia, in Italy, has met with much success in arresting the night-sweats, and diminishing the exhausting expectoration in phthisis, from the administration, every two hours, of about two grains of the subnitrate, with the same quantity of sulphur, and about seven grains of bicarbonate of soda. In four or five days, the colliquative sweats are arrested or materially diminished ; and in fifteen or twenty days, the expectoration is less copious and easier, and tin- patient altogether improved. (Journ. de Pharm. et de Chim., Juin, 1866, p. 408.) Topically, the subnitrate has been used, with great asserted benefit, as an injection in gonorrhoea and leucorrhcea, and as an applica- tion to scrofulous ulcers. For these purposes, it is either sprinkled on the diseased surface, or applied mixed with water, in the proportion of one part of the powder to six or seven of the vehicle. The subnitrate has also been used advantageously, by Dr. W. R. Hamilton, of Illinois, in protecting the skin against pitting from the small-pox eruption. H. first lubricated the face and hands well with olive oil, and then sprinkled the powder over the surface ; and repeated the application twice daily. (Am. Journ. of Med. Sri., Oct. 1865, p. 563.) The subnitrate. sprinkled in fine powder on the surface of suppurating wounds and putrescent ulcers, not only promotes suppuration, but is asserted by Riemslach to act also powerfully as a disinfectant, completely destroying the offensive odour. (Journ. de Pharm. et de Chim., 3e ser., xliii. '2'2.) II. SUBCARBONATE OF BISMUTH. BlSMUTHI SuBCAR- BONAS. U. S. This is prepared by mixing solutions of nitrate of bismuth and carbo- CHAP. I.] MINERAL TONICS. CITRATE OF BISMUTH. 425 nate of soda, and washing- and drying the resulting precipitate. By double decomposition between the two salts, nitrate of soda and carbo- nate of bismuth are produced ; the former, which is soluble, being re- tained in solution, and the latter thrown down. The process would seem to be very simple ; but, on the contrary, as given in the U. S. Pharma- copoeia, it is very complex, being rendered so by the necessity of pro- viding against the presence in the preparation of a portion of arsenic, which is often contained in the metal as found in commerce. Subcarbonate of bismuth is in the form of a white or yellowish-white powder, inodorous and tasteless, of the sp. gr. of about 4, and insoluble in water. It should not give evidence of the presence of arsenic, when mixed with sulphuric acid, and treated by Marsh's test. It was introduced into the practice of medicine as a substitute for the subnitrate, the virtues of which it possesses, with less tendency to dis- turb the stomach. It is thought by M. Fannou, of Brussels, to have the advantage over the subnitrate of being more readily dissolved by the gastric juice ; but this might be a doubtful recommendation when large doses are given, especially in an acid state of the gastric liquids, as a highly irritant salt might thus be substituted for a perfectly bland pow- der. The probability is that, as in the case of the nitrate, its efficacy in the complaints of the stomach and bowels, in which chiefly it is given, depends on this very insolubility, which, with its weight, cause it to spread over the mucous surface, and give to this a protective coating against the irritant liquids of the primal vise. The dose is from fifteen to forty grains, given three times a day before meals, and gradually in- creased if deemed advisable. It should not be administered in connec- tion with acids. III. CITRATE OF BISMUTH AND AMMONIA. Syn. Liquor Bismuthi. This preparation was made in order to meet the demand for a soluble form of bismuth, by which its effects on the system might be obtained with greater certainty, and from a smaller dose. Originally made by a secret formula, it was analyzed by Mr. Tichborne, who, having ascer- tained its composition, devised a method of preparing it, which was after- wards improved by Mr. N. G. Bartlett, of Chicago. For the mode of preparing it, the reader is referred to the U. S. Dispensatory (12th ed., p. 1U-2S). It is believed to consist of one eq. of teroxide of bismuth, one of ammonia, one of citric acid, and five eqs. of water. In the solid state, it is in transparent colourless scales, of a somewhat metallic but not dis- agreeable taste, very soluble in water, and of an acid reaction. As first prepared it was in the liquid form, and denominated liquor bismuthi; but this is not necessary, as the compound keeps well, and may be dis- solved when wanted for use. The dose of the salt is two grains, that of a solution prepared by Mr. Bartlett, for which a formula is given in the U. S. Dispensatory, a fluidrachm. 426 GENERAL STIMULANTS. [PART II. 3. Reconstructive Mineral Tonics. It will be remembered that these are tonic substances which enter essentially into the constitution of the system. The only medicines which have been satisfactorily proved to belong to this subdivision of the mineral tonics, are the preparations of iron. IRON. FERRUM. U.S. IRON WIRE. Br. It has long been known that iron is a normal constituent of the blood ; and comparatively recent researches have shown that it exists exclu- sively in the colouring matter of the red corpuscles, of which it forms an essential constituent, and, as is generally believed, in definite propor- tion.* Without it, the red corpuscles could not exist, nor life be sup- ported. In what state of combination it is contained in the colouring matter, has not been ascertained. It is certainly held by a powerful affinity ; for it is altogether insensible to the tests by which iron can be detected in all other combinations. The probability is, that it is united, in an elementary condition, either directly with the other elements of the colouring matter, or with some peculiar organic principle, having for it an affinity beyond that of any other body in nature, and capable of being overcome, through chemical agency, only by the destruction of that prin- ciple. Hence, it may be found either by burning blood, in which case it is left in the ashes, or by the instrumentality of chlorine, which destroys the animal principle referred to. The part which iron acts in the economy is wholly unknown. The theory of Liebig, which supposes it to be a carrier of oxygen from the lungs to all parts of the system, enter- ing the respiratory organs as a protocarbonate, there becoming sesqui- oxidized with the escape of the carbonic acid, and afterwards carried away with the arterial blood to supply oxygen to all the functions, and l>e reconverted into the protocarbonate, though very beautiful, has not been authenticated, and at present must be regarded as at best a plausible conjecture. That iron is the real colouring matter of the blood, has * According lo M. Le Canu, aboul 1 part of it exists in 4400 of blood, and 7 parts in 100 of hcmatosin. For the blood, the proportion is necessarily variable, as that of hematosin itself is variable; for the hematosin, it is fixed, the combination being definite (Archive* de Phyiol., de Thfrap., et y which the metal is mainly eliminated from the system, it must have been absorbed in order to pro- duce the slight increase observed. (Archives de Physiol., Oct. 1854, p. 104.) It is said also to have been found in the milk, perspiration, and bile. In what state it enters the blood is uncertain; but it is highly probable that, in part at least, it does so, as before stated, in union with an organic principle, and that, in this condition, it contributes directly to the construction of the red corpuscles. Another portion may circulate in the serum in other soluble forms, and simply act as a tonic and per- haps astringent upon the tissues. After iron has been taken in the ordinary medicinal doses for a few days, often in less than a week, its effects on the system imiy be scon in an increased redness of the complexion, the lips, and the tongue, a fuller and stronger pulse, and a general exaltation of the organic functions. These results proceed from a greater richness of the blood, in which the CHAP. I.] MINERAL TONICS. IRON. 429 proportion of the red corpuscles is increased. If the use of the medi- cine be continued, a plethoric condition may lie induced, indicated by fulness or dull pains in the head, sluggishness of mind, a full strong pulse, increased heat, and a heightened colour of the surface. It is said that pustules of acne are apt to appear on the face, breast, and back. This is a morbid condition, predisposing to active congestion, hemor- rhage, and probably inflammation. Hence the danger of an excessive and long-continued use of the natural chalybeate waters, against which they who frequent watering places should be placed upon their guard. These effects are scarcely sufficient to rank iron among medicines poison- ous to the constitution. They are but an exaltation of the healthy pow- ers and functions, such as may result from an abuse of food and other agents essential to life. The only mode in which any preparation of iron can become poisonous, is, as before mentioned, by irritating and in- flaming the stomach and bowels. II. THERAPEUTIC APPLICATION. Iron has been immemorially em- ployed in medicine. It has two modes of therapeutic action ; one, by a gentle excitement of the functions, and a somewhat constricting effect on the tissues, evinced in the surfaces to which it is directly applied, whether external or internal, and in distant organs or the system generally, through which it circulates in the serum of the blood ; and the other, as a reconstructive agent, by affording the material and the influence neces- sary for the production of new blood-corpuscles, to supply the place of those which may have been lost. In the first method, it operates as ordinary tonics possessing some astringent power ; in the second, its in- fluence is quite peculiar and characteristic, unless, as some assert, it may be imitated by manganese. Some therapeutists believe that this recon- structive operation is essentially and purely tonic ; that is, that the iron taken as a medicine acts simply by a gentle exaltation of all the blood- making functions, enabling them to form the red corpuscles more abund- antly, not by furnishing the material, but by increasing their power of assimilating nutriment. Others, again, think that it acts simply by fur- nishing an essential consiituent of the corpuscles, and that in fact it is nothing more than an article of food. It is probable that the truth em- braces both these opinions; and that the chalybeates, in augmenting the red corpuscles, really .stimulate the functions, while they render the material more accessible, and furnish it in a state more readily acted on, than as it exists in the ordinary diet. In referring to the several diseases in which iron is used, I shall endeavour to keep in view the two methods of operating here described, though they are often conjoined in the same disease. 1. As a mere tonic, iron is much and very advantageously used in debility of the digestive organs. Connected with laxatives and aroma- tics, it is among the most useful remedies in dyspepsia, and its asso- 430 GENERAL STIMULANTS. [PART II. dated and dependent affections. When no effect on the system at large is required, and the indication is simply to stimulate the mucous membrane of the primse vise, one of the soluble preparations should be preferably selected. Unless the medicine is given too largely, the tend- ency is to produce constipation; and hence the propriety of administer- ing laxatives at the same time. Should irritation of stomach or bowels be induced, the inference is that too much has been given, and the dose should be diminished within the irritating point. Not unfrequently, in these cases, the chalybeate is associated with one of the simple bitters, as well as with a laxative and aromatic; and these may be combined, in the form of pill, powder, infusion, or tincture, to suit the particular necessities of the case. The astringency of the preparations of iron renders them, in connec- tion with their tonic property, advantageous also in chronic diarrhoea attended with relaxation of the mucous tissue. The saline preparations are preferred for this purpose, especially the sulphate, and the solution of the nitrate, the latter of which was introduced into use chiefly for its supposed efficacy in this complaint. Great care should be taken not to give them in irritating doses; and they may often be usefully associated with an opiate. Passive hemorrhage from the stomach or bowels is sometimes, benefi- cially treated with the chalybeates. To the active hemorrhages from these parts they are inapplicable, in consequence of their excitant property. Even in the passive kinds, they should not be trusted to exclusively in threatening cases ; their astringency being too feeble ; and at best they are usually prescribed rather to meet some coexisting indication, than simply as haemostatics. This remark, however, though correct as a gen- eral rule, is not applicable to the officinal solution of subsitlphate of iron, which is powerfully astringent, with comparatively little* of the irri- tant property. Through the circulation they are supposed to operate beneficially as tonics and astringents in passive hemorrhages, and various excessive secretions, as in haemoptysis, menorrhagia, hsematuria, bronchorrhosa, laucorrhosa, spermatorrhoea, etc. ; but, though they are often useful in these affections, it is probably more by their influence upon the blood than their direct action on the tissues. They should never be exhibited when the complaint is associated with a plethoric condition of the circu- lation, and a sound state of the blood. General debility, independently of any special deficiency of blood, affords an indication for the use of iron as a tonic. But discrimination in necessary. To the cure of acute debility, such as occurs in lo\v fevers, the chalybeates are quite inadequate; operating both too slowly and too gently for the wants of the system. The preparations of Peruvian bark and serpentaria among the tonics, are much more effectual here. But in CHAP. I.] MINERAL TONICS. IRON. 431 the chronic weakness resulting from deficient food, enfeebled digestion, the depressing emotions, previous disease, etc., they act beneficially by gently stimulating the organic functions through the circulation; and when with the debility is connected a special relaxation of the tissues, as in scrofula, and various nameless cachectic conditions of the system, their astringency gives them additional efficacy. But the conditions of debility in which they are indicated, in reference to their tonic and astringent properties, are almost always associated with a defective or depraved state of the blood, in which their reconstructive power is wanted; so that it will be most convenient to consider the several affec- tions under that head. 2. As a reconstructive agent, iron is used whenever the red corpus- cles are relatively deficient ; and such is the case in all instances of im- poverished blood. This condition of the blood has received the not altogether appropriate name of anaemia. In women it is often called chlorosis. Some authors make a distinction between these affections. I have been able to discover none that is essential. In the female, chlorosis sometimes comes on without any appreciable cause, possibly from some derangement of the assimilative functions essentially con- nected with the peculiarities of the sex; but it is also frequently pro- duced in them, as well as in males, from obvious causes ; and there is no difference that I have been able to appreciate in the results. The symptoms are the same, the mode of treatment is the same; and the obscurity of the cause, in certain instances, is not a sufficient ground for assuming a distinct character in the affection. The varieties under which amemia appears are almost infinite. Sometimes it is a pure, original, idiopathic affection ; but much more frequently it is associated with other diseases, as their effect, their cause, or a coincident effect of the same cause. In whatever shape it may appear; so far as the anaamia itself is concerned, iron is indicated. It may not always succeed; but it should always be tried when it is desirable to correct the anaemia. Not impossibly, this condition of the blood may sometimes be intended as a safeguard against other affections, perhaps of a hernorrhagic, per- haps of an inflammatory character; and to correct it may involve the patient in the risk of mischief greater than the evils of anemia itself. In such ca^t s. caution should be observed, in the use of the chalybeates, not to carry them too far; but to endeavour as nearly as possible to pre- serve a due balance, so that the aims of nature may be effected, without incurring danger in the opposite direction. Simple anaemia from the loss of blood, excessive secretion, defective supply of food, or inefficient assimilation, is a very common affection, and in general easily recognizable by the paleness of the face, lips, and tongue. For its characteristic symptoms, the reader is referred to works on the practice of medicine. It may be mentioned here, as having a 432 GENERAL STIMULANTS. [PART II. special therapeutic bearing, that, instead of the depressed state of all the functions, which might, ti priori, have been anticipated, there is, on the contrary, as a general rule, much and very prominent disturbance of ct-rtain functions, even more so than in the opposite condition of the blood. A frequent pulse, palpitation of the heart, panting respiration, and varied nervous agitation, are often striking phenomena; and it is of the utmost importance not to mistake these, as they were formerly often mistaken, for evidences of an over-excitement requiring depletory treat- ment. There are too, very generally, especially in females, bellow- murmurs in the heart and large blood-vessels, to be heard by pressing the ear or the stethoscope upon them, which might lead an incautious observer to suspect the existence of organic cardiac disease. Sometimes, when the disease is not yet fully developed, the characteristic paleness of the cheeks may be wanting, and there may even be in the female something of the rose yet remaining. In this condition, those apparent anomalies above referred to, the palpitations, the panting*, the hysterical disorders, and especially the cardiac and vascular murmurs, become diag- nostic symptoms, by which the nature of the case may often be deter- mined. In all these cases of anaemia, iron is the great remedy; and, were it of no other use as a medicine, it would, from the possession of its extraordinary power over this complaint, be of inestimable value. Not only is the anaemia with its immediate symptoms corrected; but evils of great magnitude, which are apt to flow from a perseverance of the affection, such as dropsy, sterility, organic heart affection, and ulti- mate death from the unresisted attacks of other diseases, are prevented. A -ufficient dose of the chalybeate, repeated three times a day, and con- tinued for six or eight weeks, will very generally cure the complaint entirely. In the course of a week or two the colour will begin to return to the lips and cheeks, the pulse to acquire more stability, the appetite and digestive function to improve; the amelioration of the symptoms will advance regularly; and, at the end of the time specified, a wan, wasted, and desponding girl, apparently in the last stage of debility, and quite incapacitated for the performance of any active duty, will have been converted into a cheerful, rosy, plump, and vigorous young woman, full of energy and hope, and prepared to enter zealously upon the duties of her station. This change is effected merely by restoring the healthy proportion of red corpuscles to the blood. The remedy should be omit- ted when the cure is completed, for fear of inducing plethora. The only caution necessary is that an observant eye should be upon the individual for some months; and, upon the least sign of a return of the symptoms, the chalybeates should be again recurred to. There is a peculiar form of anaemia, different in its origin from the preceding, in which iron is scarcely less effectual. I allude to the con- dition of system often left behind by miasmatic fevers, characterized CHAP. I.] MINERAL TONICS. IRON. 433 by a sallow paleness of the surface, general languor and weakness, mental depression, feeble digestion, and often more or less dropsical eil'usion. sometimes only anasarcous, but sometimes also in one or more of the serous cavities at the same time. There may or may not be attendant disease of the viscera. I believe this condition to be a pure anaemia, resulting from the destruction of the red corpuscles of the blood by the miasmatic poison ; the yellowness bdng attributable to a changed condition of the liberated hematosin. The same condition often follows yellow fever, probably from the same cause. It is delightful to see how rapidly this condition, serious if not relieved, will yield to the conjoined use of iron and quiuia. Slight cases will often get well in a week or two, the worst generally within two months. When there is consider- able dropsy, however, bitartrate of potassa, to the amount of an ounce, taken through the day, should be associated with the other medicines. In a large number of diseases, iron is given with a view mainly to the correction of the anaemia with which they are associated. The following list embraces most of them. When, in any one of them, there is an ad- ditional indication for the use of the medicine, the fact is mentioned. Scrofulous affections are often attended with a poverty of the blood which serve- 1< sustain the diathesis, and aggravate the complaint, But there is often also a relaxation of the tissues in these affections, which calls for a joint tonic and astringent action in the remedy. Iron answers both indications; and is very often, therefore, given in the different forms of scrofula. It has; however, no specific influence over the disease, and is used only as an adjuvant to the alterative remedies, such as iodine and cod-liver oil. The iodide of iron is generally preferred, on the presumption that the effects of the iodine may be obtained along with those of the chalybeate. Phthisis may be ranked among the scrofulous diseases, and might be supposed to call for the remedy equally with the other forms. But there is a consideration connected with this affection, which renders caution in the use of the chalybeates necessary. The anaemia in phthisis is a pn> vision of nature for bringing the blood into a due relation with the capa- city of the lungs. If, with the progressive destruction of these organs, the blood should remain undiminisbed, the quantity passing through the lungs would be more than could be duly oxidized, or indeed carried through the remaining pulmonary vessels. Congestion of the lungs, with hemorrhage, and other evils from a want of due aeration of that fluid, would take place. The use of iron, if successful in its object, might counteract this purpose^f nature, by inducing a relative plethora. Never- theless, the anaemia is" often carried far beyond the point essential for its useful purpose ; and, in such cases, the chalybeates would be serviceable by lending the support of good blood to the exhausted functions, and even by obviating, in co-operation with other measures, in some degree, VOL. i. 28 434 GENERAL STIMULANTS. [PART II. the disposition to tuberculous deposition. But they should be omitted. -on 11.- the blood may be deemed to have become as much enriched as the condition of the lungs will permit, without risk of mischief. Various nervous affections offer indications for the use of chalybeate- Disorders of the nervous system are often nothing more than results of the irritation of the nervous centres, su-tained by the constant call made upon them by the functions when suffering from the want of blood. Placed as points of communication between all the functions, and the various agencies intended for the supply of these functions with tin- means of support, they are constantly receiving impressions, and sending forth influence; and, the degree of their excitement being in proportion to the amount of impression received, they are consequently most excited when the wants of the functions are the greatest. Hence, in an anemic condition of the blood, when all the functions are suffering under the de- ficiency of this essential pabulum, the nervous centres are necessarily over-excited, and exhibit their irritation by various violences throughout the system. By correcting the condition of the blood, the functions are quieted, the nervous centres are relieved, and the existing obvious dis- ease, so far as it depended on their irritation from this cause, ceases Hence the use of iron in these complaints. But it operates also on the tonic principle of giving strength to the nervous centres, and enabling them, in a certain degree, to resist the irritative impressions made upon them ; though, in this mode of action, it is inferior to the preceding sec- tion of mineral tonics, including the preparations of silver, copper, and zinc, which have the advantage over the chalybeates of a special influ- ence upon these centres, not pos.-es-cd by the latter remedies, or, at all .vent.-, in a less degree. The chalyb^ates. therefore, while they are much more energetic and more relied upon in the nervous diseases, when dependent on or aggravated by aiuemia, than the other metallic remedio mentioned, are inferior to them under other circumstances. The rational practitioner, guided by this principle, will know when to rely mainly on the chalybeates in these complaints, when to use them a- adjuvants of the other metallic tonics, and when to abstain from them as usele.-s or pM.-siMy injurious; for, of course, they could do only harm in irritation of the nervous centres dependent on or aggravated by plethora. Hysteria is one of the affections in which chalybeates are often used advantageously on the principles above stated. Neuralgia is also frequently benefited by them; and, in many in- stances of this complaint, they are among the most effectual remedies. In the treatment of neuralgia of the face, or tic9>uloureux, they enjo\ a very high reputation; but, no matter what may !* the seat of the com- plaint, provided it can be traced to anaemia as the sole or a co-operative cause, they will prove equally beneficial. In gastralgia. they sometime.- very favourably. They are often associated with the narcotic ex- CHAP. I.] MINERAL TONICS. IRON. 435 tracts, as of belladonna, stramonium, and coninm; and there is probably on the whole, no more effectual combination in the treatment of neuralgia. Chorea, associated with anemia, will often yield to the chalybeates when other remedies fail ; though, as a general rule, they are inferior in this affection to some other metallic tonics. In epilepsy, they may be tried under similar circumstances ; but little reliance can be placed upon them for the cure ; as this fearful malady has roots much deeper than an impoverished condition of the blood. In spasmodic asthma, hooping-cough, and amaurosis, they have been recommended, and may be used to meet their special indication when presented. Carcinomatous diseases are often usefully treated with iron, which, if it does not correct the tendency to the malignant growth, at least serves, in some measure, to support the system under its exhausting influence, and probably contributes at once to render the patient more comfortable, and to lengthen life. Mr. Henry Behrend, of Liverpool, has employed iron in primary syphilis, and, upon comparing the results with Ihose following the use of mercury, gives to the chalybeate treatment a decided preference; as it appears to be equally effectual, leaves the system in a healthier condi- tion, and is not followed by the occurrence of secondary symptoms. He employs the tartrate of iron and potassa. (London Lancet, Am. ed., March, 1857, p. 219.) The reader will please to understand that this statement, in regard to the relative efficiency of the chalybeates and mer- curials in syphilis, is made solely on the authority of Mr. Behrend. In the special diseases of various organs, attended with ana?mia, iron is a most valuable adjuvant. In chronic hepatitis, or the shattered state of system left behind by it. the chalybeates are very useful. Invalids from tropical climates often find their health greatly promoted, or quite restored by a residence at chalybeate springs, and by the use of the waters, especially when, as in the case of the Cheltenham waters in England, the iron is associated with saline laxatives. I am disposed to think that the chalybeate, in these cases, does good also by a direct tonic action on the liver. A similar combination of iron and saline laxatives, with the various pleas- ures of a watering place, is among the most effectual means of cure in certain cases of jaundice, which, having yielded in a great degree to other measures, continue afterwards to resist for a long time the best directed efforts of the physician. In enlarged spleen, attended with anaemia, and especially when origin- ating under minsmatic influence, the preparations of iron arc highly useful; and, in conjunction with quinia and purgatives, offer the best means of curing that often very obstinate affection. Iron is thought to 436 GENERAL STIMULANTS. [PART II. act specially on the spleen as an astringent, and, as before stated, is said to reduce the bulk of that organ in animals which are kept under its use for some time. In organic diseases of the, heart, the attendant anosmia serves often to aggravate the affection, by sustaining an excessive action of the organ. The functions, defectively supplied with blood, call on the nervous cen- tres, and they, in obedience to the call, stimulate the heart, in order to supply, by the rapidity with which the blood is sent, the deficiency in its quality. The flaccidity of the heart, too, in anemia, renders it more expansible by the forces to which it is subjected. Hypertrophy is aggra- vated by the former influence, and dilatation by the latter. Without being able to cure either of these conditions, the preparations of iron, by improving the state of the blood, may tend to moderate or control the increase of both ; and, in the case of dilatation, may possibly, by their tonic and astringent action on the tissue, even favour a contraction of the organ. B right's disease, of the kidneys is almost characteristically attended with anaemia, which contributes to the accompanying dropsy, and. when the affection consists in fatty degeneration of the organ, fatally promotes the evil by lowering the vital forces which best resist that destructive process. Iron is here indispensable, and acts powerfully, in aid of cream of tartar and digitalis, in the relief, and sometimes in the cure of the complaint. Diseases of the genital organs, with anaemia, are occasionally bene- iited by the chalybeates. Independently of their influence on the blood, they may act as tonics on the organs, and by some are supposed to exer- cise over them a special influence, peculiarly over the uterus. They have not unfrnquently relieved sterility in women ; and the story is told that they first came into vogue by curing the son of an ancient monarch of impotence. Their supposed powers in spermatorrhoea, leucorrhoea, and the passive forms of menorrhflgia have already been noticed. Jn amenorrhoea, they are among the remedies most relied on. Combined with aloes, they probably restore the suppressed, or increase the deficient menses, in a greater number of cases than any other medicine, or asso- ciation of medicines. Some suppose them to act as a direct emmena- gogue ; others, merely by improving the blood. It is probable that they .have no specific emmenagogue power, and that their main influence is owing to the change they produce in the blood; but, nevertheless, they ,probably tend, by their tonic power, to which the uterus seems pecu- liarly susceptible, to put that organ in a healthy^ondition when relaxed or debilitated, and thus enable it to perform its functions duly. In this way, they may be readily conceived to be; ommeiuigogue in OIK; instance, -and to relieve excessive menstruation or uterine hemorrhage in another. It remains only to consider the chalybeates in their relation to diseases CHAP. I.] MINERAL TONICS. IRON. 437 consisting in a depraved condition of the blood, as distinct from a mere deficiency of one of its normal ingredients. Such a condition exists in many low febrile diseases, and is supposed by not a few to be the main pathological lesion in those affections. The corpuscles are not essentially deficient in quantity here, but they, as well as the fibrin, are supposed to be diseased, poisoned probably by the absorbed cause of the fever. Now, it is not mi improbable supposition that iron, so useful in the con- struction of the red corpuscles, may also possess some efficacy in their repair. Hence, it has recently been introduced into use as a remedy in some of these afl'ections. Attention was some years since prominently called to this application of iron by Dr. Bell, of Edinburgh, who spoke in the highest terms of the efficacy of the tincture of the chloride in ery- sipelas. His practice has been imitated by many others, not only in this complaint, but in some of analogous character, particularly scar- latina and diphtheria. But it is probably in the passive hemorrhages, that the chalybeates prove most useful upon the principle of action now under consideration. Though operating in these diseases also by their astringency, they owe the great eflicacy which they sometimes evince much more to their in- fluence on the blood. In the class of hemorrhages here referred to, the red corpuscles, though not wanting in amount, are apparently diseased, and unable to supply that stimulus to the capillaries which is essential to the support of their healthy vital contractility, while the plasticity of the fibrin is so much diminished that it coagulates imperfectly. Hence the vessels allow the escape of blood ; and the means of spontaneous cure possessed in other kinds of hemorrhage, through the ready coagu- lability of the fibrin, are deficient or wanting there. The chalybeates have a tendency to correct this condition, by improving the character of the corpuscles, and probably also, indirectly, that of the fibrin; as there is every reason to suppose that this principle proceeds in part from the corpuscles, and must therefore partake of their qualities. Iron may be given in any hemorrhage of this kind; but it has probably proved, upon the whole, most efficacious in menorrhagia. III. CHOICE OF PREPARATIONS OF IRON. For many of the facts upon which the following conclusions rest, I have pleasure in acknowledging my indebtedness to a memoir by M. Quevenne, published in Bouchardat's Archives for October, 1854, in which are presented the results of a vast number of experiments, made by the author, upon the mode in which iron enters the system. These experiments were performed chiefly on dogs, in the stomachs of which an artificial opening had been made, allowing of the examination of their contents, and of the changes going on in them from time to time. Almost all the ferruginous compounds, soluble in the gastric liquors, are capable of contributing to the formation of the red corpuscles, and of 438 GENERAL STIMULANTS. [PART II. producing the general effects of iron upon the system. Two striking ex- ceptions are offered in the ferrocyanide and ferridcyanide of potassium (yellow and red ferroprussiate of potassa), both of which are soluble, but neither is capable of exercising the characteristic influence of iron on the system. They are absorbed with great facility into the blood, but they pass out unchanged with the urine ; at least the only change produced is the conversion of the red salt into the yellow before elimi- nation. Solubility in the gastric liquids is essential to the activity of a chalyb- eate ; and the degree of its solubility may be considered as an approx- imate measure of its absorbability, and therefore of its power. But the solubility or insolubility of the chalybeates in water, is no criterion of their relation to the gastric liquids in this ivspivt. On the contrary, some of the preparations most insoluble in water are most readily dis- solved in the stomach, as, for example, powdered iron, and the protocar- bonate. Indeed, the soluble salts of iron almost always undergo precip- itation in the stomach, before final solution in the gastric liquids. The precipitate is probably formed by reaction with the organic principles either of the food or of the mucus; and, in the absence of acid in the stomach, would remain undissolved. Acids do not ordinarily exist in the stomach while fasting; but, on the introduction of food, and probably of substances excitant to the stomach, though not nutritive, they are secreted with the gastric juice, to the efficiency of which they seem to be essential. The chalybeate, if introduced into the empty stomach, may possibly excite it to the production of these acids; if introduced with the food, must encounter them in the liquid by which this is dissolved. Though precipitated, therefore, it is always subsequently in a greater or less degree dissolved in the liquor of the stomach. Quevenne ascertained that, if the gastric liquid thus holding iron in solution, be treated by an alkali, a portion at least of the chalybeate is thrown down ; and this pre- cipitate was always found, on decomposition, to yield nitrogenous pro- ducts, proving that it contained an organic principle. This was probably albumen. Mitscherlich inferred, from his experiments, that in the stomach albumen unites with the salts of iron to form compounds, of which those containing the protoxide are soluble in water, those con- taining the peroxide are insoluble; but both are dissolved by the gastric acids. It is probably, then, in this state of combination with albumen, that the chalybeates, taken into the stomach, finally enter the circulation. Of the changes which the absorbed iron undergoes in the blood, in order that it may be fitted to form a part of the red corpuscles, we know nothing ; and conjecture is futile. The above considerations are calculated to aid us in the choice of cha- lybeates. In reference to their effects on the system, their mere solu- bility in water is of no advantage. In fact, it is sometimes otherwise; CHAP. I.] MINERAL TONICS. IRON. 439 for until they are precipitated, they may act as irritants to the stomach, and thus interfere with absorption, and with their own further exhibi- tion. Besides, Quevenne has shown that, as a general rule, they yield a less proportion of metallic iron than insoluble preparations to the gas- tric liquors. Of these latter, however, the sesquioxide of iron, as repre- sented by the preparation oflicinally denominated subcarbonate, is an exception; as it gives a less proportion of the metal to that liquor than any other chalybeate in use. Upon the whole, then, when tin- object is to affect the system through the absorption of iron, as soon and with as little inconvenience as possible, it is advisable to select one of the insol- uble preparations, as the powder of iron, or, if a soluble one is chosen, to employ the mildest and least irritating, as the tartrate of iron and potasta. Should a compound insoluble preparation be chosen, one of the proto-compounds should be preferred to those in which the iron is of higher equivalent value; as the protocarbonate, for example, to the ses- quioxide. If the object be solely to act on the mucous membrane of the prima> via-, as upon the stomach in dyspepsia, or on the bowels in diar- rhoea, then recourse should be had preferably to one of the more active of the soluble salts, as the sulphate, or the chloride. The best period for exhibiting the chalybeate is also a point for con- sideration. When the aim is to introduce the iron into the circulation, the preparation should be given at the commencement of a meal; as it is then better borne by the stomach, and is placed under circumstances most favourable for solution by the gastric acids. Quevenne ascertained that a dog could bear twice as much, given with food, as upon an empty stomach. A dose which would vomit or purge under the latter circum- stances, caused no inconvenience under the former. But, when the op- eration of the chalybeate is to be confined to the mucous membrane, it should be given on an empty stomach ; as it will thus operate with greater promptitude and certainty, while, as the quantity of metal that may enter the circulation is now a matter of indifference, the dose can be regulated according to the effects without inconvenience. Another fact ascertained by Quevenne is, that the quantity of a cha- lybeate absorbed is increased somewhat with the increase in the quan- tity given, but by no means proportionally; so that, in estimating the relative value of two preparations for affecting the system, one yielding iron largely to the blood, the other sparingly, we cannot supply the defi- ciency of the latter, so as to bring the two upon an equality, by increas- ing its quantity. The great multiplication of the chalybeate preparations is unfortunate, as it tends to embarrass the student and young practitioner, without affording him any equivalent advantage; for all the good that can be obtained from the whole catalogue, whether in regard to diversity of effect, or facility of administration, can be equally obtained from one- 440 GENERAL STIMULANTS. [PART II. third, or at most one-half of the number. I have seldom found occasion to prescribe, for internal use, any others than the powder (reduced iron, U. S.), the prolocarbonate (pills of carbonate of iron, U. S.), and the xubcarbonate, among the insoluble preparations; and the sulphate, the tartrate of iron and potassa, the citrates, the tincture of the chloride, and the solution of the iodide, among those which are soluble. I be- lieve that all the remedial effects which iron is capable of producing can be obtained from these chalybeates, which afford also opportunity for every desirable diversity in the form of exhibition, whether in powder, pill, mixture, or solution in water or alcohol. The preparations may be arranged under the heads of 1. those in the metallic state, 2. the oxides, 3. the salts consisting of an oxide and acid, and 4. the haloid salts. 1. Preparations of Iron in the Metallic /State. I. REDUCED IRON. FERRUM REDACTUM. U.8.,Br. Pow- der of Iron. FERRI PULVIS. U. S. 1850. Quevenne s Iron. This is prepared by passing hydrogen over sesquioxide of iron heated to redness. The hydrogen abstracts oxygen from the sesquioxide, and escapes as watery vapour, leaving the iron in a metallic state. This is powdered, and kept in well-stopped bottles. Properties. It is a dark iron-gray powder, without smell or taste. A little of it, struck with a smooth hammer upon an anvil, forms a scale having the metallic lustre. Thrown into a dilute acid, it produces effer- vescence, with the escape of hydrogen. It rapidly oxidi/es e present in every step of the process; and that, until it is completed, there shall be no avoidable exposure to the air. These conditions are fulfilled in the U. S. process, adopted from Vallet; and the resulting preparation, therefore, is the unchanged carbonate of the protoxide simply incorporated with sugar. In the British formula, oxidation is going on from the commencement of the process to the moment when the sugar is finally added ; and con- sequently a considerable proportion of the carbonate is changed into sesquioxide. It is obvious, therefore, that, of the two preparations, that of the U. S. Pharmacopoeia is to be preferred. Properties. The U. S. preparation is a soft mass, of such a consistence as to be readily made into pills. It is black, of a sweet and strongly ferruginous taste, and readily and wholly soluble in muriatic acid, with brisk effervescence. The British preparation is a grayish-green powder, having a similar taste, and in like manner soluble in muriatic acid. The former consists exclusively of carbonate of protoxide of iron with somewhat more than half its weight of sugar ; the latter has the same ingredients with an uncertain proportion of sesquioxide of iron. Medical Uses. This preparation is little used for obtaining the direct effects of the chalybeates upon the primse vise, for which it is not adapted. But, in reference to its effects on the system, it is one of the best cha- lybeates, probably upon the whole inferior to none; being at th<- same time perfectly mild in its action on the stomach, which it very seldom offends, and readily and wholly soluble in the gastric liquids, and there- fore absorbable into the circulation. Abundant experience has proved both its gentleness and efficiency. I have been in the constant habit of using it, and have always calculated, with the utmost certainty, upon the desired effects from it, so far as these might depend on the impregnation of the system. In the Pennsylvania Hospital there is a constant succession of patients, especially in the autumn, in the most pitiable state of anemic debility, often complicated with oedema of the limbs, to whom a dose of this medicine three times a day, with a little quinia and nutritious diet, in the course of from two to four weeks, and sometimes even a shorter period, restores healthy colour and strength. Indeed, whatever can be accomplished by any one of the chalybeates towards improving the blood CHAP. I.] MINERAL TONICS. COMPOUND PILLS OF IRON. 451 may be expected from this. There are others preferable for some special purpose, or on particular occasions from their solubility, or in reference to a direct action on the mucous membrane of the primes vise, but none, I believe, as a reconstructive agent, to build up a debilitated system by the restoration of red corpuscles to the blood. The dose of the pilular mass is from throe to ten grains three times a (i;iv. Five grains may be given in a pill without inconvenience. More than fifteen grains would be liable to produce irritation of the stomach or bowels. Of course, if continued so as to produce plethora, the med- icine may occasion headache and other unpleasant symptoms. There are two officinal preparations which may be most conveniently noticed here, because the aim in them, so far as their chalybeate ingre- dient is concerned, is to produce the carbonate of iron, though, from the deficiency of sugar, this undergoes a somewhat rapid change into sesquioxide. The preparations referred to are the Mistura Ferri Com- poxita, and the Pilulse Ferri Composites of the U. S. Pharmacopoeia. 1. COMPOUND MIXTURE OP IRON. MISTURA FERRI COM- POSITA. U. S., Br. This is prepared from sulphate of iron, carbonate of potassa, and myrrh, with spirit of lavender and a little sugar to flavour it, and rose- water as the vehicle. When freshly prepared, it is greenish, and may lie kept so if perfectly excluded from the air; but the least exposure changes its colour, in consequence of the sesquioxidation of the protoxide of iron of the carbonate, which results from the mutual reaction of the two saline ingredients. A large addition of sugar would have a tendency to prevent this change. It is an imitation of the antihectic myrrh mix- ture of Dr. Griffith, which at one time had considerable celebrity. It combines the effects of myrrh with those of the chalybeates, and may therefore be given in anemic states of the system, with amenorrhcea, and chronic catarrh ; but should never be administered in inflammatory con- ditions of the gastric mucous membrane. I have seldom found much benefit from it in phthisis, in which it was formerly employed. The dose is one or two fluidounces two or three times a day. 2. COMPOUND PILLS OP IRON. PILULE FERRT COMPOSITE U.S. These pills are made with sulphate of iron, carbonate of soda, myrrh, and syrup sufficient to form a pilular mass. Carbonate of iron results from the double decomposition of the two salts, but by time and exposure i.-> converted into the sesquioxide. The pills are no doubt useful as a tonic and emmenagogue; but, since the introduction into use of the pills of carbonate of iron, have no sufficient end to answer. Their in- tended effects would be better obtained by combining the latter prepa- ration with myrrh, in such proportions as might seem best adapted to 452 GENERAL STIMULANTS. [PART II. the particular occasion. The dose is from two to six pills, equivalent to about six and eighteen grains of the muss. 3. NATURAL CHALYBEATE WATERS. These belong to the present head, as they generally owe their virtues to the carbonate of iron they hold in solution. Carbonate of iron is in- soluble in water, but is dissolved by water impregnated with carbonic acid gas. Water which has been exposed to the air always contains a small proportion of carbonic acid, sufficient to enable it to dissolve a portion of the carbonate. Hence ordinary spring or river water, remain- ing long in contact with ores of carbonate of iron, would be more or less impregnated; but when waters highly carbonated are similarly exposed, they become of course much more strongly chalybeate. All chalybeate waters, when exposed freely to the atmosphere, gradually part with their iron ; the protoxide of the carbonate being converted into the sesqui- oxide, which, being insoluble, and incapable of uniting with carbonic acid, is deposited. Hence the yellowish-brown deposit in springs of this kind, and the track of a similar colour, which marks the course of a chalybeate streamlet The pure chalybeate waters act upon the system in the same manner as the officinal carbonate, and probably, from the dissolved state of the salt, with still greater facility. They are admirably adapted to produce all those beneficial changes in the system for which the chalybeates are generally given ; especially when drank at their native sources in mineral springs, where they are often aided by the in- vigorating influence of pure air, exercise, and agreeable association. They may, however, be abused ; and it is necessary to be cautious in their use in health, and not to continue them too long in debility, lest plethora should be induced, with its risk of hemorrhage and inflamma- tion, or fever. The natural chalybeate waters appear to be occasion- ally diuretic, and are thought to have proved useful in chronic nephritic diseases. Artificial chalybeate water may be made by dissolving a mixture of sulphate of iron and bicarbonate of soda in carbonic acid water. Ten grains of each of these salts, powdered and intimately mixed, and then dissolved in a tumbler of the water, will afford a lively drink, containing four grains of carbonate of iron, with a little sulphate of soda, and an excess of the bicarbonate. The whole quantity may be taken at once, morning and evening. II. SULPHATE OF IRON- FERRI SuLPf&s. U.S.,Br. Green Vitriol. Preparation. For medical purposes, this salt should be prepared by heating together dilute sulphuric acid and iron wire. The iron is oxidized at the expense of the water, hydrogen escaping with effervescence; while the acid unites with the oxide to form the sulphate of the protoxide, CHAP. I.] MINERAL TONICS. SULPHATE OF IRON. 453 which remains in solution. In order that there may be no admixture of the sesquioxide, which it is desirable to avoid, the iron should be in excess, and, after the resulting solution has been poured off, a very little sulphuric acid should be added ; care being taken, in the subsequent filtration, evaporation, and crystallization, to exclude atmospheric air as much as possible. This is the process of Bonsdorff, which has been adopted in the U. S. Pharmacopoeia, and affords a pure sulphate of the protoxide. Composition. Crystallized sulphate of iron consists of one equivalent of sulphuric acid, one of protoxide of iron, and seven of water. Properties. Obtained in the manner above described, the crystals are of a fine bluish-green colour. If quite green, they contain a considerable proportion of sesquioxide. They are inodorous, of a strongly astringent, inky or ferruginous taste, very soluble in water, and insoluble in alcohol. A moderate heat drives off their water of crystallization, and reduces them to the state of a whitish powder. By an intense heat they are de- composed, sulphurous and sulphuric acids being given off, and the red srsquioxide remaining'. Prepared by the method of Bonsdorff, they un- dergo little change upon exposure, on account of a minute quantity of un- combined sulphuric acid contained in them ; but, as ordinarily found in the shops, they effloresce in the air, and at the same time absorb oxygen, with the production of a red subsulphate of the sesquioxide. In consequence of this change, they first become quite green, and afterwards more or less covered with a whitish or reddish-brown powder; the latter colour pre- dominating after long exposure. Their solution, which reddens litmus, is at first bluish-green, but afterwards becomes successively green, green- ish-brown, and reddish, through the absorption of oxygen, and the grad- ual conversion of the protoxide into sesquioxide ; the latter being partly deposited in the state of an insoluble subsulphate of the sesquioxide, and partly remaining in solution as the neutral sulphate of the same oxide. When the liquid has assumed a clear red colour, this change may be considered as complete, and no protoxide is left. The solution, however, may be kept in the original state, by means of iron wire, which appro- priates the oxygen as fast as absorbed ; and sugar has the same effect by its peculiar influence in preventing the oxidation of iron. The sul- phate of iron of the shops almost invariably contains more or less of the sesquioxide. Incompalibles. This salt is decomposed by the alkalies, the alkaline carbonates, soaps, lime-water, the soluble salts of lime, lead, and baryta, the borate and phosphate of soda, nitrate of silver, the soluble sulphurets, and ferrocyanide of potassium. When a perfectly pure sulphate of the protoxide, it is not affected by tannic acid, or the vegetable astringents; but, as kept in the shops, it always yields a black or bluish-black pre- cipitate with these reagents, in consequence of the sesquioxide of iron 454 GENERAL STIMULANTS. [PART II. contained in it. But, though it gives precipitates with the above sub- stances, it does not follow that they are all medicinally incompatible. On the contrary, it is often given in connection with an alkaline car- bonate, with a view to the production of the carbonate of the protoxide, which is a milder salt, and may be more advantageously employed when the object is to affect the general system. The officinal compound mix- ture of iron, and compound pills of iron, are prepared on this principle. (See page 451.) Effects on the System. Sulphate of iron is locally excitant and ac- tively astringent. On the stomach, in moderate doses, it operates often very kindly as a tonic, and in the bowels is apt to produce constipation by its astringency. In larger quantities it becomes irritant, causing heat and uneasiness in the stomach, and, in excessive doses, nausea, vomiting, and diarrhoea, with griping pains. In great excess, it may even prove poisonous by inflaming the stomach and bowels. Orfilu found two drachms to kill a dog; and Dr. Christison states that he has met with a case, in which half an ounce seemed to have proved fatal in a child. (Christison's Dispensatory.) It is no doubt capable of bringing the system under the influence of iron; but it is probably never absorbed as a sulphate ; undergoing decomposition in the stomach, and forming new compounds before it is dissolved by the gastric juice. In the mean time, it exercises its excitant influence upon the mucous membrane of the stomach ; and, if given freely, with a view to the impregnation of the system, it endangers unpleasant symptoms of gastric and intestinal irritation. Therapeutic Application. From the above considerations, it may In- inferred that sulphate of iron is useful as a tonic in dyspepsia, and as a joint tonic and astringent in relaxed states of the bowels attended with diarrhoea. In the defective appetite and feeble digestion of convalescence, especially when accompanied with an atonic diarrhoea, it is particularly indicated ; and it may be used with hopes of benefit in passive hemor- rhages from the stomach or bowels. It has often, moreover, been em- ployed, with a view to its operation through the circulation, in anemic affections, ainenorrhoea, passive hemorrhages generally, colliquative sweats, diabetes, excessive secretion from the mucous membrane of the urinary passages, leucorrhoea, and chronic catarrh with exhausting ex- pectoration ; but, for reasons stated in the preceding paragraph, it is not so well adapted for the chalybeate impregnation of the system as some of the milder preparations, and has been nearly superseded by them. It has also been used in intermittent fevers, and for the destruction of the tape- worm ; but is of little real service in either of these affections. Administration. It may be given in pill or solution. If in the former method, it should first be deprived of its water of crystallization ; as, if made from the crystals, the pills would be apt to crumble from the efflo- CHAP. I.] MINERAL TONICS. SOLUTION OF SUBSULPHATE OF IRON. 455 rescence of the salt In this state, it is officinally directed under the name of Dried Sulphate of Iron (FERRI SULPHAS EXSICCATA, U.S., Br.). In solution, the salt may be given dissolved in sweetened water, in order to protect it from oxidation, or in carbonic acid water, which aids its tonic effect in dyspepsia. The dose of the crystallized sulphate is from one to five grains, of the dried from half a grain to three grains.* The British Pharmacopoeia has a preparation denominated Granu- lated Sulphate of Iron (FERRI SULPHAS GRANULATA, Br.), which dif- fers from the crystallized simply in having been made to assume the form of a coarse powder by agitation during crystallization. It is said to have the advantage of oxidizing less readily by exposure. The dose is the same. External Use. Sulphate of iron has been considerably used as a top- ical remedy. In the aggregate solid state, in powder, or in strong solu- tion, it has been used to check the oozing of blood from hemorrhagic or wounded surfaces; in weaker solution, as a collyrium in ophthalmia, and an injection in gleet, leucorrhcea, and prolapsus ani ; and, in the same form, as a wash in indolent or flabby ulcers, and cutaneous eruptions, espe- cially in the lichenous or herpetic ring-worm of the face. The strength of the solution may vary, according to the purposes for which it is used, from one to twenty grains to the fluidounce of water; the feeblest pro- portion being used in ophthalmia, the strongest to arrest hemorrhage, or with a view to a powerful alterative influence on limited surfaces, as those of diseased ulcers, and patches of chronic cutaneous eruptions. Velpeau has found ft the most efficacious local remedy that he has used in erysipelas, stating that it never fails to cut short the inflammation in one or two days. He uses a lotion consisting of about half an ounce of the salt dissolved in a pint of water, which is aplied b}- compresses, fre- quently wetted so as to keep the skin constantly moist. (Lond. Med. Times and Gaz., March, 1855, p. 239.) Sulphate of iron is one of the salts which has been applied to the in- terior of the larynx and the bronchial tubes, in the form of spray, by means of the atomizer. (See page 16.) It may be used in ulceration and chronic inflammation ; and the solution may be employed of a strength varying from one to ten grains to the fluidounce of water. 1. SOLUTION OP SUBSULPHATE OP IRON. LIQUOR FERRI SUBSULPHATIS. U. S. Astringent Solution of Sulphate of Iron. MonseVs Solution. This preparation of iron was brought into notice, a few years since, as * In a communication to the London Medical Times and Gazette (xiii. 64), it is stated by the writer that he had found the use of rhubarb, conjointly with the sulphate of iron, to prevent the blackening of the stools occasioned by the latter medicine, as by other chalybeates, when used alone, or in other form of combination. (Note to the second edition. ) 456 GENERAL STIMULANTS. [PART II. a powerful styptic, by M. Monsel, surgeon to the military hospital at Bordeaux; and was introduced into the U. S. Pharmacopoeia at the late revision. It is prepared by boiling powdered sulphate of iron in a mixture of dilute sulphuric and nitric acids until red vapours cease to escape, and the liquid becomes of a deep ruby colour. The object of the nitric acid is to sesquioxidize the protoxide of the sulphate, and of the sulphuric acid to meet the demand of the sesquioxide produced for a greater amount of acid to saturate it; but, as the quantity of sulphuric acid is not sufficient to neutralize the whole of the sesquioxide produced, the result is necessarily a subsalt of the sesquioxide ; and this, there- fore, is correctly designated in the Pharmacopoeia as subsulphate. The solution is inodorous, of a deep reddish-brown colour, and of an extremely styptic taste, without causticity. Its sp.gr. is 1.552. When evaporated to dryness, it yields a reddish salt, which is soluble in water and alcohol without decomposition. It is thought to contain 2 eqs. of srsijuioxide of iron and 5 eqs of sulphuric acid (2 Fe 2 O 3 , 5 S0 3 ), and is probably a double salt, consisting of one eq. of tersulphate of sesquiox- ide of iron (Fe 2 3 , 3 SO 3 ) and one of bisulphate of the sesquioxide (Fe 2 3 , 2 S0 8 ). The property to which it owes its therapeutic value is that of pro- ducing a speedy and firm coagulation of the blood, whereby it is enabled to arrest hemorrhage more quickly and effectually than most other styp- tics; while it is less irritant than the other medicinal sulphates. It is used to suppress bleeding from wounds, also spontaneous hemorrhage from the mouth, nostrils, and fauces, and from the uterus, whether active or passive. It is said to have proved peculiarly efficacious in chancre. The solution has also been used internally, and, in consequence of its exceeding astringericy, with little relative irritating power, would seem to be peculiarly applicable to hemorrhage from the stomach and rectum ; being swallowed in the former case, and administered by enema in the latter. It may be given in the dose of from three to ten drops. 2. SOLUTION OF TERSULPHATE OP laON. LIQUOR FERRI TERSULPHAtis. U. S. Solution of Persulphate of Iron. Er. Appendix. This solution was introduced into the Pharmacopoeias chiefly as a step in the preparation of various important clmlybeates, and is there- fore less immedfately interesting to the practitioner of medicine than to the pharmaceutist. Containing the sesquioxide of iron, and yielding it in a state peculiarly suitable for combination with acids, it is used very con- veniently in the formation of other salts having the sesquioxide for their base. It is sufficient to say of it, that it is prepared by boiling sulphate of iron with a mixture of dilute sulphuric and nitric acids, in such pro- portions that the protoxide of iron shall be completely sesquioxidi/nl, and the resulting sesquioxide neutralized by the sulphuric acid; that CHAP. I.] MINERAL TONICS. SOLUTION OF NITRATE OF IRON. 457 the solution thus obtained is a clear reddish-brown liquid, inodorous, sourish and extremely astringent to the taste, and, according to the U. S. Pharmacopoeia, is of the sp. gr. 1.320; and that it is readily precipi- tated by solution of ammonia, yielding a hydrated sesquioxide of iron, which is highly interesting to the physician, as the only reliable anti- dote to arsenic. As the antidotal efficacy of this hydrated sesquioxide of iron is proportionate to its freshness, it is important that a portion of the solution should always be kept on hand, ready for the preparation of the antidote at the moment it may be wanted. 3. SULPHATE OF IRON AND AMMONIA. FERRI ET AMMO- NIA SULPHAS. U.S. Ammonio-ferric Alum. This is a new officinal of the TJ. S. Pharmacopoeia, introduced as a substitute for ammonia alum, which it resembles in composition ; the sesquioxide of iron being substituted for alumina. Hence it has been called ammonia-ferric alum. It is prepared by dissolving a due pro- portion of sulphate of ammonia in boiling-hot solution of tersulphate of iron, with insufficient water to hold, when the solution cools, the salt formed by their combination. It consists of 1 eq. of tersulphate of ses- quioxide of iron, 1 of sulphate of ammonia, and probably 24 eqs. of water (Fe s 3 , 3 SC^+NH^SC^-f 24 110). \\ may be given in the same complaints in which alum is employed, and has been especially recommended internally in leucorrhoea, diar- rhoea, chronic dysentery, and other complaints requiring the joint use of astringent, tonic, and chalybeate remedies. The dose is from three tp fifteen grains twice or three times daily. III. SOLUTION OF NITRATE OF IRON. LlQUOR FERRI NITRATIS. U.S. LIQUOR FERRI PERNITRATIS. Br. Preparation. This preparation, first made known as a remedy by Mr. William Kerr, of Scotland, in 1832, has been adopted as officinal in the U. S. and Br. Pharmacopoeias. As made by the process of Mr. Kerr, and according to former officinal directions, by simply dissolving iron wire in nitric acid, with the addition of water to give it a certain strength, it was a solution of the mixed nitrates of the protoxide and sesquioxide of iron, and consequently, on exposure to the air, was apt to become turbid by the further oxidation of the protoxide, and the deposition of a subnitrate of the sesquioxide. Mr. Kerr obviated this effect by adding to the solution a little muriatic acid, which dissolves the sesquioxide as fast as formed. By the present formula of the U. S. Pharmacopoeia, which was framed according to suggestions of Prof. Procter, it is believed that the difficulty at first experienced has been obviated, and a solution obtained of the nitrate of the sesquioxide of iron without any protoxide what- ever. (See U. S. Dispensatory, 12th ed., p. 1199.) Properties. The solution, as made by the former process, is of a dark 458 GENERAL STIMULANTS. [PART II. colour, and apt to become turbid ; by the improved method, is of a pale- amber colour and permanent. The taste is ferruginous, acid, and very astringent, but not corrosive. All substances are incompatible with it which form insoluble compounds with sesquioxide of iron, and soluble compounds with nitric acid; consequently, ferrocyanide of potassium, phosphate of soda, and the alkaline sulphurets ; and with all the vege- table astringents it affords copious black precipitates. The alkalies and alkaline earths precipitate the base. Medical Use. This preparation operates like the soluble salts of iron in general ; that is, locally as an astringent, and either a moderate exci- tant or irritant, according to the dose, or the strength of the solution employed ; and upon the system at large, as a tonic and reconstructive agent; though, in these latter respects, much inferior to the protosalts of iron, or the metal itself in impalpable powder. It would no doubt prove useful in debilitated states of the stomach and bowels, in the absence of inflammation ; and will occasionally cure diarrhoeas connected with this condition of the alimentary canal. It was as a remedy in diarrhoea that it was introduced into practice; and much testimony has been adduced in its favour. From the trials I have made with it, I do not consider it superior to the other soluble chalybeates for this purpose, especially the sulphate, when care is taken not to administer that remedy in an over- dose. From the experiments of Quevenne, it may be inferred that it must be decomposed and undergo precipitation in the stomach, like the other soluble salts of iron, and consequently does not reacli the seat of its operation in the small intestines, in the state of nitrate. The very blackening of the stools is alone evidence of decomposition. The dose is from five to thirty drops, from two to four times a day, which may IK: gradually increased, if necessary, while borne without inconvenience. In an over dose it will irritate and inflame, if not corrode the stomach and bowels. It should be borne in mind that the British preparation is about twice as strong as that of our Pharmacopoeia ; and should not be given in more than half the dose. The solution has been locally used as an injection in leucorrhoea, di- luted so as to produce only a slight smarting sensation ; but it is prob- ably inferior, in this and other mucous discharges, to the sulphate of iron, as being less astringent. IV. PHOSPHATE OF IRON.FERRI PHOSPHAS. V. S., Br. Phosphate of iron is prepared, according to the directions of our offici- nal code, by mixing solutions of sulphate of iron and phosphate of soda. A double decomposition takes place, resulting in the formation of sul- phate of soda, which remains in solution, and phosphate of iron, which is precipitated. This is then washed and dried. If the salt of iron employed be a pure sulphate of the protoxide, the resulting phosphate CHAP. I.] MINERAL TONICS. PHOSPHATE OF IRON. 459 will contain the iron in the same condition, and will be white when thrown down; but this almost never happens; and if it do, oxygen will be quickly absorbed, and the salt assume its characteristic colour. Composition. As employed, this salt always consists of a mixture of the phosphates of the protoxide and sesquioxide of iron, which are in variable proportion. As the phosphoric acid is tribasic, the composition of the protosalt, which greatly predominates, is two equivalents of pro- toxide of iron, one of water, and one of the acid; that of the sesquisalt, probably one equivalent of sesquioxide, and one of acid. Properties. Phosphate of iron is a bluish- white powder, nearly taste- less, insoluble in water, but soluble in the acids. Medical Use. Its operation is that of the insoluble chalybeates gen- erally; that is, it produces the usual effects of the chalybeates on the system, without much affecting the mucous surface of the stomach. It was brought prominently before the notice of the profession by Mr. Carmichael, of Dublin, in his work on cancer, published in 1809, as a remedy in that disease, in which he employed it both internally, and as an application to the ulcerated surface. In a treatise on diabetes, pub- lished in 1825, Dr. Venables speaks highly of its usefulness in that dis- ease ; and Dr. Prout confirms his favourable estimate, stating that he regards it as an excellent remedy. (Stom. and Sen. Dis., Lond. 1848, p. 50.) The late Dr. Thos. T. Hewson, of Philadelphia, was in the habit of using it for the general purposes of the ferruginous prepa- rations; and, at his recommendation, it was introduced into the Pharma- copeia of the United States. It is no doubt a good chalybeate, capable of doing what can be accomplished by iron in the improvement of the blood, and of the general health, and is thus far useful in cancer and diabetes ; but it has no special power over these formidable diseases, and is altogether inadequate to their cure. It is probably in no degree supe- rior to the pill of carbonate of iron, if equal to that excellent prepa- ration. The dose is from five to ten grains, which may be given in the form of powder, pill, or electuary. Locally, it may be applied to can- cerous ulcers, either by being dusted over them, or in the form of a lotion suspended in water, or mixed with water or glycerin to the consistence of a thin paste, and spread over the surface. Other combinations of phosphoric acid and oxidized iron have been recommended; but there is probably no one which surpasses the officinal phosphate, either in mildness or efficiency. 1. PYBOPHOSPHATE OF IRON. FERRI PYROPHOSPHAS. U.S. Under this name, a preparation of iron has been introduced into the present edition of U. S. Pharmacopoeia, consisting of sesquiphosphate of sesquioxide of iron, which is insoluble in water, and citrate of ammonia, by means of which it is rendered soluble. It is denominated pyrophos- phate in the Pharmacopoeia, because the acid contained in it is the form GENERAL STIMULANTS. [PART II. of phosphoric acid, disposed to unite with two eqs. of base, and called pyrophosphoric, because produced by the action of heat on the tri- basic acid. (See U. S. Dispensatory.) The salt is in scales of a green- ish colour, and an acidulous somewhat saline taste, and is wholly soluble in water. It is a mild chalybeate, not disagreeable to the taste, and probably capable of being used for the same systemic effects as the other ferruginous preparations, while it has the advantage over several of them that, from its solubility, it may be administered in any desirable form, whether in pills, watery solution, or syrup. The dose is from two to five grains. 2. SYRUP OP PHOSPHATE OP IRON. SYRUPUS FERRT PHOS- PHATIS. Br. Several syrups of phosphate of iron have been proposed. The British syrup contains the phosphate of iron of the Pharmacopoeia, dissolved by means of phosphoric acid, and duly incorporated with sugar. Another syrup proposed by Soubeiran contains the pyrophodphatfe of iron. A formula for it is contained in the U. S. Dispensatory (12th ed., p. 1144). A preparation essentially like it may be made by dissolving the pyrophosphate of iron of the U. S. Pharmacopoeia in a little water, and mixing the solution with syrup. A compound syrup of phosphate of iron, called chemical food, from the circumstance that it contains many of the mineral constituents of the system, which may be supposed to contribute in this form to its nourish- ment and support, has been much used in general practice, without having yet obtained officinal sanction. A formula for its preparation will be found in the U. S. Dispensatory (12th ed., p. 1143). It is very doubtful whether any material advantage can be obtained from it which may not be obtained from the simple syrup, with such additions as the wants of the system may at any time require ; while many of its ingredients must generally be quite superfluous, as the system seldom needs the whole. The dose of the British syrup is one or two fluidrachms, each contain- ing 3.5 grains of phosphate of iron. By dissolving half a drachm of the U. S. pyrophosphate in a fluidounce of syrup, an equivalent preparation may be made, of which a fluidrachm would be a medium dose. V. TARTRATE OF IRON AND POTASSA. FfiRRI ET Po- TASS.E TARTRAS. U. S. FERRUM TARTARATUM. Br. Tartarated Iron. Syn. Ferri Potassio-tartras. Ftrrum Tar- f'ln'zatum. This is among the most valuable of the chalybeates. It is prepared, according to the method of Soubeiran, which has been adopted in the U. S. and Br. Pharmacopoeias, by adding irradually to a heated mixture of bitartrate of potassa and water, the recently precipitated hydrated sesquioxide of iron (see page 443), constantly stirring, until the latter CHAP. I.] MINERAL TOXICS. TARTRATE OF IRON AND POTASSA. 461 ceases to be dissolved ; then filtering, evaporating 1 to the consistence of syrup, and drying in thin layers. Composition. It is probable that, in the above process, half of the tar- taric acid leaves the bitartrate of potassa, and combines with the ses- quioxide. According to Soubeiran and Capitaine, the salt contains 30.49 per cent, of the sesquioxide. It may be supposed to consist of one equivalent of tartrate of potassa, and one of basic tartrate of ses- quioxide of iron (one eq. of acid and one of base F 2 3 ), chemically com- bined ; the latter ingredient probably acting the part of an acid in the compound. Buf other vic\vs have been taken of its chemical nature; and its insensibility to certain reagents which ordinarily act strongly on iron in its soluble forms, would seem to show that its metallic constituent is in a peculiar state of combination. Properties. As above prepared, the salt is in translucent scales, of a ruby-red colour, and permanent in the air; but, as formerly made, and still frequently found in the shops, it is in the state of a dark-greenish or olive-coloured powder, slightly deliquescent on exposure. The prepa- ration is inodorous, of a mild, sweetish, slightly chalybeate, and not dis- agreeable taste, freely and wholly soluble in water, slightly so in alcohol, and considerably in diluted alcohol or wine. Its watery solution is not rendered blue by ferrocyanide of potassium, nor precipitated by the alkalies at ordinary temperatures, nor sensibly affected by the ordinary acids. Astringent vegetable infusions, however, affect it in the same manner as other ferruginous solutions. Medical Use. In one or another form, this chalybeate has long been in use ; but is not at present, I think, employed as much as it deserves to be. With little disposition, notwithstanding its solubility, to irritate the stomach, and almost destitute of astringency, it is yet capable of readily imparting its iron to the s} r stem, and produces all those effects upon the blood and the tissues which characterize the ferruginous pre- parations. Without, therefore, being a very efficient remedy in dys- pepsia, diarrhoea, or hemorrhages from the primae viae, in which it is inferior to other soluble salts, it may be employed with advantage when- ever the object is to improve the blood, or produce a tonic impression directly on the system. With a view to these results, and without refer- ence to a specific or peculiar influence of any kind, I should prefer it to all other soluble chalybeates. It may require to be exhibited in a larger dose than they ; but, even in equivalent quantities, in relation to the iron it gives to the blood, it is less irritant to the stomach. Another advant- age is its less tendency to constipate. Its want of unpleasant taste, as well as its general mildness, admirably adapt it to the cases of young children ; and it is wonderful how soon it will restore a healthy colour to their cheeks, in the lowest states of anaemia, when purely functional. The dose for an adult is from ten to thirty grains, three or four times a 462 GENERAL STIMULANTS. [PART II. day, to be given in solution. Three or four grains of it may be given to a child from two to four years old. Wine of Iron (ViNUM FERRT, Br.\ which is a vinous solution of this salt, has been long in use as a chalybeate. The British Pharmacopoeia prepares it by simply dissolving the tartrate of iron and potassa in sherry wine. Formerly the London College directed it to be made by digesting iron wire in sherry wine for a month. The iron was oxidized at the ex- pense of the air or water, and then combined with the excess of tartaric acid of the bitartrate of potassa always present in wine, forming a salt which was probably essentially the same, so far at least as medical effect is concerned, with the one above described. The present plan, there- fore, while yielding an equally efficient preparation, is preferable in point of precision ; as, by the old method, the strength of the preparation depended on the character of the wine. The preparation is a weak chalybeate, adapted to cases requiring the use of iron, and in which the patient has been in the habit of using wine regularly. It has the ad- vantage over an aqueous solution, of not being liable to the spontaneous decomposition of the organic acid. The dose is from half a fluidounce to two fluidounces, two or three times a day. VI. TARTRATE OF IRON AND AMMONIA. FERRI ET AMMONLE TARTRAS. U.S. Preparation. This is made, according to the process of Professor Procter, by dissolving freshly prepared hydrated sesquioxide of iron in a solution of bitartrate of ammonia, then evaporating by means of a water-bath, and drying in thin layers, as in the instance of the last-men- tioned salt. The equivalent in excess of tartaric acid in the bitartrate unites with an equivalent of the sesquioxide of iron, and a double salt is formed, consisting probably of one equivalent of basic tartrate of the sesquioxide of iron acting as the acid, and one of tartrate of ammonia acting as the base, united, according to Prof. Procter, with four equiva- lents of water. Or, if tartaric acid be considered as bibasic, with a doubled equivalent, the new salt may be considered as composed of one eq. of tartaric acid and one of each of the bases, and to be, what its name imports, a tartrate of iron and ammonia. When incinerated, the salt leaves 29 per cent, of sesquioxide of iron. Properties. It is in brilliant, dark-brown, almost blackish scales, or small, irregular, angular fragments, like those of the East India kino ; but, by transmitted light, it exhibits a garnet redness. The taste is sweetish, moderately ferruginous, very slightly styptic, and not disagree- able. The salt is very soluble in water. In its reagencies it resembles tartrate of iron and potassa, with which also it is closely analogous in composition, ammonia taking the place of potassa. Medical Uses. In medical properties, as well as in chemical nature, CHAP. I.] MINERAL TONICS. CITRATE OF IRON. 463 tin's salt bears a close resemblance to the preceding; and all that has been said in relation to the tartrate of iron and potassa, of its want of unpleasant taste, general mildness, efficiency as a chalybeate in its oper- ation upon the system at large, and inapplicability to the treatment of stomachic and intestinal affections, belongs equally to this salt. It may be used in any case in which it is desirable to impregnate the system with iron, and in which a soluble preparation is wanted. Another ad- vantage of both these salts is that they may be given with the alkaline carbonates, and generally with other saline medicines, without undergo- ing decomposition. The dose is from five to thirty grains, three times a day. The first quantity mentioned is sufficient to begin with, unless in urgent cases. VII. CITRATE OF IRON. FERRI ClTRAS. U.S. The U. S. Pharmacopoeia directs this salt to be made by evaporating the officinal Solution of Citrate of Iron (LIQUOR FERRI CITRATIS, U. S.) to the consistence of -syrup, and then spreading it on plates of glass to dry. The solution is prepared by gradually adding to a heated solution of citric acid, freshly precipitated hydrated sesquioxide of iron (see page 443) until it ceases to be dissolved, and the acid is saturated. A direct union takes place between the acid and oxide, resulting in the formation of a salt consisting of one equivalent of citric acid, and one of sesquiox- ide of iron. Citrate of iron is an uncrystallizable salt, and, as above prepared, is in translucent laminae of a fine garnet-red colour, of a mild ferruginous taste, slowly soluble in cold, but readily in boiling water. It is a mild chalybeate, and may be employed to obtain the gen- eral effects of iron on the system, either in pill or solution, in doses of from three to ten 'grains, three times a day. It has been considerably used in this country. The officinal solution is a convenient form for administration, and may be given in the medium dose of ten minims, equivalent to five grains of th> salt. CITRATES OF THE PROTOXIDE and of the BLA^ or MAGNETIC OXIDE OF IRON have been prepared, but have no special advantage to recom- mend them. CITRATE OF IRON AND QUINIA (Ferri et Quiniae Citras, U. S.) is the name given to a preparation made by heating together recently precipi- tated quinia and officinal solution of citrate of iron, until a solution is effected, then evaporating, and drying upon glass plates. It is in thin, garnet-red scales, of a bitter, slightly chalybeate taste, and soluble in water. It is a double citrate of iron and quinia; but, as usually found in the shops, contains a large excess of the salt of iron. It may be used us a tonic, and wou'd be especially adapted to that anemic condition of 464 GENERAL STIMULANTS. [PART II. system which so frequently follows our autumnal fevers; but I can see no advantage it possesses over a mixture of the citrate of iron with sul- phate of quinia, while it has this disadvantage, that the relative quantity of the two salts cannot be adjusted to the particular indications of the case. The dose is about five grains. VIII. CITRATE OF IRON AND AMMONIA. FERRI ET AMMONIA CITRAS. U.S.,Br. Preparation and Composition. This salt is made by mixing officinal solution of citrate of iron and water of ammonia, evaporating at a heat of 150 or less to a syrupy consistence, and then drying on glass plates. The chemical composition of the resulting compound is not exactly determined ; but it probably consists of one equivalent of citric acid, one of sesquioxide of iron, and one of ammonia. Mr. Redwood found the salt of commerce to contain variable proportions of the sesquioxide, from 31 to 34.5 per cent. (Pereira, Mat. Med., 3d ed., p. 793 ) When the officinal salt is incinerated In the air, it yields 26.5 per cent, of the ses- quioxide. Properties. This salt is in very thin, shining scales, of a bright, almost ruby-red colour, and of a sweetish or acidulous, slightly chalybeate, very feebly styptic, and not disagreeable taste. It is readily soluble in water, but almost insoluble in alcohol. Ferridcyanide of potassium does not change it blue; though with the ferrocyanide it yields a copious blue precipitate, and caustic potassa and lime-water decompose it, throwing down the sesquioxide with escape of ammonia. It is not decomposed by the carbonates of the alkalies. I am told that ammonia escapes when it is heated. Medical Uses. All that has been said of the medical applications of tartrate of iron and potassa, and tartrate of iron and ammonia, is equally applicable to this salt, which is closely analogous to them in composition and properties. It is an excellent chalybeate, and may be given when- ever it is desired to bring the system under the influence of iron, and a soluble preparation is wanted. It is less calculated than some other soluble salts of iron, tMaieet the indications for the tonic and astringent effects of the chalybeates on the alimentary mucous membrane. The dose is from five to thirty grains, the former being sufficiently large for a commencing dose in ordinary cases. Several other salts of iron have been recommended at different times, and received more or less attention, of which very brief notices must suffice; as none of them have come into general use, and probably none are capable of producing effects which cannot, to say the least, be quite as conveniently and advantageously obtained from those already de- scribed. CHAP. I.] MINERAL TONICS. LACTATE OF IRON. 465 1. ARSENIATE OF IRON. FERBI ARSENIAS. Br. This is an officinal of the British Pharmacopoeia, made by mixing solutions of sulphate of iron, and of arseniate and acetate of soda. A white precipitate falls, which soon becomes green on exposure to the air. It is amorphous, inodorous, insipid, and insoluble in water, but is readily dissolved by muriatic acid; and, when first formed, consists of three eqs. of protoxide of iron and one of arsenic acid. On exposure, however, the protoxide absorbs oxygen, and the preparation, therefore, contains a portion, though indefinite, of the sesquioxide. It has been in- troduced into use, under the idea that it might exercise upon the system the combined virtues of arsenic and iron. It is in fact useful in cuta- neous affections, such as yield to arsenic ; but the proportion of iron con- tained in it is too small to be of account ; and this salt must be regarded simply as arsenical. In this respect, I know no superiority which it possesses over Fowler's solution. The dose is from the eighth to the tenth of a grain, which may be given in the form of pill three times daily. 2. ACETATE OF IRON". FERRI ACETAS. Acetate of protoxide of iron is in small, green crystals, which decom- pose rapidly on exposure to the air; acetate of sesquioxide of iron is uncrystallizable, and, in the solid state, deliquescent ; it is only, there- fore, in solution that either of these salts can be conveniently kept. The Dublin Pharmacopeia directed a Tincture of Acetate of Iron (TINCTURA FERRI ACETATIS), which was made by mixing alcoholic solutions of the sulphate of sesquioxide of iron and acetate of potassa. A double decom- position took place, resulting in the formation of sulphate of potassa, which was precipitated, and acetate of sesquioxide of iron, which re- mained in solution. The liquid was then expressed and filtered. The tincture thus made is transparent, of a deep-red colour, and a strong, ferruginous taste. It is an agreeable and efficacious chalybeate, and was a favourite with Dr. Percival, who is said to have introduced it into the Dublin Pharmacopoeia. In this country, it is seldom or never used. The dose is from twenty minims to a fluidrachm. 3. CITRATE OF IRON AND MAGNESIA.. FERRI BT MAGNE- SIA ClTRAS, This is made by dissolving freshly prepared hydrated sesquioxide of iron in citric acid, saturating with carbonate of magnesia, evaporating to the consistence of syrup, and drying in thin layers. It is in trans- lucent scales, of a greenish -yellow colour, and an acidulous, slightly chalybeate taste, very soluble in water, but insoluble in alcohol. It has the general properties of the ferruginous preparations, and may be given in the dose of five grains or more, in pill or solution. 4. LACTATE OF IRON. FERRI LACTAS. U. S. Under the impression that lactic acid is ordinarily present in the gas- ric juice, that it is consequently the form of lactate which the ferruginous VOL. i. 30 466 GENERAL STIMULANTS. [PART II. preparations introduced into the stomach generally assume, and that in this form they enter the circulation, MM. Gelis and Conte were induced to recommend the use of the lactate of iron in medicine, as more likely than other chalybeate^ to find its way readily into the blood, and to produce the required effects on the system. Some trials that were made confirmed their views as to the efficiency of the salt, and it was for a time con- siderably used ; but further experience has shown that it is not superior to other salts of iron ; and, from the experiments of Quevenne, it would appear that it is no less liable than others to undergo precipitation in the stomach. It may be made either, as directed in the U. S. Pharmacopoeia, by di- gesting iron filings in lactic acid, or by double decomposition between lactate of lime and sulphate of iron. In the former case, the iron is protoxidized at the expense of the water, and then combines with the acid to form a lactate of the protoxide; in the latter, the same salt re- mains in solution after the precipitation of sulphate of lime. The lactate may be obtained from the solution in crystals in the ordinary mode, or in the form of scales by evaporating to the consistence of syrup, and then spreading thinly on glass or porcelain to dry. Lactate of protoxide of iron is in greenish-white crystalline grains or crusts, of a mild ferruginous taste, little changed on exposure to the air, slowly and sparingly soluble in water, and scarcely soluble in alcohol. The watery solution becomes yellowish on exposure, in consequence of the partial sesquioxidation of the protoxide ; and the dry salt is some- times met with of the same colour, probably from the same cause, or from want of care, in its preparation, to avoid this source of impurity. In its effects on the system, lactate of iron is not unlike the sulphate, but is less astringent It is capable of exciting, and, in over-doses, of irritating the stomach, and may, therefore, be used as a gastric stimulant in dyspepsia, though less efficient than some others in diarrhoea, and hemorrhage from the mucous membrane of the prim vise. It may also be employed to produce the effects of iron on the system at large ; but is inferior for this purpose to powdered iron, or the pill of the carbonate, or even to the milder soiuble salts, as the tartrate of iron and potassa, and the tartrate or citrate of iron and ammonia, because more liable to irritate the stomach when freely administered, "and consequently inca- pable of imparting so much iron to the circulation within a given time. The dose is one or two grains, three times a day, which may be gradually increased so as to amount to twelve grains daily. It may be given in powder, pill, or syrup. 5. VALERIANATE OF IRON. FERRI VALERIANAS. Dub. This preparation was introduced into the Dublin Pharmacopoeia, prob- ably under the impression, that the valerianic acid contained in it might superadd to the tonic action of the iron, in chlorotic cases, the peculiar CHAP. I.] MINERAL TONICS. CHLORIDE OF IRON. 467 antispasmodic influence of the oil of valerian. It is, however, so easy to mix a little oil of valerian with one of the preparations of iron, that, even admitting the peculiar additional virtue supposed to be acquired, it is scarcely a sufficient reason for increasing the already overburdened catalogue of the chalybeates. Accordingly, the preparation has been omitted in the Br. Pharmacopoeia. The salt is made by double decom- position between the sulphate of sesquioxide of iron and valerianate of soda ; sulphate of soda being left in solution, and valerianate of sesqui- oxide of iron precipitated. The latter is then washed, dried, and kept in well-stopped bottles. The salt is composed of three equivalents of acid and one of sesquioxide. It is in the form of a loose, dark-red powder, with a slight odour and taste of valerianic acid, insoluble in cold water, soluble in alcohol, and deprived of its acid by boiling water. It is also decomposed by the acids, which liberate valerianic acid, recognizable by its peculiar, very offensive odour. The preparation is thought to be specially adapted to anemic cases associated with hysteria. One grain is mentioned as the dose, to be repeated three or four times a day. 4. Preparations of Iron in the State of Haloid Salts. I. CHLORIDE OF IRON. FERRI CHLORIDUM. U.S. Sea- quichloride of Iron. Ptrchloride of Iron. This is properly the sesquichloride or perchloride of iron. Though long- and very largely used in alcoholic solution, and more recently, to a considerable extent, dissolved in water, this chalybeate has until of late never been kept in the dry state, and was for the first time introduced into the U. S. Pharmacopoeia at the last revision. It is prepared by first treating iron wire with muriatic acid, by which the protochloride is pro- duced in solution ; then bringing this to the state of sesquichloride by adding nitric acid, and a further quantity of muriatic acid, to the heated solution ; and lastly evaporating and crystallizing The simplest expla- nation of the process is that, in the first step, iron attracts sufficient chlorine from the muriatic acid to convert it into the protochloride, while the hydrogen of the acid escapes with effervescence ; and, in the second, the nitric acid gives up a portion of its oxygen to the hydrogen of the muriatic acid in excess, thereby liberating enough chlorine to bring the protochloride of iron to the state of the sesquichloride. Thus procured, the chloride of iron is in crystalline fragments, of an orange-yellow colour, inodorous, of a strongly styptic and ferruginous taste, very soluble in water, deliquescent, and soluble in alcohol and in ether. It consists of two eqs. of iron and three of chlorine, and is rep- resented by the formula Fe a Cl s , with a variable quantity of water of crystallization. That it is a sesquichloride of iron, containing no proto- chloride, is proved by its affording a blue precipitate with the ferrocy- 468 GENERAL STIMULANTS. [PART II. anide, but none with the ferridcyanide of potassium. The only objection to it in the solid state is its liability to deliquescence, which can be guarded against by keeping it in accurately closed bottles. It undergoes no change on exposure. There are two officinal preparations of it; the tincture, which is chiefly employed internally; and the watery solution, which is used locally. It has been employed as a local styptic in a seini-deliquesced state, and found to be extremely efficient. For this purpose, Mr. J. Z. Lawrence keeps it in a bottle loosely closed, and, as it deliquesces, applies the thick liquid portion, by means of a spun- glass brush, to bleeding surfaces. MM. Jodin and Aubrun, of Paris, have used it internally in pseudomembranous croup, with great asserted success, giving it in quantities varying from ninety grains to half an ounce, in divided doses, very frequently repeated, in the twenty-four hours. (Ann. de Therap., 1861, p. 201.) But these I should consider as very hazardous doses, and justifiable only under desperate circum- stances. The solid sesquichloride has proved an efficient remedy in that obstinate and painful ulceration about the toe-nail, resulting from the pressure of the edge of the nail upon the flesh. The powder is intro- duced beneath the protruding flesh, and sprinkled on its surface. The pain quickly subsides, and the patient is able to walk in a few days. (Bost. Med. and Surg. Journ., Oct. 22, 1863, p. 240.) 1. TINCTURE OF CHLORIDE OF IRON. TINCTURA FERRI CHLO- RIDI. U.S. TlNCTURA FERRI PERCHLORIDI. Br. FERRI MURIATIS TINCTURA. Ed. Muriated Tincture of Iron. Preparation. This was formerly prepared by dissolving subcarbo- nate of iron (U. S.) in muriatic acid, and, after filtration, adding alco- hol to the solution. As the subcarbonate of iron of the U. S. Pharma- copoeia consists mainly of sesquioxide of iron, and this, by reaction with muriatic acid, is converted into sesquichloride, there is obtained by this process a solution of sesquichloride of iron in alcohol, with only so much water as was contained in the muriatic acid used. But there is usually, in the subcarbonate above referred to, a small, though uncertain propor- tion of carbonate of protoxide of iron, producing with the muriatic acid a corresponding proportion of protochloride, which remains in the solu- tion. But protochloride of iron, exposed to the air, is converted, by tin- absorption of oxygen, into sesquichloride and se'squioxide, the latter of which, being insoluble, has a tendency to render the preparation turbid. If there be an excess of muriatic acid present, it will dissolve the quioxide as fast as formed, and thus preserve the liquor clear ; but, as this was not the case in the old U. S. formula, the tincture was apt to be- come turbid on standing. A precipitate was slowly produced, which formed crusts on the bottle, and in this state was insoluble in an excess of CHAP. I.] MINERAL TONICS. TINCTURE OF CHLORIDE OF IRON. 469 muriatic acid, probably from its peculiar state of aggregation.* Another inconvenience incident to the preparation was that, in consequence of the muriatic acid of the shops falling short of the officinal sp. gr. 1.16, the whole of the subcarbonatc directed was not dissolved, and the resulting tincture was, therefore, too weak. If the strong acid could not be ob- tained, this defect might be obviated, as suggested by Mr. A. P. Sharp, of Baltimore, by passing a little muriatic acid gas, from some liquid mu- riatic acid heated in a Florence flask, through a bent glass tube, into the mixture of the subcarbonate and acid, until a perfect solution was ef- fected, and then proceeding as directed in the officinal process. (Am. Journ. of Pharm., xxvii. 103.) But most of the disadvantages above mentioned have been obviated in the new process adopted in the present Pharmacopoeia, in which a pint of aqueous solution of the sesquichloride is first made by the succes- sive action of muriatic and nitric acids on iron wire, as in the process for preparing the solid sesquichloride ; and three pints of alcohol are then added. But, in order to obtain satisfactory results even with this method, it is necessary in the first place to be provided with materials pure and of due strength, and then faithfully to carry out all the direc- tions. (See U. S. Dispensatory.) Properties. The tincture of chloride of iron is a deep-brown liquid, which, in very thin layers, is yellowish, and, applied to white paper, produces a yellow stain. It has a sour, very astringent, and strongly chalybeate taste, and an odour resembling that of muriatic ether, a little of which is probably generated by reaction between the muriatic acid and alcohol. It should have the sp. gr. 0.990; and a fluidounce of it should yield when diluted, and precipitated with ammonia, an amount of sesquioxide of iron weighing, after being washed, dried, and ignited, 29 grains. It is sensible to the ordinary tests for iron. The following substances produce precipitates with it; namely, the alkalies, alkaline earths and their carbonates, acetate and subacetate of lead, nitrate of silver, astringent vegetable infusions, and mucilage of gum arabic. Effects on the System. This preparation is locally excitant and astrin- gent, and, in excess, highly irritant. Swallowed in moderate doses, it acts as a tonic and astringent upon the alimentary canal, increasing the appetite, promoting digestion, and causing constipation of the bowels. More largely used, it irritates the stomach, and, in great excess, acts as a poison by inflaming the gastric and intestinal mucous membrane. Ohristison, in his treatise on poisons, mentions a case in which death * Prof. Procter ascertained, at my request, that this precipitate was not an oxy- chloride of iron, for it was dissolved by sulphuric acid without the evolution of muriatic acid. It was, therefore, probably sesquioxide, rendered, as suggested in the text, insoluble in excess of muriatic acid by its peculiar molecular condition. 470 GENERAL STIMULANTS. [PART II. appeared to result from swallowing a fluidounce and a half of the tincture. There were symptoms of inflammation in the stomach and bowels during life, and the marks of it after death. Upon the system in general it pro- duces the ordinary effects of the chalybeates, and is thought, moreover, by some, to operate as a diuretic, and to exert a peculiar influence on the urinary organs. Though I have used the medicine considerably, I have not noticed the latter effects, but I do not wish to be understood as denying them. Attention has recently been called to an extraordinary power of coagulating the blood, possessed by a strong watery solution of the sesquichloride, when injected into the blood-vessels; and the tincture would probably have a similar effect. Therapeutic Application. The tincture may be used with advantage as a tonic in dyspepsia, and a joint tonic and astringent in diarrhoea of relaxation, and in passive hemorrhage from the stomach and bowels. It may also be used with a view to bring tlie system under the influence of iron, and is with many a favourite remedy for this purpose; but it has the disadvantage of being liable to irritate the stomach, if given somewhat too freely; and is inferior, I think, for this purpose, to the powder and carbonate, and to the milder soluble salts, as the double tartrate, or am- monio-citrate. There are, however, special purposes which it may be better calculated to fulfil than those preparations. Through the chlorine in its composition, it has been considered as having alterative proper which render it more efficient in scrofula than the chalybeates generally ; and it has, therefore, been associated with other chlorides, as those of barium, calcium, and sodium, in the treatment of that affection, when complicated with anaemia. It is supposed also to be men- < Hi'M.'ious than most of the chalybeates, in checking hemorrhage from the uterus and urinary passages. It has, indeed, enjoyed considerable reputation. in consequence of the special influence ascribed to it over the urinary organs. In anemic cases of dropsy, in which chalybeates are indicated, it might be selected preferably to others, from its supposed possession of diuretic powers. It is also well adapted to those cases of ami-mia. in which there is a coexisting indication for nitromuriatic acid, as in the form of cachexia attended with copious formation of oxalate of lime in the urine. I have seen this combination very speedily successful under such circumstances. Some surgeons of eminence have found it peculiarly efficient in spasmodic stricture of the uretl>ra, iu which it must be used more freely than for other purposes; ten minims being given every ten minutes until it produces the desired effect or nauseates. It has also been recommended in dysury from weakness of the muscular coats of the bladder, in chronic mucous discharges from the same viscus, and from the pelvis of the kidney, in leucorrhcea, gleets, and the advanced stages of gonorrhosa. A very natural explanation of the efficacy of this tincture in diseases of the urinary passages was that, being eliminated along CHAP. I.]- MINERAL TONICS. TINCTURE OF CHLORIDE OF IRON. 471 with the urine, it came in contact with the interior surface of the pas- sages, and produced its effects by an immediate action on the seat of the disease ; but Dr. A. H. Hassall, of London, has satisfactorily de- termined, by repeated experiments, that neither the chloride itself, nor either of its constituents, passes out with the urine ; and this explana- tion, therefore, must be abandoned. (Lancet, Dec. 1864, p. 740.) But the absence of the tincture from the passages is no proof that it may not act directly on the diseased tissue ; for, if it circulates with the blood, it comes really more closely into contact with the tissue than if merely passing over the outer surface of it; and, if it has any special relation to these organs, it thus has the opportunity of exercising its full influ- ence on them. A new application has, within a few years, been made of the tincture by Mr. C. Hamilton Bell, of Edinburgh ; to the treatment, namely, of erysipelas. He gives it internally, in doses of from fifteen to twenty- five drops every two hours, continued night and day, throughout the complaint, employing no other treatment, except to operate freely on the bowels in the beginning, and afterwards to keep them regularly open. At the time of his published notice, he had used the remedy for twenty-five years, with invariable success. (Ed. Month. Journ. of Med. Sci., A.D. 1851, p. 498.) Other practitioners have employed the remedy, and reported favourably of its effects. I have myself used it in many cases, which all terminated in health at the usual period; though the same result might possibly have happened under other modes of treat- ment; for, within my observation, this complaint has almost always ended favourably, unless in individuals previously broken down by in- temperance or disease. Still, after so uniformly favourable an experi- ence, running through several years of hospital practice, I cannot but think that there is real efficacy in the remedy. Dr. H. L. Byrd, of Savannah, Geo., has employed a similar treatment, with great supposed advantage, in scarlet fever, and considers the rem- edy, from his experience with it in twenty cases, as superior to all others in that complaint. He gave it in doses varying according to the age, from half or three-quarters of a drop for an infant six or seven weeks old, to ten drops for a child eight years old, and at intervals varying from four to eight hours. (Charleston Med. Journ., ix. 165, March, 1854.) The tincture has also been given, with supposed benefit, in pseudo- membranous angina, or epidemic diphtheria, in which the blood is believed to be depraved in a manner somewhat analogous to that which characterizes erysipelas. It ha also been recommended as especially efficacious in purpura haBmorrhagica. The dose of the tincture for ordinary purposes is from ten to thirty 472 GENERAL STIMULANTS. [PART II. minims, which may be increased to one or two fluidrachms, two or three times a day. Externally the medicine has boon employed as a stimulant and astrin- gent application to venereal warts, and cancerous and fungous ulcers; and as a styptic to bleeding surfaces. 2. SOLUTION OF PERCHLORIDE OF IRON. LIQUOR FERRI PERCHLORIDI. Br. A strong solution of perchloride of iron having come into extensive use as a styptic, the British Pharmacopoeia adopted it as officinal, and gives a process for its preparation. Unfortunately, however, from certain defects in the formula, the resulting preparation is not a pure solution of the sesquichloride of iron, but contains also a portion of the protochloride and an excess of nitric acid. The preparation was not adopted in the U. S. Pharmacopeia; because, directions having been given for preparing the solid sesquichloride, nothing more is necessary to prepare a solution of any desired strength than simply to dissolve this in water. When properly made, the solution has an orange colour, and a strongly ferruginous and styptic taste. It unites with water and alco- hol in all proportions. The strength of the British solution in sesqui- chloride is probably about four times that of the U. S. tincture of the chloride. Medical Properties and Uses. This preparation is used almost exclu- sively as a local styptic: a property which it owes mainly to its extraor- dinary power of coagulating the blood. M. Pravaz, a surgeon of Lyons, in France, found that, through the influence of a few drops of it thrown into an artery or vein, all the blood for an extent of somewhat more than an inch, was coagulated, in the course of a few minutes, into a firm clot. It has been employed especially in the treatment of varices and aneurismal tumours. In the cure of varin-s. it is asserted to have proved among the most efficient remedies known. For this purpose, a solution has been recommended containing about one part of the salt to two parts of water, for aneurisms about one part to four. But this operation is not without danger; as cases are on record of death from its injection into naevi of the face in infants, consequent on the direct passage of the solution through a vein of the mevus into the heart, where the blood was coagulated. Caution, therefore, is necessary, in perform- ing the operation, to introduce the solution very slowly. (Med. T. and Oaz., June, 1864, p. 683.) It has also been used to check hemorrhages in surgical operations, applied upon pledgets of lint, and for the cure of panniform keratitis, being for this purpose dropped into the eye. (See N. Am. Medico-chirurg. JRev.,\. 117.) It is said to effect the cure of hemorrhoids, applied to them after blistering. Solutions of various strengths, to suit special purposes, may be made by dissolving six, three, two, and one and a half drachms in a fluidounce of distilled water. CHAP. I.] MINERAL TONICS. AMMONIATED IRON. 473 The British solution may be given internally in the dose of from two to ten minims. Applied locally to certain obstinate cutaneous affections, as eczema, lichen agrius, etc., it is said in some instances to have ef- fected speedy cures. Perchloride of iron is one of the substances of which the solution has been used, in the form of spray, by means of the atomizer. It may be employed in this way in diphtheric affections and chronic inflammations of the air-passages, and in pulmonary hemorrhage. The strength of the solution, in ordinary chronic inflammation, may be from half a grain to two grains to the fluidounce of water; for diphtheria and hemorrhage from two to ten grains. II. AMMONIATED IRON. FERRUM AilMONIATUM. U. S. 1850. Ammonio-chloride of Iron. When the subcarbonate of iron of the TJ. S. Pharmacopoeia (sesquiox- ide of iron) is digested with muriatic acid, a reaction takes place, by which the sesquicltloride of iron is formed in solution. If now a solu- tion of muriate of ammonia be added, and the mixed liquids evaporated to dryness, we obtain the preparation under consideration. It is proba- bly nothing more than a mixture of sesquichloride of iron and muriate of ammonia, the former amounting only to about 15 per cent. Ammoniated iron is in crystalline grains of a fine reddish-orange col- our, and sharp saline, and chalybeate taste. It is deliquescent, and soluble in water and alcohol. Its incompatibles are the same as those of the preceding article. Under the name of flores martiales or martial flowers, a preparation closely analogous to this has long been known, since the times, indeed, of Basil Valentine, which was procured by subliming a mixture of sesquioxide of iron and muriate of ammonia. The sesquioxide was probably converted, at the expense of a part of the muriatic acid of the muriate of ammonia, into sesquichloride of iron, which then chemi- cally combined with the remainder of the muriate. The preparation differed from that now officinal in having a yellow colour, and a slight peculiar odour. Medical Uses. The great predominance of the muriate of ammonia renders this a feeble chalybeate, while it imparts aperient, and, as some suppose, alterative properties, which give it a somewhat peculiar char- acter. It is particularly applicable to cases, which offer indications at once for the influence of iron and of a deobstruent agent. Such are pre- sented in anemic states of the system, with swollen lymphatic glands as in scrofula, with enlarged liver, or with chronically hepatized lung. At present, however, it is little used; and it is no longer officinal, hav- ing been abandoned both in the U. S. and Br. Pharmacopoeias. The dose is ten or twelve grains to begin with, which may be given in pill, 474 GENERAL STIMULANTS. [PART II. solution, or electuary. The London College directed a tincture, which, being a useless preparation, has been omitted in the British code. III. IODIDE OF IRON. FERRI IODIDUM. Br. Preparation. Iodide of iron is prepared by simply mixing the two ingredients together, with the presence of water, which dissolves the resulting compound, and, after filtration, yields it by evaporation. The iron is employed in the state of filings, or of wire ; but the latter is pref- erable, as it is in general purer. The preparation consists of one equiva- lent of iron, one of iodine, and five of water; but, if considerable heat is employed in drying it, the proportion of water is smaller. It should be kept in a well-stopped bottle. Properties. When the solution of iodide of iron is very carefully evap- orated, with the exclusion of atmospheric air, the salt is obtained in the form of green, transparent, tabular crystals ; but, as ordinarily prepared, it is a greenish-black substance, of an astringent chalybeate taste, very deliquescent, and very soluble in water and alcohol. At a moderate heat it melts, and on cooling solidifies into a dark-gray, crystalline ma.-s, of a metallic lustre. At a higher heat, with exposure to the air, it is decomposed ; the iodine escaping, and the iron absorbing oxygen, and remaining behind as the sesquioxide. Upon the slightest exposure to the air, even at ordinary temperatures, the iron attracts oxygen and passes into the state of sesquioxide, while the iodine becomes free. Analogy would lead to the supposition that, as in the case of the pro- tochloride of iron, the metal would be divided between the oxygen ab- sorbed, and the principle previously combined with it, forming the qui-iodide and sesquioxide; but that iodine is liberated is shown by the fact, that the altered substance colours starch blue. This change has almost always happened, in some degree, with the iodide of iron of the shops, which, on that account, is seldom entirely soluble in water. A solution of the iodide undergoes this change much more rapidly than the solid salt, quickly depositing the sesquioxide, and thus becom- ing weakened as a chalybeate. There are, however, two means of pro- tecting the solution against this change; one by introducing into the bottle containing it some iron filings, or a coil of iron wire, the other by incorporating it with a considerable proportion of sugar. A solution protected in the latter method is officinal, and will be described. In the former method, the free iron immediately takes all the oxygen which that of the iodide absorbs from the air; and the protiodide, therefore, remains unchanged in the solution. Incompatible 8. Precipitates are produced in the solution of iodide of iron by the alkalies and their carbonates, lime-water, magnesia, soaps, hydrosulphuric acid and the soluble sulphurets, ferrocyauide of potas- , the soluble salts of lead, copper, silver, and mercury, but not those CHAP. I.] MINERAL TONICS. IODIDE OF IRON. 475 of zinc, by the soluble phosphates, all the astringent vegetable infusions, and many other organic substances. Effects on the System. Iodide of iron has both the topical and consti- tutional effects of the other soluble salts of the metal, increasing the ap- petite, improving digestion, enriching the blood, and operating generally as a tonic; but it is less astringent than the sulphate, and probably less so than the nitrate or chloride; and, moreover, possesses peculiar properties quite distinct from its powers as a chalybeate, and attribu- table to the iodine it contains. These are evinced in its alterative, diuretic, and laxative effects. Dr. A. T. Thompson states that, shortly after its administration in large doses, both iron and iodine may be found in the urine ; but it is not mainly in the form of iodide of iron that it is thus thrown off. The experiments of Quevenne show that but a small por- tion of the metal passes by the kidneys, while the iodine passes abund- antly ; proving that the two constituents are separated in the system, and most of the iron retained. (Arch, de Physiol. de Bouchardat, Oct. 1854, p. 104.) We can thus explain the two classes of effects produced, one belonging to the chalybeate ingredient, the other to the iodine. In over-doses, iodide of iron proves irritant to the stomach and bowels, caus- ing epigastric uneasiness, nausea, vomiting, purging, and griping pains. Very largely taken, it would probably induce serious gastro-intestinal inflammation; though I have seen no account of positively poisonous effects. Therapeutic Application. This medicine was first employed by Dr. Pierquin so early as in the year 1824. It is now among the most pop- ular of the chalybeates, though employed chiefly in a special class of cases. It may be used as a gastric tonic in dyspepsia, or with a view to the general effects of iron on the system, as in simple chlorosis, or in the anemic condition attended with amenorrhoea, leucorrhcea, etc.; but its best effects are displayed in cases of scrofulous disease, and other forms of local tumefaction or induration, in which there is at the same time an indication for the improvement of the blood. It is only in the absence of all febrile excitement and gastric inflammation, that it should be resorted to*in such cases; but, when properly accommodated to the state of the system, it is an excellent remedy. In swellings of the lymphatic glands external or internal, diseases of the bones, ligaments, and joints, and ulcerative and eruptive affections of the skin, when these can be traced to a scrofulous taint; in chronic enlargement of the thyroid gland, mamma, testicle, ovary, liver, and spleen ; in various subacute or chronic swellings and indurations without special seat, or known pecu- liarity of character; in all these affections, it may be considered as indi- cated when they exist conjointly with an anemic state of the blood, and a general deficiency of vital force. Without this associated condition, and in all cases in which the excitant properties of the chalybeate on the 476 GENERAL STIMULANTS. [PART II. system may be contraindicated, some other preparation of iodine, espe- cially iodide of potassium, should be preferred. Iodide of iron has also been used with advantage in secondary syphilitic affections, in like man- ner connected with anemic debility. It is said, moreover, to have been successfully employed in diabetes. A solution of it containing from one to two drachms in a pint of water, has been employed locally as an in- jection in gonorrhoea and leucorrhcea, and as a lotion in ulcers. Administration. The dose of iodide of iron is two or three grains three times a day, which may be increased to ten grains, if not found to disturb the stomach. The administration of it, in the pilular form, is attended with some difficulty, in consequence of its deliquescent prop- erty, and extreme proneness to chemical change. Various modes of obviating these objections have been proposed Perhaps the best method would be to evaporate to a pilular consistence the officinal solution of the iodide, which is protected from change by sugar; or the preparation might be directly incorporated with sugar when made into pills ; or, as suggested by Prof. Procter, a little reduced iron might be added to the mass with the same view. But, even though protected against oxida- tion, the pills would still be liable to deliquescence. To obviate both disadvantages, they might be covered with a coating of impervious matter, by dipping them into a chloroformic solution of caoutchouc and drying them. It will be noticed, in the following paragraph, that these suggestions have been carried into effect in the recent revision of the U. S. Pharmacopoeia, even to the impervious coating, though the mate- rial for coating the pills is not the one here proposed, and is probably preferable to it. Pills of Iodide of Iron (PILULE FERRI IODIDI, U. S.) are ordered by our officinal code to be made by first forming the iodide in strong solution by a direct combination of the two ingredients, then incorporating the solution with a little reduced iron, sugar, and marshmallow in powder, and finally evaporating to a pilular consistence, and dividing into pills. Thc.se are directed to be coated with balsam of Tolu, which to a con- siderable extent preserves them from the injurious influence of the air, while the reduced iron and sugar still further protect .them from the oxidation of the iron. Each pill contains about a grain of the iodide of iron and one-fifth of a grain of reduced iron. Two or three of them may be taken two or three times a day. Syrup of Iodide of Iron (SYRUPUS FERRI IODIDT, U. S., Br.). So- lution of Iodide of Iron (LIQUOR FERRI IODIDI, U. S. 1850). This is directed by the U. S. Pharmacopoeia to be prepared by dissolving iodine and iron filings together in water, filtering the solution into a certain pro- portion of syrup, in a bottle, previously heated to 212, and then adding sufficient syrup to produce the requisite measure. This preparation differs from the solution of iodide of iron of the U. S. Pharmacopoeia CHAP. I.] MINERAL TONICS. FERROCYANIDE OF IRON. 477 in having a larger proportion of sugar, which was needed for its preser- vation, and which is now sufficient to authorize the preparation to be placed among the syrups. It is on the whole the most convenient form for the administration of iodide of iron. The syrup is transparent, and of a pale-green, or yellowish-green colour, and without sediment. By exposure to light, in a closely stopped bottle, it becomes nearly colourless. It is the common form for the administration of iodide of iron, and is greatly preferable to the pill. When it is swallowed, care should be taken to wash out the mouth well, in order to avoid possible injury to the teeth. The dose of the U. S. preparation is from twenty to forty minims, which should be diluted with water, but only at the moment of exhibition. IV. FERROCYANIDE OF IRON. FERRI FERROCYANIDUM. U. S. Pure Prussian Blue. Preparation. As the Prussian blue of commerce is always more or less impure, this preparation should be made specially for medical use. The U. S. Pharmacopoeia directs that to the officinal solution of tersul- phate of iron a solution of ferrocyanide of potassium should be added, and that the precipitate produced should be washed on a filter, and dried. Portions of the iron of the tersulphate, and of the potassium of the fer- rocyanide, change places, so as to form sulphate of potassa and ferro- cyanide of iron, of which the former either remains in the solution, or is dissolved out in the washing, leaving the latter pure. Composition. Ferrocyanide of iron consists of three equivalents of ferrocyanogen (which contains one equivalent of iron and three of cya- nogen), four equivalents of iron, and six eqs. of water ; the last ingre- dient being essential; as it cannot be separated without decomposing the salt. The compound, however, as in the case of other haloid salts, may be looked on as consisting of a hydracid and an oxide of iron, the hydro- gen of the water going to the ferrocyanogen, and the oxygen to the iron. In this view, the salt would be a hydroferrocyanate of the sesquioxide of iron, and would consist of three eqs. of hydroferrocyanic acid (each containing one eq. of ferrocyanogen and two of hydrogen), and two eqs. of sesquioxide of iron. Commercial Prussian blue always contains, besides the above compound, a portion of uncombined alumina and sesquioxide of iron. Properties. The pure salt is in the form of a rich deep-blue powder, inodorous and tasteless, insoluble in water and alcohol, and unaffected by the dilute acids. Strong sulphuric acid dissolves without decom- posing it, concentrated nitric and muriatic acids decompose it, and the alkalies separate sesquioxide of iron. Effects on the System. From the insipidity of Prussian blue, its insol- ubility even in dilute acids, and the fact that it is formed whenever fer- 478 GENERAL STIMULANTS. [PART II. rocyanide of potassium meets a salt of iron in the body, even in the circulating liquor sanguinis, a fair inference is, that it would probably have no other effect on the system than such as might result mechan- ically from the presence of an insoluble powder in the stomach and bowels ; and this view would seem to be supported by the experiments of M. Coullon, who found it without action in several different species of animals. (Jlerat et De Lens, ii. 531.) Therapeutic Application. Notwithstanding, however, its presumed inertness, it has been much commended by some practitioners. Dr. W. Zollickoffer, of Maryland, first called the attention of the profession to it as a remedy in intermittent and remittent fevers, in which he was in- duced by his observations to consider it superior to Peruvian bark. ( Am. Med. Recorder, July, 1822, v. 540.) Dr. Samuel Jackson, late of North- umberland, employed it with success in a large number of cases, but found it to fail in many. (Am. Journ. of Med. Sci., ii. 33f>, A.D. 1827.) Dr. Hasse, a German physician, found it effectual in an epidemic inter- mittent which prevailed at Gastrow in the spring of 1827 ; but he gave doses of a grain of the salt with a scruple of pepper, the latter of which was probably much the more efficacious of the two. (Hufeland's Journ., quoted by Merat and de Lens, ii. 531.) Dr. Eberle speaks of it favour- ably from his own observation and experience. (Mat. Med. and Therap., 4th ed., i. 321.) Many other physicians have borne a somewhat hesita- ting or equivocal testimony in its favour. I tried it myself in a number of cases, soon after it first came into notice, with some success, but with so many failures that I soon abandoned it. The medicine has been given with supposed success also in chorea and epilepsy, but associated generally with others, so as to leave the real agvnt of cure doubtful, and sometimes in such doses as to leave no doubt as to the inefficiency of the Prussian blue. Thus, M. Burguet, of Bordeaux, gave from one- eighth of a grain to four grains a day; and Dr. Kirckhoff, of (Jhrnt, sup- posed that he cured epilepsy with from half a grain to six grains in the day. Dr. Bridges, of Philadelphia, employed it in a case of obstinate facial neuralgia, with considerable relief, after the ordinary remedies had been tried with little or no effect. It will have been observed that all these diseases, in which efficiency has been claimed for it, are of a character to be readily affected through the mind; and in which any- thing will occasionally effect apparent cures in which the patient may have confidence, or even strong hope. I am not prepared, however, to say, that the mere presence of an insoluble agent in the primie vise, acting only mechanically on the mucous surface, may not prove useful in nervous diseases, and local affections of the membrane itself. The dose, as given by different practitioners, varies extremely. Gen- erally, from four to six grains have been given several times a day. In- stances are mentioned above in which the dose was reduced to the eighth CHAP. I.] MANGANESE. PHOSPHATE OF LIME. 479 of a grain, and Dr. Jackson, late of Northumberland, gave in some cases two drachms during the interval in intermittents, finding it to lie easily on the stomach. This latter fact tends strongly to favour the idea of its inertness, in reference to any direct influence on the system in general. Besides the preparations of iron, other substances have been to a certain extent remedially employed, under the impression that they might supply deficiences, in the system, of certain constituents derived from the min- eral kingdom. Manganese, having been found in the blood, has been like iron sup- posed to constitute a normal ingredient of that fluid; and, under this impression, has been used in certain conditions of anaemia as an adjuvant of the chalybeates, or a substitute for them. At one time the compounds of this metal were considerably prescribed ; but, with one exception, the permanganate of potassa, they have fallen into comparative neglect; and this owes its importance to quite other properties than those of a reconstructive tonic. This salt will be treated of with the Disinfect- ants ; and I may then take occasion to allude to some other prepara- tions of this metal; but, for a full account of them, the reader is referred to the IT. S. Dispensatory. Phosphate of Lime has been supposed to be useful in certain cases of diseased bones, by supplying a deficiency of earthy matter, as in rickets, scrofulous affections of the bones, etc.; but it is not, I believe, the defi- ciency of material that here constitutes the difficulty, so much as the power of assimilating them ; and phosphate of lime is probably almost always sufficiently supplied with the food. Nevertheless, it may be used with- out disadvantage, even if productive of no great benefit. It has been adopted in the U. S. Pharmacopoeia, under the title of Precipitated Phosphate of Lime (C aids Phosphas Prsecipitata, U. S.), and directions are given for preparing it from calcined bones. (See U. S. Dispensatory, 12th ed.) It is a white, inodorous, tasteless powder, insoluble in water, but readily dissolved by diluted nitric, muriatic, and acetic acids. The acid being tribasic, it consists of three eqs. of lime and one of phospho- ric acid. Beneke has suggested its use in diseases of defective nutri- tion, as scrofula, phthisis, etc., from the circumstance that it is an ingre- dient in the ultimate cells ; but the same reason for doubt exists here as in the former case of diseased bones; it is not the material, but the assimilating power that is wanting ; for, in many of these cases, the insol- uble phosphates are discharged in excess by the kidneys, showing that there is no deficiency of them in the blood. The dose is from ten to thirty grains. It may be given in powder, or dissolved in water, with 480 GENERAL STIMULANTS. [PART II. the aid of a little muriatic or nitric acid, which will often probably greatly add to its efficiency. Hypophoaphites. On the same view of supplying a supposed defi- ciency of material in the system, the hypophosphites have been em- ployed to furnish phosphorus to the tissues; and with this object have been especially recommended in the treatment of phthisis. Experience, however, has shown their entire want of control over this disease ; and there does not appear to me to be sufficient reason for introducing them into the already overburdened catalogue of remedies. All needful in- formation in relation to them will be found in the third part of the U. 8. Dispensatory (12th ed.). CHAP. I.] DIFFUSIBLE STIMULANTS. 481 SECTION SECOND. Diffusible Stimulants. UNDER this division of General Stimulants are included those which act quickly and energetically, but only for a comparatively short period. In the degree in which they possess the stimulant property they differ much among themselves ; but, as a general rule, they greatly exceed, in this respect, the permanent stimulants, embracing the astringents and tonics, which have just been under consideration. One of the laws of all stimulation, whatever may be its degree, is that it is followed by a depression proportionate, at least approximately, to the previous exalta- tion of the function or functions excited. Hence, the remedies belonging to the present section, as they exceed the astringents and tonics in rapid- ity and extent of stimulant action, leave behind them a more speedy and greater depression. General Therapeutic Remarks on Diffusible Stimulation. The condition to which this therapeutic process is applicable, is ob- viously that of general depression of the actions or powers of the sys- tem. To a considerable extent, the observations made upon tonic stimulation in reference to the possible injury from its abuse, and to the conditions of depression or debility admitting and calling for its employ- ment, are applicable also to this variety, and need not be repeated. Only a few remarks, more particularly bearing on the subject at present under consideration, are required. As a general rule, the diffusible stimulants may be resorted to in cases of considerable, and especially of rather sudden or acute pros- tration, which tonics and nutritious food are either too slow in action, or too feeble in stimulant power to counteract. But some cautions are necessary. Sometimes there is great prostration of the vital actions, depending on the concentration of blood and nervous power in some large organ, or extensive structure in the interior of the body, in a state of high in- flammation. This may without caution be mistaken for real debility, and fatally treated under that impression. It occurs usually at or near the commencement of the inflammatory attack, and will in general IK' readily diagnosticated by the evidences of the existing inflammation, if VOL. i. 31 482 GENERAL STIMULANTS. [PART IT. the practitioner be on his guard. In these cases, bleeding is the great remedy, if it can be employed; the system reacting as the interior or- gans are unloaded, and the pulse rising under the lancet. But sometimes the least amount of blood lost so far impairs the powers of the heart a> still further to depress the pulse. Under such circumstances, stimula- tion may become necessary in order to excite the heart, and rouse up the circulation generally, so that loss of blood may be borne, until the relief of the internal congestion shall remove the depressing force. But it is obvious that the stimulation must be such as will not be likely to con- tinue into the period of reaction, as it would much aggravate the dan- ger of inflammation. Therefore, reliance should mainly be placed on external stimulation, which can be withdrawn at any moment when de- sirable ; and, if this should prove insufficient, the stimulants of briefest action should be preferred, as heat, the ammoniacal preparations, and those of ether. Another analogous condition, in which precisely the same cautions should be observed, is that collapse of system which generally attends violent concussion of the brain, and not unfrequently occurs after any severe shock upon the system, as from accidental injury, or a surgical operation. The nervous centres are here prostrated, and all the vital functions fail in consequence. Sometimes reaction never takes pla< : but when it does, inflammation and fever almost always ensue, and might be greatly aggravated by the previous injudicious use of stimulants. But these are sometimes essential to assure reaction. The external, and those of brief action are here also indicated ; and those especially should be avoided which would peculiarly stimulate the organ likely to become the seat of inflammation, as the brain in concussion. Again, collapse calling loudly for diffusible stimulation sometimes occurs in the cold stage of febrile diseases, particularly those of a typhous and malignant character, and the exanthematous. Here also reaction will take place if the patient survive ; and, although equal caution in regard to prolonged stimulation is not necessary as in the former in- stances, the reaction itself being often tainted with debility, yet injury may be done by a too zealous employment of the measure, and the stim- ulants of long-continued action, and greatest influence on the brain, should be resorted to only when it becomes obvious that external and brief internal stimulation will not answer. But when debility occurs in the course of acute disease, as in the va- rious febrile affections, diffusible stimulation may be employed without scruple, and usually in a degree exactly corresponding with the apparent call for it. Here there is no danger of subsequent reaction. The prom- inent indication is to support the system until the depressing agency shall have ceased, and either the system have recovered its energies, or the disease run its course. CHAP. I.] DIFFUSIBLE STIMULANTS. Even the coexistence of inflammation does not, under such circum- stances, altogether contraindicate the use of stimulants, though it should dispose to greater watchfulness not to exceed the necessary point. Va- rious inflammations occur in the course of fevers of the low or typhoid character, in which the blood and nervous force are both greatly impaired, and often will not sustain life unless by the aid of the diffusible stimu- lants. Local measures, even moderate cupping or leeching, fomentations, blisters, etc., and the careful use of the mercurials, may be employed for the inflammation, while stimulants may be freely used to support the functions, and nutritive matter to supply a better blood. This remark, too, is applicable even when the inflammation may have been the original affection, provided the symptoms of typhous debility, and a depraved or poisoned blood supervene. Examples of this kind we have in typhous pneumonia, typhous dysentery, malignant sore-throat, and the prostrate or malignant forms of scarlet fever, smallpox, and erysipelas; and there is scarcely one of the exanthematous fevers, or of the local inflammations to which the remark will not apply. Another condition of debility, often demanding the free use of the dif- fusible stimulants, is that which attends acute febrile affection or inflam- mation occurring in persons previously worn out by enfeebling disease, bad living, or habits of intemperance. In the last case, it is generally necessary, even when the lancet may be employed for the cure of the inflammation, to administer stimulants to support the heart and nervous centres, which would refuse to act without them. This is an important therapeutic principle in the treatment of habitual drunkards, and even of those who have been long in the habit of using ardent spirits in great excess, though never obviously intoxicated. Again, when the system is exhausted by profuse evacuations, as in the hemorrhages, cholera, diarrhoea, etc., by long-continued disease of almost any kind, or by copious suppuration, the result of antecedent in- flammation, or is prostrated under the influence of gangrene from the same or some other cause, diffusible stimulants are often necessary to support life until the system recovers its powers, or the processes referred to shall have terminated, as they usually have a tendency to do, in health. Often, in these cases, tonics and a nutritious diet, or even the latter alone, may be sufficient; but frequently also the diffusible stimulants are essential. Whenever, moreover, the blood becomes, so impaired by an absorbed or otherwise introduced poison, as to be incompetent alone to the support of the vital functions, diffusible stimulants must be freely used, in order to sustain life as long as possible, in the hope that the poison may be thrown off, or that the blood and solid tissues may pass through the series of morbid changes set on foot by the poison, and return to the sound condition. Thus, purulent infection, the state of system resulting 484 GENERAL STIMULANTS. [PART II. from poisoned wounds, as in dissection, and the poisonous condition produced by the bites of serpents and other venomous animals, will some- times recover under potent stimulation, when the patient might perish without it. Finally, there are diseases in which the nervous centres appear to be prostrated, without any observable vitiation of the blood, and without at first any considerable failure in the actions of the heart; in which, however, powerful stimulation is sometimes essential. Not to mention delirium tremens, in which this condition of the nervous centres results from the withdrawal of a wonted stimulus, and which often imperiously demands stimulation to save life, there are tetanus, and various other violent spasmodic and nervous affections, among which mania may be sometimes included, in which the same remedial measure is often of great importance. Division of Diffusible Stimulants. Most of the general excitant influences, though they may in a greater or less degree affect the whole system, are characterized by having a preferable tendency to some one of the subordinate systems rather than to another ; and hence the stimulants belonging to this section are divided into the arterial, the cerebral, and the nervous, according as they exhibit a tendency to excite more especially the circulation, the brain, or the ner- vous tissue generally. To this rule, however, there is one striking ex- ception. Heat is a vital stimulus essential to the support of every func- tion in its normal state, and capable, therefore, when operating in excess, of producing over-excitement in all parts of the body. It is a universal stimulant, and is capable of being remedially employed as such with very great advantage. The consideration of it as a remedy falls within the scope of this work, and, in relation to its stimulant powers, belongs especially to the present section. Having, however, other therapeutic- properties, it will, in reference to these, be treated of in connection with the several classes to which it may belong, as the diaphoretics, rube- facients, epispastics, and escharotics. The following observations apply only to its properties and uses as a diffusible stimulant. Electricity is .another diffusible stimulant, which, though employed more especially in reference .to its action on the nervous system, is really universal in its influence, and can be brought to bear, as a rapid and powerful excitant, upon any one of the systems or organs of the body. This, therefore, must be considered as belonging to the present division of remedies, and will be treated of after heat CHAP. I.] DIFFUSIBLE STIMULANTS. HEAT. 485 I. HEAT AS A DIFFUSIBLE STIMULANT. It is only when of higher degree than the temperature of the body, or of that part of the body to which it may be applied, that heat is used therapcutically. No precise degree, therefore, can be fixed, at which it will take rank among remedies; for the temperature of the body which must determine this point, is itself variable. But, as a general rule, it may be said that a heat of 95 F. or upwards, may be remedial; for this is above the average temperature of the surface of the body ; and a de- cided sensation of heat will be excited by the contact of a conducting substance, at that temperature, with the skin. But, should the surface be very cold, a much lower temperature than that mentioned might prove stimulant; and, on the contrary, should it be very hot, a higher might be applied Avithout any effect of the kind. It will be remembered, therefore, that when precise degrees may be mentioned hereafter, they are to be considered not as fixed, and applicable under all circumstances; but merely as an average, and of course to be varied with the particular condition of the body at any given time. It will be found also, in the progress of these observations, that the mode in which heat is applied influences very much the degree at which it will act as a remedy. 1. Effects of Heat on the System. The first effect of heat is to excite its own peculiar sensation in the seat of application. In a moderate degree, this may not be unpleasing; indeed, when the temperature has been depressed below the normal -lundard, it is often highly grateful; but, if increased, it begins at length to become painful, and in its higher degrees is often extremely so. The excitant influence is speedily extended to the capillaries, which dilate under the stimulation, admitting a larger amount of blood, and thus reddening the surface, and producing a greater or less distension of the tissue generally. The blood of the part, thus increased in amount, and at the same time flowing more rapidly with the increased action of the vessels, receives an increment of he/it from without, which it carries through the system, to produce everywhere a degree of the same stimu- lant effect first produced upon the surface of application. The impression upon the nerves, moreover, is transmitted to the cerebral and spinal centres, exciting them to increased action. A universal stimulant influ- ence is thus exerted. The heart beats more rapidly and energetically ; and the pulse is consequently fuller, stronger, and more frequent. The respiration is hurried. The general temperature, under the universal excitation, is elevated in a degree much greater than would result from 486 GENERAL STIMULANTS. [PART II. the mere addition of caloric from without, The secretions are promoted ; all of them probably at first, under a gentle operation of the stimulant : but, when the heat is considerable and continued, the mucous mem- branes and the kidneys appear to be irritated beyond the point of free secretion, as indicated by a dryish state of the mouth, and diminished discharge of urine ; while the secretory functions of the liver and skin are augmented, so that there is usually a freer flow of bile, and greater or less increase of perspiration. An explanation of this difference in effect, and of its uses, will be given hereafter under the head of dia- phoretics. At present it is sufficient to observe that, in some instances, even the liver and skin appear to be so much irritated as to be unable to perform their functions, and the patient consequently suffers with hepatic congestion, and general heat and dryness of the surface. Along with the exaltation of the organic functions, the nervous also become excited. A moderate influence of the cause is usually attended with agreeable effects. Sensibility is rendered more acute, muscular motion invigorated, and the intellect, imagination, and feelings more or less ex- alted. But these functions, under a higher degree of the exc-itation, be- come deranged, and at a still higher are impaired ; so that a feeling of fulness and even painful distension of the head, vertigo, and other ab- normal cerebral sensations, and hebetude of the intellectual and emo- tional functions, are often experienced. This result is simply in con- formity with the general law, that, by moderate over-excitation or irritation, the functions are increased in a normal direction, by a greater amount of it, are deranged, and by a still greater, are diminished or 'suppressed. The generative functions obey the same general law; and the sexual feelings are excited, the menstrual act promoted, and the capacity for conception probably increased, under the genial influence of a moderately elevated temperature ; while they may be perverted or suppressed by its excess. Should the heat be very considerable, or con- tinued too long, a universal acute derangement of the functions may take place, constituting fever; and this is the condition of system existing in the disease called sun-stroke, and for which the name of heat-fer> / has been proposed, under this idea of its nature.* As in the case of almost every other stimulant, the excitement pro- duced by heat in the functions, i^ followed by a proportionate depres- sion. The excitability, exhausted by excessive exercise, now fails to respond to the ordinary vital stimuli, and action is of course diminished. As before stated, this may be considered as a nearly universal law of stimulation. Hence the soft, compressible, and often feeble pulse, tin- cool, pale, and relaxed skin, the muscular debility, the lassitude or indis- position to exertion, the mental languor, and the tendency to sleep. * See the article on Heat-fever in the sixth edition of my Treatise on the Prac- tice of Medicine. (Note to the third edition.) CHAP. I.] DIFFUSIBLE STIMULANTS. HEAT. 487 after the subsidence of the general excitement produced by the hot bath. Hence, too, the enfeebled state of system, the habitual languor and lassi- tude, experienced after a prolonged exposure to the heats of summer, or a residence of some months in a tropical climate. 2. General Therapeutic Application. Two main purposes are fulfilled by heat acting as a stimulant; first, to elevate the depressed, or support the failing functions; and secondly, to equalize the distribution of the blood and nervous energy, by attract- ing them away from parts where they may exist in excess towards the seat of its own immediate action. These two indications not unfre- quently exist in the same case, and are fulfilled by the same application of the remedy; as in those instances of great prostration, with concen- tration of the blood in the interior, which are presented in the initial or cold stage of malignant fevers. Here the stimulant influence of heat, applied to the surface, rouses the prostrated nervous centres and the heart, while it calls forth the accumulated blood from within, and un- loads the oppressed vital organs. Frequently also the two purposes are separately fulfilled ; as when heat is applied, in one instance, to aid internal stimulants in supporting the sinking system in the advanced stage of febrile diseases, and, in another, to draw excitement away from the brain or lungs, towards the lower extremities in threatened apo- plexy or pulmonary congestion. But it will be most convenient to treat of the special uses of the remedy, in connection with the several modes of applying it, which are next to be considered. 3. Modes of Applying Heat Therapeutically. Of the heat generated within the body by exercise, stimulation, rich diet, friction, etc., I shall not here treat, because it is a result of other measures, and, though it may be one of the means by which those measures prove remedial, it cannot be itself considered in the light of a remedy. There are two modes of obtaining the direct influence of heat; first, by preventing the escape of the natural heat of the body, and thus caus- ing its accumulation, and secondlypby imparting it to the body from other heated substances. 1. Confining the Heal of the Body. This is effected by surrounding the person with a badly conducting medium in the form of clothing, or bed-covering at night, or in that of a dry atmosphere, which is a very slow conductor. a. Clothing. Much may be done in the management of morbid tend- encies, and even of disease itself, by a proper regulation of the clothing. 488 GENERAL STIMULANTS. [PART II. Furs, feathers or down, and wool are the worst conductors of heat; tissues made of raw silk are, perhaps, next in order; then tissues of cotton, and after this linen, which is the most rapid conductor of all the materials used for clothing. It is obvious that, when the object is to keep the surface warm, a selection should be made from these substances, whether for body clothing, for bedding and bed-covering at night, or for occasional use under extraordinary exposures to cold, according to the degree of protection Avanted ; the worst conductors being chosen when it is most important to confine the animal heat. Upon the whole, the most suitable under-clothing for keeping up an equable temperature of the body is flannel, or the elastic woollen tissue now so much worn, which has the advantage over flannel that it shrinks less by washing, and is not apt to become so hard and stiff. When it is specially im- portant to preserve an equable temperature, this should be worn through the whole year, summer as well as winter; the quality being accommo- dated to the degree of heat. The fabric may be had of every diversity of texture, from the coarseness of the heaviest flannel, to the fineness almost of gossamer ; and the lightest should be chosen for summer wear. It is scarcely less important in the warm than the cold season ; for the changes of summer are very great, and the surface is even more suscep- tible to cold than in winter, in consequence of its frequent relaxation under a high temperature. Should even the lightest woollen fabric be insupportable in the most intense heat of the season, a similar tissue made of raw silk may be substituted, or, if this cannot be had, of cot- ton; but, in cases of delicate health, where the preservation of the tem- perature is important, linen should never be worn next the surface of the body, unless when the skin is excessively irritable ; and. in that case, wool, silk, or cotton should be worn over it. Persons in whom this kind of caution is essential, should be peculiarly careful to keep the feet warm and dry, either by woollen stockings, or, what is sometimes pref- erable, double stockings, one pair of silk, and the other of cotton. Oc- casionally, woollen hose keep the feet in a constant perspiration, which moistens the covering, and serves to convey away the heat; so that these parts are always cold. This evil may often be corrected by wear- ing the double hose just referred to. In wet weather, the boots or shoes should always be water-tight, when the person is exposed out of doors; but they should be exchanged for*others within doors, as they confine the perspiration, and cause the feet to be cold by making them damp. The outer covering should always be proportioned to the degree of cold. when the body is necessarily exposed to it. Some delicate individuals think they can harden themselves against cold, by habitual exposure ; and hence encounter the severest weather with insufficient covering. This is a great mistake. They frequently, I believe, expose themselves in this way to the great danger of aggravating a morbid diathesis into CHAP. I.] DIFFUSIBLE STIMULANTS. HEAT. 489 positive disease. The proper rule is never to allow one's self to become chilled for any length of time. An excellent mode of preventing the evil results of the present fashion of open dressing over the chest, is to suspend from the neck, under the shirt, a piece of doubled silk with cot- ton wadding quilted within, or a dressed rabbit's skin. At night, equal attention is necessary tfl preserve a due degree of warmth. The cover- ing should be sufficient to render the person comfortable; and, with deli- cate persons, it is better to err on the side of excess of warmth than that of cold. The habit of using mattresses in summer is very well; but feather beds should be employed, in winter, by all persons in whom the indication for sustaining a warm temperature of the body exists. I think I have known the most serious evils result from an attempt, on the part of individuals of scrofulous predisposition, to harden themselves to the influence of cold; and carelessness en this point may be equally in- jurious. It will be observed that I am not applying these remarks to the healthy and robust. For these, equal caution is not necessary; though even they would do well to exercise some care in the point under consideration. The predispositions and affections to which these observations are especially applicable are those of a scrofulous or tuberculous character. A continued depression of temperature beneath that of full health is pe- culiarly injurious in all the forms of tuberculosis, whether before or after the deposition, and in all cases of a strumous character or tendency. Hence the advantage, on the part of such individuals, of a residence in warm climates ; but, when this is impossible, much can be done by a due attention to clothing, by day and by night, and at all seasons. I do not say that temporary exposures to cold may not sometimes be useful in these persons, through the tonic influence of the reaction. But such exposures should always be purposed, not accidental ; should be em- ployed in a remedial capacity, and not left to the caprices of chance; and, when they are resorted to, the utmost care should be taken that due reaction shall ensue. When this takes place with difficulty, they should be at once abandoned. The above remarks may seem trivial to the in- experienced ; but those who have seen much of disease know, that influences of the kind here alluded to are quite as important as medi- cines, and will agree with me in the necessity of attention to them. JJut it is not in the scrofulous cachexia only that a due preservation of warmth is important. All low forms of disease, and especially the 1 1 >w fevers, are promoted by constant chilliness; and no fact is more universally admitted in medicine, than that change of temperature, and especially exposure to cold after heat, is one of the most fruitful causes of the various inflammations. The preservation of a moderate warmth of surface, not sufficient to induce perspiration, is one of the great hy- gienic rules which should be attended to under all circumstances. 490 GENERAL STIMULANTS. [PART II. b. Dry Air. Another method of sustaining the warmth of the body is to surround it with dry air, which is a very bad conductor. But dry air favours greatly the evaporation of liquids, and thus tends to act inju- riously, in many instances, on the mucous membrane of the air-passages, and on the skin. It is, therefore, only under peculiar circumstances that it can be resorted to remedially. It is indicated in patients of a debili- tated habit, with a disposition to excessive moisture of the surface, and excessive bronchial secretion from chronic disease of the air-passages. In certain cases of pituitous catarrh, or humoral asthma as it was for- merly called, with a cool perspiratory state of the surface, confinement to such air may prove useful. This is readily accomplished, in winter, by warming the external cold dry air by passing it over heated surfaces, without supplying water to moisten it, in its passage into the chamber. Great facility for this purpose is afforded by the present plan of heating houses from furnaces in the cellar. 2. Imparting Heat to the Body. The methods of accomplishing this object are numerous, and each requires a special notice. They may all be included in two divisions ; the first embracing those in which the heating body used is dry, the second those in which it is moist. There is an important difference between these two methods. By the first we obtain the effects of heat alone ; in the second, the sedative influence of moisture, and the conducting power of water, modify these effects often very materially. These influences will be considered when we come to the methods of applying moist heat, a. Dry Heat. This is imparted either by radiation, or by the direct contact of the heated medium. Insolation, or exposure to the rays of the sun, is the most effective mode of obtaining the influence of radiant heat. It is sometimes agree- ably stimulant to the old, feeble, and paralytic, and appears to act as a restorative in the debility of convalescence. As the combination of heat and light, in the direct rays of the sun, is essential to the perfect devel- opment of vegetables, so is it probably also to that of animals; and there is little doubt that this is one of the influences which, combined together in a journey through the country in the warmer seasons, tend so powerfully to build up a system dilapidated by disease, worn out by over-exertion, or languishing from the confinement, impure air, and in- door dwelling of a town life. To the scrofulous and consumptive, exer- cise in the pure sunny air is peculiarly beneficial ; and the direct warmth of the sun, by a positive stimulation and invigoration of all the vital processes, contributes considerably, I have little doubt, to the favourable influence of a residence in warm climates over a tuberculous diathesis. An excess of it may, of course, be injurious, and must be guarded against, especially its immediate action on the brain. The radiant heat of a fire may be used as a substitute for insolation CHAP. I.] DIFFUSIBLE STIMULANTS. HEAT. 491 in the old and feeble, during winter. The same mode of heating is often used for equalizing the temperature in cases of cold hands and feet; and, in attacks of spasmodic colic, or of subacute and neuralgic rheumatism from exposure to cold, a thorough heating of the feet, before a good fire, will sometimes produce a cure.* Substances used to impart dry heat to the body by conduction are solid or aeriform. Of the former class are bottles filled with hot water or heated sand; tin vessels made to fit certain parts of the body, and filled in the same manner; metallic bodies, such as flat-irons heated; hot bricks; bay* filled with heated oats, sand, or ashes, and shaped so as to lie conven- iently along various parts of the body; and towels heated as hot as the skin will bear them, and applied folded to the surface. These means may be had recourse to in the cold stage of febrile diseases ; the ad- vanced stage of the same diseases, with general feebleness and coldness of the extremities; the collapse of cholera and other bowel affections ; asphyxia, complete or partial ; the external paleness and chilliness attend- ant on severe colic, and violent spasms of the stomach, gall-duct, and ureters; in short, whenever there is an indication for the general stimu- lation of heat, or its derivative influence from irritated, congested, or inflamed organs. In cases of great emergency, when some powerful impression may be necessary to rouse the failing sensibilities of the system, a red-hot coal may be applied to the surface, especially to the epigastrium. I have known of an instance of this kind in malignant typhus, in which the patient, who had sunk below the reach of all ordi- nary stimulants, was roused by this means, and, on recovering after- wards, said that the sensation of the burning coal had been positively agreeable to him, in the state of horrible vacancy of feeling to which he * A very interesting case of resuscitation, in a new-born infant, under the influ- ence of heat, is recorded by Dr. Jos. G. Richardson, of Cayuga Co., New York, in the American Journal of Medical Sciences (January, 1867, p. 128). Induced by the success of Dr. Richardson, of London, in restoring the action of the heart by in- jecting heated blood into the coronary arteries, he conceived the idea of imitating the experiment on the living body; and, in the case of the infant referred to, find- ing all other methods, including artificial respiration, but partially successful, he caused the lower extremities of the child to be heated before a fire as highly as could be borne without producing local mischief, and then by pressing the heated blood in the veins of the limbs towards the heart, he endeavoured to introduce it in that state into the coronary vessels. The effect, he states, was "almost miracu- lous." The heart, which had before acted feebly and involuntarily, quickly began to pulsate energetically, the respiration became continuous, and the prospect of a thorough restoration was very encouraging; but subsequently, in the absence of the physician, death occurred from the officiousness of the nurse in giving nourish- ment, contrary to the injunction of the physician to avoid it. (A'ote to (he third edition.) 492 GENERAL STIMULANTS. [PART II. had been reduced. When the solid bodies above enumerated are brought into contact with the surface, care must be taken that they are not hot enough to burn the skin ; and this caution is the more necessary, because the patient is often himself too insensible at the time to give notice of the danger. It is sometimes advisable to wrap them in flannel, in order to interpose a slow conductor between them and the skin. Heated air may be employed for the same purposes. The body will support a much higher temperature of the surrounding air when it is dry, than when moist, because in the former state it is a much worse conductor. Persons have even remained, for a short time, in chambers heated considerably above the boiling point, without suffering material inconvenience. According to AIM. Berger and Delaroche, when the temperature is between 150 and 190, a smarting sensation is produced in the surface, particularly in the conjunctiva and nostrils, the veins swell, the skin becomes burning hot, the pulse is very greatly acceler- ated, even to 1GO in a minute, the respiration is laboured, and vertigo, headache, and other disordered cerebral phenomena are experienced ; but very soon a copious perspiration breaks out, and tends in a considerable degree to obviate the unpleasant effects. (Forbes, Cyclop, of Pract. Med., Am. ed., i. 286.) It is very seldom necessary, however, in order to obtain any desirable stimulant effect, that the temperature should exceed 150; and often a much lower heat will answer. The stimula- tion is greatest when the patient is wholly immersed in the hot air, so as to inhale it into the lungs; but it is a safer and equally effectual plan, for all practical purposes, to allow the hot air to be applied only to the sur- face of the body, while the patient breathes air of the ordinary temper- ature. As, in many of the cases to which the remedy is applicable, there is an indication for revulsion from the interior to the surface, the latter plan is preferable on this account. For the modes of preparing the hot-air bath, sec page 70, in the first part of this work. The hot-air bath is probably more frequently used with a view to pro- duce perspiration than as a mere stimulant. For the latter purpose, how- ever, it may be resorted to with much benefit in certain cases of prostra- tion, with coldness of the surface, to which more particular reference will be made when the therapeutic applications of the hot-water bath are considered. As this cannot always be commanded, the hot-air bath. which can generally be quickly prepared and applied with facility, may often be substituted for it with advantage.* * Through the efforts of Mr. Urquhart and others, the use of the hot-air bath has recently received great extension in England, with extraordinary therapeutic rcMilts. Of the various public and private baths, erected within the last seven or eight years, one connected with the Newcastle Infirmary, under the supervision of Sir John Fife, has yielded a large experience of this mode of cure, which, in the course of five years, has been employed in more than 20,000 cases. The complaints CHAP. I.] DIFFUSIBLE STIMULANTS. HEAT. 493 b. Moist Heat. In moist heat, two quite distinct agents are combined, which must be considered separately before their joint influence can be well understood. Heat is purely stimulant ; water, purely sedative ; and the result of their combined action will depend on the proportion in which they respectively exist in the combination. The influence, too, of cold, that is, of the diminution of heat below the normal standard of the sur- face of our bodies, must be taken into account. This is sedative; but differs in this respect from the sedative influence of water, that its de- pressing effect is always attended with a disposition to reaction, which is wanting in the operation of the latter. The sedative properties of cold and water will be more fully considered in a more appropriate place. They are here alluded to, merely to make more intelligible the properties and effects of heat and moisture combined. Water may be applied to the body, with a view to remedial action, at three different temperatures; below, at, and above that of the surface in health ; so as to produce, in the first instance, the sensation of cold; in the second, no sensation either of cold or heat; and in the third, that of heat. It is obvious that, by a bath answering to the first condition, the joint depressing influence of cold and of water would be produced ; to the second, the purely sedative influence of water; and to the third, the combined sedative influence of water, ;ui(l stimulant influence of heat. The first two conditions of the bath may be left out of view in this place, as not belonging to the sub- ject of stimulation. It is to the third only that our attention is to be now directed; that, namely, in which the temperature of the bath is above that of the surface, so as to occasion the sensation of heat. Hut Balk. In a bath of this kind, the effects are both stimulant and sedative; and whether one effect or the other shall predominate, must depend on the degree of the temperature above that of the surface of the body. AVhen the elevation is but moderate, the two influences may balance each other ; so that neither elevation nor depression of the vital functions shall be perceptible ; and this is the condition in which the bath can be longest borne, and which should be aimed at when the mere cleansing effect of water, with as little impression as possible of any kind upon the system, is required. But this equation of effect is obtained only after a short period of inversion. Heat acts more quickly than in which satisfactory results are said to have been obtained from it, are, among others, acute and chronic rheumatism, gout, neuralgia, catarrh, various throat affec- tions, diarrhoea, dysentery, diseases of the liver and stomach, dropsy, scrofulous affections, and incipient phthisis. It is not, however, as a general stimulant exclu- sively that it operates in guch cases. Its strong revulsive influence must greatly contribute to its efficiency; and, as a powerful means of producing diaphoresis, it acts both as an evacuant, and as an eliminative agent with great effect. In ref- erence to these effects of the hot-air bath, it will be more particularly noticed here- after. (Note to the third edition.) 4!H GENERAL STIMULANTS. [PART II. water; and its excitant influence, even when it is only in very moderate excess, is experienced before the water has fairly begun to operate; so that a short time must elapse before the balance is established. Nor docs the exact balance continue long. Under the stimulus of heat, the excitability is impaired, and the excitation consequently gradually ceases, and is at length followed by depression, according to the general law ; while the sedative effect of the water is increased, the longer that agent continues to operate. Hence, the short period during which the two are balanced is followed by a period of depression much greater than the antecedent elevation, and increasing with the continuance of the agent. The bath, therefore, of which the temperature is but slightly above that of the surface, can scarcely be considered as a stimulant agent ; the ex- citant effects being moderate and very brief, and the sedation soon pre- dominating. It is, therefore, as a sedative remedy that it is almost uni- formly employed ; and as such it will be considered hereafter, under the name of the warm bath. The title of hot bath should be confined to that in which the heat is felt at first rather disagreeably, and in which the excitant effect decidedly predominates, and continues to predominate for a considerable time. It is the operation of this variety of the bath that is now to be considered. The limits of the hot bath, as determined by the sensations, may be placed, in reference to the lower extreme, at the point when the heat is merely somewhat uncomfortable ; in reference to the higher, at that in which it is barely not insupportable. As indicated by thermometrical degrees, they cannot be fixed precisely; because they vary with the variable sensibility and temperature of the surface; but the lowest point may be considered as somewhere between 95 and 100 Fahr., and the highest between 100 and 112 ; and it is never advisable to exceed the decree last mentioned. At the mean of 103, the bath is actively stim- ulant, producing a strong sensation of heat, reddening and expanding the surface of the body, increasing the frequency, force, and fulness of the pulse, hurrying the respiration, and causing at first an agreeable ex- citement of the brain, not unlike the effect produced by wine, but ending. if the immersion continue, in painful sensations of fulness, distension, and vertigo. After a time, perspiration breaks out upon those parts of the body not covered with the water; and, if the patient is removed from the bath, and placed in bed, the whole surface usually becomes relaxed, and bathed in a copious sweat. The excitement gradually subsides; and is followed, if the regular succession of events is not modified through some abnormal state of the system, by universal relaxation, with depres- sion of the pulr-e, muscular weakness, feelings of languor and drowsiness, and ultimately sleep. The immersion may continue from four or five minutes to half an hour, according to the effects; the patient being always , removed when unpleasant cerebral phenomena are produced, and never CHAP. I.] DIFFUSIBLE STIMULANTS. HEAT. 495 allowed to remain when the stimulant effect is the main indication, until evidences of depression supervene. The operation of the water in the hot bath is at first, through its con- ducting power, to hasten the stimulating effects of the heat, but after- wards, by the relaxation it produces, to favour the secondary depression ; and the latter result often adds greatly to the beneficial influence of the remedy, when it is designed to act rather as a revulsive agent than as :i general excitant. The conditions indicating the use of the hot bath are 1. coldness of the surface, with either general prostration, or powerful and concentrated internal irritation, inflammation, or congestion; and 2. an abnormal state of system, in which a strong impression is required, to break up long-continued and obstinate morbid associations. The following are affections in which these indications are presented. In the cold stage of febrile diseases, particularly those of a malignant or pernicious character, there is sometimes a degree of prostration and indisposition or inability to react, which is extremely dangerous. The nervous centres seem to have become almost inert under the violence of the morbid cause, and the most important vital functions are prostrate under the want of their necessary influence. The heart acts feebly, the surface is cold and pale, and the great internal organs are loaded with the venous blood, which accumulates in them because the moving forces are unable to carry it forward. Sometimes death takes place without any reaction ; sometimes feeble and insufficient efforts at reaction are made, and the patient sinks back into the same alarming prostration as at first. In aid of other stimulant measures, the hot bath may often be resorted to, in these cases, with great advantage. Through its powerful impression on the surface, it rouses the nervous centres from their torpor, and tlm* indirectly excites the circulatory and respiratory functions; by heating the blood as it passes through the vessels of the skin, it renders that fluid more stimulating to the great interior organs, as the heart, lungs, and brain, into which it is conveyed ; and, while thus acting as a powerful general stimulant, it is no less powerfully revulsive, irritating the whole of the cutaneous capillaries to an active expansion, and draw- ing into them the blood before accumulated in the central viscera arnd great venous trunks. It is one of the most efficient agents, in such cases, in bringing about reaction. Typhus fever, pernicious miasmatic fever, smallpox, scarlatina, and epidemic erysipelas are among the diseases, in the initial or cold stage of which the hot bath not unfrequently proves useful on the principles here stated. It has, too, the great advantage over internal stimulants, that it can be at once withdrawn when needed no longer, and does not add, by a prolonged influence, to the violence of the reaction when this is brought about. In sudden prostration occurring in the advanced stages of low fevers, 496 GENERAL STIMULANTS. [PART II. in prolonged asphyxia, in the collapse of cholera, haemalemesis, and melsena, similar indications are afforded by the cold surface, the pros- trated vital functions, and the interior congestion. In the retrocession of cutaneous eruptions, the hot bath is often use- ful. In some instances, the apparent retrocession is nothing more than a sudden general prostration, in which the actions of the surface fail with those of the whole system, and which differs in nothing from the sinking spells of low fevers noticed in the last paragraph ; but, in most cases, it is owing to, or connected with the occurrence of severe internal irritation, which it is highly desirable to recall as quickly as possible to the surface. Not unfrequently, a similar condition existing previously to the eruption, retards its appearance, and sometimes it may even keep back the cutaneous affection altogether, to the great detriment of the patient. Under these circumstances, the hot bath proves serviceable by powerfully exciting the skin, and making this the seat of afflux for the irritative tendencies. The eruption again appears, or comes forth if not previously existing, and the symptoms of internal disorder cease almost instantaneously. Painful internal spasms are generally more beneficially treated by the relaxing warm bath than by the stimulant hot bath ; but sometimes they are so severe, and attended with so much general prostration, that thft former remedy is quite inefficient, and it becomes desirable to have recourse to the greater energy of the latter. Violent attacks of nervous gout in the stomach and bowels, of colic, and of spasm of the dia- phragm, are examples of this kind. The remedy acts by a revulsive impression on the general surface. Internal inflammation is usually not a proper subject for the influ- ence of the hot bath, which too much excites the circulation, and sends the blood too forcibly into the parts affected; but, in certain cases, the inflammation is so violent and extensive as to concentrate the blood and the nervous energy of the system in its own scat, with the effect of pros- trating the general functions, and inducing great apparent debility, for which, indeed, the condition has sometimes been fatally mistaken. The cold and pale surface, and feeble pulse seem to call for active stimula- tion ; while, in fact, prompt and free bleeding is indicated, and is some- times the only remedy which will save the patient. Gem-rally, under these circumstances, if a vein is opened, the blood will flow, slowly and scantily at first, but with a gradually increasing current; and, so far from still further failing, the pulse will rise, and become fuller and stronger, as the operation proceeds. This, however, is not always the case; and it is found impossible to continue the bleeding without endan- gering fatal prostration. In such a case, the hot bath is an admirable remedy. By its powerful revulsive action it calls the blood from the interior to the surface, stimulating the heart at the same time; and CHAP. I.] DIFFUSIBLE STIMULANTS. HEAT. 497 though of itself it would be altogether inadequate to the cure, and, if continued, might act injuriously upon the inflamed organ by sending the blood into it too vigorously, yet it prepares the system for the use of the lancet, and thus opens the way for a cure which might not other- wise be possible. It should of course be withdrawn the moment that it has answered its purpose. In cases of this kind, the warm bath, though useful in ordinary internal inflammations, would be quite inert; and might even be injurious by its sedative action on the surface and the heart. Extensive inflammation of the peritoneum, dysentery of extra- ordinary intensity, and violent pneumonia in the congestive stage, and occupying both lungs, sometimes present the condition referred to. Obstinate chronic enteritis, with little or no excitement of the circula- tion, and an habitually dry, palish, and cool skin, may also be advanta- geously treated with the hot bath, repeated every day, especially if made somewhat more permanently irritant to the skin by the addition of common salt : and the same remark will apply to inflammation of other abdominal viscera, presenting the same conditions. In the first mentioned affection, I have found the hot salt-bath one of the most effica- cious remedies. It was stated above that the hot bath is indicated in some obstinate long-continued affections, in which it appears to act by breaking up mor- bid associations. Possibly it may operate by a penetrating stimulation of all the tissues, which are thus roused out of their habit of morbid, action into an over-excitement, from which they may afterwards subside into health. In some such method as this, it sometimes proves benefi- cial in cases of chronic rheumatism and gout, occupying at the same time various parts of the system, distorting the joints, contracting the tendons, and not unfrequently, to a greater or less extent, paralyzing the muscles. It is not impossible, however, that the diaphoretic action of the bath may add to its efficiency. The bathing at hot springs has proved peculiarly useful in these diseases. Perhaps in the same category may be placed certain chronic and indo- lent affections of the skin, in which the tissue requires to be roused alike out of its torpor, and out of its morbid habit of acting. Caution is necessary not to use the bath at too early a stage ; and if, as often happens with stimulating applications made prematurely, it should be found to excite inflammation or high irritation, it should be immediately suspended. It should also be accompanied with alterative measures, to change the constitutional condition, while the attempt is made to relieve the local disease. In paralytic cases of long standing, in which the original cause, if affecting the nervous centres, has quite ceased to operate, and the dis- ease is sustained by a morbid indolence of the tissues concerned, whether VOL. i. 32 GENERAL STIMULANTS. [PART II. nervous or muscular, some good may be hoped for from the hot bath, in connection with other measures. The contraindications to the use of the hot bath are a plethoric state of system, determination of blood to the head, active heinorrhagic tend- encies, general vascular irritation with active congestion, aneurisms and hypertrophy of the heart, acute inflammation with well-developed fever, the febrile state generally with a hot skin, and a peculiarly irritable state of the nervous system. Local Hot Bathing. Hot water may be employed locally by semicupium, coxseluvium, pediluvium, maniluvium, fomentation, or cataplasm. For an account of these methods of application, the reader is referred to page 69. They act on the same principles as the general hot bath, but are much less powerful, and, with the exception of the semicupium, or half- bath, which is usually employed as a milder substitute for the general bath, and in cases where determination to the head or trunk is feared, are used less for general .stimulation, than for their excitant effect on some one part or organ of the body, or for their revulsive influence. Thus, the hot hip-bath is used to stimulate the uterus in amenorrhoea; and the hot foot-bath and hand-bath to act revulsively from the head or interior organs towards the extremities, whenever the latter are cold, and evidences exist in the former of active .congestion without fever, and espe- cially when gout or rheumatism has retroceded from the extremities, and it is desirable to restore it to its original seat. Hot fomentations, or hot cataplasms, are employed to relieve by revulsion either inflammation, spasm, or other irritation of interior organs over which they may be applied, or to stimulate the part to increased action, as when it is desir- able to hasten a languid external inflammation onward to suppuration, and through this to a more speedy cure. Another form of local application is the hot douche, or stream of water falling from a height, or directed with some force upon the part. This unites the effects of shock and pressure to the stimulant action of the heat, and proves sometimes more efficient than the simple application of hot water, in chronic rheumatic and gouty swellings, obstinate local palsies, and indolent tumefactions and indurations of inflammatory origin. Hot Vapour Bath. In some countries there are public vapour baths. in which numbers may be collected in the same chamber; and this is occasionally so arranged, with seats rising one above another, that per- sons may be exposed to various temperatures; the heat of the apartment increasing from below upward, because it is the tendency of the vapour to ascend. Thus, upon the level of the floor the heat may be only 110 Fahr., while in the uppermost part of the chamber it may be as high as 160 or 180. Of course, the patient inhales the hot moistened air, as well as feels its effects upon the surface. The vapour may be introduced CHAP. I.] DIFFUSIBLE STIMULANTS. HEAT. 499 into the chamber from without, or by throwing water, within, upon stones heated to redness by a furnace beneath. But, in this country, it is only the solitary vapour bath which is employed. For the various modes of preparing it, see page 71, in the first part of this work. It may be so arranged that the patient can breathe, at his pleasure, either the moistened air of the bath, or the cold external air. The heating effect of the former is greater ; but its revulsive influence is less ; and, as it has a tendency to suppress the pulmonary exhalation, it may sometimes act injuriously when the latter would be quite safe. In consequence of the less conducting power of vapour than of water, the former can be borne at a much higher temperature than the latter; while, for a corresponding reason, the vapour bath may be intolerable at a temperature at which dry air could be borne without inconvenience, the latter being a slower conductor. According to Dr. Forbes, the heat- ing effect of the hot bath, at from 98 to 106, is equal to that of the vapour bath, when the air is breathed, at from 110 to 130, and when it is not breathed, at from 120 to 160 (Cyc. of Pract. Med., Am. ed., i. 255); and these are the temperatures within which the methods respectively may be employed ; though, in each, the heat may be raised with impunity considerably above the highest point mentioned. The effects of the vapour bath, and of the hot bath, are essentially the same in reference to stimulation and revulsion ; but the former is attended with much more copious perspiration during its continuance than the latter; the contact of water with the surface having great effect in pre- venting extravasation from the blood. Another difference is that the relaxing or sedative effect of the vapour is less than that of the water; and that consequently the stimulation of the former, though more slowly induced, is longer sustained, and is accompanied with a less degree of soothing influence. The vapour bath may be used for the same purposes us the hot bath, but is, upon the whole, less efficient and less agreeable. In its extemporaneous form, it may be employed when circumstances may render it impossible, or extremely inconvenient to prepare and apply the bath of heated water. It is also preferable, in some instances, when the indication is to produce profuse perspiration with a stimulant effect, as in certain cases of chronic rheumatism. Local vapour baths may be applied by exposing any part of the body to the steam escaping from boiling water, which may be readily confined by a suitable arrangement of woollen or other clotlis. But they are employed more for the relief afforded to inflammatory, and other painful affections, by the copious perspiration they induce in the part, than as stimulant agents. The same may be said of the hot vapour douche, which consists in a jet of heated vapour directed on some part of the surface. It differs from the simple application of steam only in exposing the part to successive 500 GENERAL STIMULANTS. [PART II. portions of vapour, instead of continuously to the same ; and the effect is consequently somewhat greater. It may be applied by causing 1 steam to pass through a pipe from a vessel of boiling water ; or, in relation to the meatus auditorius of the ear, by holding the orifice of the rueatus over the small end of a funnel, the larger end of which is placed over a vessel of water boiling hot. In the latter case, the remedy may be used, as a stimulant to the ear, in cases of defective hearing from deficiency of nervous power. Finally, healed vapour may be applied exclusively to the lungs by in- halation, and thus made to act as a stimulant to the bronchial tubes when enfeebled, and exposed to the excessive production of mucus in consequence of this relaxed state ; but the measure would require to be conducted with much caution. At a lower temperature, so as to pro- duce, not the stimulant effects of heat, but the soothing and emollient effects of mere moisture, it may often be used with benefit. But this action of the remedy belongs to another section. For the modes of ap- plying vapour by inhalation, see page 75. Hot Water as Drink. Hot water has the same stimulant effect, when taken internally, as when applied to the surface ; but it is almost never used except as a vehicle for other substances, the action of which it often very much promotes, and, even in this mode of administration, is much less employed with a view to its stimulant action, than as a diaphoretic. In cases of great prostration, it may sometimes be advisable to exhibit stimulant drinks heated rather than cool, as their effects are thus both hastened and augmented. H. ELECTRICITY AS A DIFFUSIBLE STIMULANT. In treating of electricity as a remedial agent, I shall take it for granted that the reader is already acquainted with its chemical and physical prop- erties, and with the prevalent opinions of its nature. In this place it is to be considered only in relation to its physiological and therapeutical effects, and to the methods of employing it as a remedy. As these effects are materially modified by the modes in which it is developed or excited, and applied, the latter division of the subject must be first treated of, in order that what may be said on the former may be understood. I wish here to express my indebtedness for much which follows to the excellent work of M. Duchenne de Boulogne, who, by his thorough and laborious experimental investigation of electricity in its medical rela- tions, the sagacity with which he has traced the various ramifications of its influence, and the ingenuity and perseverance with which he has ap- plied the knowledge thus obtained to successful therapeutic results, has given a precision to the subject which it before much wanted, and lui* opened a new era in the history of the remedy. CHAP. I.] DIFFUSIBLE STIMULANTS. ELECTRICITY. 501 1. Modes of Development or Excitation. For medical purposes electricity is developed or excited in four some- what distinct methods; 1. by friction, in the form of common elec- tricity; 2. by contact and chemical reaction, in the form of galvanism ; 3. by magnetic induction, in the form of electro-magnetism ; and 4. by a combination of magnetic and galvanic induction, as by the volta- electric apparatus. a. Excitation by Friction. General Observations. Electricity excited by friction is usually de- nominated static, conveying the idea that it is stationary or not in action, while in the form of galvanism it is said to be dynamic, as being essen- tially in movement, and exercising power. Though this distinction is not very precise, it may serve at least the purposes of nomenclature. A very great difference exists between the phenomena exhibited by these two forms of electricity ; the static having in a high degree the proper- ties of attraction and repulsion, and, when brought into movement, ex- ercising great mechanical power ; the dynamic exhibiting its energy more in developing heat, and producing chemical change. It is supposed that this difference depends, not on any essential diversity of character, but on the different states of the electricity developed in the two methods ; that excited by friction having little quantity, but great tension or inten- sity, by which it is able to overcome resistance, while that set in move- ment by contact and chemical reaction has feeble tension, but large quantity. These terms, however, are rather conventional, intended to represent certain qualities in convenient language, than absolutely ex- pressive of the fact ; for it is by no means universally admitted that electricity is a distinct substance, to which the term quantity is at all applicable, unless as a figure of speech. .Means of Excitation. Static electricity is developed by means of fric- tion between two substances, and this is usually effected by an apparatus called the electrical machine, constructed in different methods, for an account of which I must refer to works on chemistry or natural philoso- phy. To every ^achine is attached an insulated conducting body called the prime conductor, which receives upon its surface the electricity as it is excited, and retains it for a considerable time, in consequence of the non-conducting property of the dry air around it. Thus developed, the electricity acquires a degree of tension, proportionate to the power and working of the apparatus, by which it is enabled to break its way through the resisting air to neighbouring bodies, producing a stream of light in its passage, and a very perceptible sound. When the tension is very great, the spark, as this flash is t called, may be many inches long; when very slight, it may be even less than an inch. In order that the 502 GENERAL STIMULANTS. [PART II. electricity may escape in this way, the body approaching the conductor must be rounded or flat; as, if pointed, it receives the electricity quietly, and almost insensibly from the conductor. Silent Conduction. If any part of the person be brought into contact with the prime conductor, the electricity passes silently into and through it, or along its surface, into the earth, in search of the equilibrium to which it always tends. Sparks. If, instead of coming into absolute contact with the excited prime conductor, a part of the body be made to approach it within a cer- tain distance, greater or less according to the degree of electric tension, the fluid passes to the body by sparks, which produce a decided sensation as they are received. By means of rods or chains of metal, or other con- ducting substance, in contact at one end with the prime conductor, and having a rounded knob at the other, the electricity may be conveyed to any convenient distance from the machine, and applied by sparks to any part of the body. These communicating instruments are called directors, and must be insulated from the hand of the operator by some non-con- ducting substance, such as glass, which may at the same time serve as a handle. Electrical Bath. Another method of applying static electricity is by placing the patient upon a stool, insulated by glass legs, and then con- necting him with the prime conductor. His body thus shares the elec- tricity with the conductor, and acquires precisely the same relations towards the machine and other surrounding objects. In this way it may become saturated with the fluid, which escapes very slowly and silently from the hairs, finger and toe nails, and the surface of the body generally ; the hairs rising up and standing apart under its repellent force. Sparks may now be drawn from any part of the body by the approach of a blunt conducting substance; and, liy keeping the machine constantly in action, this condition may be indefinitely prolonged. By communicating with the negatively excited, instead of the positive prime conductor, it is ob- vious that the body may itself become negatively excited ; and, by vary- ing the connection, the peculiar effects of either of these two modes <>f the electric influence may be separately obtained. This method of ap- plying electricity is denominated the electric bath. $ Electric Aura. This is a current of electricity directed to any pan of the body, through the air, by means of a pointed insulated director, con- nected at one end with the excited prime conductor by a chain, and, at the other and pointed extremity, held near, but not in contact with tin- portion of surface to be acted on. The electricity silently and invisibly issues from the point, and, expanding cone-like as it passes through the air, spreads itself out broadly upon the surface. Exactly the reverse takes place, when a similar point is held near the body, itself in a state of electric excitation upon an insulated stool. Little if any sensation is in either case experienced. CHAP. I.] DIFFUSIBLE STIMULANTS. ELECTRICITY. 503 Leyden Jar and Electric Battery. By these instruments the greatest force of the electricity of friction is obtained. The jar is a broad-mouthed glass bottle, coated within and without by tin-foil, excepting the upper part of both surfaces, where it is bare. With the inner coating is in contact a chain, connected with a metallic rod, which passes upward through a cork, or other material closing the mouth of the bottle, and ends in a round metallic ball at top. When this ball is put in communi- cation with the excited prime conductor of the machine, the inner coat- ing becomes positively charged, while, at the same time, by the laws of electric induction, the outer coating passes into the negative or opposite state. If now a conducting substance be connected with the inner coat by means of the knob, and directly or indirectly with the outer, the equilibrium is instantly restored, and the whole force of the movement is exerted upon the connecting material. If this be the body, a shock is felt, proportionate in degree to the extent of the coated surfaces, and the amount of the charge. It may be so slight as to occasion little incon- venience, or so powerful as to destroy life like a flash of lightning, which, indeed, is nothing more than the spontaneous discharge of an analogous electric arrangement in the atmosphere, or between that and the earth. But to obtain a shock of such extreme violence, it would be necessary to make the bottle of an unwieldy magnitude ; and the same end is at- tained by connecting together a number of bottles by their inner and outer surfaces respectively, so that the whole may be discharged at once. Such an arrangement is called the electric battery, and affords an instru- ment of immense power. The current of electric force may, with either the jar or battery, be made to penetrate through the skin, and enter deeply into the body; and, by means of directors connected with the opposite excited surfaces, may be conveyed from one end of the body to the other, or through it from side to side, or from one part to another of a limb, or through very lim- ited portions of the body, at the pleasure of the operator. The directors must of course have insulated handles, and their knobbed free extrem- ities must be applied at the opposite extremities of the part through which the current is to pass. If the object be to direct the electricity into a single muscle, both extremities, as directed by M. Duchenne, should be applied immediately over the muscle, with the space of an inch or more between them. A repetition of graduated effects may be obtained through the jar, by placing its ball in communication with the excited prime conductor, and its external surface, in any convenient method, with one of Lane's elec- trometers, in such a manner, that the ball of the electrometer shall not be in absolute contact with it, but within striking distance of the elec- trical spark. By means of chains, insulated directors may be connected with the prime conductor and the electrometer, and their knobs applied 504 GENERAL STIMULANTS. [PART II. at the required points of the surface. When the machine is set in mo- tion, and the jar becomes charged, at the moment of connection through the body, the electrical current passes between the knob of the electro- meter and the outer coating of the jar, to establish the equilibrium. If the intervening space is large, the shock will be necessarily severe, for great tension will be necessary to overcome the resistance of the air; if very small, the shock may be slight ; so that its severity may be regu- lated by regulating this interval, and at the same time attending to the working of the machine. Care should be taken that the jar should be fully discharged before commencing operations ; and then the handle of the machine should be turned more or less frequently, and more or less rapidly, according to the effect required. b. Excitation by Contact and Chemical Action. Galvanism, or the dynamic form of electricity, is excited by the contact of two metals, or other conducting bodies, with the presence of a fluid capable of chemical action on one only of the two, or on one more than on the other. A change of electrical condition takes place in the one most easily affected chemically; the other assumes an opposite condi- tion ; and at the moment of communication between them, whether by the absolute contact of the two, or by means* of another metal, an at- tempt to restore the equilibrium takes place, with the effect of develop- ing electrical phenomena. The apparent current of force is from the metal chemically affected, through the liquid, to the one not affected, and then through the connecting material to the point of origin. But, as the cause is constantly operating, the electrical condition is constantly dis- turbed, and no equilibrium is in fact established, but a constant circle of action maintained until the exciting agency is exhausted. Anything susceptible of change by electrical influence, if placed in the circuit, will feel the effects in a degree proportionate to its susceptibility, and the force developed. From a simple circle, as above described, but slight effect is obtained - 9 yet enough to be very sensible. To increase the effect, these simple circles or elfiuents must be multi- plied, so as to form what are called galvanic batteries, or voltaic piles ; and the power developed is in proportion to the number of the elements employed. Numerous methods of attaining this eml have been devised, which it is not my object to describe. One thing is common to all of them ; namely, that the associated metals, or other conductors, in earh pair, and the several pairs themselves always bear the same relation to one another; and the successive pairs must be connected by a conduct- ing medium. The extremes of the arrangement are consequently of opposite character; and, when they are made to communicate, the accu- mulated force of the whole battery is exerted in the line of communica- tion. These extremes are usually denominated poles, the one at which CHAP. I.] DIFFUSIBLE STIMULANTS. ELECTRICITY. 505 the metal most acted on is placed being; the negative, and the other, to- wards which the current of force is directed, the positive. Zinc and either copper or silver are the metals usually chosen, and a diluted acid, especially the sulphuric or nitric, the exciting and conduct- ing liquid; but other metals and other liquids, and even non-metallic substances may be substituted, and various other arrangements have been shown to have a similar agency ; chemical action, however, being common to all. As before stated, the tension of galvanic electricity is very slight, and consequently but slight sparks are afforded by approaching the poles, and relatively slight sensation produced; but the influences de- pendent on quantity are strong, such as chemical decomposition, the development of caloric, and, in the animal system, the production of organic change. Application. The simplest galvanic arrangement may be applied with great facility. A small circular or oval plate of zinc, and a silver coin an inch in diameter, placed in the mouth, one above and the other below the tongue, and then allowed to touch, afford evidence of their action to the sense of taste ; and a similar pair, soldered together, may be used for very gentle stimulation to these parts ; the saliva acting as the excit- ing liquid. Another simple arrangement is to place upon two separate parts of the body, between which it is desired to establish a galvanic current, two thin oval or circular plates of zinc and silver, an inch or two in diameter, one on one of the parts, and the other on the other, and to connect the two by means of a delicate wire attached to an eye, upon the outer sur- face of each plate. The skin beneath should be moist, so as to allow the galvanic influence to penetrate through the cuticle, which is a bad con- ductor; and for this purpose a layer of any wet conducting substance may intervene between the plates and the skin. Even distant parts of the body may be connected in this way. Galvanic Chains. A series of small hexagonal plates, composed each of a zinc and a silver plate soldered together by one of their surfaces, and connected by wires so as to move freely, forms a sort of chain, which may be worn next the body, and becomes active through the perspira- tion. The chain of Pulvermacher, made of couples of minute coils of wire around cylinders of wood, and connected together by wire, acts with considerable energy. The number of elements may extend to sev- eral hundreds. Excited by being steeped in an acid liquor, it continues to act for several hours, and may be usefully employed in the treatment of superficial affections. The advantage of these and other arrange- ments with small elements is, that the peculiar galvanic stimulation may l>e obtained with less of the heating effect, which is proportionate, in some degree, to the size of the metallic plates, while the former depends more upon their number. 506 GENERAL STIMULANTS. [PART II. Batteries or piles are made of various forms, and of variable numbers of pairs, according to the amount of effect desired. They are applied by means of wires connected at one end with their opposite poles, and terminating at the other in various modes for convenience of use, by which the galvanic influence is conveyed to the person at any distance from the battery. These conductors must be insulated, in some portion of their course, by glass tubes or otherwise, so that the operator himself may not interrupt the current. Of the different methods of termination of these conductors more will be said, in connection with other electric arrangements to be considered immediately. I may mention here that the object is sometimes effected by applying the agency through the me- dium of water. Thus, both feet may be placed in vessels of water con- nected with the opposite poles, or both hands, or one foot and one hand ; and thus the currents varied in their direction through or over the body. Indeed, the whole body may be immersed; so that, when the bath is con- nected with one pole, and the body with the other, the electric current may diffuse itself through the system, in its attempts to escape at the surface. Disadvantages of the ordinary batteries used for chemical pur- poses, as Cruikshank's, Wollaston's, etc., are the disagreeable odour given out in consequence of the decompositions which take place, their unwieldy size, and the difficulty of suitably regulating their action. They are not, therefore, much employed ; though circumstances occasionally arise which render a resort to them advisable. The ordinary galvanic batteries, though they give a continuous cur- rent of a certain duration, are unable to furnish that continuity and duration of the galvanic action which is necessary to fulfil all the de- mands of the most recent galvanic therapeutics. To obviate this defect, several batteries have been contrived, known from their authors as Grove's, Bunsen's, and DanielFs batteries, which have stood the trst of trial, and one of which is now generally used, where the greatest simple galvanic effects are required. c. Excitation by Magnetic Induction. When a magnet is placed within a coil of wire insulated by being cov- ered with silk thread, the latter assumes a polar condition the reverse of that of the magnet; and, if the magnetic circuit and that of the coil be closed at the same time, a current takes place in the latter in a direction opposite to that of the former. A powerful horse-shoe magnet is thus capable of inducing an electric movement in a coil of wire, which gives rise to sensible phenomena, and with certain arrangements may be made to act with great energy. When the body is connected with the two opposite poles by any conducting material, a slight shock is felt upon the closing of the magnetic circuit, after which no sensation is perceived, and no obvious effect produced, until the circuit is broken, when another CHAP. I.] DIFFUSIBLE STIMULANTS. ELECTRICITY. 507 sensation stronger than the first is experienced, by the instant alteration of the current before its entrance into repose. If, by any contrivance, this interruption of the circuit be made rapidly, the quick succession of the shocks becomes painful, and the effect may be increased so as to be quite insupportable. Upon this principle it is that the electro-magnetic machine is composed. Electro- Magnetic or Magneto-Electric Machines. Different machines of this kind have been devised by different persons. Among them probably those of Clark, Dujardin, and the Messieurs Bre- ton are best known. The current is broken in these instruments by a rotary movement given to the armature of soft iron, by which it is altern- ately brought into and removed from apposition with the magnet; but the coil of insulated wire, called the intensity coil, is in some of them placed around the armature, and in others around the magnet. This difference is of no great account, as the armature always becomes tem- porarily a magnet when in connection with the proper magnet, and con- sequently induces a current in the coil around it. But M. Duchenne, considering none of them capable of effecting all the objects attainable by a perfect machine of this order, endeavoured, by combining the best parts of those in use with improvements of his own. to make an instru- ment approaching nearer to his conception of what is desirable than any one hitherto invented. As this instrument, at the time when the first edition of this work was published, was, I believe, quite unknown in this country, I gave in a note a figure of it copied from one in M. Du- chenne's treatise, with his explanation of its construction and principles. This description, as no longer necessary, has been omitted in the second and present editions. I would simply state, in relation to the instrument, that the chief additions made by M. Duchenne were a graduator of the currents, by which the intensity may within certain limits be increased or diminished at pleasure, and a second superimposed coil of insulated wire, much finer than the first, by which the intensity is greatly increased, and which, though used in the volta-electric machines, had not previously been applied to the electro-magnetic. d. Electric Excitation by Galvano-magnetic Induction. If within a coil of insulated wire a piece of soft iron be placed, and a galvanic current be passed through the coil, the soft iron becomes mag- netized, and continues so as long, and only as long, as the current is maintained. Now this temporary magnet exercises an inductive power on the wire, similar to that produced by a permanent magnet, and in- creases the force of the galvanic current in the former. If, over the coil of wire alluded to, another be placed consisting of smaller wire, this also acquires an induced state of electric action, and the intensity of the gal- 508 GENERAL STIMULANTS. [PART II. vanic current is still further augmented. If, again, the current be inter- rupted, phenomena are produced of the same character as those already referred to as resulting from a similar interruption of the current in the electro-magnetic apparatus. Upon these principles instruments have been invented for the therapeutic application of electricity, which have of late been much in use, and, together with the electro-magnetic machine, have almost superseded the methods formerly employed. Volta- Electric Machines. Galvano- Magnetic Induction Machines. Electro- Dynamic Machines. A large number of these machines have been contrived in England, France, and Germany, as those of Newman, the Messrs. Breton, Keller, etc. The following are the essential parts of the apparatus: 1. a pri- mary and secondary coil or helix of insulated wire; 2. a bundle of soft iron wires to be introduced within the coil ; 3. a contact-breaker, by which the current is interrupted, and which is made to act through the influence of the galvanic current itself; 4. a galvanic battery or pile, consisting of one or more pairs, which is to furnish the influence by which the whole apparatus is set in operation; and 5. a pair of insulated metallic directors or conductors, which are to be connected with the poles of the apparatus, and by means of which the electricity is applied to the body. The terminations of these directors are called by M. Du- cbenne excitors, and are of various character and form to meet special indications. (See page 509.) To put the machine in operation, the galvanic battery is first made to act, and the electric influence is conveyed to the ends of the larger and inner wire, which thus becomes the connecting medium between the poles of the battery. A galvanic circuit is thus established, the inten- sity of which is greatly increased by the reaction upon each other of the spirals through which the influence is propagated. At the same time the bundle of wires within becomes mairnrti/ed. and the outer wire acquires an induced state of great energy, and in an opposite direction to the original current. It is, however, by the frequently repeated interruption of the currents that they acquire their great physiological and remedial power, as in the electro-magnetic machine. The contact-breaker which produces this effect operates on a very simple principle. A slip of metal movable at one end, and kept in its place by a spring, is so situated that the movable end forms a part of the circuit, which passes through its point of contact. But being also near, though not in contact with the iron which becomes magnetized by the current, as soon as this is estaln lished, it is attracted by the nuuriietic force, and separated from its pre- vious connection. The circuit is thus broken, the magnet loses its power, the attraction ceases, and the spring forces the movable slip back to its original position. This restores the current, and the same opera- CHAP. I.] DIFFUSIBLE STIMULANTS. ELECTRICITY. 509 tion is repeated as before ; so that there is a constant and rapid succes- sion of intermissions, as long as the machine acts; the contact-breaker producing a sensible sound, as it flies rapidly backward and forward be- tween the metallic boundaries of its movements. The wires which serve to convey the influence of the machine to the patient, and which are of course attached to its opposite poles, are often themselves made to increase the intensity of the current, by being thrown for a portion of their length into the spiral form. I shall not attempt to describe the various instruments employed, and must content myself here with referring the reader to a note, in the first edition of this work, in which an account is presented of one of the most recent and most perfect, which has been arranged by M. Duchenne. By consulting this account, he will be put into possession of all that will be necessary to enable him to understand and apply not only this, but other apparatuses of the same kind.* * Exciters, or Terminations of the Directors. Before proceeding to treat of the effects of electricity on the system, it will be expedient to make a few remarks on the different modes of application, by the directors. The form of the terminations of the free ends of the conducting wire or chain, by which the influence is conveyed to the patient, is of some importance. These term- inations are called excitors by M. Duchenne. When electricity is to be applied by the aura, they should be pointed ; when by sparks, rounded ; when by contact, they may be of any form which the practitioner may deem most convenient; the mere touching of (he excitors by any part of the surface being sufficient. Spherical, olive- shaped, or conical terminations (Fig. 2) are very common. Sometimes cylindrical pieces of metal are used, which the patient can hold in his hand. Sometimes a me- tallic shoe is made to fit the foot, which terminates one pole, while the other is applied to some other part of the body. The excitors may be straight or variously Fig. 1. Fig. 2. Fig. 3. curved, and when to be applied by an operator, must, as before stated, have an in*u- lating handle. It is often necessary that the surface of the body to which they are applied should be moist, to enable the influence to penetrate through the cuticle. In such 510 GENERAL STIMULANTS. [PART II. 2. Effects of Electricity on the System. As electricity is probably identical under whatever aspect it may pre- sent itself, its effects under similar circumstances are probably also iden- tical; but, in the different conditions in which it is actually developed, it exhibits striking differences of operation, which render necessary the consideration of it, in the present relation, as before in regard to the methods of development, under its several distinct forms. Its charac- teristic effects, as a general rule, are to excite sensation and muscular contraction, and, indeed, to augment the functions of all the organs on which it may be brought specially to act; consequently, under favouring circumstances, to promote digestion, absorption, circulation, animal tem- perature, secretion, and the nutritive and assimilative processes ; in other words, it appears to be capable of acting as a universal stimulant, though more especially directed to the vital properties of sensibility and muscu- lar contractility. In its influence upon sensation, it produces effects corresponding with the functions of the several senses ; causing pain, when acting on the nerves of general sensation ; the perception of light, when on the organ of vision ; a peculiar taste, when on the tongue and palate; smell, when on the olfactory organs; and sound, when on the ears. Muscular contraction is caused by it, whether directed to the muscle exclusively, to the nerves of motion, or to the nervous centres of motion In the higher exertion of its powers, like some other stimu- lants, it has the effect of overwhelming the vital functions, and producing apparent direct prostration, even to a fatal issue. Witness the effects of a violent shock, and especially of a stroke of lightning, which often destroys life instantaneously, and, when it fails to do this, generally leaves the patient for a time more or less prostrate, senseless, and paralyzed. a. Effects of Electricity Excited by Friction. The effects of a mere accumulation of electricity in the system have not been satisfactorily determined. We feel often very differently before and after a thunder-storm. Many persons imagine they can detect by their sensations the approach of certain changes in the weather, before any evidence of such changes is presented by ordinary signs. I know neuralgic persons who suffer much more in certain kinds of weather than in others, though completely protected against any influence of cold or instances, the ends of the excitors should be covered with buckskin or other similar material, which will imbibe nnd retain moisture. A sort of hollow cylinder con- taining a wet sponge (Fig. 1) should be used, when it is desirable to cover some extent of surface. M. Duchcnne uses sometime-* a bunch of fine wires, iu the form of a brush or broom (Fig. 3), the wires being fixed at one end iu u hollow cylinder, irom which they project at the other, and the cylinder being screwed upon an insu- lating handle. CHAP. I.] DIFFUSIBLE STIMULANTS. ELECTRICITY. 511 moisture. These results have been vaguely ascribed to the electrical condition of the system, and possibly with some justice ; but it would be difficult to adduce positive proof of the fact ; and, when we attempt to reduce the phenomena within any general rules, they quite elude our grasp. Silent Conduction. When the body, by contact with an excited prime conductor, becomes the route through which the electric current passes, however powerful may be the machine, and however rapid the current, no observable effect is produced either upon the sensations, or any of the functions. The Aura. This is said to operate as a mild stimulant to the portion of surface upon which it is made to act ; and has sometimes been em- ployed for this purpose in affections of very delicate organs, as the eye. But the influence, if any, must be extremely slight. The Electric Bath. Very different statements have been made as to the effects of electricity accumulated in the system, in a state of insula- tion. Some have found it to increase the frequency of the pulse, and promote the secretions, especially those of the skin, kidneys, and salivary glands, and have obtained great supposed advantages from it in rheu- matic neuralgia, and paralytic diseases. Giacomini, while admitting that the positive electric bath produces no impression on any one of the interior functions, imagined the negative to be powerfully depressing, and capable of advantageous use as a contra-stimulant agent It is not im- possible that, in certain very susceptible individuals, the bath may have some influence ; but I have found no effect from it in my own person, and the same I believe to be the experience of most who have tried it ; and, without calling into question the accuracy or trustworthiness of those who have made opposite statements, we are, I think, justified in :it loast suspecting, that the phenomena observed were really ascribable to the mental state of the persons acted on, and in no degree to the elec- tricity. As to the supposed cures of rheumatism, neuralgia, and palsy, we know well how powerful mental influence is in many cases of those affections, and how often the favourable changes which have taken place spontaneously with time, have been ascribed to the last remedy used. But, though we may doubt the remedial influence of simple elec- trical accumulation, yet the bath may be made a means of gentle stimu- lation to the surface, by the sensation produced when the electricity is drawn from the body, under these circumstances, by sparks. Sparks. The spark, whether drawn from an excited prime conductor by the body, or from the excited and insulated body by other substances, is attended with more or less sensation, of a sharp, pungent character, very slight when the spark is small, but painful when the electric tension is very great, though seldom so severe that it cannot be readily borne. The electricity scarcely penetrates beyond the surface ; yet it in some 512 GENERAL STIMULANTS. [PART II. degree excites the skin, and, if the operation is continued, produces rubefacient swelling, and some tenderness to the touch. It may there- fore, be occasionally used with advantage in this method, as a gentle excitant in inactive states of the surface, and as a revulsive in internal diseases of no great severity. It may be concentrated in one spot, or applied extensively over the surface ; and, for the latter purpose, the bath probably affords the most convenient means. By the interposition of flannel, which may cover the ball of the director, or be applied to the surface of the body, a great number of minute sparks may be drawn rapidly, with less discomfort to the patient. Leyden Jar. When the body is made the connecting medium between the two surfaces of a Leyden jar, a quick painful sensation is expe- rienced, denominated the shock, which is always disagreeable, and may be so violent as to be quite insupportable. This is attended with a quick, jerking, muscular contraction, and even the deep-lying muscles may be brought into energetic action. If applied to the hands, the sensation is felt chiefly in the wrists, elbows, and breast. If directed so as to reach the nervous centres, the shock radiates through the whole system. When severe, its first observable effect, independently of the sensation and spasm produced, is to depress function by overwhelming it. Thus, the skin for a short distance around the point of entrance is whitened, and its temperature lessened, while the follicles project in consequence of the shrinking of the tissue. The part is also more or less benumbed. If the shock is passed through a nerve of sensation, numbness is apt to be felt in the parts supplied by it ; and a severe shock through the brain or spinal marrow, produces, in the former case, mental confusion, forgetful- ness, dimness of vision, etc., in the latter, feebleness approaching to paralysis of the lower limbs. The violence of the effect is proportionate both to the electric intensity and quantity. A small jar, highly charged, will produce a greater effect than a larger one feebly charged ; but, the intensity being equal, the degree of effect is then proportionate to the quantity, or to the magnitude of the apparatus. The shock from an electric battery is capable of producing temporary insensibility, and prob- ably death. After fatal effects from lightning, streaks of redness are said to be sometimes observed along the surface ; and the blood is, in general, fluid, and the muscles flaccid, as if universal death had taken place immediately. The depression occasioned by the shock from the jar speedily passes off, and is followed by more or less reaction. In this method of application, electricity may sometimes be usefully employed for exciting parts which lie deeply, and are extremely insusceptible, or in rousing a torpid system by the shock, or for depressing nervous excite- ment by its first overwhelming effects; but it is impossible to limit it* action precisely to any one muscle or part ; and there may be hazard, in cases of great depression, of dangerously adding the prostration of the shock to that already existing. Allusion has been before made (seepages CHAP. I.] DIFFUSIBLE STIMULANTS. ELECTRICITY. 513 502-3) to a mode of regulating the remedy which will obviate this latter danger. In some instances, the subcutaneous adipose tissue is so thick, or the cellular tissue so edenaatous, that the dynamic currents will not pen- etrate them. ID such cases recourse may be had to the jar. b. Effects of Dynamic Electricity. This includes both galvanism, strictly speaking, and the electricity developed by induction. Dynamic electricity differs, in its attendant physiological phenomena, materially from the static. It produces sen- sation, but in a much less degree, in proportion to other effects. Thus, a galvanic battery, capable of powerful chemical action, will give only a slight tingling sensation to the part at which the current enters; while the continuance of the current gives rise to effects which never proceed from a continuous current of machine electricity. The dynamic current causes also contraction of the muscles, and even energetic contraction, but without the violent shock to the system produced by the other form. Another important point of difference is that its influence can be directed to a certain part, and in a considerable degree limited to that part ; so that a diseased muscle, for example, which may have lost its sensibility, and iu which the electric stimulation may be strongly indicated, may be acted on by means of the galvanic or inductive current, with little or no disturbance or injury to neighbouring and more excitable tissues. This alone gives a vast superiority to this form of electricity over the st;it if. as a therapeutic agent. For the methods of effectually localizing the action of galvanism, we are greatly indebted to M. Duchenne. Formerly no attempts of the kind were made, or quite ineffectually, until the method of acupuncture was applied .by M. Sarlandiere to this object; but the necessity for this has been superseded by the methods of M. Duchenne, which, while less unpleasant, are even more effectual. 1. Effects of Galvanism. In the physiological operation of galvan- ism, there are effects produced which cannot be completely separated, and which often interfere injuriously with one another when the agent is employed therapeutically. The current may be either continuous or inter- mittent; and the effects of the two modes of application differ materially. The continuous current, while it produces sensation in the skin, exer- cises also an influence over the organic actions, giving rise to heat, irri- tation, and inflammation in various degrees, according to its power and continuance, sometimes ending in absolute cauterization. The most powerful current, if introduced into a muscle, occasions but slight, irreg- ular, or partial contractions, while it causes a sense of burning heat, even in the depths of the tissues along its course. In the intermittent current, the organic action of the battery, or its tendency to produce heat, inflammation, and disorganization, is dimin- ished ; while its power of exciting sensation and muscular contraction is VOL. i. 33 514 GENERAL STIMULANTS. [PART II. greatly increased. This difference is readily explicable. At every break- ing of the current, there are three physiological actions; one at tin- entrance of the current, one at its cessation, and a third in the interval. Sensation and muscular contraction are produced chiefly at the entrance, and much less at the moment of interruption, while in the interval, or during the continuance of the current, there is little comparative influ- ence on the sensibility, none or scarcely any on muscular contractility, but a strong tendency to provoke inflammation or organic change. It follows, therefore, that if the current be frequently interrupted, sensation and contraction will be proportiouably increased, and organic action diminished ; and thus the intermittent current can be more effectively applied to the former purposes, the continuous to the latter. There is one effect which, according to M. Duchenne. tin; galvanic current produces beyond all other modes of electric action. It has great influence on the organ of vision, and, if made to operate on the face or scalp, where the fifth pair of nerves, which are mainly sensitive, are dis- tributed, it occasions dazzling luminous sensations. These flashes art- produced strongly at the entrance of the current, feebly at its cessation, and very slightly, so as to be appreciable only in a dark room, during it> continuance. By a rapidly recurring intermission of the current, there may be kept up a constant succession of the luminous phenomena. They are produced chiefly on the side to which the application is made, more powerfully as the median line is approached, and on both sides, when the excitors connected with the two poles are both placed at that line. An important inference is deducible from this fact, in determining the thera- peutic application of the agency; namely, that galvanism is to be pre- ferred when the indication is to excite the retina, and its application to the face avoided in the opposite indication. I need scarcely state that the interruption of the galvanic current may be effected by withdrawing the excitors, and a succession of .intermis- sions more or less rapid obtained, by their more or less rapid withdrawal and reapplication. But there is much inconvenience in this manual operation; it is almost necessarily effected comparatively slowly and irregularly ; and, even at best, the continuous current, while it lasts, is exercising its organic in- fluence, and may at times be productive of great inconvenience. While, therefore, the galvanic battery is preferable in all ca.-es in which the object is to excite inflammation or other organic change, it is highly desirable to obtain the means of exciting at will the nervous properties of sensibility and muscular contraction, without endangering the integ- rity of the tissues. Such means are supplied by the form of electricity developed by induction, whether through the electro-magnetic, or volta- electric instruments. 2. Effects of Induced Electricity. In the operation of the instruments above referred to, it is at the moments when the circle is closed, and CITAP. I.] DIFFUSIBLE STIMULANTS. ELECTRICITY. 515 when it is broken, that the effects are produced ; no phenomena what- ever being excited between these two points of time. While the circle remains closed, the electric force appears to be quite quiescent. This is the important point in which the induced electricity differs, in its physio- logical and therapeutical effects, from the galvanic. That the fact is as stated may be shown by a simple experiment. If a frog's muscle be placed in the electric circle, it contracts instantaneously when the circle is closed, then becomes perfectly quiescent, and continues so until the circle is broken, when it again contracts, and more strongly than at first But, though there are thus shown to be two actions, one at the closing, and the other at the breaking of the current, it is only the latter which is strong enough to be effective in the human subject; the one occurring at the closure of the circle being scarcely perceptible, though sufficiently powerful to produce contraction in the muscles of a frog. It is to this power of strongly exciting sensation and motion, without producing in- flammation, that the inductive instruments owe their great superiority, as therapeutic agents, over other galvanic arrangements, for the general purposes which are aimed at in the use of electricity. However pow- erful their operation, or however long continued, though they may pro- duce insupportable pain, and the most energetic muscular contraction, they never cause disorganizing inflammation ; and, though a little erythe- matic redness of the skin may be produced, with erection of the papillae, the effect quickly subsides upon the cessation of the action. It is obvious that, the more rapid the succession of the intermissions, the more rapid will also be the succession of the muscular contractions produced by them ; and thus a method is offered of controlling the effect, to a considerable degree, by diminishing or increasing the number of in- termissions. The contractions, however, are severally more powerful, when at long than short intervals; but, by their very frequent repetition, the muscle may be kept in an apparent state of steady contraction, sim- ilar to that produced under the influence of the will. There is a sort of vibratory movement in the fibres ; but, to the touch, the muscle feels as though steadily contracting. An influence analogous to the healthful stimulus is thus obtained, which has a tonic effect on the muscle, and promotes its nutrition. Hence its application in cases of relaxation from debility, and in atrophy of the muscles. Though the contractions are more powerful at long intervals, yet, in relation to sensation, the more rapid the succession of intermissions, the greater is the effect. Hence, when it is important to awaken sensibility, as in cutaneous paralysis, the instrument should be made to act rapidly. On the contrary, a rapid movement is contraindicated in disease of the brain, upon which the pain may react injuriously; in cases of great natural susceptibility; and in operating on delicate organs, as the tympanum of \/he ear, different parts of the face, and the testicle. But this is not all the merit of these machines. By varying their 516 GENERAL STIMULANTS. [PART II. mode of application, different physiological effects are obtained, each sus- ceptible of beneficial therapeutic use. Thus, the current of the two wires, the larger and smaller, or, as M. Duchenne designates them, the currents of the first and second order, differ materially in their effects. The machine with the double wire operates much more powerfully on the face and eyeballs in producing luminous phenomena than that with only one wire; and the effect, according to M. Duchenne, is much greater from the electro-magnetic than the volta-elcctric apparatus. Even with a feeble action of the former, considerable reaction is produced upon the retina; while the latter operates in this way only when somewhat in- tensely excited, and when the exciters are applied to the emerging points of the fifth pair, or to the globe of the eye itself. The current from the first order (larger wire) of the electro-magnetic instrument produces no stronger an impression than the volta-elcctric. But the luminous phe- nomena, excited by these machines, even by the second current of the electro-magnetic, are much feebler than those which result from simple galvanism. Moreover, the current of the first wire appears to have a special influ- ence over muscular contractility, that of the second over cutaneous sen- sibility; that is, though both currents act on both properties, yet one produces a greater relative effect on the one, the other on the other. (Electrisation Localisee, pp. 15, 16.) Cutaneous insensibility will often yield promptly to the current of the second order (small wire), when that of the first has no effect whatever; but, in very susceptible persons, it will be advisable to have recourse to that of the first or larger wire, because less disturbing to the sensibility. , 3. Methods of Application. In describing the instruments for the development of static and gal- vanic electricity, and the effects of these two modes of electrical excite- ment, I have probably said us much as may be necessary in relation to their method of application. But the following observations upon the application of induced jelectricity, derived almost exclusively from the work of M. Duchenne, appear to be necessary, to place the reader on a level with the state to which therapeutical electrization has been brought by that indefatigable investigator. 1. To the Muscles. Faradisation of the Muscles (Duchenne).* To * The term faraditation was invented by M. Duchenne, and applied in honour of the distinguished chemist, Faraday, who has done so much for elecirical science. As the name of electricity is given to the static form of this agency, and galvanism to that developed by contact, with chemical action, M. Duchenne considered himself authorized to give that offaradism to the induced form of dynamic electricity, and faraditation to its application. (Note to the second edition.) CHAP. I.] DIFFUSIBLE STIMULANTS. ELECTRICITY. 517 affect the musc-lcs, we may operate either through the nervous plexuses and trunks, or directly on the muscles themselves. In the former case, we necessarily influence at the same time several associated muscles ; in the latter, we may limit the action to a single muscle. The two exciters, or terminations of the directing conductors, should be placed near to each other, at distances varying from one to four inches. If the skin is well moistened, the electric influence penetrates readily through it to the parts beneath. When it is required to operate on the larger muscles, as those of the trunk for example, the cylinder with the moist sponge (Fig. 1, page 509) should be used. For small muscles, as those of the face or intercostals, or for deep-seated muscles, the conical exciters (Fig. 2, page 509), covered with thoroughly moist- ened leather, as the finger of a glove, are to be preferred. The latter also are preferable when it is desirable to excite the muscles through a nerve. The moist skin is a better conductor than the wet sponge; and, when a powerful effect is demanded, the conical cxcitors may be sometimes ad- vantageously used even for large muscles, being in this case moved from point to point. To apply the instrument efficiently, the practi- tioner must of course have made himself acquainted with the precise situation of the muscles, and course of the nerves supplying them. Their depth below the skin must also be well understood. The influence is never to be directed to the tendons. To act on a muscle duly, its whole surface must be covered ; and consequently, if this is large, the excitors must be moved from point to point successively until the purpose has been accomplished. The muscle is known to be contracting by its firmness or hardness under the fingers ; and it often happens that one part of a single muscle will be relaxed, while another contracts. The thicker the muscle, the more intense must be the current applied. In the face, it is difficult to avoid affecting the nerves so abundantly distributed over it. One of these is known to be touched when the contraction extends to several muscles simultaneously. Should this happen, the excitors should be moved a very short distance from the point, until the effect is no longer produced.* When a muscle, on account of its depth, cannot be reached directly by the electric influence, it may be excited by means of its supplying nerve. The excitement of a nerve, or of a muscle, always produces in the healthy state both a sensation and contraction. But the suscepti- * M. Duchenne found that the muscles contract most readily if certain points are touched by the excitors. Dr. R. Remak, of Berlin, ascertained that these points correspond with the points at which the nerves enter the muscles; and that the degree of contraction produced is exactly proportionate to the number of motory nerve fibres embraced by the current at its place of entrance. (Med. Times and Gaz,, May, 1858, p. 479.) Note to the tecond edition. 518 GENERAL STIMULANTS. [PART II. bility of different nerves and muscles is very different in degree ; and a force which will affect one but slightly, will on another act with gre^u energy. Again, while one part is unusually excitable in relation to con- tractility, another is more so in relation to sensibility. It is against the latter that the operator must be particularly on his guard, prepared to withhold his hand, or diminish the force of the instrument, when the in- fluence becomes excessive. Sometimes the sensibility to pain is so great, as to preclude this method of electrization. It is apt to be particularly strong in the muscles of the face, supplied by the fifth pair. The excitor should never be placed over the points corresponding with the suborbitar or mental nerve ; and the excitation of the frontal nerves produces severe pain, which radiates through the head. The muscles of the eyelids, of the alse nasi, and of the upper and lower lips, are peculiarly susceptible. Of the muscles of the neck, the platysma myoides, the upper half of the sterno-mastoid, and the external edge of the upper half of the trapezius, are much more excitable than the remainder. The great pectoral and the muscles of the subspinal fossa are rather sensitive ; the deltoid and the muscles of the arms somewhat less, the anterior being much more so than the posterior. The long dorsal and the sacro-lumbar are but slightly sensitive. The gluteal and fascia lata muscles are very much so, compared with those on the outer and posterior parts of the thigh ; those of the internal crural region more so than those of the external. The posterior muscles of the leg are but slightly sensitive compared with the anterior and external. At the moment of contact, even when the surface is moist, severe pain is sometimes felt in the skin, which soon ceases. In such cases, in order to obviate the effect, the exciters should be brought into contact before application, so as to restore the equilibrium, and then gradually separated to the necessary distance. 2. To the Skin. If static electricity is employed for exciting the skin. it is necessary that it should be of feeble intensity, as it would otherwise penetrate the deeper tissues. The dynamic form is preferable; care being taken to have the surface of the excitors quite dry, so as to confine the influence to the skin. But the electricity of induction, thefaradttm of M. Duchenne, is here specially advantageous, when mere excitation without organic disturbance of the surface is wanted ; as it never, like galvanism, produces severe inflammation or cauterization. If, however. a powerful revulsive effect is desired, for the relief of chronic internal affections, galvanism is preferable. An excitor containing the moist sponge having been applied to one point of the surface, the other excitor, quite dry, is to be held by the operator, and, after the skin has been thoroughly dried by rubbing upon it lycopodium or other absorbent powder, is to be passed rapidly over the part; or cylindrical or olive-shaped dry excitors may be moved from CHAP. I.] DIFFUSIBLE STIMULANTS. ELECTRICITY. 519 point to point over the skin. Sometimes advantage may accrue from using the wire brush (Fig. 3, page 509) as an excitor, which may be moved over, or struck lightly on the surface. M. Duchenne calls this latter process fustigation. The wires may also, in certain cases, be kept in contact with the skin ; but this cannot be long borne, in consequence of the violent pain produced. The latter mode of electrization he calls electric moxa, as having, I presume, the powerful irritant and revulsive influence of that agent, without its organic results. It is applicable only when there is great cutaneous insensibility, or it is desired to promote the dispersion of white swellings, and other chronic tumours or tume- factions. The application of the electrified hand of the operator, under the in- fluence of an intense current, excites lively sensation in the face, but is insufficient for other parts of the body. 'The rounded metallic excitors act powerfully on the face, even with a slight intensity of current, and sufficiently on the skin of the trunk and other parts of the body, except that of the hands and the soles of the feet. For the last-mentioned parts the wire brush must be used, which has three times the power of the blunt excitors. The inner and middle parts, however, of the soles of the feet have more susceptibility. No single therapeutic agency is so efficacious in exciting cutaneous sensibility as "faradisation." It may be graduated to any required de- gree of impression, from a slight tingling to the most violent pain ; the excitement in its higher grades is not exceeded by that of a burn, yet no disorganization takes place, not even so much as vesication ; it may be carried rapidly over the whole surface of the body ; and the pain sub- sides instantly, and almost completely, when the operation ceases. To Internal Organs. Most of these may be reached either directly by the excitors, or through the nerves which supply them. In affections of the rectum, one of the metallic olive-shaped excitors, upon a stem insulated by a covering of caoutchouc, may be introduced into the bowel, while the other is carried from point to point about the anus. If the sphincters are debilitated or paralyzed, the excitor may be brought into apposition with them; if the muscular coat of the rectum, it should be passed successively over the whole inner surface of the bowel. Constipation, incontinence of the feces, and prolapsus of the rectum may often be advantageously treated in this way. In the same manneifphe hypogastric plexus posterior to the rectum may be excited. The bladder and rectum are but slightly sensitive to pain from the electric impression. The latter, therefore, may be resorted to in oper- ating on the former, an excitor being introduced into both; but care must always be taken, in using instruments for the purpose, that the stem should be completely insulated. The vesical excitor may be carried over the whole surface of the bladder. Should the rectum be too irritable 520 GENERAL STIMULANTS. [PART II. for tlie purpose, the two excitors may be introduced through a double caoutchouc canula into the bladder; the instrument being so contrived that the excitors should not be allowed to meet. The bladder, however, should be quite emptied of urine, as this fluid would otherwise serve to connect the poles. The uterus may be operated on by a somewhat similarly contrived double instrument. This organ also has but little sensitiveness unless in pregnancy. The pharynx may be entered by an olive-shaped excitor, properly supported, which may be passed along the posterior part, while the other pole is applied to the nape of the neck. It is necessary to avoid the lat- eral portions of the pharynx, for fear of injuriously exciting the pneu- mogastric, glosso-pharyngeal, and accessory nerve of Willis, which are in this vicinity. In complaints of the larynx, as aphonia, one of the excitors may be passed down the pharynx below the posterior part of the larynx, while the other is applied, moistened, to the external parts answering to the crico-thyroid muscle. The inner excitor is then to be brought forward against the larynx, and passed upwards and downwards. The stomach, liver, lungs, and heart cannot be acted on directly, but may be reached through the pneumogastric nerve. By making the ap- plication to the lower portion of the oesophagus, which may be done by the introduction of a suitable instrument, insulated by a caoutchouc cov- ering, except at its extremity, and placing the other excitor at the pit of the stomach, the influence may be directed to the stomach and liver. If the upper part of the nerve is acted on by applying the pharyngeal ex- citor to the upper and lateral part of the pharynx, and the second to the nape of the neck, all the viscera mentioned will be put under the electric influence. But these operations require much caution, as the vital organs concerned might be unduly and dangerously affected; and M. Duchenne relates a case, in which a patient fainted under the second of the operations just mentioned, and, upon recovery, stated that \\c had experienced a feeling of suffocation, and indescribable precordial sensa- tions. On a repetition of the operation, with intermissions of a second, the patient did not faint, but had the same precordial sensation each time. To the Special Senses. For the sight, galvanism is preferable to elec- tricity by induction, as it is more powerfully stimulant to thd(Brgan of vision.* If either of the inductive machines be used, the electro-mag- * Dr. Julius Althaus, of London, who is high authority on electrical subjects, st.ites that a very feeble galvanic current applied to the face, such as may be excited by the contact of a silver and copper coin, is sufficient to cause a flash of light ; while. if a number of large plates are used, as in Grove's or Daniell's battery, the influence on the retina is so great, that instantaneous blindness might result. The effect is CHAP. I.] DIFFUSIBLE STIMULANTS. ELECTRICITY. 621 netic with a double wire should be preferred, as the more energetic of the two. The application may be made carefully to the ball, and around the orbit. In operating on the ear, the external meat us should be half filled with warm water, and a metallic wire from one of the poles should be intro- duced into the liquid, while the other excitor is applied to the nape of the neck ; or the second excitor, protected by caoutchouc, except at the end, may be introduced through the nostrils, so as to come into contact with the Eustachian tube. As the tympanum, however, is very sen- sitive, great caution must be observed. When the electric influence is wanted in the organ of smell, a small sound, protected as usual except at the extremity, may be passed over the Schneiderian membrane; when in that of taste, the same instrument may be passed over the sides of the tongue and the palate; the second excitor, in both cases, being applied to the back of the neck. To the Male Genitals. The testicle being very sensitive, must be operated on with caution; two excitors being placed near each other upon the scrotum. For operating on the vesiculse seminales, one ex- citor may be introduced into the rectum, and the second into the bladder, if there be no contraindication ; otherwise the latter may be applied on the external surface. In insensibility of these organs generally, the in- fluence should be directed along the whole course of the urethra, as well as to the different parts externally. Notwithstanding the localization effected by these methods, a secondary influence will sometimes be extended to the nervous centres, against which it is necessary that the operator should be on his guard. The pain itself produced in the part necessarily affects the cerebral centres; and, when care is taken to limit the current by keeping the poles near together, this is the chief, if not exclusive source of general disturbance that may be apprehended. In cases of paralysis of sensation, as well as motion, none of this effect is experienced. The muscle may contract; but, however long the operation may be continued, the patient is sensible of no incon- greater when the current is directed to the mucous membrane, whether of the eye, the nostril, or the mouth, than to the skin, and greater when to the skin previously moistened than dry. But, though thus energetic in its action on the organ of vision, tW continuous or galvanic current exerts little influence over the muscles of the- face, which are powerfully acted on by faradism or the interrupted current, while the latter has little action on the eye. Hence the great importance of a proper discrimination in the application of the different currents to affections of the face. For deficiency in the nervous power of the retina, galvanism would be the remedy; in palsy of the muscles, faradisation ; and if, in the latter case, galvanism should be employed, it would not only do no good to the muscles, but might seriously disturb the healthy vision. (Med. T. and Gaz., Aug. 1862, p. 219.) tfole to the third edition. 522 GENERAL STIMULANTS. [PART II. venience. Even reflex action from the spinal centres is excited by this localixed contraction only in certain pathological conditions. But when there is no loss of sensibility, much care is necessary. Certain indi- viduals are, from idiosyncrasy, so exceedingly susceptible, that a slight influence, even insufficient to cause local sensation, occasions faintness, giddiness, dimness of vision, nausea, vomiting, and general feelings of torpor or numbness. These persons are unfit subjects for the use of the remedy. The pain occasioned by the interrupted current has been em- ployed successfully in overcoming the obstinacy often exhibited in feigned diseases. Under the impression that the electricity is employed as a remedial agent, the malingerer, unwilling longer to submit to the pain, acknowledges himself cured by the remedy. (Dr. Addinel Hevvson, Am. J.of Mtd. Sci., Jan. 1861, p. 111.) Acupuncture. In 1825, M. Sarlandiere proposed the direct application of the electric influence to deep seated parts by means of acupuncture; and, seconded as the measure was by the recommendation of Magendie, it acquired for a time great reputation, and was extensively resorted to. It consisted in introducing very sharp needles through the skin into the part or organ which it was desired to excite, particularly the muscles, and passing the current through them, so that in proceeding from point to point of the needles it must necessarily traverse the part. But the results have not corresponded with the first sanguine expectations, and the measure is at present seldom resorted to. Nor is it now necessary medical practice; as the methods of M. Duchenne accomplish the same end more effectually and less disagreeably. The objections urged by M. Duchenne against it are, 1. that the electrization of the muscle cannot be separated from that of the skin ; 2. thaf the cutaneous excite- ment being confined to the course of the needle, surfaces of considerable extent could not be stimulated; 3. that the contractions caused by it are irregular and cannot be foreseen ; 4. that to excite the whole of a muscle, especially a large one, so many needles must be introduced that few patients would be found willing to bear the pain; and 5. that, if it be de- sired to excite the muscle by passing the needle through the nerve, the operation is almost always impracticable. Nevertheless, acupuncture may sometimes be usefully employed by surgeons for the discussion of tumours, and for promoting the coagulation of the blood in aWirisms. Platinum, or gold needles, should be used preferably to steel; as the latter may become oxidized, and thus irritate the parts. When a gal- vanic battery is used, the parts penetrated by the needle are apt to become inflamed, and a caustic effect is not unfrequently produced. CHAP. I.] DIFFUSIBLE STIMULANTS. ELECTRICITY. 523 Great importance has been attached to the transmission of the electric current along the nerve, and in one direction rather than another, in imi- tation of the course of nervous influence. But much of what has been said on these points has been purely theoretical. M. Duchenne has come to the following conclusions. 1. In man, whatever may be the direction of the currents, or the degree of vitality of the nerves they traverse, the same results are always produced, when the conductors are applied to any portion of the course of the nerves ; namely, muscular contractions and sensations. 2. A current prolonged for a considerable time along a healthy nerve, whether it be continuous, or interrupted with rather short intermissions, weakens neither the contractions, the sensations, nor the voluntary movements, and produces no reflex phenomenon above the point excited. 3. A current long protracted in a nerve considerably de- bilitated, notably lessens its excitability, but without influencing the voluntary motions. 4 Changes in the direction of the current exercise no appreciable influence over the muscular contractility or sensibility in man. 5. Electrization of the terminal nerves of a limb produces sensa- tions only in the points excited. 6. The currents which pass from the nervous extremities to the nervous centres, act principally on the sensi- bility of the limb, and produce, above the point excited, contractions which are irregular, and little proportionate to the intensity of the sensa- tions. 7. Finally, the mode of electrization, by reflex action, has little efficacy in the treatment of palsy, and sometimes causes persistent neu- ralgia in the excited limb. (Duchenne, pp. 99, 100.) Should there be cerebral lesion existing at the time, it might do serious mischief. (Ibid., p. 9t.) A fact worthy of recollection is, that electric excitation of the surface is more effective in bringing on reflex muscular contraction, than excitation of the muscles themselves. (Ibid., p. 33.) 4. Therapeutic Applications. Under the impression that nervous power is nothing more than a form of electricity, which some physiologists were at one time disposed to believe, it was imagined that the latter agent might be made ex- tremely useful in disease, by supplying the deficiency, or correcting the redundancy of the former. Theoretical notions, founded on this basis, have always had, and continue to have more or less influence upon ther- apeutics. It has been supposed that nervous action in excess might be controlled by the use of negative, and when deficient might be replaced by that of positive electricity. It has been considered important, through the direction of the electrical current, to imitate the natural pre- sumed nervous currents ; for one purpose to send the influence in one direction, for another in another direction ; to procure in certain cases its transmission by one set of nerves rather than another; in short, to 524 GENERAL STIMULANTS. [PART II. make use of electricity as if it were really the true nervous fluid, and wield it, as that instrument is wielded under the powers of life, for the maintenance of all the functions in their due action and subordination. It is true that this supposition of the identity of the two agents has been quite abandoned, under the irresistible contradiction of experiment;* but there still remains the undoubted and extraordinary analogy between them, to sustain the conjecture that the}- might operate under similar laws upon the system, and that consequently electricity might, in many instances, be substituted for the nervous influence, if brought to bear on the system in a similar manner. I fear, however, that it will be neces- sary to abandon this view of the powers and uses of electricity. With the facts at present known in relation to its effects on the sys- tem, it is best to consider it simply as a universal excitant, capable of stimulating any function or organ upon which it can be brought to bear directly into increased activity, and having this special advantage over every other remedial agent, that, by its peculiar nature, it is capable of being directed to, and in a great degree limited in, any part which it may be desirable to operate upon exclusively. It must be borne in mind that it is not by its accumulation that it is capable of fulfilling any thera- peutic purpose, but only by movement; and hence it cannot be brought to exert a direct simultaneous influence upon the whole system ; for it is scarcely possible so to direct its current, that it should pass at the same time through all parts of the body. It is, therefore, though a universal stimulant, necessarily more or less local in its therapeutic action at any one time. With its universal stimulant power, it exercises a special excitant influence upon the properties of sensation and muscular contraction ; and upon this influence its most important remedial applications are based. Through the quick and powerful impression it makes upon the nerv- ous centres, commonly designated as the shock, it is capable, if not car- ried too far, of arousing the whole system, and thus fulfilling another important indication. By this same shock, in its more forcible application, it overwhelms, and for a time depresses or suspends function; and by a continued exci- tant influence, it exhausts excitability, and thus may induce secondary depression. It may consequently be made use of occasionally as a sed- ative agent. In the depressing influence of the shock, it has, if prop- * This was demonstrated by the experiments of Matteucci and others; but an observation of M. Duchenne shows, in a striking point of view, the distinction of the two actions, the nervous, namely, and electric. According to that author, the muscles may be wholly insensible to electrical influence, and yet capable of acting under the influence of the will. (Electrisation Lucalisee, etc., p. 402.) CHAP. I.] DIFFUSIBLE STIMULANTS. ELECTRICITY. 525 erly managed, this great advantage, that, as it acts mainly on the nervous system, the reaction which follows is also mainly nervous, and, therefore, not disposed to lead to fever or inflammation. Again, it may, in certain forms, be made to produce inflammation, and thus act revulsively. The influences hitherto mentioned have been vital. But it also pro- duces chemical effects, of which we may sometimes avail ourselves ther- apeutically. From what has been just stated, the following practical indications for the use of electricity may be deduced: 1. to excite any particular function or organ which may be inactive or torpid, and which may stand in need of stimulation ; 2. especially to stimulate parts in which sensa- tion or the normal power of motion may be defective or wanting, as in paralytic conditions of the muscular power or general sensibility, or of the special senses; 3. to awaken the system generally from a state of tor- por, as in asphyxia, syncope, and the poisonous effects of the narcotics; 4. to benumb deranged sensation, or suppress excessive muscular con- traction, as in neuralgia, some forms of rheumatism, and tetanus; 5. to operate revulsively by inflaming or irritating the skin, as in various in- ternal and subcutaneous affections, including chronic inflammations, rheumatism, etc.; 6. to alter morbid nutrition by stimulating the disinte- grating process, and thus promoting the absorption of indolent tumours; and 7. through its chemical agency to effect various objects, as the coag- ulation of the blood in aneurisms, the solution of stone in the bladder, and the extraction of poisonous metals from the system, for all which purposes it has been recommended and employed. It is, I believe, in some one of the above methods, or some combination of them, that it operates as a remedial agent. But to render it practically useful, we must be more precise, and consider severally the various diseases in which it may be used; pointing out in each the particular circum- stances which may indicate or contraindicate it, and the particular modes of application most appropriate. 1. Paralytic Affections. It is only by stimulating the paralyzed part, or the nervous centre or nervous trunk supplying it, that electricity operates in the cure of palsy. It is obvious, therefore, that it is wholly inapplicable to cases in which the affection depends upon high vascular congestion, inflammation, or other organic disease of the nervous centres. It is not less obvious that it can be of no use, when similar disease in the connecting nerves pre- vents the transmission of influence from the centres, even though these may be in a healthy state. Under these circumstances, so far from being serviceable, it may do serious harm, not only when applied directly GENERAL STIMULANTS. [PART II. to the diseased centres or nerves, but even when limited to the panv- ly/.eil part ; for any excitement in this part reacts upon the nervous cen- tres, and of course upon the nerves which convey impressions to them But, when all excitement in nervous centres or trunks has subsided, when the organic injury has been repaired, and the continuance of the palsy is owing simply to debility in the centres, or the habit of inertia. or defective nutrition in the paraly/ed part, the electric influence is strongly indicated, and often doe- great service. The same remark is applicable to cases of palsy from wounds or other mechanical injuries of the nervous centres or trunks. It is vain to stim- ulate the palsied part until the wound has healed, or the injury been repaired. But after this event, it not unfrequently happens that the palsy persists, and sometimes seems as if it would persist indefinitely, unless the sluggish centre be stimulated, or the paralyzed part restored, by suitable excitation, to its proper organic condition and due sensibility. Perhaps, under these circumstances, no one agent is so efficient as elec- tricity, because no one can be brought to bear so accurately upon the seat of the disease. It must be observed that, in thus limiting the power of electricity in paralytic affections, I have reference to the excitant power of the remedy over the muscle. But, as will be shown directly, electricity may some- times be used with great effect in the cure of certain chronic cases of in- flammation ; and thus, in cases of palsy dependent on chronic inflam- matory thickening of the supplying nerve, a cure may be hoped for h\ the antiphlogistic power of the agent directed to the diseased part of Un- nerve. In all cases of palsy arising from simple debility or depression of the centres, and all those of local origin, not dependent on irreparable los.- of parts, or other organic injury, much good may be hoped for from electricity. In relation to the precise circumstances under which, in the ra-rs above mentioned as indicating this agent, it may be used with the greatest benefit, to the precise modes, moreover, in which it may be most effectually employed, and the probable results in each case, nothing has appeared which, so far as I am able to judge, approaches in value the recent contributions of M. Duchenne to this branch of therapeutics. In the following remarks on the use of the remedy in palsy, the reader will please to ascribe to that author most of the credit of what he mav find in them that is meritorious. In the first place, it may be stated, as a general rule, that application directly to the palsied part is much more efficacious than when made through the medium of the nerve supplying the part. In palsy, the sensibility and power of motion may both be lost, or either, without the other. CHAP. I.] DIFFUSIBLE STIMULANTS. ELECTRICITY. 527 In reference to the condition of the muscles, palsies may be classified according to the mode in which the part affected is influenced by the electric current; and, by attention to these differences, great assistance is gained, not only in diagnosis, but in the proper application of the rem- edy. There are two classes of the affection; one in which the muscle does not contract, or contracts but. slightly and inefficiently, under the electric stimulus, and the other in which it responds readily to the stimulus, and contracts whenever it is applied. In one case the electro- contractility is lost or impaired, in the other it remains untouched. To the former class belong palsies depending on lesions, traumatic or otherwise, of the spinal marrow or nervous trunks proceeding from it, and the palsy of lead; to the latter all the purely cerebral palsies, whether proceeding from hemorrhage, inflammation, or other lesion, the palsies denominated rheumatic and hysterical, and those dependent on atrophy or fatly degeneration of the muscle itself, which exhibits this property so long as any of the muscular fibre is left. The electro-sensi- bility, or susceptibility to painful impression from electricity, is some- what differently modified. Generally speaking, a loss or diminution of electro-contractility is accompanied with the same condition of electro- sensibility ; but with integrity of the electro-contractility, the sensibility may be normal, increased, diminished, or quite lost. Having made these preliminary observations, we will proceed to the consideration of the special palsies. The reader will remember that it is the electricity of in- duction, the form, namely, developed by the magneto-galvanic or magneto- electric machines, that is employed, unless the fact is otherwise specially stated. We may sometimes use M. Duchenne's term of faradisation, to signify this mode of applying electricity. 1. Palsy from Cerebral Hemorrhage. This generally assumes the form of hemiplegia; but it may also be paraplegic or local. The reader will bear in mind the observations above made, in relation to the circumstances under which electricity becomes applicable in this affec- tion. No attempt should be made to employ this agent, until there is reason to think that the effused blood has been absorbed, and a cyst or cicatrix only remains, without inflammatory action. It will seldom be proper to begin with the use of it until six or seven months after the commencement of the disease. If employed too early, there will be great danger of producing hazardous congestion or inflammation of the brain, through the reaction upon it of the local disturbance. To obviate this as far as possible, the exciters should be placed as near each other as may consist with the object of sending the current into the muscle, so as to confine the disturbance within the narrowest limits. If, in cases of cerebral hemorrhage, after from five to eight months, the palsy per- sists without any contraction of the muscles, a cure may be expected with considerable certainty under faradisation ; if there be permanent 528 GENERAL STIMULANTS. [PART II. contraction, little hope of a cure need be indulged; as this condition indicates a persistent state of cerebral inflammation or softening-, which is not likely to cease.* If there be only temporary, or irregular con- * Dr. Robert Remak, of Berlin, asserts, as the result of numerous trials, that the application of the continued current, as produced by the elements of Daniel!, Grove, and Bunsen, has the effect of immediately relaxing the tonic spasms of the muscles attending hemiplfgia from cerebral hemorrhage, and rendering them amenable to the action of the will. He affirms, too, that by the continued application of the constant current to the nerves and muscles, he has obtained curative effects greater than he had been able to obtain by any other mode of applying electricity, in acute and chronic rheumatism, cerebral hemiplegia, paraplegia, muscular atrophy, chorea, stammering, trembling of the limbs, and cramps. ( Med. Times and Gaz., May, 1858, p. 479.) Note to the second edition. The late Berlin Professor, Dr. Robert Remak, referred to in the preceding note, was one of the highest German authorities on the subject of medical electricity, and the great advocate for galvanization, or the use of the constant current as :\ therapeu- tic agent, in contradistinction to the induced or interrupted current, the faradisation of M. Duchennc. Shortly before his decease, he delivered a course of lectures at the Hospital "//a Charite"," of Paris, setting forth his peculiar views, a translation of which is published in the New York Medical Journal for June, July, and August, 1866 (pp. 185, 279, and 357). The following are some of the more interesting points, which I have thought it due to the subject of electrical therapeutics to place before the readers of this work. The constant galvanic current is, according to Prof. Remak, incomparably superior, in the treatment of diseases, to all other elec- trical currents; and, in the majority of instances where this is useful, the induction currents are rather injurious than otherwise. He appears to prefer, for the de- velopment of galvanism, the battery of Daniell, which affords a more constant cur- rent than that either of Grove or of Bunsen, and the objection to which, of re- quiring daily cleansing, has been obviated by recent improvements. He applies the current to the surface by means of metallic electrodes covered with muslin or wool, moistened with water, which communicate with the conducting rods by a bundle of silver wires, with gutta percha or caoutchouc envelopes (p. 188). He prefers the surface of application of those instruments to be as broad as circum- stances will admit; but it of course must vary in size according to the part to which it is applied. The general effect of a prolonged application of the constant current is increase of the temperature of the body, followed by perspiration, and often a long sleep and subsequent general feeling of repose. Of the local effects the most curious are those upon the special senses, which are not produced by the induction cur- rent. Thus, a very feeble current applied to the face occasions flashes of light, and a peculiar modification of taste. Though, in a healthy state of the organ of hear- ing, 'little effect is produced; yet, in nervous deafness, the gentlest application of the current to the petrous bone causes sounds. The retina is most sensitive to the positive pole, the gustatory nerves to the negative ; and the auditory nerve is more sensitive at the opening of the circuit than at its close. Another effect of the constant current is a species of vertigo, which is apt to happen when the applica- tion is made to a certain limited space, as in the auriculo-maxillary fossa. A de- scending current acts more energetically on the nerves of sensation, an ascending on those of motion; the former at the point of exit, the latter at that of entrance. CHAP. I.] DIFFUSIBLE STIMULANTS. ELECTRICITY. 529 tractions, the prognosis is less favourable than with none, but not alto- gether unfavourable ; as this condition may be owing to an unhealthy excitability of the spinal centres, consequent on a diminution of cerebral power. Nor must the mere stiffening of a muscle, arising from its The two electrodes act differently on the blood-vessels; the positive dilating them and reddening (he skin, the negative producing a contrary effect, after continuing from five to ten minutes in action. Dr Remak makes a distinction between the con.f treatment, as to give no sign of contraction when electrically excited. At least muscles which have been apparently wasted away almost to nothing recover their healthful size, and their power of action. It is said that the atrophy precedes the fatty degeneration ; and it may be sup- posed that the shrinking is only in consequence of tin- absorption of the inter-fibrous matter ; but M. Duchenne thinks that new fibres are cre- ated ; and, if so, there is no reason why the muscle might not grow after partial destruction from fatty degeneration, as well as from any other cause. The treatment of the affection generally requires an apparatus of CHAP. I.] DIFFUSIBLE STIMULANTS. ELECTRICITY. 535 great force and rapid intermissions ; and a feeble instrument may fail altogether. Each application, however, should not continue longer than eight or ten minutes, for fear of exhausting the muscle, and thus hasten- ing its destruction. The sensibility of the muscles, which is at first blunted, in general rapidly increases, and it is necessary gradually to diminish the energy of the treatment ; but it should be sustained at the highest point possible. A similar affection is sometimes met with in infancy, and may be treated in the same way. 10. Paralysis of the ft I adder. Dysury. Incontinence. Difficulty in evacuating the bladder sometimes proceeds from palsy or debility of the abdominal muscles; the urine being forcibly expelled if a catheter is in- troduced. In such cases, the affection will generally yield promptly to faradisation of those muscles. In proper palsy of the muscular coat of the bladder, the electricity may be applied in the manner already described (see page 518), either by exciters introduced into the rectum and bladder, or into the bladder alone, or one into the bladder, and the other moistened and moved over the hypogastric region externally. Sometimes there is loss of sensibility in the mucous coat of the bladder; so that the urine accumulates because the patient is unconscious of its presence. All that is requisite for its evacuation is the exercise of the will. Here -it is advisable to make the application directly to the in- ternal coat. In incontinence depending on paralysis of the sphincter or neck of the bladder, one excitor should be introduced into the rectum, and moved over the parts corresponding with the levator ani, while the metallic ex- tremity of the other is brought, through the urethra, into apposition with the neck of the bladder. 11. Impotence may sometimes be usefully treated with electricity in this manner, applied to the organs of generation externally, and to the vesiculae seminales through the rectum or urethra. 12. Paralysis of the Rectum, and of the Sphincter Ani. Palsy of the rectum, which is indicated sometimes by an obstinate constipation, may often be relieved by faradising the rectum directly, in the manner before described. (See page 518.) In prolapsus ani, which is generally, when considerable, connected with relaxation of the sphincters of the anus, and in incontinence of the feces dependent on the same cause, one excitor may be introduced into the anus, and the other, in the form of a wet sponge, applied externally to the perinffium. The operation may be continued eight or ten minutes. Obstinate cases of prolapsus in children have been promptly cured by this treatment. 13. Palsy of the Larynx. Aphonia. When not dependent on organic lesion, or symptomatic of some other disease, this will sometimes yield 536 GENERAL STIMULANTS. [PART II. to local faradisation applied to the muscles from without, and the skin also, or l)v operating through the pharynx. (See page 519.) The loss of the strength and character of the voice, often incurred by those who speak much in public, may be relieved by the same measure. Other modes of applying the remedy, as by successive discharges through the organ from a powerful battery, by a galvanic current introduced by means of acupuncture, and by the simple apparatus of a small zinc and silver plate (see page 504), one on one side, the other on the other of the larynx, have also proved successful. But in these cases electricity, like all other measures, not unfrequently fails without any assignable cause. 14. Cutaneous Anaesthesia, or Loss of Sensibility in the Skin. The loss of sensibility in paralytic muscles is generally remedied at the same time with loss of motion. But sometimes the two conditions exist sepa- rately; and insensibility of" the skin is not a very uncommon affection. In this isolated state, when not dependent on organic lesion of the nerves, it is generally an hysterical affection, and yields readily to the electrical influence. When it affects the face, the best method of applying the remedy is by the hand, which usually proves sufficient for the cure. If not, the blunt excitors may be applied, and these will often answer for other parts of the body. But sometimes a more energetic impression is required for the general surface, which may be obtained by means of "fustigation" with the brush of wires. (See page 508.) The excitors should generally be carried from one point to another of the surface, until the whole affected part has been electrified. Sometimes, however. the insensibility is so great that it is necessary to leave the bunch of wires for some time in contact, until sensation is produced. First a tingling is felt, then a burning sensation, and this soon increases so thai it can be borne no longer. As the skin becomes more sensitive, it i> necessary to return to the blunt excitors again In a few instances tin- return of sensibility, in a small space, is followed, without further appli- cation, by its extension over the whole part atl'ected; but much more frequently it is necessary that every part should be subjected to the con- tact of the instruments. Sometimes the affection returns after having yielded, but may be cured by repetitions of the application. It is in the hands and soles of the feet, that the inconvenience of this paralytic con- dition is greatest, and the cure of it most important. 15. Amaurosis. Electricity should never be employed in this affection, if there be any reason to suppose that it depends on active congestion. inflammation, or other organic disease in the nervous (-(Mitre of vision, the nerve itself, or its expansion on the retina. In purely functional cases, it may sometimes be used with benefit; but galvanism is here more effective than the induced electricity. In doubtful cases, it may l applied over the face and about the orbit in the first place, in order to CHAP. I.] DIFFUSIBLE STIMULANTS. ELECTRICITY. 537 excite the eye through the ramifications of the fifth pair, which have a peculiar influence over vision when galvanically excited; and, if this measure is unsuccessful, the application may be made to the ball of the eye, in order directly to excite the optic nerve ; one pole being placed in the orbit, and the other at the back of the neck. Acupuncture of the parts about the eye has been brought to the aid of galvanism ; and many cures of incomplete, and some of complete amaurosj.s have been reported, supposed to have been obtained in this way. (See Channing, Medical Application of Electricity, Boston, 1852, p. 87.) The electro-magnetic instrument with two wires may also be used for this purpose, though less effective than the battery. 16. Deafness. In nervous deafness, faradisation of the chorda tym- pani has been followed by happy results. Great care must be exer- cised in conducting this operation. While the patient lies on his side, the meatus auditorius should be half filled with water; a wire connected with one of the poles should then be introduced so as to touch neither the tympanum nor the walls of the passage; and the wet sponge excitor, connected with the other pole, should then be applied to the nape of the neck. The slightest power of the instrument should be first exerted ; not greater than may be sufficient to cause the least possible sensation when the excitors are applied to the end of the tongue ; and then in- creased as may be found necessary. A slight buzzing sound is first pro- duced by this operation in the ear when healthful, followed by tingling, and then, with the increase of the force of the current, by severe pain ; the tingling, with a sense of numbness, extending to the side and ante- rior part of the tongue. There is also a peculiar taste produced. M. Duchenne has seen this process cure, in a short time, cases of deafness which had long resisted energetic measures, under the most competent practitioners. It is not impossible that the same measure might be use- ful in deafness of organic origin, provided all acuteness of symptoms had passed. The functional disorders of hearing which are so common, and so frequently alluded to by writers under the name of tinnitus aurium, often yield with the utmost facility to the remedy. It is asserted that galvanism has proved useful by promoting the absorption of pus and coagulable lymph in the cavity of the tympanum, and in exciting the secretion of wax when deficient. 17. Smell and Taste. In paralytic conditions of these functions, as well as in palsy of the muscles of the tongue, the application of electricity may be made in the manner statdil in page 520. Stammering, which may possibly sometimes be connected with de- bility of the muscles of the tongue, and other parts concerned in articu- lation, is said to have been benefited by a galvanic current directed from the tongue to the surface of the throat. 538 GENERAL STIMULANTS. [PART II. 2. General and Local Relaxation, Debility, or Torpor. Under this head may be enumerated a considerable number of affec- tions in which electricity has been found more or less useful. In asphyxia and syncope it may be resorted to in reference to the shock upon the system, and, in the former, to promote contraction of the diaphragm. In asphyxia, or a state approaching it, arising from nar- cotic poisoning, especially that from opium, it has been employed, with striking success, in several cases, among which may be mentioned one recorded by Dr. Page, of Valparaiso, and a second by Dr. James Russel, of London. Electro-magnetism was used in both these cases, the direc- tion being, in one case, from one side to the other through the heart; in the other, from the back of the neck to the sternum, by which respiration was restored. In asphyxia from drowning, a current of galvanism has been passed into the diaphragm, by cutting down to the muscle below the seventh rib, with the apparent effect of saving life. Acupuncture would probably have answered the same purpose. In these cases of asphyxia and syncope, it is probable that the mere shock upon the ner- vous centres, occasioned by pain, has great influence in rousing the pa- tient; and, for the production of this effect, nothing is more powerful, prompt, and safe than the electro-magnetic current with rapid intermis- sions.* Artificial respiration, when desirable, may be most conveniently pro- duced, according to M. Duchenne, by calling the diaphragm into action, through a vigorous impression on the phrenic nerve, where it passes the anterior scalcnus muscle. This nerve, after the union of its three roots, descends from without inwardly before the anterior surface of the scale- nus. It is at this point that it is necessary to make the requisite appli- cation. Some difficulty is thrown in the way by the sterno-mastoid and platysma-myoid muscles, which cover the scalenus. But by depressing the skin from without inwards, with two fingers placed along the outer border of the clavicular fasciculus of the sterno-mastoid, then separating the fingers, and maintaining the pressure, access may be obtained to the anterior surface of the scalenus, without the interposition of the other muscles. One of the excitors is to be placed between the fingers, in such a manner as to cross the direction of the phrenic nerve. While an as- sistant holds the instrument in this position, the second excitor is to be similarly applied on the opposite side. Then the operator takes hold of both by their isolated handles, and the machine is set in motion. Any * A remarkable case of resuscitation after drowning, by means of the induction apparatus, and electro-ncupuncture, by Dr. A. C. Garratt, of Boston, is recorded in i lie JJoston Med. and Snry. Journ. (Sept. 6, 1801. p. 89). It is well worth perusal, ns an example of success rewarding faithful and long-continued effort, under ap- parently the most discouraging circumstances. (A'ole to the third edition.) CHAP. I.] DIFFUSIBLE STIMULANTS. ELECTRICITY. 539 of the inductive machines will answer the purpose, if properly graduated, and of very rapid intermissions. The exciters should end in a small metallic cone, which should be covered with moist leather. The instant that the current is passed, the lower ribs expand, the abdominal walls rise, and air rushes with sound into the lungs. After a second or two, the current is broken, the walls of the chest subside, and expiration takes place. To complete the expiration, an assistant presses upon the chest and abdomen. In another second, the operation is resumed ; and this artificial respiration, perfectly imitating the natural, may be kept up as long as maybe necessary. (Electrisation Localise, pp. 485-6 ) In poisoning from opium and other narcotics, even when threatening symptoms of asphyxia have not yet appeared, the painful excitation of the electro-magnetic machine is useful, independently of its influence on respiration, by stimulating the nervous centres, and sustaining life until the action of the poison has passed. A case of this kind has been re- ported by Dr. Bullock, of Wilmington, Delaware. (Am. Journ. of Med. Set., N. S., xxviii. 5750 In general muscular relaxation, the excitant influence of electricity may perhaps sometimes be usefully employed, by rapidly faradising the different muscles successively. In debility of various functions it has been used with supposed, and no doubt often with real benefit. In dyspepsia, a current of galvanism may be passed from the nape of the neck to the epigastrium, or immediately through the stomach, from before backward. Torpid liver may be treated in the same way, the current being sent in various directions through the organ, so as to traverse the whole of it as far as possible. Suppression of the secretion of milk is said to yield frequently to fara- disation of the mamma, sometimes after three or four daily applications of the remedy. It should not be carried so far as to occasion contrac- tion of the pectoral muscles, or severe pain. Each operation may con- tinue fifteen or twenty minutes. The induced current is here the most effective. Constipation dependent on inertia of the bowels has >ften been treated advantageously with electricity. Allusion has already been made, under palsy of the rectum, to the mode of treating it when arising from that cause. In other cases, the current may be made to pass from the fundament, or from an excitor introduced into the rectum, to the pit of the stomach, or to various points over the surface of the abdomen ; or it may be directed through the bowels from before back- ward, or from side to side. Ameaorrhcea has been treated by electricity with great success. Dr. Golding Bird states that he has never known it to fail in exciting men- 540 GENERAL STIMULANTS. [PART II. struation, when the uterus was capable of performing that function. (Lond. Med. Gaz., June, 1847.) After proper attention to the general health, a dozen shocks of the Leyden jar were passed through the organ. from the sacrum to the pubes, and the measure was repeated daily, if necessary. Flooding after delivery is said to have been effectually controlled by galvanism, which produces contraction of the uterus. Dr. Radford, who has employed the remedy for this purpose, states that it may be so ap- plied as to excite not only tonic, but alsg intermittent contraction, and suggests it as a means of hastening tedious labours. He used a coil machine, applying one pole to the os uteri, and the other to the walls of the abdomen over the fundus. The conductor introduced into the vagina must be covered with a non-conducting material, except at its extremity. (Prov. Med. Journ., Dec. 1844.) Dr. F. W. Mackenzie has found a tained galvanic current, sent through the uterus longitudinally from the upper portion of the spinal cord, to be very useful in promoting contrac- tion of the uterus in hemorrhage with threatened abortion, and. in < of placenta praevia, in facilitating delivery and preventing hemorrhage. (Med. Times and Gaz , March, 1858, p. 271 ) In a cool, dry, inactive state of the skin, especially when connected with interior disease, much benefit may be expected from electric stimu- lation of the surface, which is accomplished, in the mildest method, by withdrawing sparks from the body in the electrical bath ; in the severest. through the agency of the electro-magnetic machine, and M. Duchenne's wire excitor; and, in intermediate grades, by the different arrangements at command. Indeed, electricity, in its various forms and modes of ap- plication, affords to a practitioner, suitably provided with apparatus, a powerful method of revulsion to the surface, of which he may avail him- self in a great number of diseased conditions. Indolent ulcers may be stimulated into a healing condition by making their surfaces the recipient of the galvanic current, either through the moist sponge excitor, or their own wet div.-sings connected with one of the poles, or by covering them with a plate of silver or copper forming one of the constituents of a galvanic arrangement, of which a zinc plate. applied tofauother portion of the surface, and connected with it by a wire, may form another. Opacity of the cornea may, according to Dr. Althaus. 1>< generally cured by faradisation, which is greatly preferable to ordinary galvanism for this- purpose, because so much less likely to disturb the retina. The negative pole should be applied over the closed eye, and the positive held in the hand of the patient. The application may continue fit minutes, and be repeated every other day. A cure may be expected in from one to three months. (Med. T. and Gaz., Sept. l.si;->. p. 271.) In the photophobia of scrofulous ophthalmia in children, extraordi- CHAP. I.] DIFFUSIBLE STIMULANTS. ELECTRICITY. 541 nary s1*ecess has been obtained by Dr. Addinell Hcwson, of Philadel- phia, from the ordinary galvanic current, applied over the supra-orbital branch of the fifth nerve. He made use of Pulvermacher's chain bat- tery of sixty links, using vinegar as the exciting agent. The applica- tions were usually made every throe or four days, and for a minute or two each time ; but they might be repeated daily without disadvantage. Great relief followed the first application, and a cure was in general effected. (Am. J. of Ned. Sci., Jan. 1860, p. 114.) 3. Neuralgic and Rheumatic Affections. Neuralgia. Electricity has been found curative in many cases of this affection, operating, it would seem, sometimes directly by the benumb- ing influence of its excessive power, sometimes revulsively. These two methods require different applications of the electric influence. If the object be to operate revulsively, the plan of Duchenne may be followed of confining the action to the skin (see page 517); if to benumb the nerve, a moistened extremity of one conductor should be applied over the nervous trunk as far up as may be, the other over one or more of its branches in which the pain may be felt. Excessive cutaneous sensibility, which is a frequent attendant upon hysteria, yields 1n general readily to faradisation. The treatment is ap- plicable only to purely functional cases, and not to those dependent on lesions of the nerves or their centres. In the application of the remedy, the skin should be kept perfectly dry. Sometimes fustigation may be used ; in other cases, the blunt exciters, carried from point to point over the sensitive part, will be sufficient. The instrument should work with rapid intermissions, and with an intensity as great as the patient can well bear; and the operation may be continued from two to five minutes. A feeling of numbness follows the first pain, with an agreeable sense of relief. Sometimes a single sitting is sufficient; but more frequently the complaint returns after some hours, though with diminished intensity; and several applications are required before the cure is effected. In many cases, however, only temporary relief is obtained. A similar excessive sensibility of the muscles sometimes occurs, which may cither be conjoined with the cutaneous affection,* or may co- exist with insensibility of the skin. Though usually more resistant than the pure cutaneous affection, it often yields promptly to a similar excita- tion of the surface. In neuralgia of the face, tongue, etc., galvanism and electro-magnet- ism have both been used with occasional success; the former being sometimes aided by acupuncture ; but the general result has not been very encouraging. Sciatica is an extremely obstinate form of disease, sometimes appar- ently purely neuralgic, sometimes rheumatic, and in other cases attended 542 GENERAL STIMULANTS. [PART IT. with inflammation of the neurilemma. When purely functional, it will sometimes yield to faradisation, after vain Attempts to cure it by other means. Occasionally it will give way, fur a time, to a sudden and violent pain excited by fust igat ion, or the contact of the wires, in any part of the surface. The measure, however, is more effectual when put in opera- tion in the vicinity of the part. The skin must be thoroughly dried, so as to prevent the current from penetrating to the nerve, in which case the pain is aggravated. The relief at first procured is temporary ; but. by repeating the fustigation upon each return, or at relatively short in- tervals, for six or eight times, the disease will often yield entirely. The most obstinate cases in the hospitals have recovered under the remedy. Electro-puncture is asserted also to have been used with advantage; but the cutaneous excitation is preferable. Angina pecioris, in one striking instance under the care of M. Du- chenne, yielded speedily to electro-cutaneous excitation applied to the mammary region. At the moment of the application of the two metallic excitors, which proceeded from a powerful machine graduated to the maximum, and working- with rapid intermissions, the patient uttered a loud cry, so as to render it necessary to interrupt the operation ; but the pain of the angina, which had been excessive, ceased at once. By repeating the operation at each return, the disease appeared to yield entirely. In other neuralgic cases, whether external or in the viscera, the rem- edy has operated with equal success. It should be recollected that it is the cutaneous excitement that is produced here; the current being pre- vented from penetrating beneath the skin by drying it thoroughly with some absorbent powder. In colica pictonum, M. Briquet effects prompt relief by faradisation of the surface of the abdomen. For an account of his mode of apply- ing the remedy see my Treatise on the Practice of Medicine (<>th ed.. vol. i. p. 748). Rheumatism. In the neuralgic form, this complaint will often yield with great facility to the electric influence ; and it is probable that many of the cases treated successfully under the names of neuralgia, sciatica, angina pectoris, etc., have been either of this character, or gouty. Bui ordinary muscular subacute rheumatism, such as lumbago, pleurodynia. torticollis, etc., will also frequently yield to the remedy as to a charm. Sometimes a single faradisation of the skin, is sufficient to effect a cure : but more frequently the pain returns, and five or six applications may be necessary for the purpose. It should not be abandoned until the last vestige of pain has been removed. Rheumatic arlhralgia will also often yield happily to the remedy. To acute inflammatory rheuma- tism it is wholly inapplicable. In chronic rheumatism of the joints, gal- vanism, with the aid of acupuncture, has sometimes proved efficient; but CHAP. I.] DIFFUSIBLE STIMULANTS. ELECTRICITY. 543 electro-magnetism would probably be safer, as less likely to excite inflam- mation, with an equal degree of power. Rheumatic contraction of the muscles, which not urtfrequently affects the face, neck, shoulder, and parts of the chest, and which has a very disagreeable distorting effect, will generally yield to this remedy applied to the skin. M. Duchenne also cures the affection by bringing the an- tagonistic muscles into play through the electric current, and thus estab- lishing an equilibrium between them. 4. Spasmodic Affection*. Many of these complaints have been treated by electricity, with varia- ble success, as hysteria, epilepsy, chorea, etc., and Matteucci even ven- tured to recommend it in tetanus, on the ground that a continuance of the electric current exhausts after a time the excitability of the muscles ; but experience has not yet pronounced in its favour. In spasmodic asthma great relief is said to have been sometimes obtained by passing a current of galvanism from the nape of the neck to the pit of the stomach. Hiccough has been treated effectually, it is said, in the same way. 5. Indolent Swellings. Various tumefactions, hypertrophic, rheumatic, and scrofulous, the result of simple chronic inflammation, or left behind after sprains or other injuries, have from time to time been treated by electricity in its different forms, and with more or less success.* The remedy probably operates as a simple excitant, hastening suppuration when the tendency is to that result, promoting the absorption of exuded fibrin and other secretions or depositions, and stimulating the disintegrating process, so as to favour resolution. Dr. Remak, of Berlin, states that he has found the constant current, produced by the arrangements of Daniell, Grove, and Bunsen, to have a powerful effect in resolving inflammatory tumours, by dilating the blood-vessels and promoting absorption. (Med. Times and Gaz., May, 1858, p. 479.) It is highly probable that cases of palsy, de- pendent on chronic inflammatory thickening of the spinal membranes or ligaments, or similar thickening from exudation in the theca of nervous * Serous effurions may ba removed in the same way by the promotion of absorp- tion ; ami cases of hydrocele have been treated effectually by both galvanisation and faradisation, after failure with iodine injections and the seton. The method of proceeding is to introduce two acupuncture needles into the fluid, one at one end of the sac, the other at the other, and then connecting these with the poles of the induction machine or galvanic battery. A mild current should be used at first, to be gradually increased until the patient complains. The operation should continue for about twenty minutes. Sometimes the swelling disappears within twenty-four hours; sometimes three or four operations are necessary. (Althaus, Med. T. and Gaz., Sept. 1862, p. 27l.j .Vote to the third edition. 544 GENERAL STIMULANTS. [PART II. trunks, or the passages which they traverse, might often be relieved by the galvanic influence brought to bear on these conditions, could their seat be precisely ascertained. Even strictures of the urethra are said to haye been cured by the same means. 6. Extra-uterine Pregnancy. Electricity is said to have been successfully resorted to by Professor Burci, of Pisa, in an extra-uterine pregnancy, in order to prevent the further development of the foetus, and favour its absorption. Two needles connected with an electro-magnetic instrument were introduced into the tumour. Much pain was produced by the successive shocks ; but only one application was necessary. The tumour ceased to grow, and grad- ually shrivelled. (Med. and Surg. Reporter, xi. 112.) 7. Therapeutic Application of Chemical Influence. Electricity has been employed for three distinct purposes, in reference to its chemical reagency : 1. for the cure of aneurisms, through its coag- ulating influence upon the blood; 2. for the solution of calculi in the blad- der; and 3. for the abstraction of metallic substances from the system. 1. Cure of Aneurisms. It has been experimentally proved that a current of galvanism, sent through the blood in the vessels, has the effect of coagulating it. By some, this effect is ascribed to a chemical, by others, to a vital influence. It was supposed that, directed through the blood of an aneurismal tumour, it might have the same effect, and that it might thus be employed with some hope of success in the treatment of these tumours. The experiment has been tried, and some cases of apparent cure, with others of failure, have been reported. The needles for this purpose should be made of gold or platinum ; because, if of steel, they might undergo chemical change, and thus become irritant in their course. They should be introduced so that their points may enter the blood, and there should be no contact between them. A battery of ten or fifteen pairs may be used, and the operation continued fifteen or twenty minutes, or longer. One of the risks incurred is of irritating the sides of the opening into the tumour, so as to form an eschar, which, on sep- arating, may give exit to the blood. To avoid this, it has been proposed to coat the needles with shellac, except at the points ; but this docs not seem to have answered.* * The following observations, in relation to this subject, are derived from a paper by Dr. Althaus, published in the Medical Times and Gazette (Aug. 1862, p. 219). Clots are produced only at the positive pole, where acids are liber- ated from the decomposition of the salts of the blood; while at the negative pole, where alkalies are set free, the blood is rendered more fluid. Consequently to succeed in the treatment of aneurisms, it is necessary that only the positive pole should be made to act directly on the blood. Another cause of failure is CHAP. I.] DIFFUSIBLE STIMULANTS. ELECTRICITY. 545 The same measure has been employed for the obliteration of varicose veins, with apparent success, in several instances. 2. Solution of Calculi in the Bladder. The idea of destroying calculi in the bladder by means of the decomposing power of galvanism having been suggested, MM. Prevost and Dumas performed some experiments on a phosphatic calculus out of the body, by which they succeeded in partially dissolving and utterly breaking up the stone through this influ- ence. They afterwards proved, by introducing a calculus into the blad- der of a dog, and, by means of two insulated conductors passed through the urethra, bringing to bear upon it a powerful battery, that the opera- tion might be performed with safety, and with some chances of success within the body. But I am not awara that any useful results have been obtained by the process; the prominent objection to it being the insol- uble character of the urinary calculi, which prevents a vigorous decom- posing influence from being exerted upon them. 3. Elimination of Metallic Substances from the System. In the first edition of this work, an account was given of a plan of withdrawing metallic substances from the system, by the agency of galvanism. The patient, seated on a wooden bench in an isolated metallic bathing tub, containing water slightly acidulated with nitric, muriatic, or sulphuric acid, held in his hand a conductor from the positive pole of a galvanic buttery, the tub being connected with the negative pole. It was thought that, through the agency jf the current, the metallic salt in the system was decomposed, and the metal, being withdrawn, attached itself in patches to the sides of the tub. Reflection has convinced me, what I was at first disposed to believe, that such a result in the human system is quite impossible; and Prof. E. H. Clarke, of Boston, states that he has satisfied himself of its impracticability by numerous experiments. (Am. Journ. of Med. Sci., N. S., xxxiii. T4.) Some years since, much attention w T as paid to the asserted advant- ages of electro-magnetism as an anaesthetic agent in the extraction of teeth. Dr. J. B. Francis, claiming to be the discoverer of the principle, secured his right under our patent laws to its exclusive application. The subject was examined by a committee of the Franklin Institute of Phil- the use of faradisation instead of galvanization; the former Laving little influence in promoting coagulation. The character of the needle used is also of some im- portance, the most oxidizable metal being preferable. Therefore, in the treatment of aneurisms, ''a steel needle covered with zinc, and connected with the positive pole of a pile of twenty pairs of Bunsen's, Grove's, or Daniell's battery, feebly charged, should be inserted in the centre of the sac, and the circuit closed by placing a metallic plate, connected with the negative pole, on the surface of the tumour." Coagulation is produced in fifteen or twenty minutes. (Note to the third edition.) VOL. i. 35 546 GENERAL STIMULANTS. [PART II. adelphia, who, after a careful investigation, reported in favour of the efficiency of the process employed. This consisted simply in passing the current from a magneto-galvanic machine through the tooth at the moment of extraction. A conductor from one pole was placed in the hand of the patient, and a wire from the other was attached to the forceps, by the contact of which with the tooth the circuit was com- pleted. In numerous instances, the operation, according to the state- ment of the patients, was without pain; and the electric current, if care was taken to avoid the soft parts, occasioned little or no inconven- ience. It was supposed that the nerve of the tooth, becoming benumbed by the electric influence, was rendered insusceptible to painful impres- sion. The statements on the subject were received with incredulity by many scientific men, who did not think it possible that so powerful and speedy a benumbing effect should be produced by any amount of electric influence insufficient to occasion suffering to the patient ; and many experiments afterwards made either proved less successful or failed entirely. The fact seems to be that, under the influence of a new sen- sation, and of new and strange manipulations, the attention of the patient was excited, and the cerebral centres so occupied as, in many instances, to be for the moment partially at least insensible to impres- sions usually productive of pain; on the same principle, probably, as that which operates when the pain of a violently aching tooth ceases entirely upon a mere visit to the dentist. It is certainly not impossible to pro- duce a local benumbing effect by electric influence; but to do so the impression must be very powerful ; so much so as to overwhelm nervous function by excess of excitement, and beyond anything that it would be prudent to employ for the mere purpose of saving pain in the extraction of a tooth. CHAP. I.] ARTERIAL STIMULANTS. 547 OL.A.SS I. ARTERIAL STIMULANTS. THESE are diffusible stimulants operating especially on the circulatory function, with little comparative influence on the nervous system. They have sometimes been called Incitants or Simple Stimulants; but it has seemed to me that the name here given best expresses their peculiar character. Of course, they in some degree affect the nervous system ; for one great general function can scarcely be considerably excited with- out more or less involving the others ; but their primary and prominent action is upon the heart and arteries. The obvious effects produced by the arterial stimulants, as a class, are a sensation of warmth or heat in the stomach, increased frequency and force of pulse, and augmented temperature of the surface. They, in general, also act as powerful irritants to the skin when directly applied to it, and indeed to any sensitive part with which they may come into contact. Each one, however, has characteristic properties, distinct from that of simple diffusible stimulation. They may be employed in all cases calling for stimulation, when the action of the heart is depressed, and are frequently thus used both ex- ternally and internally. They are specially applicable, and preferably to the other classes of diffusible stimulants, in those cases, enumerated in the general observations made upon diffusible stimulation, in which reaction must follow the state of prostration. In the collapse attendant upon severe injuries, and that which occurs at the commencement of febrile diseases, they are peculiarly indicated; because they have no special influence on the brain, and are not likely, therefore, as alcohol and some other cerebral stimulants, to affect that organ injuriously, when reaction takes place. They are, in general, contraindicated by gastric inflammation, because brought into immediate contadPwith the inflamed part, and acting upon it with their whole stimulant power. A great number of medicinal substances have the property of stimu- lating the circulation. Not to mention the nervous and cerebral stimu- lants, which, in accordance with their ,very definition, have this power, and, in some instances, in a very high degree, there are many others dis- tributed among the various classes. But all of these have other prop- erties which serve to place them elsewhere, and for which they are chiefly employed as medicines; and, though their action upon the heart and 548 GENERAL STIMULANTS. [PART II. arteries may sometimes be incidentally useful, they are seldom or never employed with an exclusive view to this effect. The aromatics approach nearest in their properties to this class ; but they are much more power- ful as local than as general stimulants; and their application, as internal remedies, is almost restricted to affections of the alimentary canal. Mustard, copaiba, guaiac, mezereon, cantharides, savine, and many others, more or less excite the circulation ; but each one of them be- longs to some other class, as the emetics, diuretics, diaphoretics, em- menagogues, or alteratives ; and they are almost never given as arterial stimulants simply. The medicines strictly belonging to this class are very few, and might, perhaps, be still further limited; for carbonate of ammonia, which I at- tach to it, has, in addition to its influence over the heart and arteries, an action upon the nervous system, which would almost entitle it to a place among the nervous stimulants. I. CAYENNE PEPPER. CAPSICUM. U. S., Br. Syn. Eed Pepper. Origin. Cayenne pepper is the fruit of Capsicum annuum, an annual plant from one to three feet high, inhabiting mtertropical America, and supposed by some to be a native of the East Indies. It is cultivated in most civilized countries, and abundantly in the United States. Other species contribute to the Cayenne pepper of commerce. The fruit as grown in Cayenne, in South America, from which the medicine derived its common name, is said to be the product of Capsicum frutescens, and perhaps also of G. baccatum. Much of the powdered Cayenne pepper used in this country is brought from the W. Indies. Under the name of Liberia pepper, considerable quantities of a small fruit, about an inch in length, are imported from the coast of Africa. It is probably identical with that known in England as Guinea pepper, which Dr. Pereira ascer- tained to be the product of C. frutescens. Properties. This fruit is a light shimig berry, of various size and shape, and usually of a red or orange-red colour. The variety n employed in medicine is of a conical form, about as long as the finger, rounded at the base, and somewhat curved towards the smaller end. When cut open, it is seen to have two or three cells, containing Hat whitish seeds, and a very loose medulla. When dried, it shrinks, be- comes wrinkled, and assumes a darker colour. As employed in medicine, capsicum is in the form of a powder, which is bright-red when fresh, but gradually fades, and in time loses almost CHAP. I.] ARTERIAL STIMULANTS. CAYENNE PEPPER. 549 all its colour. That imported is usually lighter coloured than our own, being brownish-yellow rather than red. It has a slight, peculiar, some- what aromatic odour, and a bitterish, extremely pungent, burning, almost fiery taste, remaining long upon the tongue. It imparts its virtues to water, but more freely and largely to alcohol. Active Principle. The virtues of capsicum probably reside in a pecu- liar resinoid matter, and, in a less degree, in a volatile principle on which its odour depends, but which does not appear to have been yet isolated. The capsicin of Braconnot contains the active matter of the fruit, but has been ascertained by Prof. Procter to be complex. The crystals, in which, as stated in the preceding edition of this work, the active principle was supposed to have been obtained, have proved, on further examina- tion, to have been a salt of lead, from the acetate of that metal used in the process. From the most recent experiments it would appear that the activity of capsicum resides in a peculiar oleaginous liquid substance, which, however, is itself complex, consisting probably, of a bland fixed oil, and an acrid resinoid principle, which has not yet been procured in a pure state. For this principle when obtained uncombined, the name of capsicin should be reserved.* Effects on the System. Cayenne pepper produces a sensation of heat in the stomach, diffuses a general glow over the system, and somewhat ex- cites the pulse. In ordinary doses, it has no observable effect whatever on the brain, or general nervous system. Locally it is powerfully stimu- lating, more so proportionably than in its operation upon the circulation, and in this respect approaches the aromatics. On the skin it acts as a rubcfacient. When taken into the stomach in excessive doses, it is ca- pable of producing gastro-intestinal inflammation, with violent burning pain, vomiting, and purging; and is said to have caused vertigo and a sort of intoxication, but on insufficient authority. Any cerebral symp- toms it produces are probably secondary and sympathetic. Used too largely and too long as a condiment, it may give rise to chronic irritation or secondary debility of stomach, and, by an over-stimulation of the blood-making functions, may favour the development of gout. Therapeutic Application. The medicine may be used for the general purposes of the arterial stimulants, though less excitant to the circulation than others of the class. It has been employed as a safe stimulant in the cold stage of pernicious fever, and occasionally, as an adjuvant to other stimulants, in low typhoid fevers, when the stomach has been tor- pid, and the patient troubled with flatulence. In the low and malignant forms of scarlet fever, it has been much and advantageously employed ; and it may be considered as among the best stimulants in that affection. * See U. S. Dispensatory (12th ed , p. 208) ; and a paper by Mr. David Preston, in the American Journal of Pharmacy (May, 1865, p. 161). 550 GENERAL STIMULANTS. [PART II. I have myself given it frequently, and been satisfied of its beneficial effects. It is used both internally, and as a gargle. In the latter mode of application, I know nothing better adapted to that condition of the fauces, in which the mucous membrane has assumed a dark-red colour, and has begun to slough, or appears to be on the point of doing so. But it has also seemed to me useful in almost all varieties of the sore-throat of scarlatina, in which, so far from irritating, it often soothes ; at least patients have frequently assured me that, though it burned their mouth in its passage, it had quite a contrary effect upon the fauces, which it greatly relieved. In the early stage of scarlet fever, there is sometimes great backward- ness in the appearance of the eruption. A few purplish points may serve to indicate the nature of the case, and the vain struggle of the sys- tem to throw out the irritation upon the surface. Along with this con- dition there may be coma, or a disposition to it, with an appearance of general prostration. In such cases, Cayenne pepper may be freely used, both internally, in connection with other stimulants, and outwardly as a rubefacient. It has been used, as a pervading stimulant of the capillaries, in old cases of palsy; and has been highly recommended in uterine hemorrhage, in doses of from five to ten grains, repeated every ten minutes until the hemorrhage ceases. (Brock, Assoc. Med. Journ., June, 1854, p. 582.) In the Dublin Medical Press, Dr. Lyons recommends capsicum very highly in the early or forming stage of delirium tremens, stating that a single dose of twenty grains will usually cut short the disease; though, in persons of extremely intemperate habits, it may be necessary to repeat the dose three or four times. (Med. Record, Aug. 1, 1866, p. 260.) As a local stimulant, it has been much employed in atonic states of the stomach, usually in connection with other medicines, to the action of which it is supposed to render that organ more sensible. The same influence is also extended to the bowels. It has been thought to be specially useful, in this way, in drunkards, whose stomachs have lost their excitability under the influence of strong drink. It has been given, with this object, along with sulphate of quinia in intermittents, with the simple bitters in dyspepsia, and with the cathartics in flatulence and con- stipation. It has also been specially recommended in the dyspepsia of gouty persons, and in convalescence from delirium tremens. Taken in the dose of a teaspoonful, at the very commencement of sea-sickness, it is said sometimes to set aside that affection. Much efficiency has also been recently claimed for it in hemorrhoidal tumours, given to an amount of from ten grains to two scruples in the course of the day. (Ann. de Therap., 1858, p. 90.) Topically, it is occasionally employed as a gargle at the commence- ment of ordinary angina, as a direct application in relaxation and elon- gation of the uvula, and externally as an active rubefacicut. CHAP. I.] ARTERIAL STIMULANTS. OIL OF TURPENTINE. 551 Administration. The dose of the powder is from five to ten grains, to be repeated, in acute cases, every hour or two, in chronic cases, three or four times a day. The powder may also be used locally as a cataplasm, or as an application to the fauces. In young children, who cannot gargle, I have found much advantage, when the use of capsicum in this way was indicated, as in the gangrenous condition of the fauces in scarlet fever or malignant sore-throat, from mixing the powder with water into a sort of semifluid paste, and diffusing this over the fauces, several times a day, by means of a camel's-hair brush, or some similar implement. Should the child swallow a portion, it will be all the better. In the same way, it may be applied to the elongated uvula. The medicine is sometimes used also in the form of infusion (!NFU- SUM CAPSICI, U. &), which is made in the proportion of two drachms to eight fluidounces of boiling water, and given in the dose of half a fluid- ounce. In the same form, it may be employed as a gargle; but, for ordi- nary cases of sore-throat, it should be diluted with from four to eight parts of water. The formula for the infusion of Dr. Stephens, which has been much used in scarlet fever, both internally and as a gargle, directs that two tablespoonfuls of the powder, and a tablespoonful of common salt, should be macerated for an hour in a pint of liquid consisting of equal parts of boiling-hot water and vinegar. This is to be strained, and given in the dose of a tablespoonful every half hour. The officinal Tincture (TINCTURA CAPSICI, U. S.) may be used inter- nally in the dose of one or two fluidracbms; as a gargle, mixed with water or rose-water in the proportion of half a fluidounce to eight fluid- ounces; and externally, hot and undiluted, as a rubefacient. It may also be applied of full strength, by means of a camel's-hair pencil, to the relaxed uvula, II. OIL OF TURPENTINE. OLEUM TEREBINTHIN^E. U.S., Br. Origin. As used in this country, oil of turpentine is obtained exclu- sively from our common or white turpentine, by distillation. Properties. It is a limpid, colourless liquid, of a strong, peculiar odour, and a warm, pungent, bitterish, and very characteristic taste. This odour and taste have been assumed as a standard of comparison ; and, when similar properties are observed in other bodies, they are said to be terebinthinate. The oil is lighter than water, volatilizable, highly imflammable, very slightly soluble in water, scarcely soluble, when quite pure, in cold officinal alcohol, and readily dissolved by ether. On expo- 552 GENERAL STIMULANTS. [PART II. sure to the air, it absorbs oxygen, and becomes yellowish and thicker, in consequence of the formation of resinous matter, which is held in so- lution in the oil. In time, it is in this way rendered very impure. But, as the resin formed is readily soluble in alcohol, the oil may be purified by agitation with that fluid, which dissolves the impurity, and leaves the oil fit for use. When quite pure, it is composed of hydrogen and carbon exclusively; but, as found in the shops, it almost always contains oxygen absorbed from the air. EFFECTS ON THE SYSTEM. The first effect of oil of turpentine, when given to a healthy person in moderate doses, is usually a feeling of warmth in the stomach, which is followed by a glow over the system, and, after a short time, by increased frequency of the pulse. There is also generally an increased secretion of urine, which has a violet odour; and, after the oil has been taken for some time, a tcrebinthinate smell is perceptible in the breath, and the exhalations from the skin. The oil is said, moreover, to be diaphoretic. This effect I have not noticed as a common event ; though, in certain conditions of low fever in which it is given, I have often observed a soft and natural state of the skin follow- ing a dry and hot condition ; but this change I have ascribed rather to the effect of the medicine in relieving the disease, and removing a source of irritation to the surface, than to its direct action on the perspiratory function. The kidneys and urinary passages are the parts in which the operation of the oil, after entering the circulation, is most obvious. Though, as stated above, the urinary secretion is usually increased under the stimulation of the medicine, yet, after some days, irritation is often produced, amounting even to strangury, and attended occasionally with bloody urine; and the secretion is now diminished, instead of being aug- mented. With these phenomena, there is an entire absence of any evi- dence of special action on the brain or nervous system generally. From larger quantities, if within the limits of two fluidrachms, no other observable effects ordinarily result than perhaps some increase of the phenomena mentioned, and a disposition to disturb the bowels, \\ Inch is sometimes also evinced even by the common medicinal doses. If the quantity be increased beyond half a fluidounce, up to one, two, or three fluidounces, a greater degree of general excitement is produced, in which the brain now participates; feelings of fulness of the head, and slight vertigo, being experienced, and sometimes, it is said, drowsin <-.-. or a confusion of mind bordering upon intoxication. A condition resem- bling trance is said to have been experienced in one instance. In the doses mentioned, the oil not unfrequcntly occasions nausea, and some- times vomiting; and in a short time, usually within an hour or two, purges actively; after which the cerebral symptoms subside. These symptoms may possibly bo the result of a sympathetic impression upon the brain, extended from the irritated stomach, as might be inferred CHAP. I.] ARTERIAL STIMULANTS. OIL OF TURPENTINE. 553 from their quick occurrence, and their rapid disappearance upon the dis- charge of the oil by the bowels. Another evidence, to the same effect, is that large doses of the oil are less apt to produce irritation of the urinary passages than the smaller doses frequently repeated; showing that an equal amount of absorption has not taken place. The severer head symptoms are most apt to occur when the medicine does not, as sometimes happens, operate on the bowels. In this case, too, the exha- lations from the skin and lungs are highly terebiuthinate, and the urine has the violet odour strongly. Like most other stimulants, the oil sometimes appears to act as an emmenagogue. It can scarcely be considered poisonous ; as not less than four fluid- ounces are asserted to have been taken without serious consequences. On the lower animals, however, it would seem to act deleteriously; for two drachms, given to a dog, are said to have proved fatal in three min- utes, with symptoms of tetanus, and great prostration. (Pereira, Mat. Mat., 3d ed., p. 1193.) A case, moreover, has been recently recorded, in which death was supposed to have been occasioned in a woman by six fluidounces of the oil ; but the circumstances of the case are so ob- scure, as to leave the real cause of the fatal result uncertain. (See Am. Journ. of Med. Sci., X. 8., xxxvi. 5G2.) As to the alleged poisonous effects resembling those of lead, said to have been produced by exposure to the exhalations from a newly -painted room (Gaz. Med. de Paris, 1855, No. 52), and which were ascribed to the oil of turpentine used in the paint, there cannot be the least doubt that they were really owing to the lead which must have risen with the vapours ; for long exposure to the pure vapours of the oil, which is not uncommon in this country, never occasions such effects; while, as before stated in this work, it is well known that painters who use this oil in mixing their paints are pecu- liarly liable to lead-poison. The oil is undoubtedly absorbed. Ticdemann and Gnaelin detected it in the chyle of animals to whom it had been given. The odour of the urine, and that exhaled from the lungs and skin, are of themselves suffi- cient proof. It may be absorbed into the system when inhaled in the form of vapour. I have had under my care a young- man, attacked with strangury and bloody urine, from being confined on board of a vessel loaded with turpentine, during a voyage from North Carolina to New York; and he informed me that another of the crew was affected in the same manner. When applied to the skin, the oil acts usually as a powerful rube- facient. THERAPEUTIC APPLICATION. From the variety and importance of its therapeutic effects, oil of turpentine deserves to rank among the most valuable medicines. In regard to some of these effects, the anthelmintic, 554 GENERAL STIMULANTS. [PART II. namely, the rubefacient, and those exerted on the urinary organs, it will be considered elsewhere. In this place, it is to be treated of mainly as a stimulant, either generally to the system, or locally to the alimentary mucous membrane. Cold Stage of Fevers. In consequence of the absence of any direct effect on the brain, at least in ordinary stimulant doses, the oil may be given in all instances of depression or collapse, occurring in the cold stage of febrile diseases, when internal stimulation is required. In some cases of this kind, I have known it to be very useful; and it may be given with great freedom. Low Fevers generally. It has also been considerably used as a stimu- lant in low states of fever, especially when the existence of disorder of the brain may be supposed to contraindicate the alcoholic liquors, and other cerebral stimulants. In typhus and typhoid fevers it has long been employed with this view; and I found it in use upon entering into the practice of medicine, nearly fifty years ago. But it was given only as a stimulant, and, though successful in some instances, appeared in others to display little remedial power. I claim to have discovered the principle upon which its special success in these cases depended, or at least the precise circumstances under which it proved successful ; so that its employment may now be regulated with considerable confidence of gaining the results aimed at. As a mere stimulant, it may be em- ployed in most instances of low fever, but must take rank with others of the class, and indeed below several of them. In regard to the special object which I now have in view, it can be replaced, so far as I know, with equal benefit, by no other medicine. The advanced stage of the fever named specifically typhoid fever, but for which I have ventured to propose the name of enteric fever, affords the condition here referred to. I may, perhaps, be excused if I relate the circumstances which led me to this discovery; as I shall thus be able to produce a stronger impression on the reader than by a mere abstract statement of results. In the year 1823, I had under my care a case of fever of the kind then known as nervous fever, or slow remittent, or typhus mitior, by which titles it was variably and somewhat indefi- nitely called, in the advanced stage of which, violent peritoneal inflam- mation came on, ending speedily in death. On examination, I found a number of ulcerated surfaces in the mucous membrane of the ileum, in one of which, near the cfficum, a large perforation existed, through which a portion of the contents of the bowels had passed into the peritoneal cavity. In this case there had been tympanitic abdomen, and the tongue, after having parted with apportion of the fur in the centre, leaving a smooth moist red surface, had suddenly ceased to advance in the clean- ing process, and become quite dry before the occurrence of the perfora- tion. Not long previously to this, I had witnessed a fatal case in the CHAP. I.] ARTERIAL STIMULANTS. OIL OP TURPENTINE. 555 practice of a friend, which, after an abortive attempt to clear the tongue in a similar manner, with a similar dry ness afterwards, had become ag- gravated, and ended fatally. Comparing these cases, I was induced to think that the peculiar condition of the tongue referred to, with the tympanitic abdomen, might be the result of the ulceration of the ileum, and that, if I could find a medicine which would correct this ulcerative condition, I might possibly in future save my patients under similar cir- cumstances. Not long afterwards another case presented itself, having the same distinctive characters. Terebinthinate remedies having been found useful in ulcerative affections of the bowels, it occurred to me that the oil of turpentine might possibly answer my purpose in this instance. I gave it accordingly. In twenty-four hours, the tongue showed a dis- position again to become moist, a little white fur began to appear on the part before denuded, there was an amelioration of the other symptoms, and from that time the march towards health was uninterrupted under the continued use of the remedy, though I had in the beginning almost despaired df my patient. Other cases occurred afterwards, of the same character, and with the same results; and from that time to the present, though I have seen great numbers in my private practice, in consulta- tion, and in the Pennsylvania Hospital, I have lost only two, presenting thr phenomena mentioned. Of these two, one exhibited, on examination after death, such an amount of disease in the ileum as to have rendered a fatal issue unavoidable; and in the other, a small ulcerated opening was found at the bottom of an offset of the bowel, or cul-de-sac, about an inch and a half in depth, into which, as it was filled with mucus, the oil had been unable to penetrate, so as to come into contact with the surface of the ulcer; while several large ulcerated patches in the ileum were rapidly cicatrizing, showing the probably beneficial influence of the remedy on them. A brief account of the use of the oil in this condition of febril' and of the circumstances which led to it, was pub- lished in the North American Medical and Surgical Journal for April, 1826 (page 272). When the admirable work of Louis on typhoid fever appeared. I at once recognized, in his description, the disease which had exhibited the phenomena above mentioned. The ulcerative condition referred to, I had previously considered as liable to occur in any pro- tracted fever. I now learned that it was the characteristic lesion of a special disease. My therapeutic views, therefore, were immediately transtWivd to the typhoid fever, which Louis had enabled us accu- rately to diagnosticate, and. having tried the remedy in this affection, I found my best hopes fulfilled. Ever since that time, I have been in the habit, in my lectures in the University of Pennsylvania, of strenuously recommending the oil of turpentine in the treatment of enteric or typhoid fever, and have done the same in my work on the Practice of Medicine, always restricting its use to the period of probable softening and ulcera- 556 GENERAL STIMULANTS. [PART II. tion in the diseased glandular patches, and expressing my belief that it was no specific in that disease, but might be confidently relied on as having a favourable influence over this peculiar morbid affection of the bowel, and vastly diminishing the danger from that source. Abundant testimony has been given to me, by practitioners from various parts of the Union, of very favourable changes having taken place in the mor- tality of the disease, after they had adopted the practice here recom- mended. It will be best, probably, after this brief history, that I should state distinctly, the condition under which, in enteric fever, the oil may be beneficially employed, and the principles upon which I believe it to act. Enteric or Typhoid Fever. Though the oil may be of some use as a mere stimulant in this disease, it is, in that respect, of but comparatively little value, and cannot be depended on to the exclusion of wine-whey, carbonate of ammonia, and nutritious aliment, in low conditions of the fever. But the oil will accomplish what these cannot. It acts most hap- pily in stimulating the diseased patches of Peyers glands, and the iso- lated glands of the same kind, whereby the softened and disorganized matter is more readily thrown off, and the ulcerated surfaces disposed to heal, when they might otherwise be unable to do so. The remedy, therefore, is to be given at the period' during which the discharge of the softened matter is going on, and ulcers are forming, or in existence. This is usually, I believe, about the middle, or towards the close of the second \veek. Before this time I count upon no material service from the oil. It is now that the tongue becomes dry; and the occurrence of this dry state, of the tongue, in a decided degree, is the signal for commencing with the use of the remedy. I give it usually in doses of ten drops every two hours, but sometimes increase to fifteen or twenty drops. At the end of twenty-four, or at the furthest of forty-eight hours, there may very generally be seen a return of moisture with a white fur on the .surface of the tongue at the sides, for its whole length, leaving the surface in the middle still dry and often cracked. With this amendment there is often also a diminution of the tympanites, a cooler and moister skin, and a less frequent pulse. The same change goes on till the whole tongue becomes moist, and covered usually with a whitish fur, which then gradually disappears, commencing from the tip and edges. Sometimes, even when there has been no dryness of the tongue in the ease, I have found the oil to act favourably in ameliorating the symptoms; and 1're- quently, when the disease has appeared to linger in its advanced stages, and, though not severe, to show a perverse disposition to hang on to the patient, I have seen it almost immediately enter into convalescence under the use of the remedy. Again, when the case is marked in its pro"! by the cleaning of the tongue by flakes or in patches, leaving a red and smooth surface, as if deprived of the outer layer of the epithelium and CHAP. I.] ARTERIAL STIMULANTS. OIL OF TURPENTINE. 557 papillag, and when the surface of the tongue, whether completely or only partially cleared, instead of remaining moist, as it does in favourable cases, becomes very dry, with an aggravation of the general symptoms, I take it for granted that there has been a corresponding unfavourable change in the intestinal ulceration, indicating the use of the oil. It is precisely under these circumstances that, previously to my original use of the oil, I had seen a majority of the cases that came under my notice prove fatal ; and, since the use of it, only two. I do not claim for the oil any specific power over typhoid fever. It will not prevent death from iutercurrent pneumonia, or meningitis, or various other sources of mischief; but I do think, as the result, too, of great experience in the disease, that so far as the mere affection of the intestinal glands and its direct consequences are concerned, it will vastly diminish the chances of a fatal issue. The reason why, in the special condition of the tongue last described, the favourable effects of the remedy may be almost cer- tainly calculated on, is that, at the commencement of the cleaning pro- cess, the proper idiopathic disease has about run its course, and would almost certainly end well, but for an unfavourable change in the condi- tion of the ulcerated surfaces ; and whatever, therefore, will favour the healing of these, will in all probability secure a favourable termination. I have been more particular in this account of the use of oil of turpen- tine in enteric fever, because I have great confidence in the efficiency of the remedy myself, and wish to prevail on others to use it by showing the grounds of this confidence, and pointing out the precise circumstances under which, according to my experience, it should be employed. Scarlet Fever. In the advanced stage of this complaint, a troublesome diarrhoea not unfrequently supervenes, which is sometimes, I believe, sustained by ulcers in the small intestines. It is not uncommon for this condition to be attended by a dry tongue, as in enteric or typhoid fever. Under these circumstances, I have prescribed the oil of turpentine with apparent benefit. Dysentery and Diarrhoea. Whenever, in the course of these com- plaints, whether acute or chronic, the tongue exhibits a smooth surface, as if deprived of its papillary structure, and at the same time becomes perfectly dry, I always unhesitatingly employ the oil of turpentine, be- lieving that this aridity indicates a deficiency of the vital forces, which calls for the stimulating property of the oil, while the probable existence of ulcers in the bowels requires its alterative action. In chronic dysen- tery, particularly, I have repeatedly seen the happiest changes effected by the remedy, under the precise circumstances mentioned, and would strongly urge upon the reader a trial of it. One instance occurs to me, in which the patient had been very long ill, and was reduced to the lowest condition compatible with life. No one who saw the case had any hope of a cure. But the same favourable change took place, under the use of 558 GENERAL STIMULANTS. [PART II. the oil, as in the analogous condition in enteric fever, and the patient recovered. I seldom fail, in such cases, in restoring moisture, and an otherwise favourable condition to the tongue, even though the disease may prove ultimately fatal. The oil should be combined with a little laudanum in these cases. Gastritis and Yellow Fever. In the last stage of inflammation of the gastric mucous membrane, when the skin has become damp with cool sweats, hiccough has set in, and the patient vomits dark matter; in short, when symptoms of threatened gangrene appear, the oil of turpentine with laudanum sometimes offers a last chance for safety. It acts as a stimulant and alterative to the diseased surface, while it somewhat stim- ulates the system. I have seen at least one apparently desperate case recover from such a. condition under the use of it. Now this condition is very frequently presented in the second stage of yellow fever, antici- patory or attendant on black vomit. The oil has been highly recom- mended under these circumstances, being commenced with after the sub- sidence of the primary fever. Some have even employed it throughout the disease; but in the early stage, when the gastritis is yet active, the use of a powerful local stimulant like this would not correspond with my views of sound therapeutics. Puerperal Fece.r. Dr. Brenan, of Dublin, has spoken in the strongest terms of the usefulness of this remedy in puerperal fever. He gave it in doses of one or two tablespoonfuls every three or four hours, and at the same time covered the abdomen with flannels saturated with the oil. There is no doubt that benefit may accrue from the external use of the remedy in the way mentioned ; and, in the malignant forms of the dis- ease, when the blood is impaired, and the inflammation partakes of the same depraved character, it is not impossible that the powerful revulsion towards the inner from the outer surface of the bowels may have proved useful. The recommendation of Dr. Brenan has not been without the support of other highly respectable practitioners; but the remedy has not been adopted by the profession generally; and it certainly appears to be contraindicatcd in all cases of genuine- vigorous inflammation, in which it might be proper to employ the lancet. I cannot, however, speak of it from experience. Chronic Rheumatism and Gout. Oil of turpentine has considerable reputation in these affections, more especially the former, in which it is said to have sometimes proved very efficacious. It lias been more par- ticularly recommended in this disease, in the forms of lumbago and sciatica. The oil is undoubtedly a penetrating remedy, reaching the minutest capillaries, and apparently acting on them with considerable energy. It may thus prove alterative in some of those obstinate rheu- matic cases, which have taken so deep a hold of the tissues, as to be in- capable of being unseated by anything which cannot be brought to bear CHAP. I.] ARTERIAL STIMULANTS. OIL OF TURPENTINE. 559 with considerable force immediately upon the molecules of the tissue affected. I have no faith whatever in the diaphoretic action of the oil, to which some have been disposed to ascribe, in part at least, its effi- ciency in rheumatism. The medicine has not only been used internally, but has also been applied in the form of a bath of the vapour, at a tem- perature of from 140 Fahr. to 160, which is said to be well borne. In this case it is probable that the diaphoretic effect of the heat may add to the efficiency of the oil. (Arch. Gen., 4e ser., xxviii. 80.)* Nervous Diseases. Cures are stated to have been effected by the oil of turpentine in neuralgia, chorea, epilepsy, and tetanus; and it is probable that, largely employed, it may sometimes cure these affections, when purely functional, by its strong influence upon the ultimate con- stituents of the tissues through the capillaries, and its revulsive action towards the alimentary canal; but I cannot recommend it on the ground of my own experience. A case of recovery from trismus nascentium, under its use, is reported by Prof. H. L. Byrd, of the Oglethorpe Medi- cal College in Georgia. (Chariest. Mud. Journ. and Rev., xii. 474.) Hemorrhages. Oil of turpentine -is among our best haemostatics. Some have supposed that it operates in the hemorrhages by an astrin- gent property. But I have not been able to discover that it has this property in the slightest degree. On the contrary, its tendency is to expand the capillaries of the part with which it is brought into contact. * For a particular account of the origin, construction, application, and uses of these terebinthinate vapour-baths, the reader is referred to an article by Dr. M. Macario, in the numbers of the Archives Generates for April and May, 1859, pages 385 and 533. By this writer it is stated that cures are sometimes obtained in chronic polity, rheumatic, neuralgic, and catarrhal affections, which have resisted all other remedies. He does not think the temperature should be higher than between 110 and 140 Fahr., which is sufficient for all the objects aimed at. The patient is placed wholly within the balh, the vapours of which, therefore, act as well through the respiratory organs as upon the surface of the body. When there is no great occasion for haste, it is sufficient to administer the bath every other day. Under the influence of the bath, the pulse generally becomes more frequent, some- times beating 130 in the minute, while the respiration remains normal ; the whole surface is reddened; and a profuse perspiration breaks forth, which, however, does not have the effect of weakening the patient. Very seldom is headache or other evidence of congestion of the brain experienced. As effects of the bathing, more- over, the appetite and thirst are increased, and digestion accelerated; the urine, though remaining about normal in quantity, acquires a strong violet odour; and occasionally, especially in nervous subjects, the nervous system is considerably dis- turbed, as shown by restlessness, irritability, and want of sleep. The skin is some- times covered with a miliary eruption, and sometimes affected with furuncles in vari- able numbers and size. M. Macario considers the baths applicable not only to the affections mentioned, but also to chronic affections of debility, as scrofula, stiffness and contraction of the limbs, and palsies of a rheumatic character. They ore contra- indicated in acute diseases generally, attended with phenomena of excitation. (Note to the second edition.) 9 560 GENERAL STIMULANTS. [PART II. But we do not know the precise condition of the minute vessels in hem- orrhage; and it may well be, that the stimulant and alterative influence of the oil upon them may check the hemorrhagic tendency without dimin- ishing their volume. The conditions which I have considered as pre- requisite to the use of the oil, are the absence of general febrile excite- ment, and of active congestion in the part affected. Under these cir- cumstances, it may be tried in any of the hemorrhages; but that in which, according to my own observation, it has proved most efficient, is the haemoptysis of consumptive patients, or of persons supposed to be consumptively inclined. In this affection, it has proved in my hands more effectual than any other remedy, or combination of remedies. I was first induced to employ it, from having noticed its great efficiency in a medical student more than thirty years ago, who had employed it in his own case, in a very severe attack. This student is now Dr. James L. Pierce, of Philadelphia. Since that time, I have used it very success- fully, and sometimes when all other remedies had been without effect. Should evidences of active congestion be present, they should be re- moved by cups or leeches before the use of the oil ; at least this is the method which I have generally followed. Chronic Bronchitis. This affection, when attended with copious ex- pectoration, is said to have been advantageously treated with the oil ; as have other excessive mucous discharges. Dr. D. S. Brandon, of Georgia, speaks favourably of its use in stoma- titis materna, having found it very efficient in the dose of twelve drops three or four times a day. (Am. J. of Med. Sci., April, I860, p. 576.) Affections of the Stomach and Bowels. In gouty spasm of the stom- ach, flatulent colic, excessive flatulence without xpasm, and a tympanitic slate of the abdomen, the oil is often beneficial through its direct stimu- lant influence. In tympanites, given both by the mouth, and in the form of enema, it is one of the most effectual remedies. It may be employed also in hiccough, and has been recommended, in combination with ether, as one of the best remedies in biliary calculi. But experience has not proved its efficiency in the latter affection; and it is difficult to imagine in what way it could prove serviceable, unless possibly sometimes by relaxing the spasm attending the passage of these calculi through the ducts. The external use of the oil will be treated of under the rubefacients ; its employment in affections of the urinary passages, under that of diu- retics; and its application as a vermifuge, under the anthelmintics. ADMINISTRATION. The dose of the oil for the purpose of a general stimulant is five to twenty drops, repeated every half hour, hour, or two hours, in acute cases, and three or four times a day in chronic. But the dose may be much increased if thought advisable. Should it occasion strangury or bloody urine, it should be suspended. It may be admin- CHAP. I.] ARTERIAL STIMULANTS. CARBONATE OF AMMONIA. 561 istered dropped on sugar, or in the form of emulsion, made by suspend- ing it in water by means of gum arabic and loaf sugar; each tablespoonful of the emulsion containing a dose of the oil. Laudanum may often be usefully added, either when the oil is disposed to purge, or when there is an indication for the checking of diarrhoea at the time of its admin- istration. Its use in the form of enema will be treated of under the head of the cathartics. It has been recommended in the form of bath, for its constitutional im- pression, by Dr. T. Smith of Cheltenham, England, who employs in each bath from five to ten fluidounces of the oil, a fluidounce of the oil of rose- mary, and two pounds of carbonate of soda. Its external use in the form of a vapour-bath in chronic rheumatism has already been noticed. In scabies it is said to effect an immediate cure, if the patient sprinkle about a fluidounce of it, before going to bed, upon the sheets and the clothing in which he is to sleep. (Am. Journ. of Med Sci., N. S., xxxiv. 232.) Skoda recommends the inhalation of its vapour in gangrene of the lungs. III. CARBONATE OF AMMONIA. AMMONITE CARBON AS. U.S.,Br. Preparation. Carbonate of ammonia is prepared by subliming a mix- ture of carbonate of lime and muriate of ammonia. The muriatic acid and lime, reacting upon each other, produce chloride of calcium and water; and the water thus formed unites with the carbonic acid and am- monia to generate the compound under consideration, which rises in vapour, and is condensed in a proper recipient. During the process a portion of ammonia is liberated. The cake formed by the condensation of the vapour is broken into lumps, which should be kept in a well-stopped bottle. Composition. This is not a neutral carbonate, as its officinal name implies, but either a sesquicarbonate, consisting of three equivalents of carbonic acid, two of ammonia, and two of water, or, as some chemists prefer to consider it, a compound of one equivalent of the proper car- bonate of ammonia and one of the bicarbonate. When purified by a second sublimation, it is said to lose a portion of carbonic acid, and to become the 4-5 carbonate of ammonia, thus acquiring more stimulating properties. Properties. The salt, as kept in the shops, is usually in whitish lumps, more or less rectangular, hard, fibrous, translucent, of a characteristic VOL. i. 36 562 GENERAL STIMULANTS. [PART II. very pungent odour, and an acrid, alkaline, yet somewhat cooling taste, with a burning sensation in the throat, which renders it difficult of admin- istration to persons of very sensitive fauces. It is very soluble in cold water, and freely dissolved by proof spirit ; but is scarcely soluble in pure alcohol. By heat it is wholly volatiliaed. Exposed to the air, it gradually parts with the proper carbonate of ammonia, and is ulti- mately converted into the bicarbonate, becoming at the same time quite white, opaque, and disposed to crumble. I have noticed that, after long exposure, the resulting substance deliquesces, and ultimately assumes the liquid form. The lumps should always be translucent when held up to the light ; otherwise they have undergone more or less completely the change just referred to. which is a deterioration, as the bicarbonate is much It <- stimulating than the officinal salt. A loss of odour, and of the property of changing to brown the yellow colour of turmeric paper held over it. are also signs of deterioration. Incompatible^. A solution of carbonate of ammonia is decomposed by most acids; by potassa, soda, and their carbonates; by lime-water and magnesia ; alum and corrosive sublimate ; by the soluble salts of lime, lead, zinc, and iron, excepting the tartrate of iron and potassa and tin- analogous ferruginous compounds; and by most salts with excess of acid, as the bitartrate and bisulphate of potassa. Effects on the System. Carbonate of ammonia is irritant in its local action, and an energetic stimulant to the system. Taken internally, it occasions a sense of heat in the stomach, increases the frequency and force of the pulse, and produces a general glow through the system. Though sometimes causing a sensation of fulness in the head, it has no conspicuous influence over the special cerebral functions; and there are few substances so actively stimulant to the circulation, with so little obvious effect on the brain. It appears to excite more or less the gen- eral organic nervous system, and might even rank with the nervous stimulants: but its influence on the circulatory system is so much more decided, and its best therapeutic uses are so closely dependent on this action, that I have concluded to rank it in the present class, with this explanation as a caution to the learner. Asa diffusible stimulant, it is remarkably characterized by the brevity of its action. With its general stimulant influence on the circulation and organic- nervous system, it has a tendency to increase the secretions. It often produces more or less diaphoresis, sometimes operates as a diuretic, and appears to act on the pulmonary organs, if not as an expectorant, cer- tainly as a special stimulant of the respiratory function. In over-doses it irritates the stomach, and, if not discharged by vomit- ing, which generally happens when it is given very largely, may produce dangerous inflammation of the mucous membrane, with severe burning CHAP. I.] ARTERIAL STIMULANTS. CARBONATE OF AMMONIA. 563 pain. It is probably only in this way that it is capable of acting as an acute poison in the human subject; but Huxham relates a case in which its long-continued use was followed by a cachectic state of system and depraved state of the blood, as indicated by hemorrhage from the nose, gums, and intestines, pustular eruptions on the surface, dropping out of the teeth, and a general wasting of the body, with hectic symptoms. The patient ultimately died from the effects of the poison. These prob- ably depended mainly upon a constantly sustained excess of alkalinity of the blood. Two drachms and a half given to a dog were found by Or- fila to produce gastric inflammation with tetanic spasms. The obvious antidote, should an over-dose be taken, would be one of the mild vegeta- ble acids, as the acetic in the form of vinegar, the citric in that of lemon or lime juice, or the tartaric. Therapeutic Application. In an impure form this salt has long been used in medicine, under the names of sal volatile, salt of hartshorn, etc. It may often be very usefully employed. In consequence of the energy and, at the same time, brevity of its stimulant action, it is admirably adapted to all those cases of sudden depression or collapse, which, if the patient survive, must be followed by febrile reaction, if not acute inflamma- tion. The want of any special influence on the brain adapts it peculiarly to those in which the reaction will be likely to be attended with inflam- mation or great vascular excitement of that organ. Instances of the kind are not unfrequently presented in the cold stage of febrile diseases, the collapse of concussion of the brain, and the prostration of any sud- den shock. Under these circumstances, it is an admirable adjuvant of the hot bath. In all fevers, assuming in (heir progress a low form, requiring stim- ulation, this is one of the first of the diffusible stimulants which may be had recourse to. In typhus and enteric fevers, in the various exanthe- mata assuming a typhoid condition, especially scarlatina, smallpox, and malignant erysipelas, and even in the phlegmasiae when attended with the same state of system, it may often be used very advantageously, as- sociated with other stimulants, especially with wine-whey, and the pre- parations of Peruvian bark. Its tendency to produce softness or moist- ure of the skin, 'adds to its usefulness ; and sometimes, when the breath and exhalations from the patients have a sour smell, as they are apt to have in low fevers, its property of neutralizing acid, may be considered a peculiar recommendation. In the malignant pustule, carbuncle, glanders, metastatic abscess, and all cases of purulent infection of the blood, and other affections of a similar kind, accompanied with a depressed condition of the system, it may be used, conjointly with other stimulants, with hope of benefit. There are few conditions in which it acts more happily than in the advanced stages of the different pectoral inflammations, when the oc- 564 GENERAL STIMULANTS. [PART II. currence of suppuration with a tendency to prostration calls for the use of stimulants. I have frequently seen it of the greatest possible service in pneumonia under these circumstances, when the severe oppression of breathing, the cool skin, the feeble pulse, and the sweats at night, have indicated the probable approach if not occurrence of the third stage of the disease, and the absolute necessity of supporting treatment. I do not think it is going too far to say that I have repeatedly, in this con- dition, known it to be the main agent of safety to the patient. It prob- ably operates, under such circumstances, not only by a general stimu- lation of the circulatory and nervous systems, but also by a special excitation of the ultimate tissue of the lungs, concerned in the respiratory function. In a somewhat less degree, it often proves serviceable in pro- tracted acute bronchitis, with a suppurative condition of the mucous membrane. In chronic bronchitis also, and in phthisis, when the lungs are loaded with pus, and too feeble to discharge it effectually, the car- bonate of ammonia yields much relief by stimulating the expulsive power. It has been recommended both in chronic and acute rheumatism. There is a condition of the latter affection in which it may be very ap- propriately employed. This condition consists in an asthenic state of system, probably dependent on impoverished blood, in which, though there may be considerable inflammation, it is apt to be movable, changing its seat from place to place, and a good deal of nervous irritation mingles with it, along with a frequent but feeble pulse, a tendency to paleness, and, perhaps, coolness of the surface, and sweats during sleep. This is altogether different from the typhoid state of the system, with depraved blood, and yields more happily and speedily to a well-directed stimula- tion. Perhaps the use of the medicine may be ascribed in part to its alkalinity, which is indicated sometimes in these cases by an excess of acid in the system. In chronic rheumatism the medicine is usually given in connection with guaiacum, in the form of tiie ammoniated tincture of that resin; and probably acts by stimulating, in a manner similar to that of oil of turpentine, the ultimate structure of the inflamed tissue into a new action, which may supersede the old. The medicine has been recommended in scrofula; but it exercises no special influence over the diathesis, and only proves beneficial sometimes in states of depression attendant on this disease, as in a similar .state in any other. As an antispasmodic in the nervous affections it has received high commendation. Hysteria and epilepsy are the particular complaints in which it has been most praised. In the former affection it will no doubt often prove beneficial, partly, in all probability, by a direct stimulation of the nervous centres, but much more, I believe, by obviating the flat- ulence, spasmodic pains, and other disordered sensations in the stomach and bowels which so often attend and aggravate the disorder. In epi- CHAP. I.] ARTERIAL STIMULANTS. CARBONATE OF AMMONIA. 565 lepsy, when entire!}' functional, it may sometimes prove beneficial. Dr. Pereira thought he had derived much advantage from it both in epilepsy and hysteria, given in doses of fifteen or twenty grains three times a day, and continued steadily for two or three weeks. Dr. Barlow recommends carbonate of ammonia in diabetes, in con- junction with a diet of animal food and the cruciferae, exercise, the warm bath, and opiates ; but experience has not proved it to possess any special influence over that complaint. (Brit, and For. Med. Rev., Oct. 1841.) Cazenave has found it useful in scaly affections of the skin ; but a much more effectual remedy, in these complaints, is arsenic in some one of its medicinal forms; and it is scarcely advisable to postpone the cure by using substitutes which exercise a comparatively feeble, and at best uncertain influence over the disease. Carbonate of ammonia has been much commended for the possession of certain antidotal virtues. In the depressed state of system resulting from sedative poisons, such as tobacco, digitalis, and hydrocyanic acid, it is obviously indicated as a rapid and active stimulant; but, in regard to hydrocyanic acid, it has been supposed to have special powers as an antidote. Whether it can be of any service chemically by neutralizing the poison, is a matter of some doubt; but it should at least be employed as one of the most efficient agents, if not the most efficient, in counter- acting its effects. Either in this form, or that of solution or spirit of ammonia, the vola- tile alkali has obtained great credit, as an antidote to the bites of poison- ous animals. Numerous cases are on record in which, applied locally and taken internally, it has been supposed to prevent the poisonous effects of the bites of serpents. But as these bites often produce no fatal effects if left alone, it is extremely difficult to decide upon the amount of credit which the supposed antidote may really merit. The reputation of the medicine was mainly based on the apparent success of the eau de luce, a liquid containing ammonia as its chief ingredient, which was y mixing a fluid- ounce of a saturated solution of the salt with three fluidounres of olive oil. An imperfect soap was thus formed; but the union of the oil with the carbonate is less perfect than with the solution of ammonia, and the preparation is consequently less elegant than the officinal liniment of ammonia. CHAP. I.] ARTERIAL STIMULANTS. WATER OF AMMONIA. 567 There are several other ammoniacal preparations which are more or less used internally for their stimulant effects. 1. WATER OF AMMONIA. AQUA AMMONIA. U. S. LIQUOR AMMONI.E. Br., U.S. 1850. Solution of Ammonia. This is water impregnated with gaseous ammonia. As it is much more used as an external irritant than as a stimulant internally, it will be more particularly treated of among the rubefacients. Its effects upon the system are essentially the same as those of the carbonate above de- scribed, and it may be used for the same purposes ; but, as it would be more likely, if given in excess, to irritate or inflame the stomach, the salt is generally preferred. As a stimulant antacid, it is sometimes used in heartburn, and in sick-headache dependent on acidity of stomach ; and it has had considerable reputation as an antidote to the poison of ser- pents, being applied for this purpose to the bite, as well as taken intern- ally. There is some reason, however, to doubt its efficiency; and, though it may be employed, it should never be relied on to the exclusion of more efficient measures. When taken by accident undiluted, or in- sufficiently diluted, it produces severe inflammation of the mucous mem- brane of the mouth, fauces, and stomach, and may even vesicate or act corrosively. The antidotes are the vegetable acids. Much more caution is requisite in applying this to the nostrils, in order to revive fainting persons, or to rouse from positive syncope, than the carbonate, in conse- quence of the causticity of the vapour. Several instances of severe inflammation of the air-passages are on record from this cause, some of which proved fatal. In one of the instances, the vapour of the ammo- nia was inhaled as an antidote to hydrocyanic acid. The dose is from ten to thirty drops, which should be given in one or two fluidounces of water. Water of ammonia, much diluted, has recently been employed extern- ally, with a view to constitutional effect, by Mr. John Grantham, of Kent, England, with great apparent advantage in certain cases. The affections in which it seemed to be most efficacious were purpura hsemorrhagica, with internal hemorrhages from various points, and of a most serious character, and scarlatina with great general depression; but the remedy is probably applicable to all cases of low disease connected with a mor- bid state of the blood. He applies, over the whole surface of the body, by means of a sponge, a mixture of from one and a half to two fluid- ounces with two quarts of water, heated to 120. (Ned. Times and Gaz., May, 1860, p. 521.) 2. SPIRIT OF AMMONIA. SPIRITUS AMMONIA. U, S. This is a solution of gaseous ammonia in officinal alcohol, and differs, therefore, from the last-mentioned preparation only in the menstruum. It has about the same proportion of ammonia as the watery solution, and 568 GENERAL STIMULANTS. [PART II. consequently about the same strength. It may be used for the same purposes, and requires the same caution. The dose is from ten to thirty minims in one or two fluidounces of water. 3. AROMATIC SPIRIT OF AMMONIA. SPIRITUS AMMONUB AROMATICUS. U. S., Br. As now directed in the U. S. Pharmacopoeia, this is simply a solution in alcohol, in fixed proportions, of carbonate of ammonia, water of am- monia, and the volatile oils of lemons, nutmeg, and lavender. The British formula differs in submitting the same ingredients, the oil of lavender excepted, to distillation. The proportion of water of ammonia is sufficient to convert the officinal carbonate used, which is a sesquicar- bonate, into the neutral carbonate. The spirit of ammonia has an agreeable pungent odour, and the peculiar taste of ammonia pleasantly qualified by that of the aromatic oils. Upon the system its effects are the same as those of the officinal carbonate of ammonia, and it may be employed for the same purposes. The use of it, however, is generally confined to cases in which its influence as a stomachic stimulant, or slight excitant of the nervous system is wanted. Hence, it is given to obviate nausea and vomiting in debilitated states of the stomach, to relieve flatulence and flatulent pains, and to correct gastric acidity, and the heartburn and sick-headache which frequently attend it. Languor, fainlness, and the slight nervous disorder incident to hysteria are often relieved by it; and it is occasionally used to remove the lighter symptoms of intoxication caused by alcoholic drinks. It is a good addition to saline cathartics in weak conditions of the stomach. The dose of it is from half a fluidrachm to a fluidrachm, in a wine^ ful of water. IV. PHOSPHORUS. U.S. Preparation. This is obtained by first decomposing the phosphate of lime, contained in calcined bones, by means of dilute sulphuric acid, and afterwards decomposing the excess of phosphoric acid in the super- phosphate thus procured, by heating the latter with charcoal, which takes the oxygen of the acid, and escapes as carbonic acid, while the phosphorus distils over, and is received under water, where it hardens. Properties. As usually kept in the shops, phosphorus is in cylindrical sticks, of a light-yellowish colour, translucent, t:i>teless, of an odour like that of garlic, quite insoluble in water, very slightly soluble in alcohol, of which a fluidounce dissolves only about a grain,* and considerably * M. Laharraque supposed that alcohol might dissolve a grain and a half to the ounce (Diet, dt Ma'. M>'/.. Mi'-rut et De Lens, v. 277] : and Dr. Holing, of Montgom- ery, Alabama, found that an ounce would dissolve a grain, or possibly a little more. CHAP. I.] ARTERIAL STIMULANTS. PHOSPHORUS. 569 more soluble in ether, chloroform, and the fixed and volatile oils. In the absence of air, it melts and is volatilized by heat. It is extremely in- flammable, taking fire at 100 Fahr., or with slight friction at ordinary temperatures, and sometimes when held between the fingers without friction. Exposed to the air at common temperatures, it undergoes a slow combustion, emitting white fumes, which shine like flame in the dark. Hence, it must be kept under water ; but, even thus protected, it appears to unite with the absorbed oxygen of the water, as it is as- serted to impart active properties to the liquid. Phosphoric acid results from its rapid, phosphorous acid from its slower combustion. To the latter it no doubt owes its alliaceous smell.* Effects on the System. Phosphorus is generally admitted to be irritant to the stomach, and powerfully stimulant to the system, especially to the circulation. It is said also to stimulate the nervous centres, strongly to excite the sexual appetite, and to promote the secretions, especially those of the skin and kidneys. Its stimulant action is highly diffusible, oper- ating promptly and but for a short time, so that to sustain its effects, the dose must be frequently repeated. When given in moderate medicinal doses, it is said to occasion a feel- ing of warmth in the stomach, to increase the frequency and fulness of the pulse and the heat of the skin, to invigorate the mental functions and muscular power, to stimulate the sexual organs even to priapism in the male, and to act more or less energetically as a sudorific and diuretic. It is asserted that the urine sometimes becomes phosphorescent, and that a garlic odour may be perceived in the breath. When an oleaginous solution of phosphorus is thrown into the veins of an animal, the expired air becomes luminous in the dark, showing that phosphorus is eliminated by the lungs ; and, if the animal be killed and examined, these organs are everywhere congested, and spots of yellowish hepatization are found here and there. (Cl. Bernard, Med. T. and Gaz., April, 1860, p. 390.) Given more largely, it often causes burning pain in the stomach, vom- iting, purging, and great epigastric tenderness; and, in its highest degree of action upon that organ, gives rise to severe inflammation, and some- times even to gangrene and perforation. Upon the system at large the poisonous action is said, after great excitement, evinced by a rapid pulse, heat of skin, headache, giddiness, sometimes delirium, pains and cramps (W. Orleans Med. and Surg. Journ., x. 736.) Dr. Crawford, however, of N. Orleans, found that absolute alcohol dissolves two grains to the fluidounce. (Med. Times and Gaz., Feb. 1859, p. 222.) * It is an interesting fact, in relation to phosphorus, that its slow combustion in the air is entirely prevented when the air is impregnated with the vapours from tar. The fame effect is produced even more rapidly by several of the volatile oils, as those of mint, lemons, and turpentine, and by the vapours of benzine. (Journ. de Pharm. et de Chim.,3e s6r., xxxix. 331 and 414.) Note to the third edition. 570 GENERAL STIMULANTS. [PART II. in the extremities, paralysis in different parts of the body, and various other symptoms, to be accompanied with convulsions and insensibility before death. A jaundiced hue of the surface has often been noticed. The probability, however, is that, in most fatal cases, the result has been attributable to intense inflammation or disorganization of the mucous membrane of the stomach. The quantity capable of causing death is exceedingly variable. Lobelstein Lobel asserts that he has seen poison- ing produced in a maniac twenty-five minutes after the administration of one-eighth of a grain in substance (Herat et de Lens, v. 281); Dr. Christison mentions an instance of fatal result from one grain and a half: while Dr. Pereira once administered sixteen grains to Chabert, famous as the fire king, without any injurious consequences. (Pereira, Mat. Mcd., 3d ed., p. 332.) In certain cases of fatal poisoning, putrefaction is said to have been singularly retarded. (Arch. Gen., 5e ser., p. 374.) A slow poisoning results from long exposure to the fumes of phos- phorus, as in the manufacture of lucifer matches. The operation of the poison is said to be first experienced, occasionally at least, in toothache and caries of the teeth ; but necrosis of the jaws is the ultimate and characteristic effect. This has been ascribed by some to the direct ac- tion of the fumes upon the bone through the teeth ; but it is scarcely possible that an acrid substance should act so powerfully from without, and yet exhibit no effect on the soft parts ; and phosphoric acid, which has been conjectured to be the agent, does not act similarly upon those exposed to the air of factories impregnated with it. Besides, the disease of the jaws is not the only effect. Sallowness of the complexion, bloated face, a dull expression of the eye, and gastric derangement have also been noticed; and a case is on record in which copious inhalation of the vapour produced various functional derangement, ending in failure of the sexual functions, paralysis, and death in three years. (Arch. Gen., Feb. 1853, p. 219 ) The probability is that the fumes of the phospho- rus, consisting either of phosphorous or hypophosphorous acid, enter the circulation through the lungs, and act specifically on the jaws, as mercury does on the gums. The fumes of phosphorus are said to be locally irritant to the mucous membranes of the eye and the air passages, and to have produced serious inflammation in the latter. When phosphorus is burned in contact with the skin, it sometimes leaves a peculiarly troublesome and obstinate ulceration behind it, as I have experienced in my own person. Thi> has been ascribed to the irritant properties of the phosphoric acid remaining in the wound. Mode of Operation. Phosphorus itself, unchanged, is probably quite inert Its entire insolubility, the perfect impunity with which it can In- handled, and its want of taste when quite clean, are evidences to this effect. Its whole influence probably depends on changes which it under- CHAP. I.] ARTERIAL STIMULANTS. PHOSPHORUS. 571 goes in the stomach, or in the blood after absorption.* In relation to its direct influence on the gastric mucous membrane, it may be supposed to produce its simple excitant effect through some one of the acids resulting from its oxidation, and. when it is taken very much divided in solution, the probability is that it is mainly the phosphorous acid which is pro- duced, and which acts. This is of course conjectural ; for we do not know the precise effects of that acid when given in substance. It may be that the heat evolved by the slow oxidation of the phosphorus may have some effect in producing the excitation of the mucous membrane. But, in relation to its violent and poisonous action on the stomach, to the high inflammation, corrosion, and gangrene which have sometimes resulted, I am among those who ascribe them to the active combustion of the phosphorus.f This takes fire at 100, and the heat of the stomach probably is equal to that degree or above it. Atmospheric air is often contained in the organ. These then are the two requisites for combus- tion; and it is probable, whenever phosphorus is swallowed in the solid state, and comes into contact with the air, that it takes fire. Thus we can explain why it is that, when serious accidents have occurred, it has generally been from phosphorus taken undissolved. Hence too the great uncertainty in its poisonous effects. It may be readily understood that a grain, or even a small fraction of a grain, taking fire in contact with the surface of the stomach, may produce fatal disorganization ; while sixteen grains may be swallowed with impunity, if shielded from the air, or if no air is present. The effects on the system are almost certainly the result of absorption. That in one form or another the phosphorus enters the circulation, is proved by the alliaceous odour of the breath, and, as has been asserted, of the blood. It is probably in the state partly of phosphorous acid, and partly of phosphoric acid, that it is taken up. The odour of the breath would seem to indicate the former, the excess of phosphates in the urine * Recent experiments by M. Blondlot prove that phosphorus slowly rises in va- pour at 104 F.; and as this is but little above the ordinary interior temperature of the body, it is not improbable that the phosphorus may be volatilized in the stom- ach, and that it is really in the state of vapour that it is absorbed. (Journ. de Pharm. et de Chim., Nov. 1866, p. 323.) Note to the third edition. j- Strongly confirmatory of this opinion is the fact, ascertained by Orfila and Ri- gaut through experiments on dog, that phosphorus, in the allotropic state de- nominated red phosphorus, is wholly destitute of poisonous properties. (Ann. de Therap., 1857, p. 284.) Now this variety of phosphorus does not undergo com- bustion at ordinary temperatures, and consequently will not take fire in the stom- ach. It is true that its want of poisonous properties may be ascribed to the non- production of phosphorous acid by its oxidation. But it has been ascertained that it really does undergo a slow oxidation at. ordinary temperatures. (Jahretbericht, 1857, v. 46.) Consequently its harmlessness is fairly ascribable to its incombusti- bility. (Note to Ike second edition.) 572 GENERAL STIMULANTS. [PART II. the latter. It is not impossible that the phosphorus itself, in the state of solution, or in that of vapour (see note, p. 571), is also absorbed; and the fact must be admitted, if it is true that the urine sometimes becomes phosphorescent under its use.* It is not impossible that the poisonous effects of the absorbed phosphorus may be owing to its combustion in the blood. This supposition is favoured by the fact that phosphoric acid, given to dogs in much larger doses than that in which phosphorus proves fatal, has evinced no poisonous effect. (T. B. Groves, Fharm. Journ. and Trans., xvii. 510.) If phosphorus should have been taken in dangerous quantities, it should be immediately evacuated by an emetic, with copious draughts of mu- cilaginous drinks to envelop the poison, and keep it as much as possible from the action of air in the stomach ; magnesia being at the same time given to neutralize any acid which may have resulted from its oxidation. Should symptoms of inflammation or corrosion remain after the evacu- ation of the poison, they must be combated by the ordinary methods, such as leeches followed by emollient cataplasms to the epigastrium, mucilaginous drinks, or opiate enemata; while one of the alkaline bicar- bonates may still be exhibited to neutralize any acid that might remain. It has occurred to me that, should a piece of solid phosphorus be swal- lowed, the free use of carbonic acid water, with bicarbonate of soda in solution, might be useful until the poison could be evacuated. The car- bonic acid evolved from the liquid by the heat of the stomach would fill its cavity with a gas, which not only does not support combustion, but, mingled largely with atmospheric air, suppresses the supporting power of it also; while the alkaline bicarbonate would neutralize any free acid present, and still further increase the atmosphere of the acid gas. It has been recommended to wash the burns produced by inflamed phos- phorus on the surface with an alkaline solution, in order to remove the phosphoric acid. Therapeutic Application. The use of phosphorus as a medicine takes date from the middle of the last century. Though now little employed, in consequence of its frequently violent effects, it has at different times and by different persons been used in a great number of diseases; and, properly guarded, is probably capable of useful therapeutic application. Nervous diseases, acute and chronic, as epilepsy, palsy, catalepsy, hypo- chondrias^, functional apoplexy, tetanus, periodical headache, vene- real exhaustion, and amaurosis ; intermittent fevers; smallpox; vari- * Though, as stated in the text, the free oxidation of phosphorus in the stomach is probably owing to its combustion, yet it appears to be capable of rajiHly ami fatally poisoning the system through absorption also; as this effect has resulted, without any decided stomachic symptoms during life, or any evidence of materi.q derangement of the mucous membrane of the stomach after death. (See Am. Journ. of tied. Sci., N. S., xxxv. 288.) CHAP. I.] ARTERIAL STIMULANTS. PHOSPHORUS. 573 ous other febrile diseases of a low or malignant form; retrocedent eruptions; hemorrhages; different forms of gout and rheumatism; cholera, diarrhcea, and colica pictonum; chlorosis and amenorrhcea; sterility and impotence; and even the phlegmasise, as typhoid pneumo- nia, calarrhal croup, chronic pleurisy, and bronchitis, have been enu- merated by authors among the diseases in which phosphorus has been employed and recommended. A sound discretion, however, would select, from this list, the affections in which its known powers might justify its use. The collapse which takes place in the early stage of certain fevers ; great prostration occur- ring in the course of febrile diseases generally; the alarming depression sometimes attendant upon the retrocession of scarlatina, erysipelas, etc.] in short, all low states of the system requiring prompt and powerful stimulation, and in which ordinary stimulants fail ; these afford the conditions under which the practitioner would be justified in having re- course to this energetic remedy. In cases, too, of morbid depression of the generative powers, whether in the male or female, it would appear to be indicated, through one of the best established of its physiological properties. It may, moreover, be tried in old and very obstinate rheu- matic and paralytic cases, when no discoverable organic lesion renders any amelioration altogether improbable. Administration. With proper caution in its use, no serious danger need be apprehended. In the first place, it should never be given in the solid or undissolved form, not even in a state of mechanical division, however minute. It should be exhibited in solution; and, happily, its different menstrua take up so small a portion of it, that it is brought into contact with the stomach in an extremely diluted state, and the combustion of its particles, should this take place, could do little or no injury.* In the second place, it should not be administered when the * M. Tavignot, however, who has used phosphorus very extensively, affirms that the pilular form is preferable for internal use; being perfectly safe, as he prepares the pills, and much more acceptable to the patient. He first dissolves one deci- gramme (1.5 grain) of phosphorus in eight grammes (about two drachms) of sweet almond oil, with the aid of a water-b:ith, and then with eight and a half grammes of butter of cacao, and eighteen grammes of marshmallow, forms a mass, which he divides into one hundred pills. To a child from three to seven years old he gives at first one, and then two pills daily. It will be noticed, however, that even in the pill of M. Tavignot, the phosphorus is really in solution, so that the direction in the text still holds good. M. Tavignot affirms that, in the quantity of four milligrammes (O.UGO grain) daily, phosphorus may be given fur months without the least dan- ger. He also uses it externally in the form of a liniment, made by dissolving, with the aid of a water-bath, one part of phosphorus in four hundred parts of sweet almond oil, and one hundred parts of naphtha. This is applied by friction, and alterwards by means of flannels impregnated with it. He uses the pills and the liniment conjointly. (.-i/i. de Therap., 1SGG, p. 100.) Note to the third edition. 574 GENERAL STIMULANTS. [PART II. stomach is quite empty, unless accompanied with copious nutritive or enveloping material, which would secure the mucous surface against its concentrated effect. Very different opinions have been advanced as to the suitable dose. A mean between the extremes would give one grain during the day, in divided doses, frequently repeated. The only suitable preparations are solutions in ether, chloroform, olive or almond oil, or some analogous menstruum. Ether and olive oil each dissolves about four grains to the fluidounce. Objections to the former menstruum are the length of ma- r-eration necessary, which renders extemporaneous preparation difficult, and the great liability to the loss of the ether, and the consequent pre- cipitation of the phosphorus, when the solution is kept. The solution in oil is preferable, as it is made more speedily, and keeps better. It is prepared, according to the Prussian Pharmacopoeia, in which it is desig- nated as Oleum Phosphoratum, or Phosphorated Oil, by putting twelve grains of phosphorus, minutely divided, into a fluidounce of almond oil, melting the phosphorus by means of a water-bath, and then agitating until solution seems to have been effected. As the oil really dissolves but four grains, the undissolved portion should be separated by decanta- tion or filtration. This oil should be phosphorescent when exposed to the air. The dose of it is from five to ten drops, which may be repeated, in cases of urgency, every half hour; in ordinary cases of debility, every hour or two through the day. It should be given in emulsion with one of the aromatic waters, so made that a tablespoonful may contain a dose of the phosphorus. Dr. R. M. Glover proposes chloroform as a solvent. This dissolves one-fourth of its weight of phosphorus, and has* the advantage that the solution is not inflammable. (London Lancet. Jan. 8, 1853, p. 34.) The preparation should be made extemporane- ously, in consequence of the great volatility of chloroform. One minim of a saturated solution, mixed with fifteen minims of ether and half a fluidounce of wine, might be given, in acute cases, every two or thn-i hours. Dr. Glover also proposes a solution of phosphorus in cod-liver oil, containing half a grain to the ounce, for use in scrofula. (See U. S. Dispensatory.) CHAP. I.] NERVOUS STIMULANTS, OR ANTISPASMODICS. 575 S II. NERVOUS STIMULANTS. Syn. Anlispasmodics. Tins class of medicines is characterized by the property of stimulating the nervous system generally, without specially acting on the brain. Most of them are also more or less stimulant to the circulation, increasing the frequency of pulse and heat of skin, and often exciting the secretory functions ; but these properties are incidental, and not essential to them as a class; and some, as coffee and tea, are nearly or quite destitute of them. Their peculiarity is simply that they stimulate the nervous centres generally and equably, without concentrating their force upon upon any one or a few of these centres; and the possession of this prop- erty would of itself be sufficient to entitle any medicine to a place in the class. . It is this universality of their action that distinguishes them from the following class, or that of cerebral stimulants. As one of the nervous stimulants may superadd to its own characteristic property that of the arterial stimulants, so may it also possess additionally the peculiar influ- ence of the cerebral stimulants, only that its own action would in that case be swallowed up or overwhelmed in this more powerful influence ; and such really appears to be the case with some of the nervous stimu- lants. Thus, while assafetida, valerian, coffee, tea, etc., can scarcely be made to evince, in any quantity, or by any mode of administration, a peculiar tendency to operate on the cerebral centres beyond others, some medicines, much used and very efficient as nervous stimulants, if given more fnvly than is necessary for the exertion of tfceir influence in this way, not only operate on the brain specially, but do so with great energy; as is the case with ether, camphor, and opium, which, in small doses, produce all the effects of the present class. The only difference between these two sets of nervous stimulants is that, while both, in certain doses, stimulate equably the general nervous system, the former cannot be made to operate specially on the brain, and the latter can be made so to act by simply increasing the dose ; that is, in small doses they appear to operate diffusively and equably, and in larger, besides this general impression, superadd a special one upon the brain, which quite covers, if it does not supersede the first. In order to avoid unne- cessary repetition, T shall treat of these latter remedies exclusively with 576 GENERAL STIMULANTS. [PART II. the cerebral stimulants; as their most important therapeutic uses wo.uld attach them to that class ; and it will be easy to point out their appli- cations as nervous stimulants, when they are considered individually. Ether, camphor, and opium, therefore, will be found among the medi- cines of the next class. The medicines here denominated nervous stimulants are generally called antispasmodics in therapeutic treatises, in consequence of the property of relaxing spasm, which they certainly possess under favour- able circumstances, in a very high degree. But spasm depends on so many causes, and is associated, as an effect, with so many diiferent pa- thological conditions, that the number of remedies applicable to its relief would scarcely fall short of the whole therapeutic catalogue. Depend- ent often upon inflammation, it may be treated advantageously by all the means which prove useful in the latter affection ; that is, by most of the evacuants, revulsives, sedatives, and alteratives; in other instances, having its origin in debility, it will yield to astringents, tonics, and stim- ulants; and, in a third set of cases, being excited or sustained by various diseases in the different organs and functions, it must be encountered by. measures calculated to restore the affected organ or function to health. Again, this class of medicines is by no means confined, in its therapeutic agency, to spasmodic, diseases. It is equally effectual in numerous other nervous disorders, to which more particular reference will be made di- rectly. The nervous stimulants are but a very small section of the great host of antispasmodics, while they are themselves much more than mere antispasmodics. The name, therefore, being, in our sense, much too comprehensive, and, in another, scarcely in a less degree too restricted, should be abandoned, with other titles of a similar therapeutic origin, as the antiphlogistics, antiscorbutics, antisyphilitics, etc., which it has been found impossible to retain in any well-considered pharmacological classi- fication. I have proposed a name for the class which simply expresses one of their most prominent properties, and the one for which they are most used in medicine. 1. Effects on the System. It has been already stated that most of these medicines stimulate t he- circulation, and consequently increase the temperature of the surface. Indeed, this effect is often more obvious in health than their influence over the nervous system. The latter is so diffusive that the balance of the functions is little disturbed ; and, no one being prominently affected, there is no striking departure from their healthy condition. Yet some influence upon the nervous functions may almost always be observed. A feeling of cheerfulness, a gentle exhilaration of the spirits, greater vividness of the fancy and energy of intellect, a disposition and capacity for increased muscular action, and some excitement of the organic func- CHAP. I.] NERVOUS STIMULANTS, OR ANTISPASMCDICS. 577 tions, which are more or less under the influence of the nervous centres, and particularly the function of secretion, may generally be noticed. In great excess, some of them produce disordered sensations in the head, as feelings of fulness, vertigo, and headache; but very rarely do any of them, not belonging also to cerebral stimulants, occasion delirium, intox- ication, or stupor. But in disease their effects are very obvious; the most violent apparent disorder of the nervous functions yielding some- times promptly to their influence. They are for the most part highly diffusible, acting quickly, and soon ceasing to act. They differ, however, much in this respect ; and some of them continue to operate for a considerable time. Most of them are either volatile, or contain a volatile principle, which is often highly odorous, and generally disagreeabl} r so to those unaccus- tomed to it, though it is often rendered tolerable and even agreeable by habit. Many persons acquire a strong relish for the smell and taste of as>tifetida and garlic. It has been thought by some that the nervous stimulants produce their remedial effects exclusively, or nearly so, through the organ of smell. I have never been of that opinion. They will often operate energetically when taken in the form of pill so as to conceal their smell and taste, and not unfrequently will produce the most prompt and powerful effects when given by enema. In some instances, they do probably act by an impression made on the nostrils, which is conveyed through the com- municating nerves to the nervous centres; but, in general, there can be no doubt that it is through the alimentary canal that they affect the system. In relation to some of the more odorous, as musk, assafetida, and garlic, the odour which they impart to the exhalation from the lungs and skin, is an incontestable proof of their absorption ; and the strong probability is, in reference to all of them, that the active principle enters the circulation, and is carried with the blood to the parts upon which it is to operate. When their volatile principle is inhaled into the lungs, it finds a ready entrance into the circulation ; and some of the class, when applied externally, are absorbed with consideraBw facility; as is cer- tainly the case with garlic, and probably with assafetida. 2. Therapeutic Application. - The special application of this class of medicines is to the relief of nervous disorder. They are used in all affections of this kind, whether the result of over-excitement, or of depression of the nervous centres, provided only they are purely functional; that is, unconnected with active congestion or inflammation, or any other organic disease in those centres. This may at first sight seem singular ; that the same remedy should prove useful in morbid excess and morbid deficiency of action ; but the apparent anomaly is not insusceptible of explanation. VOL. i 37. 578 GENERAL STIMULANTS. [PART II. The characteristic effect of these medicines is to stimulate the nervous centres. It will, therefore, be readily conceded that they may prove serviceable in disease, consisting in a depressed state of the nervous functions. But how can they, by their stimulating power, relieve a disease, consisting essentially in an already morbidly excited condition of the parts upon which they act ? To answer this question, we must admit, as a starting point, that there is only a limited amount of nervous excitability in the system; in other words, that, taking the whole nervous system together, it is insus- ceptible of unlimited exaltation, and that there is a point beyond which its actions cannot be elevated. Again, it must be admitted that the nervous energy is transferable, like the blood, from one part to another : that an over-excitement in one or more parts will call it off from others : and that in health there is a general tendency to an equilibrium of dis- tribution. By supposing the existence of a nervous fluid, this reasoning might, perhaps, be rendered somewhat more intelligible; but 1 avoid this advantage, as the existence of such a fluid has not been proved ; and the argument is equally cogent without it. Admitting the above propositions, which I believe are nothing more than statements of facts susceptible of satisfactory demonstration, we have only further to recol- lect, that the nervous stimulants are characterized by the universality and equability of their action on the nervous centres. Suppose now that one of the cerebral centres is irritated into diseased action, which ex- hibits itself in spasms of the muscle directly connected with and de- pendent on that centre. A nervous stimulant is administered. It of course excites all the centres, operating on the one diseased in the same degree as on the others. Each becomes the seat of an attractive effort calling to itself as much of the nervous power as may correspond with the degree of excitation applied. All, therefore, draw with a united force upon the surplus in that one centre, in which there is supposed to be a morbid accumulation. To this united force it can oppose only its own attractive force, under the irritation to which it is exposed. If, therefore, the combined excitat^a applied to the nervous centres generally, is not less than that existing in the one diseased, under the morbid irritation, united to the excitation of the remedy, which it shares equally with the others, it must part with its surplus, and be reduced to the general level, or near it ff the causes of irritation shall have ceased, and the disor- dered centre be continuing to act morbidly simply from having begun to do so, the equilibrium can be entirely restored, and the disease cured. If not, the equilibrium is but partial or temporary; and the disease, though relieved, will be liable to return. The nervous stimulants, th> fore, though they may afford much relief, even during the continuance of the cause, cannot be expected to effect a cure until this shall have ceased to act. CHAP. I.] NERVOUS STIMULANTS, OR ANTISPASMODICS. 579 In former times, these stimulants were said to prove useful by equal- izing excitement. This term conveys succinctly the idea which I have endeavoured to demonstrate in the above paragraph. Our predecessors could not but notice the effect, though I am not aware that they have attempted a precise explanation. Their notions of the influence of the nervous centres were less definite, probably, than those now prevailing. Functional nervous disease may be, in the first place, idiopathic, or self-existent, and alone ; or, secondly, it may be idiopathic, and asso- ciated with other diseases ; or, thirdly, it may depend upon other dis- i-;ie of the brain, as the third or fifth pair, and these forces to balance each other in the normal state, it follows that whatever excites the sympa- thetic centre in the medulla oblongata, or paralv/.cs the basic centres referred to, will produce dilatation of the iris, while a paralyzing influ- ence on the sympathetic centres, or one of an excitant character on the others, will equally produce contraction ; so that, while two cerebral stimulants differ in their mode of affecting these special centres, they may correspond in their effects on the remainder of the cerebro-spinal CHAP. I.] CEREBRAL STIMULANTS. 631 axis, or while one acts on one of the centres, and the other on the other, they may both act in the same manner, and with the same effect, that is, may both be excitant, or both depressing. Though differing so much among themselves, there are affinities be- tween certain articles of the class, which might serve to arrange them in subdivisions, having, to a considerable extent, a common therapeutic basis. They might thus be arranged in groups, of which one would contain alcohol and ether, another opium, extract of hemp, lactucarium, and hyoscyamus, and a third belladonna and stramonium ; the other in- dividuals of the class remaining isolated. By considering them succes- sively according to these relations, we may, sufficiently for practical pur- poses, fix in the recollection of the student the resemblances referred to. Before proceeding to a general account of the mode of operation, and therapeutic properties of the class, it will serve to prepare the way, if we dwell for a short time on certain peculiarities in cerebral pathology, which, if not understood, will inevitably lead into great confusion. It is a well-established fact, that opposite morbid conditions of the brain, or parts of it, express themselves by similar phenomena; and the law probably holds true of the nervous centres universally. Pain and other morbid sensations, spasm and other forms of irregular muscular action, delirium partial or complete, mild or severe, chronic or acute, and every grade of stupor, from slight drowsiness to the deepest coma, may all arise, and frequently do arise, from the two opposite affections of irrita- tion and depression of the cerebral centres. For proofs of this, and for an explanation, which, in the opinion of the author, may serve to reconcile the apparent contradiction, readers are referred to the article on functional diseases of the brain in his work on the Practic of Medicine. It would occupy more space than could be spared to repeat them here. But the application of this fact to the subject now before us is of great practical importance. From a certain similarity in their obvious effects, medicines essentially different in character have been associated together in the minds of writers and practitioners, and been considered as nearly identical in nature, so that they might be interchangeably employed under the same circumstances, without disadvantage. !Now, as opposite morbid causes, acting on the same cerebral centres, may produce the same morbid phenomena ; as, for example, insufficiency and excess of blood in the brain may either of them produce delirium, coma, and con- vulsions; it follows necessarily that medicines, which in excess are al- ways morbid causes, may also, though really opposite in character, give rite to closely resembling, if not identical symptoms. Thus, of the medi- cines usually ranked together as narcotic, because they produce the common effect of stupor, some operate as direct stimulants, others as direct sedatives to the nervous centres ; and it will be readily understood that, if such medicines are used remedially, under the impression that 632 GENERAL STIMULANTS. [PART II. they are identical in character, the most serious consequences might ensue. Opium is stimulant to the nervous centres, aconite is sedative : but both in over-doses are capable of producing coma. In a case of active congestion of the brain, in which the latter may be useful, the former could do only injury; and vice versa. To administer them, there- fore, indiscriminately, because of their common stupefying effect, would be a grievous error. But a case more in point, because there is reason to think that attention has not yet been sufficiently called to it, is that of ether and chloroform. Both of these are powerful anesthetic agents; and, under the impression that their mode of action is essentially iden- tical, they have been used and recommended in similar cases, with little discrimination. The one is, in fact, a most energetic cerebral stimulant. the other an equally powerful cerebral sedative : is it, therefore, surpris- ing that, used indiscriminately, one of them at least should have occa- sioned so fearful an amount of mortality ? The importance of guarding against such a therapeutic error is, it appears to me, an irrefragable argument in favour of the division I have made of the narcotic medi- cines into classes, founded not on phenomena which are readily misin- terpreted, but on their real physiological influence on the brain, and the general system. Effects on the System. The first effect of a cerebral stimulant, given in doses calculated to bring its characteristic influence into operation, is more or less to excite the stomach. In a short time, its influence extends to the general system, showing itself usually, in the beginning, by a moderate increase in the activity of the sensorial functions, and in the movements of the heart. But very quickly more obvious cerebral phe- nomena are ^hibited ; while the circulation may or may not be propor- tionably excited. The sensorial functions are now perverted. Abnormal sensations are felt in the head, such as fulness, pressure, confusion, swim- ming, giddiness, singing in the ears, perhaps pain; the mind wanders more or less ; the voluntary movements are apt to become irregular ; and intoxication or delirium may supervene. Jsext succeeds a gradual dimi- nution of the sensorial functions. Heaviness and languor, or a feeling of general and pleasing calmness, soon deepens into drowsiness, and this at length into stupor, which more or less closely resembles natural sleep, according to the character of the narcotic used. All these are the direct eiVects of the medicine. The stupor continues for a length of time vary- ing from one or two to twelve hours or more, according to the particular article used, gradually diminishing from its greatest intensity, till the patient at length becomes fully awake, when the direct operation of the medicine is passed. But now a condition of depression takes place, moiv or less corresponding with the previous excitement, and the strength of the direct impres.-idii. This is characterized by feelings of languor and dejection, often with more or less general or local uneasiness, especially CHAP. I.] CEREBRAL STIMULANTS. 633 headache, by a pale, cool, and relaxed state of the surface, and feeble- ness of the pulse, and by a depressed state of the gastric functions, as indicated by want of appetite, nausea, and perhaps vomiting. These symptoms may be so slight as to be scarcely noticed, or they may be severe and extremely uncomfortable to the patient, but from appropriate doses ate seldom serious. After a few hours they gradually pass away, under healthy vital influences, and the previous state of system returns with little or no appreciable change. From larger doses of the medicine, the primary excitant impression is stronger, but shorter, the succeeding period of stupefaction deeper and more lasting, and the secondary depression greater, more protracted, and more serious. In very large quantities these medicines become poisonous. The symp- toms of excitement and exhilaration, though sometimes intense, are very brief, and the subsequent stupor profound and alarming. Instead of being confined mainly to the cerebral centres, the influence of the poison extends to the centre of respiration in the medulla oblongata, which may be overwhelmed by the force of the poison, and death may result from this cause. Or the direct effects of the narcotic may pass over without fatal consequences, and the patient may lapse into the secondary condi- tion, and perish from the universal prostration of his functions. If the dose of the poison has not been quite sufficient to destroy life, he rises slowly and with difficulty from the profound depression, and may not for several days recover his previous state of health, perhaps even for a much longer time, if any organic lesion shall have taken place. The course of the symptoms has been given above ; but they require explanation. First, it may be proper to observe that the description is applicable only as a general rule. Special phenomena are sometimes exhibited by the individual narcotics, which it will be most convenient to treat of along with their other properties and effects. The first impression on the stomach is due to the direct contact of the medicine, which operates both on the nervous and vascular tissue of the organ, exciting it to an increase of function, which is followed by the same stupor, locally, if we may so express ourselves, as that experienced by the general system. It is not impossible that the original gastric ex- citation may be sympathetically propagated to the cerebral centres, giving rise to the first phenomena of general stimulation, and afterwards increasing the direct influence of the medicine when it reaches the brain through absorption ; but we have no positive evidence to this effect; nor indeed have we, in relation to some of the narcotics, any demonstrative proof that they are absorbed at all. But, as some of them are known to be so, the inference is quite allowable that they are all taken into the circulation, or at least their active prin^ples ; and it is most probable that 634 GENERAL STIMULANTS. [PART II. their constitutional effects are chiefly, if not exclusively, produced in this way. The impression of the medicine on the cerebral centres is probably throughout, so long as its direct influence remains, of a stimulating char- acter. That it is so at first, is rendered obvious by the symptoms. Some have ascribed the stupefaction which ensues to a sedative operation. I cannot agree with them. I cannot conceive that a medicine, in its direct influence on an organ, shall pass so speedily from a stimulant to a seda- tive action. A true sedative condition will result, but that is after the medicine has ceased to act directly. It is not difficult to explain the oc- currence of intoxication and stupor upon the principle of continued stim- ulation. I have demonstrated elsewhere that, in the continuous opera- tion of an excitant directly upon any organ, the first effect is an increase, the next a derangement, and the last a depression or suspension of its function. These results probably follow the gradually increasing amount of blood drawn into the organ by the irritation, at first in quantities merely sufficient for the support of the increased function, afterwards sufficient to derange it, though still increased, and lastly congesting the organ to a point at which its function is embarrassed and impaired, or quite overwhelmed. Applying this general rule to the operation of the cerebral stimulants, we have first the simple excitation, as shown by the obvious phenomena; next, the perverted excitation, exhibited in the men- tal confusion, or intoxication; and thirdly, the overwhelming congestion, as evinced by the drowsiness and stupor. But when the immediate ope- ration of the medicine has ceased, either in consequence of its decompo- sition or elimination, the stimulated organ is left to its own powers. Its excitability having been exhausted by the previous over-action, it is in- susceptible to the ordinary healthful influences of the blood and other vital agents, and consequently acts feebly, or for a time ceases to act. Hence the prostration which follows the cessation of the direct opera- tion of the medicine. The exhausted organ, however, if not fatally depressed, recovers its excitability by rest, and, being again able to feel and respond to its healthy stimuli, returns to its normal state of action. When poisonous quantities have been taken, death occurs in one of two ways. Either a nervous centre essential to life, as the respiratory centre in the medulla oblongata, is so far overwhelmed by the active congestion as to be unable longer to perform its office, in which case the function of respiration ceases as a necessary consequence; or the general depression following the enormous preceding excitement of the cerebral centres generally, and of the whole system, is too great for reaction, and tin- patient dies completely prostrated. In the former ease, which is l>y far the most common, the respiration ceasing, the blood is no longer oxygen- ated in the lungs ; the capillariea^onsequently refuse to carry it forward ; the heart, failing to receive a supply necessary to the support of its CHAP. I.] CEREBRAL STIMULANTS. 635 function, now in its turn ceases to act; and death takes place finally because the blood no longer circulates. In proof that the above is the true explanation of the operation of the cerebral stimulants, dissection after death always shows congestion of the brain, when the patient has not died of pure prostration after the poison has ceased to act. Death, then, from the cerebral stimulants is usually an example of asphyxia. The heart, as in the same affection from other causes, con- tinues to beat for a short time after respiration has ceased, sometimes in a greater or less degree for five minutes, thus affording the opportunity for the employment of recuperative measures, even after apparent death. Brodie first proved, by experiments on the lower animals, that, after apparent death from a narcotic poison, life might be saved by artificial respiration. The blood, being thus supplied with oxygen, begins again to move onward; and the heart, which has not yet quite ceased to beat, receiving a due supply, resumes its normal action, and the phenomena of life return. All that is necessary now is to continue the artificial res- piration, until the nervous centres shall be in a condition to resume their function, and to support the strength of the patient against the secondary prostration. In several instances, these measures have been successful in the preservation of human life. The cerebral stimulants are capable of producing their characteristic constitutional effects, to whatever part of the body they may be applied; a fact which strongly corroborates the idea of their operation through absorption. Of the ordinary avenues by which they are introduced into the system, with a view to remedial effect, they operate most speedily through the subcutaneous areolar tissue or lungs, next through the stomach, and after this through the rectum, or the skin deprived of the epidermis; and the duration of their effect is usually inversely propor- tionate to the rapidity with which it is induced. The local effects of the cerebral stimulants upon the surface of appli- cation arc analogous to their general effects, probably through their direct action upon the vessels and nerves of the part. They first excite the actions of the part, then diminish its sensibility, and lastly leave it, upon their removal, in a somewhat depressed condition; unless, indeed, their first stimulant impression shall have been sufficient to induce a positive inflammation, which will complicate the result. This class of medicines, more rapidly than perhaps any other, lose their effect upon repetition. Each successive stimulant impression serves, in some degree, to lessen the excitability of the organs acted on ; and, if time is not allowed for the system to recover its normal state before a renewal of the impression, this diminution of the excitability must be constantly and steadily continued. To produce a given effect, the dose of the medicine must be increased pajt passu with the diminution of the excitability; and there are no fixed limits within which this augmen- 636 GENERAL STIMULANTS. [PART II. tut ion is restrained. As the medicines have no corrosive effect, and therefore do not directly destroy the organization of the parts on which they act, the quantity which an individual may attain the ability to sup- port, with present impunity, is enormous. In Dr. Chapman's Therapeu- tics the case of a woman is mentioned, affected with cancer of the uterus, who took three pints of laudanum, besides a considerable quantity of opium daily, enough probably to kill from fifty to one hundred healthy individuals. (2d ed., ii. 236.) But the protracted use of the cerebral stimulants in excess is often attended with the most deplorable consequences in the end. As before explained, under the head of the Tonics, there are two great evils flow- ing from this abuse; the one, a gradual wearing out of the excitability of the system, and a consequent gradual depression of its functions and powers; the other, the production finally, in some one or more of the organs upon which the stimulant specially acts, of a low chronic inflam- mation, the result of the incessantly repeated irritation. This complica- tion of general debility Avith local disease almost necessarily destroys life in the end, if it be not previously cut short by the occurrence of some accidental affection, which the exhausted frame is unable to sup- port. More will be said on this point when the particular cerebral stim- ulants are treated of, which are most liable to be thus abused. When the system has become habituated to one of these stimulants in great excess, its sudden withdrawal is sometimes followed by the most alarming prostration; and this is a fact which it is highly import- ant to bear in mind, in the treatment of the diseases of individuals who are the victims of such self-indulgence. Even in their inflammatory affections, when depletion may be necessary to save life, though the habitual stimulant may be lessened, it should not be altogether withheld. When called to a patient suffering under the effects of the abuse here referred to, the only remedy is the total abandonment of the evil habit. But this should, if possible, be effected gradually. Should the patient be under his own control, and unable or unwilling to persist in such a course of gradual reduction, the best substitute is to throw aside the particular stimulant abused at once and completely, and to support the strength by other stimulants of analogous powers, but less injurious in their effects, and possessing less attractions for the patient; then grad- ually to diminish the amount of this support, and ultimately withdraw it altogether. Therapeutic Application. The therapeutics of this class of medicines will be most conveniently treated of under the several individual articles; as there is so much specialty in their uses, that few general observations would be applicable to the whole, or even the greater number. There are, however, a few consideral^ns which it may be proper to present CHAP. I.] CEREBRAL STIMULANTS. 637 in this place, to spare inconvenient explanations and useless repetition hereafter. General Stimulation. Among the cerebral stimulants are medicines which are most powerful and most relied on under circumstances calling for the most vigorous support to the depressed or exhausted system. In consequence of the universality of their stimulant power, and especially of their influence over the functions of the brain, the due maintenance of which is essential to life, they are better adapted than any other class of medicines to diseases of debility, in which these functions may partici- pate in the general prostration. The only circumstance which centra- indicates their use, and which might preferably direct the attention to other stimulants, is the existence at the moment, or the probable occur- rence at the period of reaction, of active congestion or inflammation of the brain. Relief of Pain, Spasm, etc. Besides general stimulation, they are much employed for the relief of pain, the relaxation of spasm, and the composure of nervous irritation generally. All these effects they pro- duce by rendering the nervous centres insensible to impressions of an irri- tant character, and incapable of radiating influence from themselves. It must be remembered, however, that, in thus operating, they stimulate the centres instead of depressing them. Their influence comes under the general law already referred to in these preliminary remarks, namely, that irritation of an organ, in its highest grade, diminishes or depresses the function of that organ, probably by overloading it with blood. When the sensorial centres are thus stimulated, the impression sent to them from the suffering part is no longer felt, and pain of course ceases. Or, if the pain originated in disordered function of the centre itself, the feeling is equally abolished ; because the function itself is temporarily supprcssed. The same explanation applies to spasm and other forms of nervous derangement. If they originate in external irritation transmit- ted to the sensorium, they are relieved when the sensorium can no longer feel the irritation ; if in disorder of the seusoriuin itself, they cease temporarily with the cessation of its function. But it frequently happens that pain, spasm, and other nervous disorder, originate in a de- pressed condition of the nervous centre ; perhaps in a deficiency of its supply of good blood. The centre, under these circumstances, becomes a negative point towards which nervous force may be supposed to flow from the periphery corresponding with it, which suffers from the loss, and exhibits that suffering in one of the modes alluded to. The cerebral stimulants meet the indication here precisely. They sustain the de- pressed centre by a direct excitation, and by supplying it with good blood, when this is to be had, and sometimes even when it may happen to be wanting ; for they often serve, by stimulating the blood-producing functions, to improve its character, and increase its quantity. But of 638 GENERAL STIMULANTS. [PART II. course the cerebral stimulants are altogether unsuited for the relief of disordered nervous phenomena, when dependent on active congestion or inflammation of the brain itself. No one but a homreopathist would think proper to prescribe alcohol or opium in acute cerebritis or recent apoplexy ; and the homoeopathist himself, in doing so, escapes the crime of manslaughter only by the absolute nothingness of the dose. The term anaesthesia has been applied to the loss of sensation under the influence of narcotic medicines, and anaesthetics to the substances capable of producing it. By some writers the anaesthetics have been raised to the dignity of a class ; and if we regard symptoms or obvious effects simply as the basis of classification, such an association would be altogether proper ; but I have elsewhere given my reasons for consider- ing such a plan as very defective, of which the strongest is that similar symptoms are often produced by medicines wholly different in their es- sential mode of action, and a class founded on this basis must often include medicines which are, in other respects, wholly different, and consequently endanger serious errors in practice. Thus, anesthesia may result from cerebral stimulants or cerebral sedatives, from excess of cold, from me- chanical compression, and various other agencies, directly or indirectly, which could not, I think, be thrown together on any just basis of arrange- ment. After considering, however, the different agents used for their anaesthetic effects in the several classes to which they properly belong, it may not be amiss to enumerate them together, and thus recall them to the mind of the student in relation to their very important practical pur- pose ; and I shall probably pursue this course before dismissing their consideration altogether. Production of Sleep. This is another purpose which some of the ce- rebral stimulants are, beyond all other medicines, calculated to fulfil. They produce the effect, in all probability, simply by so congesting the sensorial centres as temporarily to suspend their sensibility to impres- sions, and their power of action. Sleep necessarily ensues, and is more or less profound, according as the centres are more or less deeply affected. It will be remembered that the congestion is, in these cases, merely the result of a stimulation of the centres inviting the blood into them, and may occupy, therefore, only the minute portions of cerebral matter of which the proper centres may possibly consist; differing altogether from the universal congestion caused by forces driving the blood into the brain, or by obstruction preventing its return. Sleep may equally be produced by influences on these same centres, depressing them below the point of impressibility or of action, as is probably the case with chloro- form. This, too, is probably the source of sleep in health ; the centres ceasing for a time to act, under the loss of excitability, temporarily ex- hausted by their activity in the waking state. But several of the cerebral stimulants produce the therapeutic effects CHAP. I.] CEREBRAL STIMULANTS. ALCOHOL. 639 referred to in the last two paragraphs, in the manner of the nervous stim- ulants or antispasmodics, and in doses too small to give rise to their characteristic effects upon the brain. Pain, spasm, etc. are thus relieved by them, not by rendering the nervous? centres insensible to impression, but probably by equalizing the excitement, the disturbance in the balance of which has occasioned the disorder. In producing sleep, their effect, thus given, is wholly different from their ordinary and characteristic ope- ration. It is only when rest is prevented by nervous disturbance, that they are capable of acting in these small doses. The patient sleeps be- cause the disorder which interrupted his rest has been relieved, not from the direct impression of the medicine on his nervous centres. A little paregoric, two or three grains of camphor in solution, or half ateaspoon- ful of Hoffmann's anodyne ; doses which would have scarcely an observ- able effect in health, will often have this composing influence in disease. Different names have been conferred upon articles of this class, ex- pressive of certain effects produced by them ; as narcotics because they stupefy, anodynes because they relieve pain, anaesthetics from producing insensibility in general, and soporifics or hypnotics from causing sleep. I. ALCOHOL. I propose first to give a general account of alcohol, its effects, and medical uses, and afterwards to treat of the forms in which it is used, and of what may be peculiar to each. Alcohol is the product of a chemical process denominated vinous fer- mentation, by which, at a temperature between 60 and 90 Fahr., and with the aid of a nitrogenous material called yeast or ferment, sugar, either contained in certain vegetable juices or infusions, or dissolved in water, is converted into alcohol and carbonic acid, the latter of which escapes with effervescence. The liquids thus prepared, containing the newly-formed alcohol, are called fermented liquors. Many of them are employed in medicine, especially wines and malt liquors. When these are submitted to distillation, the alcohol conies over mixed with a con- siderable proportion of water, and a small proportion of other volatiliza- ble matter contained in the liquid employed. The liquids thus distilled are called ardent spirits, of which there are numerous forms, varying with the character of the fermented liquor from which they are prepared. Among them are brandy, rum, gin, and whisky, all of which are oc- casionally used in medicine. By subjecting the ardent spirits to another distillation, or as the process has been called, to rectification, the alcohol comes over with much less water, and a smaller amount of other impu- rity, and now constitutes rectified spirit, or, as it is named in the U. S. 640 GENERAL STIMULANTS. [PART II. Pharmacopoeia, simply ALCOHOL. It must be noticed, however, that this is not pure chemical alcohol, but still contains water, and has the sp. gr. 0.835. It is the strongest alcoholic liquid recognized in our officinal code prior to the last revision, when a more concentrated preparation was introduced, with the title of ALCOHOL FORTIUS, or Stronger Alcohol, for use in certain pharmaceutical processes. This has the sp. gr. 0.817, and is still far from being pure alcohol ; but there is little or no occasion for anything stronger, for the use of the apothecary. As a chemical agent, however, it is sometimes necessary to have a still purer alcohol, which can be procured by further distillation ; and, if quicklime be added to the liquid before it is distilled, all the water is retained, and alcohol comes over quite free from that liquid. This is called pure, absolute, or anhydrous alcohol. Of pure alcohol it is only necessary to say that it is a colourless, vol- atile, inflammable liquid, of the sp. gr. 0.794 at 60 Fahr., of an agreea- ble pungent odour, and a burning taste, capable of combining in all pro- portions with water and ether, and composed of 4 equivalents of carbon, 6 of hydrogen, and 2 of oxygen. The latest view, and the one now generally received, of its precise chemical constitution, is that it is a hydrated oxide of a compound radical called ethyl; in other words, con- sists of 1 equivalent of ethyl (C 4 H 5 ) and 1 of oxygen, combined with 1 eq. of water. 1. Effects on the System. The following observations have reference to alcoholic beverages in general, and not to any one distinct form ; but the effects described are to be understood as exclusively those of the alcoholic ingredient. When any particular fermented or distilled liquor has peculiar properties, inde- pendently of the alcohol it may contain, these will be mentioned when the liquor itself is treated of. Alcohol appears to be a universal stimulant. It excites the part to which it is applied, the circulatory and nervous systems, the digestive, nutritive, and reproductive functions, and, under favourable circum- stances, the various secretions; but its most powerful and character- istic effects are those produced upon the brain. Bernard has shown that it increases the formation, by the liver, of the material out of which sugar is generated in that organ. (Arch. Gen.. Juin, 1850, p. 735.) Local Effects. When applied, sufficiently concentrated, to the skin or mucous membranes, its immediate effect is to induce paleness, with imnv or less pain, according to the sensitiveness of the part : alter which the blood-vessels expand, heat and redness are produced, and sometimes in- flammation. If the application be continued for some time, the tissue shrinks, and becomes wrinkled and hardened, in consequence, as some suppose, of the affinity of the alcohol for moisture, which it is thought to CHAP. I.] CEREBRAL STIMULANTS. ALCOHOL. 641 abstract from the part, or of its property of coagulating albumen and fibrin, which are thus solidified in the tissue. It certainly has been proved by Orfila, when thrown in considerable quantity into the veins of the lower animals, to coagulate the blood ; and, when injected into the cel- lular tissue, to produce the same effect in the neighbouring blood-vessels. But, in the former instance, it is brought into direct contact with the blood, so as to exercise all its chemical influence upon the albumen and fibrin of that fluid; and, in the cellular tissue, it easily penetrates the extremely tenuous walls of the capillaries, and is in like manner enabled to act, in a concentrated state, directly upon the blood. Its influence in these cases is chemical ; and, in general, death in the one case, and local death in the other are the consequences. But in its condensing or solidifying action upon the skin, we have no proof of any chemical agency. It probably simply increases the vital contractility of the tissues, in the same manner as the astringents. The surface is thus rendered more capable of resisting injury, which would scarcely happen if its organization were impaired. It is a common mode of preventing bed-sores, to wash frequently the parts liable to pressure with brandy, or other form of ardent spirit. General Effects. When taken into the stomach, alcoholic drinks pro- duce a feeling of warmth in the epigastrium, which is soon followed by increased frequency and force of the pulse, heat and flushing of the face, brilliancy of the eyes, and a characteristic sensation in the head ; a sort of slight swimming or giddiness, which serves as a warning to the pru- dent not to allow the effects of the stimulant to proceed further. The spirits are at the same time exhilarated; there is a more rapid flow of thought and fancy ; and increased energy is given to any emotion or passion that may predominate. There is, too, in general, a greater dis- position to give expression to the thoughts and feelings of the moment; the restraints of modesty or timidity are removed; the tone of voice be- comes louder and more energetic; and the limits have been approached, which cannot be transgressed without hazard. Beyond this point, if the drinking be continued, the control over the judgment is lost, and latent feelings are betrayed, or new ones arise, which are by no means always creditable. Persons, however, are very differently affected. Some are cheerful and good natured, others disposed to a fondling friendliness of manner, others, again, positive, domineering, or disputatious; and ex- pressions are often used, or offence taken, in the excitement of the mo- ment, which not unfrequently lead to the most sad results. The thoughts can now no longer be commanded. The ideas become confused, fancies are changed into realities, and various delusions are apt to occur, which often lead to corresponding acts. It is in this state that the absurd fol- lies, or deplorable violences are perpetrated, with which the annals of drinking teem. The species of delirium entitled intoxication has now VOL. I. 41 642 GENERAL STIMULANTS. [PART II. come on. In common English, the individual is drunk. Not unfre- quently the senses are perverted in this condition ; and double vision is one of its well-known characteristics. With all this cerebral disturb- ance, there is continued vascular excitement, the secretion of urine is generally much augmented, and the sexual propensities often powerfully stimulated, especially in the earlier stage. At the commencement of in- toxication, the control of the will over the muscles begins to be impaired ; and, after a time, it is quite lost. Each muscle may contract regularly ; but the associated action necessary for the attainment of any particular object cannot be commanded. Hence the staggering of drunkards, their zigzag movements, the frequent tumbles, and often vain efforts to regain their feet. At length, the disordered functions gradually subside into insensibility ; first heaviness and vacancy of expression come on, then drowsiness, and lastly deep sleep or a sort of coma, from which, how- ever, the patient may generally be roused more or less completely. If he cannot be roused, he is vulgarly said to be dead drunk. The pulse subsides along with the nervous excitement, but, though slow, remains often full, and of a certain strength, such as characterizes compression of the brain. The sleep or insensibiHty continues for several hours, perhaps from six to ten on the average; and, during this period, the pulse gradually declines in strength, the skin relaxes, and not unfre- quently copious perspiration takes place. The awakening is attended with headache, general uneasiness, and feelings of languor and depres- sion; the pulse is feeble, and the skin cool and relaxed; and a want of appetite, often nausea and vomiting, clamminess of the mouth, and a furred tongue evince depression of the digestive organs following their great excitement. This condition passes off gradually; and, under the influence of cool water, fresh air and exercise, and the usual appliances of health, the system recovers its tone ; and, in the course of a day or two, no traces of the debauch may remain, except, perhaps, the feeling of degradation. Now and then, instead of the series of phenomena above presented, nausea and vomiting come on at some period in the progress of the de- bauch, and the further development of the symptoms is prevented. The patient goes to bed, and sleeps off the effects of the stimulant. If the drinker have the prudence to cease before other cerebral dis- turbance is produced than the slight swimming of head alluded to, the excitement of system will gradually subside, perhaps with a copious diuresis, and there will be little observable depression afterwards. Should he, however, repeat the potation every day. he will, after a time, begin to find that, as the period approaches for recurring to the stimulant, there are feelings of uneasiness and of a want to be supplied, which are the inevitable penalty of over-indulgence ; and there is always some danger, under these circumstances, of the formation of a very pernicious habit CHAP. I.] CEREBRAL STIMULANTS. ALCOHOL. 643 Every day, more and more will be required to relieve the uneasiness, and produce feelings of exhilaration ; and, if the temptation to increase the quantity is yielded to, the power of resistance gradually diminishes, and confirmed intemperance ensues. The only preventive of this course of deterioration, when once entered upon, is to break off the use of the drink altogether, or to fix positive limits for the quantity daily used, which shall not be exceeded ; and this quantity should not be large enough to produce sensible exhilaration. The former plan is much the safer. The moderate use of these drinks, when a certain limit is never ex- ceeded, and this falls short of obvious cerebral excitement, may be con- tinued by many persons for a lifetime without serious injury. The sys- tem accommodates itself to the stimulus, which enters into the regular means of life, and no observable difference will be noticed between such an individual and another of the same natural constitution who is abste- mious, except that the former, when from any cause diseased, has prob- ably somewhat diminished powers of resistance, and stands more in need of artificial support. But, if carried to the borders of intemperance or beyond them, the stimulant soon makes itself felt, in an individual before healthy, by an increased vigour or at least activity, of the digestive, assimilative, and nutritive functions. More and perhaps richer blood is made out of the same quantity of food, and the system passes into a plethoric condition, as shown by the fuller and stronger pulse, and the general redness of the surface, especially of the face. At the same time, the increased fulness of habit, and weight of body, prove that the nutrition has been promoted equally with the other processes ; and in fact all the functions of the or- ganic life are in a higher state of activity. This condition of things may continue long, in a constitution originally well balanced, without serious injury ; and the individual may think himself in a high state of health. He is, however, on the brink of disease, and the slighest accident may precipitate him into it. If a considerable excess is maintained, the coun- tenance, instead of the ruddy hue and fulness of health, assumes a deeper tint and a bloated appearance; and the signs of an excessive indulgence become obvious even to the most unobservant. Poisoning by Alcohol. Every serious injury to the health, resulting either from a temporary debauch, or from the habit of drinking alcoholic liquids to excess, I consider as falling strictly under this head. First I shall treat of the acute, and secondly of the chronic poisoning. Acute alcoholic poisoning is that in which life is endangered by large quantities of the stimulant taken at once, or in successive portions at short intervals, so that the conjoint eifect is felt at the same time. Sometimes, in such cases, death is almost instantaneous. Ortila, m his Toxicology, mentions two instances of this kind. Two soldiers drank. 644 GENERAL STIMULANTS. [PART II. each, four litres (eight pints) of brandy. One died immediately, the other while they were bearing: him to the hospital. It is probable that, in such cases, death results from an overwhelming impression on the stomach, affecting the brain sympathetically; and that the symptoms are those of great prostration from the first. But such instances are extremely rare. Generally there is a brief ex- citement, followed speedily by coma, from which, when the result is fatal, death usually takes place at a period varying from twelve to twenty-four hours. The symptoms differ considerably in different cases. In some, the coma is so profound that the patient can be made to show no signs of sensibility or intelligence; in others, he can be partially and tempora- rily roused. The pulse is usually slow and full, sometimes natural as to frequency, but towards the close extremely feeble, and at length im- perceptible. The respiration is also slow. The face may be flushed, with a venous hue, or may be pale. The pupils, though occasionally contracted, are more commonly dilated. Complete immovability of the pupil is an unfavourable sign. Convulsions are rare. Death results from the suspension of the respiratory process, either through the direct alcoholic congestion, or the secondary prostration of the nervous ivnm-s in the encephalon. When recovery takes place, as the affection was functional, the patient, upon the disappearance of the coma, returns to health, after a short period of secondary depression, with an aggravation of the symptoms already mentioned as characterizing the same stage in an ordinary debauch. Another mode of acute alcoholic poisoning is by the supervention of apoplexy. This generally occurs in persons predisposed to that affection. In such cases, even a comparatively moderate indulgence may produce 'this effect by determining blood to the brain. It is no very uncommon event for persons thus predisposed to be attacked at the table. But <><- casionally the result is to be ascribed purely to the alcohol. The quan- tity of blood thrown into the brain produces a general congestion of the organ, and sometimes positive sanguineous effusion takes place. The patient may recover from either of these conditions; but, in the latter, paralytic symptoms will be apt to remain. A third mode of poisoning is by the superinduction of inflammation of the brain or its meninges. This condition is either left behind after the disappearance of the coma, or the symptoms of the two conditions are commingled. Whenever, with more or less stupor, there are de- lirium, convulsions, tonic contraction of the flexor muscles, and local or partial palsy, the existence of the inflammatory complication may be con- sidered as pretty certain. This condition of things, however, is more apt to accrue from a continued debauch of several days, or weeks, than from one hard drinking spell, unless there may have been a predispo- CHAP. I.] CEREBRAL STIMULANTS. ALCOHOL. 645 sition to the affection. It is a very dangerous condition, and many die of it; often sinking into a state resembling typhoid fever before death. Still another mode of poisoning is by acute inflammation of the stom- ach and bowels. Gastritis, in a greater or less degree, I have fre- quently witnessed, in the Pennsylvania Hospital, among patients brought in while labouring under the effects of strong drink. But it is very sel- dom fatal. Instances, however, are on record, in which this seems to have been the immediate cause of death. The accidental deaths resulting, in the coma of drunkenness, from ex- posure to cold, from drowning, or from various kinds of violence, as when the body is run over by a locomotive on railroads, do not properly fall into this category ; though they are useful warnings, and may be appropriately enumerated in the list of evils consequent upon this terri- ble vice. Chronic Poisoning. A great diversity of evils arise from the habitual use of alcoholic drinks. I shall treat of them in the order of their suc- cessive occurrence. 1. The stimulant influence of alcohol renders the system at all times more liable to inflammatory attacks' from ordinary causes, especially in the earlier stages of its habitual use, or in those persons who employ it in such a manner as not materially to impair the energies of their sys- tem. It has this effect, first, by inducing a plethoric state of the blood, which predisposes to inflammation, and, secondly, by stimulating the circulation, and thereby acting as an exciting cause when a predisposi- tion already exists, or aiding other irritant influences. 2. Conjointly with the use of rich food and stimulating condiments, it contributes to the development of gout. In persons predisposed to this disease from inheritance, it hastens its appearance; and, in those not predisposed, it is quite sufficient, in conjunction with the other agencies mentioned, to originate the diathesis. But, of those who abuse alcoholic liquors, only a comparatively small number are attacked with gout. This demands explanation. The origination of the gouty diathesis re- quires the co-operation of causes which, without materially impairing the vital forces, shall produce and sustain an habitual state of plethora and excitement. In great excess, alcoholic drinks rapidly wear out the ex- citability of the system, and induce an indirect debility, which leads to various other disorders, but is incompatible with the generation of the gouty constitution. More moderately used, however, and with rich food, they stimulate the blood-making functions, without so rapid an exhaus- tion of the excitability. A greater amount of food, therefore, is con- verted into blood than without the aid of the stimulant, and a state of plethora is produced, which the continuance of the same habit sustains. The abuse, consequently, of wines and malt liquors is more apt to cause gout than that of ardent spirits ; and hence the prevalence of this dis- 646 GENERAL STIMULANTS. [PART II. ease among the rich and luxurious. But the amount of exercise taken has also much influence over the result of alcoholic stimulation. By vigorous exercise the plethora induced by wine-drinking and a rich diet is repressed, the excess of blood is consumed by the excess of the excited functions, and the equilibrium of health is preserved. Hence, a person of somewhat luxurious habits of eating and drinking may counteract their effects by proportionally vigorous exercise. It is from a conjunc- tion of the moderately luxurious with sedentary habits that we are to look for the development of gout. Again, an excess in the use of alco- hol which would soon indirectly wear out the powers of a sedentary man, if counterbalanced by violent bodily exertion, may tend to sustain the system at a point of elevation favourable to this disease. An individual may become intoxicated at his table every evening, and yet, if he spend all the morning in some active exercise, as on horseback in the chase, may ward off the prostrating influences of the poison, and escape with only the penalty of gout. It is not so much, therefore, the particular quality of the liquor drank, whether it be wine, or whether rum, which determines the occurrence of gout preferably to general debility, as it is the quantity of the stimulus used, and the other attendant circum- stances. 3. Another evil arising from the abuse of alcohol is the direct produc- tion of inflammation in the organs upon which its stimulant agency is most strongly exerted. Sometimes this inflammation is acute ; but much more frequently it is chronic, and the necessary result of a long-sustained irritation. The organs upon which alcohol especially expends its force are the stomach, the brain, and, secondarily, the lungs and the liver. These, therefore, are most frequently affected ; but the bowels, kidneys, heart, and arteries sometimes participate in the disease. Evi- dence of this is exhibited not only by the symptoms during life, but by the appearances upon dissection. Every physician is familiar with the chronic gastritis of drunkards. Inflammation of the brain or its mem- branes is scarcely less common, though, in the acute state, often con- founded with delirium tremens, and, in the chronic, masked by the disorder in the cerebral functions incident to habitual intoxication. Reference is often made, in the records of insane asylums, to intemper- ance as one of the causes of insanity. There are some persons who always have an attack of this disease, when they indulge in the use of alcoholic drinks. The duty is devolved upon the lungs, partly at least, to throw off, in the form of vapour, the portion of alcohol not expended in the nutritive process. Hence, bronchitis is a common disease of drunkards; and other pectoral inflammations arc not unfrequent. The liver is another of the emunctories through which the superfluous alco- hol is thrown off, probably in the form of fatty matter. This organ, therefore, is kept constantly in a state of undue excitation, and, as a re- CHAP. I.] CEREBRAL STIMULANTS. ALCOHOL. 647 suit, is not unfrequently inflamed. Disease of the liver is among the most common complaints of habitual drunkards ; and though, as will be seen directly, it is not exclusively inflammation that occurs, yet this does take place in a considerable proportion of cases. Out of seventy-three cases of drunkards examined after death by Dr. P. Ogston, of Aberdeen, Scotland, the liver was found generally hypertrophied in nine, and par- tially in two cases ; and, though this hypertrophy may possibly have been in some instances the pure effect of a sustained over-excitement, yet much more probably there was in all an admixture at least of inflam- mation during life. It is not necessary to refer more particularly to the other organs mentioned. In all of them lesions are frequently found, which may be best explained by the supposition of the previous exist- ence of chronic inflammation. 4, From the constant stimulation of the whole system, and especially of the brain, the excitability is so far exhausted that, on the withdrawal of the stimulus, a condition of extreme prostration takes place, which often ends fatally, unless counteracted. The brain, left without its ha- bitual support, exhibits its suffering in a peculiar kind of delirium, called delirium tremens or mania a potu, the characteristics of which are sin- gular hallucinations, the fear of some present or impending evil, sleep- lessness, and muscular tremors. This has been considered by some as inflammation of the brain. But, in its pure form, it has nothing to do with inflammation. It is the simple result of the withdrawal of the alcoholic stimulus, and is a condition of real depression in the cerebral centres, showing itself by the irregularities referred to. It is, moreover, relieved by restoring the stimulant impression by means of alcoholic drinks or opium. In the Pennsylvania Hospital, I have had frequent opportunities of watching the attack and removal of this affection. I have, in numerous instances, seen it coming on more or less completely when the wonted stimulus has been withheld, and have almost as con- stantly seen it yield to a renewal of the stimulus. It will be observed that I am now speaking of pure delirium tremens. But there are often mixed cases of a very different character. In these, some inflammatory and febrile attack has rendered the patient careless of the stimulant, or averse to it. The cerebral centres, left unsupported, fall into the abnor- mal state ucder consideration, and there is now a mixture of local inflam- mation with delirium tremens. Not unfrequently the inflammation is the direct result of the alcoholic stimulus. The patient, goaded by his insatiable thirst for the poison, gives himself up for a period to the most frantic indulgence, until he is at length brought up by an attack of in- flammation of the brain or the stomach, the direct result of the excessive quantity of alcohol taken. Then the debauch ends, and, the drink being suspended, delirium tremens along with the meningitis or gastritis seizes on its victim. These attacks, unless promptly and efficiently treated, 648 GENERAL STIMULANTS. [PART II. especially the rneningeal cases, are very apt to terminate fatally, and sometimes do so even under judicious treatment; while the simple deli- rium tremens, which constitutes the vast majority of cases, is curable almost certainly, if the patient be prevented from sinking into a fatal prostration from the want of support. But it is not only upon the withdrawal of the wonted stimulus that the effects of depressed function are experienced. With the constant repetition of the excitement, there is as constant a diminution of the excitability, so that the stimulated functions can be sustained only by a steady increase in the quantity of the stimulus, until the time at last comes when no quantity that can be taken is sufficient to support the working of the exhausted organs. It is surprising how much ardent spirit the system can be brought to bear. Two or three pints of raw spirit are consumed daily by some confirmed rum-drinkers. But, as just stated, even should no organic mischief happen in the mean time, the functions must at last fail. In relation to the stomach, dyspepsia; to the bowels, constipation ; to the liver, insufficient secretion, are ordinary results. The circulatory and respiratory functions are also enfeebled ; the generative function is impaired; and even nutrition, at first over- stimulated, now fails, and the patient becomes either emaciated, or pale and bloated. The cerebral functions also suffer greatly. The intellect is enfeebled, the power of self-command is lost, and the predominant propensities or passions, whatever they may happen to be, are scarcely resisted. The influence of the will over the muscles is greatly impaired, and the patient is subject to habitual tremors when not under the fullest action of the stimulus. These tremors sometimes deepen into positive paralysis, though there is reason to think that, by this time, the brain has become organically deranged. 5. The last stage of physical degradation is now reached. The failure of the functions both organic and nervous leads inevitably to degenerate organization. The blood is depraved, nutrition suffers, and different parts of the frame undergo various degradation ; those being most af- fected the functions of which have been previously most stimulated, and consequently most exhausted. In many instances, the vital forces have been so prostrated, in particular organs, that chemical influences predom- inate, and the tissue is converted more or less into oil. This, is the fatty degeneration. In other instances, the disorganization is less complete; and abnormal tissues bearing some resemblance to the fibrous, cartilagi- nous, or bony, take the place of the healthy structure. The brain, the stomach, the liver, the kidneys, and the heart and blood-vessels are pe- culiarly the seats of this organic degradation ; and their great vital func- tions suffer accordingly. The most diversified forms of functional or organic disease are presented in different cases, most of them tending to a dropsical condition, in which the patient is at last apt to perish, if he CHAP. I.] CEREBRAL STIMULANTS. ALCOHOL. 649 has escaped the numerous dangers which have beset him almost from the beginning, and which cause vast numbers to be carried to a prema- ture grave. The cirrhosed or fatty liver, the granulated kidney, the hypertrophied or dilated heart with its various valvular disease, the ossified blood-vessels, and the depraved blood, deficient in red cor- puscles, but abounding in oil and carbon, are the most frequent causes of the dropsy. Dr. Magnus Huss, Professor of Clinical Medicine in Stockholm, has described a paralytic affection, which he denominates alcoholism us chron- icus, and which he ascribes solely to the poisonous influence of alcohol. It is very common in Sweden, where intemperance is said to prevail to a fearful extent. The affection shows itself first in tremors and unstead- iness of the voluntary muscles, usually commencing in the upper ex- tremities, then extending to the lower, and at length involving the muscles of the trunk. The trembling is often violent, particularly on the occasion of any voluntary effort, and is greatest in the mornings before the patient has had recourse to his accustomed stimulus. Sensation after a time begins to be affected ; formication occurs here and there ; and at last both sensation and the power of motion are lost over a greater or less extent of the body, the special senses being not unfrequently in- volved. Instead of this paralytic condition, the poisoning may assume the spasmodic or convulsive character, marked at first by twitchings, and afterwards various irregular muscular contractions, terminating in positive epileptic paroxysms. All these phenomena are readily explica- ble. The first failure of muscular power is probably the result of mere exhausted function in the brain ; but the more serious subsequent results must be ascribed to the organic changes which have, in the mean time, been going on in the cerebral tissue. 6. Another and not the least evil of the abuse of alcoholic liquors, is the increased danger given by it to other diseases ; partly through the impaired state of the constitution, which renders it less able to resist them ; partly through the impossibility, under which it places the physician, of using that energy in the treatment which the diseases may require ; and, in some degree also, in consequence of the relative inertness of alcoholic remedies in the intemperate, in whom they are most needed. I have purposely avoided the consideration of the moral aspect of in- temperance, which, even if we confine our views to this world, presents an amount of evil, far exceeding the physical, terrible as this must be acknowledged to be. Appearances on Dissection. When death has occurred suddenly from, enormous quantities of the poison, no pathological appearance need be expected after death ; the stomach and brain being at once overwhelmed by the violence of the shock. In the more protracted cases of acute 650 GENERAL STIMULANTS. [PART II. poisoning, the signs of inflammatory congestion of the stomach are sometimes, though not always presented; but there is usually congestion of the brain, with occasional effusion into the ventricles, which has the odour of alcohol, and in one instance is said to have been inflammable. Congestion of the lungs is also an occasional result of acute alcoholic poisoning; and, in the case of a child recorded by Dr. John Ashhurst, appeared to btj the cause of death, through the copious effusion into the air-passages. (Am. Journ. of Med. Set., July, 1863, p. 128.) In cases of habitual drunkards, dying either directly from the effects of the poison, from suicide, or other forms of violent death, and from accidental diseases, there is almost always some lesion discoverable, which may be fairly ascribed to the poison; sometimes the direct conse- quence of constant irritation, as hypertrophy ; sometimes of pure defi- ciency of action, as atrophy; very frequently of inflammation, and still more frequently of various degeneration. Out of 117 cases examined by Dr. Ogston, only one was without some discoverable lesion.* The lesions were most numerous in the brain and its appendages, and after this, successively, in the respiratory organs, the liver, the circulatory organs, the kidneys, and the alimentary canal. That the smallest number should have been found in the stom- ach and bowels is not what might have been anticipated; but the prob- ability is that more of the lesions in this structure were to be ascribed to the alcohol exclusively than in the others, unless the brain be excepted. It will of course be understood that many of the morbid appearances would have been found in temperate persons; but assuredly in greatly less proportion. In the brain the most frequent changes were thicken- ing of the arachnoid, effused serum, injection of the pia mater, and indu- ration or softening of the cerebral substance ; in the respiratory organs, pleural adhesion and partial emphysema; in the heart and its append- ages, hypertrophy and dilatation, obesity, valvular disease, pericardial adhesion or thickening, and atheromatous or osseous deposition or degeneration in the large vessels ; in the stomach, extraordinary diminu- tion of size or atrophy, congestion, softening of the mucous membrane, and hypertrophy or thickening of the walls, which, however, was seen in three only out of the whole number of cases; in the liver, fatty degen- eration, hypertrophy, cirrhosis, and the nutmeg appearance ; jn the kid- neys, hypertrophy, congestion, and fatty degeneration. (Brit, and For. Med.'Chir. Rev., April and October, 1854.) * Of the different organs, the brain and its appendages were affected in 108 of the cases, or 92.3 per cent.; the respiratory organs in 74, or 63.24 per cent.; the liver in 66, or 66.4 per cent.; the heart and its appendages, including the aorta and pul- monary artery, in 56, or 47.86 per cent.; the kidneys in 51, or 43.58 per cent.; and the intestinal tube in 48, or 41 per cent. (Brit, and For. Med.-chirury. Rev., July, 1*55, Am. ed., p. 145.) CHAP. I.] CEREBRAL STIMULANTS. ALCOHOL. 651 Treatment of Alcoholic Poisoning. In the acute cases, the prominent indication, in the earlier stage, is to evacuate the stomach; for which purpose recourse may be had to emetics or the stomach-pump. The latter is the most effectual method, though, in the absence of the neces- sary implements, the former should not be neglected. At the same time, cold water should be freely and steadily applied to the head, and sina- pisms or other rubefacients, or hot pediluvia to the lower extremities. Pouring cold water into the ear has been recommended, in order to rouse the patient from stupor; and, with the same view, in its first application, it may be poured from a height on the head or shoulders. Bleeding, either general or local, or both, should be used when the pulse is full and strong, and organic mischief in the brain is apprehended. Should respi- ration be suspended or nearly so, it should be supported artificially, until nature may be able to maintain the function, or undoubted death shall have taken place. In the stage of prostration, after the direct action of the stimulant has ceased, and nothing remains but the depression conse- quent on the previous excitement, the system should be supported by external and internal stimulation. When the patient cannot swallow, the stimulant should be injected into the stomach or rectum. Carbonate of ammonia, or aromatic spirit of ammonia may be used, so far diluted as not to injure the mucous membrane ; and even brandy may be resorted to, especially in the form of milk-punch by the stomach. It is not now the presence of the alcohol that is endangering life. It is the prostra- tion; and that may be very properly counteracted by a smaller amount of the stimulus, so as to cause the system to subside gradually from its previous state of exaltation. This treatment, however, should not be employed until the skin becomes cool, the pulse feeble, and the danger from prostration obvious. In chronic poisoning, the only remedy is abstinence. It is rarely that the affection has proceeded so far, that a cure may not be effected, or the state of the system very much ameliorated, by this measure. Unless some essentially fatal disorganization has taken place, as in cirrhosis of the liver, the system may be gradually led back to health by a reversal of the process which has brought it into the diseased state. A sudden withdrawal of the stimulus, without the substitution of something of a similar character, is dangerous. Death frequently results from this cause. Delirium tremens is an almost constant consequence, when the habitual excess has been great and long continued. The chief difficulty lies in the want of co-operation upon the part of the patient. The same infirmity of will that led to the evil, is in the way of its removal. I have often, however, had patients under my care in the Pennsylvania Hospital, who have been willing to submit to the requisite restraints, and invariably they have been dismissed without evil consequences, and cured for the present of the evil habit. The simple measure is to allow 652 GENERAL STIMULANTS. [PART II. them at first somewhat less than their ordinary amount of stimulus, preferring the milder kinds when they will answer, as wines and the malt liquors, and daily to diminish the quantity, always endeavouring to sustain them above the point of sleeplessness or delirium. Opium often comes in very happily as an adjuvant, to obviate nervous disorder and produce sleep; but this also must be withheld, as the system is found capable of doing without it. Sometimes there is an advantage in partially substituting for the pure stimulus one of the bitter tinctures, especially that of hops; and recourse may be had to the nervous stimu- lants, as assafetida, valerian, and Hoffmann's anodyne, when nervous irregularities may seem to call for them. When the health has been ma- terially impaired by the long continuance of the habit, it is necessary, as the original stimulus is withdrawn, to address remedies to the system in order to correct the diseased functions, or repair the diseased organs ; such as the bitter tonics and aromatics for dyspepsia, rhubarb and aloes for constipation, the chalybeates to improve the blood, and nitromuriatic acid or the blue pill to obviate hepatic disease. When the patient cannot or will not summon resolution enough for a steady perseverance in the above plan, it is better for him to break off at once, and take the risk of the evil consequences, than to incur certain destruction from continuance in the vicious habit. Under proper medi- cal superintendence, even should delirium occur, the case may almost always be conducted to a safe issue. Of the management of delirium tremens I do not propose to treat in this place, as I have already fully considered the subject in my work on the Practice of Medicine. I would simply observe that, on the whole, I prefer the opiate plan of treatment moderately conducted, giving only so much alcoholic drink as may be sufficient to obviate prostration, and gradually withdrawing both. There is one important practical point, however, to which I would especially invite the attention of the student. He is not to consider cases of meningeal inflammation or acute gastritis, when brought on by in- temperance, and then mingled with delirium tremens, as instances purely of the latter disease. In these cases, he must deplete for the inflam- mation, while he supports the actions of the nervous centres by alcoholic stimulation, which, in drunkards, when given in less than the habitual amount, acts as a real sedative. The same rule holds in regard to in- flammatory affections, which may come on accidentally in the intemper- ate, and, in consequence of the suspended use of the stimulant, become complicated with their peculiar delirium. Dr. Marcet, of London, recommends the use of oxide of zinc in chronic alcoholic poisoning, beginning with two grains, twice daily, an hour after ineals, and increasing by two grains every three days, until th; last dose amounts to six or eight grains. (London Lancet, April, 1859, p. 346.) CHAP. I.] CEREBRAL STIMULANTS. ALCOHOL. 653 2. Mode of Operating. The operation of alcohol as a stimulant is probably dynamic, that is, the result of its influence on the vital properties of the tissues, and inde- pendent of any chemical action exerted upon those tissues. At least, we have as yet no proof of chemical change produced in the organs which it stimulates ; and all theories based upon such a change are, in the present state of our knowledge, conjectural. It is true that, in its more concentrated form, its affinity for water, and its disposition to coagulate albumen, may cause disorganization of the tissues, as any other chemical escharotic may do; but this is not its ordinary medicinal operation, to procure which it is always given much diluted. The theory that the excitement it occasions is a vital reaction against its chemical affinities, is, therefore, gratuitous. It may possibly be true ; but we have no proof of it ; and the safest conclusion is that, like any other stimulant, it pro- duces its characteristic effects simply through its relation to the vital properties, which determines that, when it is brought into contact with the living tissues, these should take on an increase of action. Its first effects on the brain may possibly result, in part at least, from the sympathy of that organ with the stomach. Indeed, so close is this relation, that any strong impression in one is very apt to make itself sensible in the other. The fact stated by Orfila, that alcoholic liquors act with less energy when injected into the cellular tissue than when taken into the stomach, seems to favour this view. -But, whether the cerebral effects have or have not their commencement in sympathy with the gastric impression, they are chiefly attributable, throughout their course, to the direct action of the alcohol circulating through the brain. That this principle is absorbed, when liquids containing it are swallowed, is beyond all doubt. Its rapid disappearance from the stomach, and its odour in the breath are sufficient proofs of the fact. But it has been found also in the urine, bile, liquors of the serous cavities, brain, liver, and the blood itself; and especially abundant in the brain, in the ven- tricles of which it is asserted sometimes to have existed in an inflamma- ble state. Dr. Ogston in one instance "found about four ounces of fluid in the ventricles, having all the physical qualities of alcohol " (Pcreira's Mat. Med., 3d ed., p. 1987); and, in another instance, while heating over a candle, three or four drachms of urine taken from the bladder of a man who was drowned while intoxicated, he observed that its vapour was set on fire by the flame. (Brit, and Fur. Med.-chir. Rev., July, 1855, Am. ed., p. 148.) Coming then into direct contact with the nervous centres, the alcohol stimulates them into excessive action, and thus gives rise to the phenomena of excitement which characterize the early stage of its operation. Every excitation of a part is attended with an increased flow of blood into it, and the active congestion increases with the excitation. 654 GENERAL STIMULANTS. [PART II. By the continued operation of the alcohol, the congestion is continually increased in the cerebral centres, which, after their brief exhilaration, become disturbed, and at length embarrassed or overwhelmed, all through the direct and continued irritation of the same agent. Hence the intoxi- cation, and ultimate stupor which follow the primary excitement. But at length, the alcohol ceasing to act, the cerebral centres become de- pressed in proportion to their previous elevation ; and general prostra- tion of the system results. The wearing out of the excitability, the ultimate general debility, and the consequent degradation of the organs, resulting from long-continued intemperance, have been sufficiently noticed. The influence of alcohol upon the brain has been ascribed to the altered and more highly carbonized state of the blood. Of this there is no proof whatever ; nor, except in the single fact of stupor, is there any resemblance between the effects of this substance and the condition of the blood referred to. From the experiments of Dr. Bocker, it would seem that alcohol diminishes the amount of the solid and fluid excretions by the urine, and the quantity of carbonic acid exhaled in respiration, without increasing the fecal discharges, the perspiration, or the loss of water by the lungs.* Hence it has been inferred that it lessens the rapidity of the normal disintegration of the solids, and consequently diminishes the general activity of the functions ; for the measure of their activity is the quantity of effete matter thrown out of the system. Hence, too, the practical inference, that it enables the body to be sustained by a less amount of food. But these are conclusions much too large for the basis on which they rest. We need many more, and much more va- riously repeated experiments, before they can be justified. Xo facts of observation seem more obvious than that alcohol stimulates the func- tions of the stomach and brain to increased activity; that it for a time invigorates digestion, promotes nutrition, increases the action of the kid- neys or the skin, according as it is directed to one or to the other, and elevates the 'intellectual and emotional functions. How it can effect all these ends, without a more rapid disintegration and renewal of the struc- ture, is inconceivable to one who considers such disintegration as a * The experiments of Dr. Bocker have been confirmed by those of Dr. Hammond, of the U. S. ArmyA (See Am. Journ. of Med. Sri., xxxii. 313 ) It may be admitted that, in the long run, alcohol diminishes the metamorphosis of the tissues, as it does all the vital functions, through the diminution of excitability and the production of debility ; but I cannot admit that this result takes place during its stimulant ac- tion; and, if the amount of excretion of all kinds be diminished, during its direct action, I should, as before stated, be disposed to ascribe the result to a more thor- ough appropriation and assimilation of the food, which prevent the useless portion of it that may reach the blood, from passing off in the shape of urea, the phos- phates, sulphates, etc. (Note to the second edition.) CHAP. I.] CEREBRAL STIMULANTS. ALCOHOL. 655 necessary attendant of every vital action. That, when taken in ex- cess, it will overwhelm and, in some measure, paralyze the functions after the first excitement is past, and that, in this way, it may on the. whole diminish the amount of the excretions; and that by the wearing influence of its long-continued abuse, the functions come at last to be in great measure prostrated, is readily intelligible. But that, during its stimulant operation, it should not promote a more rapid change of the tissues which it stimulates, is quite incompatible with the present views of the connection between the actions and the wear and tear of the system. But it is an undoubted fact that the habitual use of alcohol lessens the desire and apparent necessity for food ; and it seems to be well proved, that a labourer can do a certain amount of work with less ordinary ali- ment, if freely supplied with beer or wine, than when water alone is al- lowed for drink. But this fact is explained, at least in the early stage of the action of alcohol, not by the diminished integral change in the tis- sues, but by the double fact, that it promotes the more perfect digestion of the food taken, and at the same time supplies food itself. If the usual amount of food is swallowed, alcohol favours its digestion and conversion into blood, and hence produces a plethoric state. This reacts on the stomach, diminishing the desire for food; and hence less is taken. But, as stated, alcohol is itself in all probability assimilated. What else be- comes of it? Assuredly, but a very small portion of that taken into the body leaves it unchanged. It is certainly decomposed in the system. If, as some suppose, it were merely oxidized into water and carbonic acid, there would be a vast increase of the excretions of these products by the lungs, which, from the experiments of Dr. Bocker and some others, would seem not to be the case. It is probably converted into some one or more of the proximate constituents of the body ; and I am among those who believe that it may, through the agency of the vital forces, and in the presence of organized nitrogenous matter, be converted into any one or all of those constituents, excepting only the mineral. The one, however, which most obviously results, is oil ; and this is often gen- erated with great rapidity. It is not only visible in the increase of the adipose tissue, and in the promotion of obesity in certain individuals, but it exists also in abiiounal proportion in the blood; and the oleaginous change is probably the first step of the conversion of alcohol into mate- rials fit for organization. And why should not alcohol be capable of digestion ? It is generally admitted that many of the organic acids are so, as vinegar, citric acid, etc. Now, by a very easy change, alcohol itself is convertible into acetic acid. The inference seems to me inevita- ble, that it also is capable of being digested and assimilated. It is food, therefore, as well as a stimulant ; and this view certainly best explains the plethoric condition, and increased weight and fulness of the body, often so strikingly observable under its use, while the amount of other 656 GENERAL STIMULANTS. [PART II. kinds of food taken is diminished. But this fact in no degree justifies its abuse. The various evils to which its excess gives rise are neither les- sened in themselves, nor do they constitute a less unanswerable argu- ment against the abuse of alcohol, from the fact that it may contribute to the nourishment of the body. In opposing an enemy, it is useless if not dangerous to shut our eyes against his good qualities, and bad policy to put ourselves into a position in which we cannot avail ourselves of them. 3. TJierapeutic Application. The first great question in the therapeutics of alcohol is how far its habitual use is favourable or unfavourable to health. In the greater number of cases, judging from the experience of the world since the be- ginning of history, it is of little consequence to the health of the indi- vidual, whether he drink it or not, provided he do not exceed the limits of temperance, and especially if he confine himself to the pure fermented liquors. But there are two classes of individuals to whom this remark does not apply. In one of these classes, the possession of a peculiarly sanguine or nervous temperament, renders them strongly susceptible to injury from substances calculated, in the one instance, to favour the over- production of blood, and, in the other, to stimulate the unduly excitable nervous centres. In tfrese persons, the habitual use of alcoholic drinks, which have in a high degree both the properties mentioned, is hazardous to health, and should, therefore, be avoided. It endangers inflammation, hemorrhage, and serious cerebral disease. In the second of the classes referred to, the contrary of this proposition is true. Nature, while planting in so large a proportion of the human family a disposition to scrofulous or tuberculous complaints, seems to have provided, in the fer- mented liquors, what, if properly used, may be considered as in some degree a counteracting agent. Physicians have often noticed that drunk- ards seldom die of phthisis. In this respect, my own observation coin- cides with that of others. During my tours of hospital duty in the winter, I have met with great numbers, both of drunkards and of tuber- culous individuals; but it is very seldom that I have seen the two classes coincide. This is A singular fact, and not exactly what might have been anticipated ; for the tuberculous constitution belongs to the same ca- chectic category with that which gives a tendency to fatty degenera- tion, cirrhosis of the liver, granular disease of the kidney, etc., and is not unfrequently associated with it. A priori, it would have been im- agined that the exhausted state of general health, characterizing the ad- vanced stages of intemperance, would favour tuberculous deposition ; and the discovery of the opposite truth has been something like a surprise to the profession. This result of observation has been singularly confirmed by recent pathologico-anatomical investigations. Out of 117 cases of CHAP. I.] CEREBRAL STIMULANTS. ALCOHOL. 657 confirmed drunkards, whose bodies were examined after death by Dr. Ogston, there were only two who exhibited any evidence of tuberculous disease of the lungs. In one of these there were some latent tubercles, and in the other a single tuberculous cavity in the right lung; and in neither was this affection the cause of death. (Brit, and For. Med.- chir. Rev., April and October, 1854.) In the same number of temperate persons, of different sexes and ages, examined after death from other causes, the same result would assuredly not have been obtained.* How alcoholism acts adversely to the development of tubercle may be conjec- tured, but is not certainly known. In its earlier stages, it may be sup- posed to sustain a grade of elevation in the vital functions, and richness of the blood, above that at which there is a tendency to the deposition of tuberculous matter. But this is certainly not the case in the latter stages, during which, so long as the stimulus continues to be used, there appears to be the same exemption. Perhaps, as many suppose, it is the more highly carbonated state of the blood in the inebriate that protects him against tuberculosis. Possibly, the large proportion of oil contained in it may have some preservative tendency, similar to that ex- ercised by cod-liver oil. It would be a perverse reason that would deduce from the fact here stated an argument in favour of intemperance. As- suredly, of the two, even admitting that the security afforded is com- plete, which it is very far from being, death from pulmonary consump- tion is infinitely preferable to death from drunkenness, or even to the life of a drunkard. But a just inference is, that they who may be predis- posed to phthisis or scrofula, or may be labouring under the disease, may, with propriety, and probably with advantage, employ the fermented liquors habitually, though always in moderation. By adhering to the rule, never, under any circumstances of ordinary health, to use any one of the forms of ardent spirit, but to adhere exclusively to the fermented liquors, they may avoid the danger of intemperance, and yet obtain all the immunity which alcohol can confer. In giving the above general rules in relation to the habitual use of alcoholic liquors, it will be perceived that I confine myself wholly to the medical aspect of the question. How far an individual may feel himself bound to forego a harmless gratification, or to sacrifice* in some instances, a positive good, for the sake of an example to others of weaker will, or of a constitution more susceptible to injury from alcoholic drinks than himself, is a moral question upon which there is no occasion to express an opinion in this place. One point, however, I would urge, with what- * See an elaborate paper, by Dr. John Bell, of N. York, on the effects of alcoholic drinks in tuberculous disease, in the Am. Journ. of Med. Sci., Oct. 1859, p. 407, in which much evidence has been collected upon the subject referred to. The tendency of this evidence appears to uie decidedly to confirm the views given in the text. (Note to the second edition.) VOL. I. 42 658 GENERAL STIMULANTS. [PART II. ever weight of authority a life of observation may have given me, and \vith all the strength of expression I possess, that, whenever an indi- vidual discovers in himself the least tendency to excess in these drinks, or the least deficiency of power to restrain himself within due limits when slightly under their influence, he should promptly abandon them alto- gether, and permit no sophistry of inclination to overcome his resolution of entire abstinence for the future. In low febrile diseases the alcoholic liquors are a most valuable re- source, and, indeed, often indispensable. At least, I have very frequently met with conditions in these fevers, in which I should have quite de- spaired of a cure without their aid. They are not so well adapted to the prostration or collapse which sometimes occurs in the cold stage, at the commencement of the fever, as to the debility coming on in its course. The continuance of their stimulant influence into the stage of reaction, and their special tendency to the head, might possibly, under the former circumstances, injuriously increase the fever and cerebral disturbance; and they should, therefore, be employed only when the arterial stimu- lants may prove inadequate to the end in view. But to the latter con- dition, the debility, namely, which so often supervenes in febrile diseases, and not un frequently constitutes their greatest danger, they are adapted, beyond all other medicines, by the universality as well as energy of their stimulant property. Operating specially upon the brain, they rouse it from the torpor by which it is apt to be overwhelmed in the advanced stage of fevers of the typhoid character, and prove much more efficient in sustaining life than the arterial or nervous stimulants. They are in- dicated when the pulse is feeble, and the skin cool, and particularly when, with these evidences of debility, are associated the dark tongue, the sordes about the teeth, and the stupor or low delirium of the typhous state, indicating a depraved condition of the blood. Even when the skin is hot, if the other symptoms appear to call for their use, they should be tried. I believe they not only stimulate in these cases, but prove useful also by directly contributing, through their nutritive properties, to the improvement of the blood. Unless the prostration is sudden and alarming, the mildest form of these stimulants should be first employed, and recourse be had to the stronger only as th% increasing debility may in to require them. Thus, it is usually advisable to begin with wine- whey, then, if necessary, to advance to pure wine, and ultimately to ar- dent spirit. Should the. skin become hotter and dryer, the pulse more fre- quent, and the patient more restless and delirious under the stimulant, it should be diminished or discontinued ; but, should the contrary condition occur, should the skin heroine soft or moist, the pulse slower, fuller, and stronger, and the patient more comfortable and less disposed to delirium, it may be taken for granted that the remedy is operating favourably, and should be continued. It is in typhus, enteric or typhoid, and petevhial CHAP. I.] CEREBRAL STIMULANTS. ALCOHOL. 659 fevers, that the alcoholic remedies generally prove most useful ; but most other febrile affections sometimes assume the same low character, and require the same treatment. The alcoholic liquids may often be advan- tageously used in scarlatina, diphtheria, smallpox, and erysipelatous fever, and occasionally in bilious remittent and yellow fevers, when they present typhoid symptoms. Even the existence of inflammation, under these circumstances, does not positively contraindicate them Active alco- holic stimulation is often necessary in typhoid or typhous pneumonia. In the advanced stage of inflammation, when copious suppuration has taken place, and the patient is sinking under it, the alcoholic stimu- lants are often called for, to aid in supporting the strength until the exhausting influences shall have ceased, or, when the case is hopeless, to render the patient more comfortable, and protract his life. Such a con- dition is presented in the suppurative stage of pneumonia, abscess of tin; lungs and kidneys, purulent phlebitis, lumbar and psoas abscess, suppuration of the large joints, extensive caries of the bones, and very large or numerous ulcers upon the surface. To this category may be added various constitutional affections attended with suppurative or ulcerative conditions, as erysipelas affecting the cellular tissue, conflu- ent smallpox after the maturation of the pustules, all scrofulous affec- tions including phthisis, syphilis in the ulcerative stage, and several of the cutaneous affections, particularly rupia and ecthyma. Precisely the same indication is offered by gangrene, whether result- ing from inflammation, from purely depressing agencies, or from a vitia- ted state of the blood. The system requires support against the directly depressing influence of the gangrene, and of the processes requisite for the separation of the slough, and also to enable it to repair the injury done. It is unnecessary to enumerate all the affections in which this condition may occur. In severe internal inflammations, there is occa- sionally an abrupt cessation of the pain, with symptoms of great pros- tration, which have been supposed to indicate the occurrence of mortifi- cation, and often perhaps truly, even though certain evidence may not be exhibited by putrefaction after death. Strangulation of the bowels, whether concealed as in invaginalion, or obvious, as in hernia, very often ends in mortification. Other examples of this affection we have in gan- grene of the lungs and of the mouth, that which attends malignant ery- sipelas, carbuncle, and the malignant pustule, and lastly that arising from severe burns, injuries of the blood-vessels, arterilis, the poison of ergot, etc. In the above suppurative and gangrenous affections, and all others of a similar character, alcoholic stimulation is very frequently indicated, and sometimes strongly so. But it must be remembered that they are usually attended with more or less remaining inflammatory or systemic excitement, which requires caution in the use of the stimulant; and, as 660 GENERAL STIMULANTS. [PART II. a general rule, the fermented liquors will be preferable to the spirituous. Most frequently, in these conditions, there is also an indication for the use of opium and sulphate of quinia or other preparation of Peruvian bark. There is a state of system, essentially one of debility, in which the blood is poisoned by noxious matter absorbed into it, and which does not come exactly into either of the preceding divisions. To this belongs the condition denominated purulent infection, metastatic abscess, and pyogenic fever. It is a condition in which, probably, disintegrated pus, or other sanious secretion from vitiated sores, is absorbed into the blood, and depraves its character. Analogous to it is the state of system aris- ing from dissecting wounds. Alcoholic stimulation is often indicated in this condition. Considerable attention has recently been attracted to the asserted effi- cacy of this remedy in the state of system resulting from the bites of poisonous serpents; and cases have been recorded which go far to prove that it really possesses no inconsiderable curative powers.* The pros- tration of system which attends the operation of the poison would appear to indicate stimulation ; and the ammoniacal preparations have long been in repute as antidotes. To produce the desired effect, the alcoholic remedy, it is said, must be given very freely; and, in most of the cases, it has been pushed to intoxication. It seems, however, that the system, when strongly under the influence of the poison, resists its influence, as tetanus is known to do. In a case recorded by Dr. T. A. Atchinson in the Southern Journal of the Medical and Physical Sciences for March, 1853 (vol. i. p. 108), in which the patient, a young woman of seventeen, was found almost moribund two hours and a half after the bite of a rat- tlesnake, three pints of whisky, given in doses of a glassful every hour, though it produced reaction, and apparently saved the life of the patient, occasioned not the slightest intoxication. During the same time, how- ever, eighty grains of carbonate of ammonia were given, which has been supposed to have some power of obviating the inebriating effects of alco- hol. A young medical friend of mine informed me that, while upon an excursion in Texas, he was bitten by a poisonous serpent, and had already begun to experience alarming local as well as constitutional effects, when the progress of the poisoning seemed to be arrested by * For accounts of cases, see a paper read by Dr. Edward Ilullowell, before the College of Physicians of I'hihidophia, Dec. 1, l^oL', in the Transactions e, in cases which resist the stupefying influence of the ether, is some- times followed by serious nervous disorders, and injurious if not dan- gerous sanguineous determinations, which may last for a considerable time, and should serve as a warning to the practitioner not to urge the measure, in all instances, and at all hazards, to entire stupefaction. For many hours after the immediate effects of the inhalation of ether are over, there is an escape of its vapour from the lungs, and possibly from other emunctories, which is obvious to the senses of an observer, and which sometimes continues, according to my own observation, for one or two days or more. So striking is this effect, that a patient who has inhaled ether at bedtime, will often scent a large apartment next day with its odour. There is also sometimes a sensation of heat in .the * But very few cases of death, under the influence of ether used as an anaesthetic agent, are on record. I have seen a detailed notice of but one case. It was that of a woman in New York, for whom the inhalation of ether was used to relieve violent pain in the head. A large tumour was found in the cerebellum, which was prob- ably the real cause of death, perhaps aided by the additional stimulus of the ether, which had been given three times previously without unpleasant effects. (See Boat. Med. and Surg. Journ., Ixi. p. 245.) In the same journal (liii. 231), a case of hemi- plegia is recorded following the use of ether, given in anticipation of a surgical operation. When it is considered how extensively ethereal inhalation is used ii^this country, both by surgeons and dentists, it is remarkable that accidents have not been more frequent. At a meeting of the Imperial Society of Medicine, of Lyons, Dr. Barrier stated that, to his knowledge, there were only three well authenticated cases in which ether had caused death, and that in these 'there were extenuating circumstances. (Pharm. Journ. and Tram., July, 1859, p. 41.) Note to the second edition. Since the publication of the last edition of this Treatise, though a very few cases of death following the use of ether have been recorded, I have seen none, in which the details were given, which could be ascribed to the direct and unmixed influence of the ether, or which ought to deter from the use of this anaesthetic in cases not obviously unsuited to it, as in those with existing disease of the brain, or with a strong predisposition to it. See on this subject a paper by Dr. F. D. Lente, in the Am. Journ. of Med. Sci. (April, 1861, p. 360). Note to the third edition. 678 GENERAL STIMULANTS. [PART II. chest, attendant on the exhalation of the vapour, indicating that it is escaping by the lungs. There are two points, in connection with the influence of ethereal in- halation, which, though strictly pathological, and, therefore, not belonging exactly to the physiological effects of ether, may be most conveniently considered in this place, in order that the whole series of facts in relation to the influence of the process may be presented in one view. I allude to the anaesthetic influence of etherization by the lungs, and that which it exercises in relaxing spasm. That ether is capable, when inhaled, of abolishing sensibility, is an obvious corollary to its stupefying power. The sense of touch, as well as every other special sense, is, in the very nature of the case, suspended in coma. This, then, is no new discovery. But it was not so obvious that the general sensibility might be diminished^ and even quite sus- pended, while consciousness, and, to a considerable degree, the special senses, remain unaffected. This, however, is a most important fact in relation to etherization. Under the influence of this agent, pain is often abolished if existing, and averted when it would otherwise have been produced, before the occurrence of any degree of stupor, or of any con- siderable anaesthesia of hearing, sight, etc. The woman in childbed ceases to suffer from her labour-pains, though still conscious ; the patient under the knife of the surgeon sometimes scarcely suffers, though he may follow every step of the operation ; and the pain of violent spasm is sub- dued as by a charm, without the least degree of apparent stupefaction. An eminent medical gentleman once assured me that, while labouring under the most exquisite pain from spasm of the bladder, he had inhaled ether, with the effect of completely relieving the pain, though he retained his consciousness unimpaired, and even took pleasure in noting the re- turn of each contraction of the bladder, of which he was distinctly sen- sible, though it was quite painless. The other point referred to was the efficacy of ether when inhaled in relaxing spasm. That it should have this power, in reference to the vol^ptary muscles, so far as the cerebral centres are concerned, was al- most inferrible from the property it evinces in health of relaxing these muscles, when the system is brought completely under its influence. But the muscles of organic life usually remain unaffected, at least not materially affected, in the stupefaction, unless carried to the last degree short of absolute death. Respiration goes on ; the peristaltic movements, so far as is known, are not impaired ; the sphincters generally act as in health ; and the uterine contractions during labour are undiminished in force, though no longer painful. But over the morbid contractions of these muscles, over their spasmodic conditions, for example, etherization has great control. It is capable not only of relieving the pain of these spasms, but, in a somewhat higher degree of its action, of relaxing the CHAP. I.] CEREBRAL STIMULANTS. ETHER. 679 spasms themselves. Though, as before stated, the spasm will sometimes continue after the pain has ceased, yet the two often cease together, and, when this is not the case, the muscular relaxation generally soon follows the anaesthetic eifect. This only proves that the nervous centres of pain, and those of the involuntary movements, are not the same, and that the former usually come under the influence of the anodyne before the latter. The pains of tetanus, for instance, cease before the muscular spasms, but these also will often yield, temporarily at least, to ether. In their tetanic movements, the muscles cease to be voluntary muscles ; and are under the control of the spinal centres. From all this, it may be physiologi- cally deduced that, in etherization, the nervous centres of organic life, those, namely, of the spinal marrow, and the sympathetic ganglia, either come last under the power of the stupefying agent, or, to speak more precisely, are the least susceptible to its action. Another valuable therapeutic agency of ether by inhalation is the relaxation it often produces in the mucous tissues, with an increase of the mucous discharge. This has been noticed in the mucous membrane of the generative organs of women in childbed, and in the bronchial tubes, and may possibly extend to the others; as it is probably rather through the organic nervous centres that it acts, than directly on the tissue affected. Judging from the effects above detailed, we may pretty certainly con- clude that the cerebral centres of general sensation, and those of thought and emotion, are most susceptible to the influence of ethereal inhala- tion, that next in order are those of special sensation and the will, and that lower still in the scale of susceptibility are the centres of organic force, of which the respiratory centre in the medulla oblongata is the lowest. Perhaps there is no powerful remedy to which the system becomes more speedily accustomed than this ; so that, to sustain a given effect for a long time, it must be administered on successive occasions, in rap- idly increasing quantities ; and the amounts which have been given, in some cases, without material injury, are almost astounding, considering the powerful effect produced at first by a small quantity, and the rapidity with which the larger amount has been reached. Even while the ether, which may have caused all the characteristic phenomena, still remains in great measure in the system, it has quite lost its effects on the cerebral centres ; for the breath continues to smell of it long after all the phenom- ena of its action have disappeared. The previous habit of using alcohol or opium also greatly lessens the susceptibility to the impression of ether, showing a close resemblance between these three cerebral stimulants in their mode of action. The only morbid appearances noticed after death from ether are those incident to asphyxia ; namely, darkness of the blood, fulness of the right cavities of the heart, and congestion of the brain, lungs, etc. 680 GENERAL STIMULANTS. [PART II. In poisoning from ethereal inhalation, the shock of cold water upon the face, head, or shoulders, and the introduction of pure air into the lungs bv artificial respiration, are probably the most efficient meas- ures. When the prostration is great, the ammoniacal stimulants may be resorted to by the mouth or rectum, and external stimulation by rubefa- cients should not be neglected. 2. Mode of Operating. Ether probably operates as a stimulant by a direct influence on the vital susceptibilities of the tissues, without any chemical reaction. One proof of this is the vast amount which may be taken with impunity, after the system has become accustomed to it, by a gradual increase of the dose. The case of a chemist is recorded, who took a pint of ether daily. (Herat and De Lens, iii. 166.) When large quantities have been intro- duced by inhalation, the observable effects often cease long before the evidence afforded by the breath that a portion still remains in the sys- tem. This could scarcely be, if the effect were chemical, whether on the solid tissues, or the blood. The higher carbonization of the blood has been supposed to have something to do with the effects of ether. This, however, is probably a mere respiratory result. That the first stimulant impression on the circulation, respiration, and cerebral functions, may depend on the propagation of the local influence, through the nerves, to the nervous centres of those functions, is not impossible; and the rapid- ity with which the effect is produced might be advanced as an argument in favour of this view ; but experiments have satisfactorily shown, that the round of the circulation is accomplished in time to permit the opera- tion by this route within the actual period; so that the view referred to cannot by any means be considered as demonstrated. The probability is that most of the effects of ether are due to its absorption into the cir- culation, and direct action upon the nervous centres, the functions of which are first increased by the stimulation, then deranged, and after- wards diminished or temporarily suppressed, under the general law of irritation. I have already referred to the relative degree in which the centres are susceptible, deduced from the period at which they respect- ively come under its influence. That ether is absorbed, is almost too obvious to require proof. The odour of the breath, which always smells strongly of ether, in whatever way administered, is a sufficient evidence ; not to allude to the fact, that its odour has been noticed in the ventricles of the brain, when death has from any cause followed soon after its ex- hibition. The great difference in the effects of the medicine, as adminis- tered by the stomach and the lungs, is probably owing to its much slower absorption from the former organ. Its powerful direct stimulant action, in the liquid state, upon the stomach, producing an active congestion of the blood-vessels, may be one reason of its relatively slower absorption CHAP. I.] CEREBRAL STIMULANTS. ETHER. 681 through this organ than the lungs, when compared with some other vol- atile medicines, such as hydrocyanic acid. 3. Therapeutic Application. The use of ether as a medicine dates from an early period in modern history. I shall treat of its employment first as administered by the stomach, secondly by inhalation, and lastly as an external application. 1. Use by the Stomach. In the course of low fevers, especially of ma- lignant typhus, in cases of delirium tremens, and in other diseases of debility, sudden sinking spells occasionally take place, approaching as- phyxia in character, which require prompt and energetic stimulation of the nervous centres. In such cases ether is strongly indicated, and may be given in connection with carbonate of ammonia, or the aromatic spirit of ammonia, in order as speedily as possible to restore action, which may then be sustained, if necessary, by the more permanent stimulants and tonics. In the poisoning by mushrooms it has been recommended, probably upon similar grounds. A similar condition sometimes occurs in angina pectoris, and demands instant interference to prevent death. Here also ether is highly valuable in .connection with other medicines. In the seemingly spasmodic pains of that affection, in which it would appear that sudden cramp had seized on some portion of the cardiac muscles, and during which the whole system is extremely prostrate, ether and laudanum are the internal rem- edies mainly to be relied on. Such a condition occasionally takes place in nervous gout, constituting probably the most dangerous example of that disease. The prompt and powerful stimulation with which ether operates upon the nerves adapts it admirably to those spasmodic affections, unattended with acute inflammation, which are characterized by great depression of the circulation, coolness and dampness of the surface, and apparent gen- eral prostration. Hence its usefulness in violent spasms of the stomach, and of the bowels, attended with feeble pulse, cold skin, etc., in which it may often be advantageously combined with laudanum or other liquid preparation of opium, and given in teaspoonful doses. The same remark is applicable to spasms of the urelers and of the gall-ducts, occasioned by the passage respectively of urinary or biliary calculi. In the latter affection, it has been supposed to be peculiarly useful when combined with oil of turpentine. Upon the same grounds, too, it is indicated in the approaching collapse of cholera, attended with internal and external cramps. Its powerful stimulation of the nervous centres, in these cases, may be supposed to rouse them from the torpor into which they appear to be thrown by the concentration of the nervous energy in the suffering organ, and thus to act revulsively in the relief of the spasm. In the paroxysm of spasmodic asthma it has sometimes been used 682 GENERAL STIMULANTS. [PART II. beneficially, though less efficient in this disease than some other rem- edies. In small doses, ether acts purely as a nervous stimulant, and is much employed for the relief of various mild nervous affections. For this purpose it is usually prescribed in the form of compound spirit of ether, or Hoffmann's anodyne, under which this highly useful application of the remedy will be more particularly noticed. Ether has also been recommended in sea-sickness, in which a tea- spoonful of it may be given in a glass of sherry or madeira wine. M. Bourdier has employed it with success for the expulsion of the tapeworm, giving it both by the stomach and rectum with an infusion of male fern, and following it in an hour by a dose of castor oil. M. Lor- tet also has had favourable results. In five cases, all in which he had tried the remedy, he gave 60 grammes (nearly two troy ounces) of ether at once, followed in two hours by half the quantity of castor oil. In every case, the worm was discharged without suffering, and always either entire or nearly so, including the head. (Ann. de Therap., 1860, p. 281.) Ether is contraindicated in all cases of sthenic febrile action and acute inflammation, especially of the stomach and brain. Administration. The dose of ether is from half a fluidrachm to two fluidrachms, which, if a given effect is to be sustained, should be repeated at intervals of half an hour, or at most one hour, as the effect rapidly passes off. It may be given in one or two wineglassfuls of sweetened water, well mixed at the moment of administration, and taken cold. A useful method of dissolving it in water for exhibition, suggested origin- ally, I believe, by the late Dr. Joseph Hartshorne, of Philadelphia, is to rub it up with spermaceti, two grains being used to each fluidrachm, then to rub this mixture well with water, and to strain. As water will take up about one-ninth of its bulk of ether, the dose ought to be readily dis- solved in a wineglassful of that fluid. In France, a syrup of ether is prepared by putting one part of the ether and sixteen of syrup in a flask, with a tubulure at the lower part on the side, fitted with a cork, through which passes a short tube, the outer extremity of which is closed with a small cork. The mixture is shaken occasionally for four or five days, and then allowed to stand. The syrup, at first turbid, afterwards becomes clear, with a portion of the ether floating on the top undissolvi-d. It is drawn off through the tubulure when wauled for use, and a fluid- ounce may be given at a dose. (Trousseau and Pidoux, 4e ed., ii. 260.) 2. Use by Inhalation. Ether has long been used in this method. The late Dr. P. S. Physick was much in the habit of employing it in pul- monary affections, and invented a small extemporaneous inhaler for the purpose. It is only as an anaesthetic agent, that any claim to discovery has recently been advanced in reference to its exhibition by the lungs. CHAP. I.] CEREBRAL STIMULANTS. ETHER. 683 The way to this discovery had been gradually opened by attempts to effect the same object by other agents, and especially by the favourable result of some trials with nitrous oxide by Dr. Horace Wells, of Con- necticut; but tlje credit of the first application of ether to this purpose must be ascribed to Dr. W. T. G. Morton, of Boston. It was in Octo- ber, 1846, that the attention of the profession was called to this highly important discovery. The process was originally applied by Dr. Morton to the relief of pain in dentistry. He made known his success to the late Dr. John C. Warren, who was the first to test its efficacy in an im- portant surgical operation. Though first used to prevent pain in surgical operations, this mode of administering ether may be resorted to in a wide circle of spasmodic, convulsive, and neuralgic affections. Of the painful spasmodic diseases, it may be used advantageously in spasm of the stomach, bowels, bladder, ureters, gall-ducts, and diaphragm, in violent external cramps as those of cholera, and in tetanus. In the atrocious affection last named, it will generally afford more or less relief, and sometimes contributes to the cure. In the poisoning from strychnia it is also indicated. In infantile con- vulsions from spasm of the bowels, it should be resorted to if other means fail. The measure has been recommended in chorea, pertussis, and the convulsive affections of hysteria; but, as it will seldom cure these com- plaints, but only afford temporary relief, there may be danger of inducing a bad habit of indulgence, without corresponding benefit. I have used it with apparent advantage in peculiarly violent or obstinate hysterical convulsions, but, as a general rule, it would be more prudent to dispense with it. For the relaxation of spasm, it may also be employed in dys- phagia from spasm of the oesophagus, and in strangulated hernia. In the paroxysm of spasmodic asthma, when not complicated with acute bronchitis, it may be tried with good hope of benefit; and in the dyspnoea dependent on chronic bronchitis it is doubly useful, if carefully managed, both by relieving the distressing sensation, and favouring mucous secretion. In these cases the remedy should not be pushed to positive insensibility. Neuralgia, dysmenorrhcea, angina pectoris, and severe or obstinate nervous headaches, are complaints in which the remedy is indicated for its anaesthetic virtues. In delirium tremens it sometimes powerfully co-operates with opium in producing sleep, and may be tried in obstinate cases. It has born used also as an antiperiodic in intermittent*, and there can scarcely be a doubt, that it would frequently interrupt the paroxysms if applied about the expected period of their approach. It is, however, only in exceptional cases that there can be any occasion for its use. I would recommend that it should be tried in otherwise desperate cases of 684 GENERAL STIMULANTS. [PART II. the pernicious paroxysm of miasmatic fever, when not attended with comatose symptoms. A case has been reported by Dr. J. H. Hutehinson, of Philadelphia, one of the physicians to the Episcopal Hospital of that city, in which a young woman of twenty years was completely cured, by repeated inhalations of ether, of deafness and dumbness, probably hysterical, after a duration of several months. (Am. Journ. of Med. Sci., April, 1864, p. 412.) As an Anaesthetic Agent in Surgery. There has been no little contro- versy about the propriety of using measures to prevent pain in surgery; but the mass of the profession, influenced in some degree, no doubt, by the powerful instincts of our nature, have come to the conclusion that such measures are not only admissible, but very often advisable. The advocates for their use maintain, and, as appears to me, very reasonably, that not only is the suffering of the patient mi titrated if not entirely pre- vented, but that, in severe operations, the measure proves positively sa- lutary, and conduces to a favourable result by obviating the shock on the nervous system, which is sometimes fatal even during the operation. The objection on the score that nature intended that there should be pain in surgical operations, if it need an answer, is fully met by the simple counter statement, that nature has also presented us with a remedy for the pain. The notion that ether might act injuriously by depraving the blood, and retarding the healing process, has proved as groundless on trial, as it really was in theory. The opium which almost every surgeon formerly gave, left a much more powerful impression on the system than the brief action of ether could do; and yet no one supposed that it pre- vented the healing of wounds. Another objection to the use of ether has been the doubt, whether it really exercised the anaesthetic influence as- cribed to it, as patients, by their agitation during the operation, seem to evince some degree of suffering. But when, as has often happened, they have retained sufficient consciousness of what was going on to give an authoritative statement in the case, they have almost uniformly declared that they felt no pain or very little ; and the agitation was really ascrib- able to some dreamy delusion at the time, or merely to reflex action. The only real question, as it seems to me, is whether ether can be given safely ; for I doubt whether we have the moral right to relieve pain, at any appreciable risk of life. Reasoning from our knowledge of the effects of ether, I should say that a full dose of it, sufficient to bring on the state of anaesthesia, is less dangerous than a full soporific dose of opium, supposing in both cases the system to be in health. Etherization is certainly less dangerous than intoxication from alcoholic liquor, as the circulation is disturbed less, and the influence is much shorter in dura- tion. Nor has experience contradicted the suggestions of reason. The instances are extremely rare, if in fact there are any on record, in which etherization, employed to prevent pain in operations, has proved fatal CHAP. I.] CEREBRAL STIMULANTS. ETHER. 685 when the measure was judiciously applied, and the case properly selected. *The measure itself is certainly not accountable for the ignorance or care- lessness of the person who employs it, and should not be rejected on this score, any more than opium or mercury, or even quinia, should be re- jected for the mischief they have often done in reckless and unskilful hands. Indeed, considering the number of instances in which ether has been used, even by the most notoriously ignorant persons, it is some- what surprising that we have heard so little of its mischievous effects. This assuredly cannot be said of chloroform, which our professional brethren in Europe cling to with so much pertinacity, notwithstanding that almost every journal comes to us burdened with some fatal case, and it is presumable that many happen which never find their way into the public records. Ether has also been much employed to mitigate or annul the pains of childbirth. Upon the propriety of this application of it, there has been even greater difference of opinion, or rather there has been greater oppo- sition to the measure, than in reference to its use in surgery. Having no practical experience of my own in this branch of our profession, I feel altogether incompetent to give an opinion upon the subject, and allude to it here as a point in the history of etherization which cannot be wholly overlooked. Cautions. Ether should not be recklessly used. In cases of seriously diseased heart, active congestion or acute inflammation of the lungs, brain, or stomach, organic cerebral disease, apoplectic or active hemor- rhagic tendencies, or a generally plethoric condition, it should either be avoided altogether, or used only after a careful preparation of the sys- tem. It should be carried no further than is sufficient for bringing about the state of anesthesia, and should be at once withdrawn, if a failing pulse indicate any danger of asphyxia. The utmost care should be taken that sufficient atmospheric air is inhaled. The want of this is probably the greatest danger of the process under unskilful management. The pa- tient, by the very state of insensibility into which he is thrown, becomes incapable of giving warning through his feelings of suffocation ; and hence the greater necessity for care on the part of the operator. The rule simply is that, while the vapour of ether is admitted into the lungs, it should be accompanied with free access of the atmospheric air. Various instruments have been invented to meet the requisitions of convenience and safety in inhalation; but probably nothing is better, on the whole, than a large piece of sponge, hollowed out on one side so as to admit the nose. This should be applied saturated with the ether, so that the vapour may enter with the air drawn by inspiration into the lungs. In this way a due supply of atmospheric air is ensured ; and the only disadvantage is, that more of the ether is lost by evaporation than when it is confined within an instrument. The patient should breathe l!86 GENERAL STIMULANTS. [PART II. preferably through the nostrils. Bags containing ether should never be used.* < When an instrument is used confining the ether, from one to two fluidounces maybe employed; when a sponge, the quantity should be doubled. The operator should keep his fingers on the pulse, and, if he find it failing, should withdraw the ether. Should convulsions super- vene, he must also suspend the process. 3. External Use. Ether is used externally for two purposes, for stim- ulation, and refrigeration. For the first, it is confined to the part to which it is applied; for the second, it is allowed freely to evaporate so as to lower the temperature. In neuralgic pains, nervous headache, and nervous earache, it may be applied near the part affected, by means of a compress saturated with it, and then covered by a piece of oiled silk, to prevent evaporation. Sometimes a little of it, applied to the forehead, and held there in the hollow of the hand, will prove rapidly serviceable in nervous headache. It very quickly produces burning sensation and redness. In earache it is said sometimes to afford instantaneous relief, when dropped into the external meatus. Among the external uses of ether may be mentioned its application to the nostrils in cases of faintness,' or even positive syn- cope, in which it will often do good by its pungency. Ether dropped into the external meatus is asserted to have repeatedly cured deafness; and, when this is purely functional, we may readily ad- mit that it might yield to the remedy. The practice originated with a French lady, Mademoiselle Cleret, who, having used the ether advan- tageously in her own case, afterwards tried it with marked effect in a number of deaf and dumb children. Her statements were submitted to a commission, composed partly of medical men, who after a sufficient examination, and some trials, reported favourably of the remedy. (Gaz. des Hopitaux, Mai 8, 1860.) Dr. John J. Black, of Philadelphia, having been induced, by the suc- cessful use of ether locally in aphthous affections of the mouth by Dr. Jules Worms, to give the remedy a trial in other local diseases, report > very favourably of its efficiency in aphthous ulcerations, in thrush, in ul- cerous stomatitis, acute pharyngitis or ordinary sore-throat, diphtheria. and various chronic ulcers. The ether was applied by means of a camel's- * For the description of an apparatus, very advantageously applied by Dr. F. D. Lente, of Cold Spring, N. Y., to the production of anaesthesia for surgical purposes, nee the N. York Mtd. Journ. (Jan. 1866, p. 262). Its advantages are that it saves- the ether, and by ensuring a more steady and thorough application of the vapour, shortens the time preliminary to the anaesthetic effect. In a case in which it was used at the N. Y. Hospital, the patient was completely insensible in a minute and three-quartern, and the quantity of ether used was only an ounce and a half. (Nott to the third edition.) CHAP. I.] CEREBRAL STIMULANTS. ETHER. 687 hair pencil; and, though it sometimes occasioned a stinging pain at first, this was soon followed by an agreeable coolness and marked relief. In ordinary angina, one of its most striking effects was the rapid subsidence of the swelling, with decided relief to the patient. (Am. Journ. of Med. Sci., April, 1866, p. 350.) With a view to local refrigeration, ether may be used in any case where this effect is required upon the surface of the body ; the cuticle being sound. It is employed, however, chiefly in headaches with external heat, and in superficial burns or scald*. It may be dropped on the part, or applied on a single layer of thin muslin or linen. In strangulated hernia, it has been much commended ; the object being, in this case, to produce contraction of the strangulated part, and thus enable it to pass back through the opening. It is applied most effectually by letting it fall upon the seat of the hernia in a slender stream. A considerable reduction of the temperature can be obtained in this way. Since the publication of the preceding edition of this work, a new method of obtaining the refrigerating effect of ether, locally applied, has been introduced into use by Dr. Richardson, of London. It consists in causing the liquid to fall upon the part to be refrigerated, in the form of spray, by means of the atomizer. The cold produced is so great that the tissue may be frozen to a considerable depth ; and advantage has been taken of the local anesthesia which attends the congelation, to per- form surgical operations without pain. More will be said on this subject when the anaesthetic effects of cold are treated of. There are two officinal preparations of ether which require notice, viz. the Spirit of Ether, and the Compound Spirit of E (her. 1. SPIRIT OF ETHER SPIRITUS ^TIIERIS. Br. Spirit of Sul- phuric Elher. This is simply a mixture of one part by measure of ether and two of rectified spirit, or officinal alcohol. The only advantage of the prepara- tion is that it is readily miscible with water, and may, therefore, be taken more conveniently than pure ether. The dose of it is two or three fluidrachms. 2. COMPOUND SPIRIT OP ETHER SPIRITUS^ETHERIS COM- POSITUS. U.S. Compound Spirit of Sulphuric Ether. Hoffmann's Anodyne Liquor. Hoffmann's Anodyne. As directed in the Pharmacopoeia, this is made by mixing together half a pint of ether, a pint of alcohol, and six fluidounces of ethereal oil or heavy oil of wine. The Ethereal Oil (OLEUM JETHEREUM, U. S.), on heavy oil of wine, is \\ yellowish liquid, heavier than water, of a penetrating peculiar odour, P GENERAL STIMULANTS. [PART II. and a sharp bitterish taste, and boiling at 536 Fahr. It contains sul- phuric acid, combined with certain products of the decomposition of alcohol acting as a base or bases, and is considered by Liebig as a double sulphate of ether and etherole; the latter being another name for light oil of wine, which is a 4-4 carbo-hydrogen (C 4 H 4 ). It is obtained by distilling a mixture of alcohol and sulphuric acid, the latter being in much larger proportion than is used in the preparation of ether. A por- tion of it is usually produced in the ptocess for procuring ether, especially towards the close, and hence contaminates that product as obtained by the first distillation. But, though precise rules are given for the preparation and use of the ethereal oil in the Pharmacopoeias, it is in fact seldom properly prepared in this country ; aud the product sold as Hoffmann's anodyne, in our shops, is asserted to be sometimes prepared by continuing the distilla- tion in the process for procuring ether, after it has been stopped in refer- ence to the latter product. A mixture is thus obtained of ether, alcohol, and oil of wine, which is somewhat modified to make it suit the views of the manufacturers, and sold as Hoffmann's anodyne. It contains the ingredients of the officinal preparation, but much less of the ethereal oil. Compound spirit of ether has a peculiar odour, which it owes to the ethereal oil. In taste it is very hot, pungent, and somewhat sweetish. It should be completely volatilizable by heat and destitute of acid reac- tion ; and, when mixed with water, should have a somewhat milky ap- pearance, owing to the separation of the oil. Medical Uses. The effects of Hoffmann's anodyne on the system are essentially the same as those of ether, but somewhat modified by the oil of wine, so as perhaps to bring it more nearly into accordance with the class of nervous stimulants. Ether itself, in small doses, insufficient to disturb specially the cerebral centres, is really a nervous stimulant ; and, were it used only by the stomach, might perhaps be ranked appropri- ately with this class of medicines; as it is never given in this way for its narcotic effects. But used, as it is at present by inhalation, promi- nently as a cerebral stimulant, and conforming so closely in its effects, as thus administered, with alcohol and opium, it could not with propriety be removed from this connection. Hoffmann's anodyne is much used to quiet nervous irritation in its various forms. Among other effects is that of producing sleep; but this it does only when sleep is prevented by nervous discomposure ; so that it acts, not directly on the brain as a narcotic, but simply as a general stimulant to the nervous system, equalizing its actions, and thus re- moving the cause of wakefulness. From its common name it might be supposed to have extraordinary powers of relieving pain. If given in large quantities, it might possibly produce this effect directly, as the va- CHAP. I.] CEREBRAL STIMULANTS. NITROUS OXIDE. 689 pour of ether does when inhaled, by rendering the cerebral centres in- sensible to the irritations which occasion pain. As ordinarily given, however, it does not act in this way, but only by quieting the irritation upon which the pain may depend ; and, when this is beyond its powers, it is itself inoperative as an anodyne. In painful affections, therefore, purely dependent on functional disorder, it will occasionally afford relief; in the pains of a surgical operation, and those dependent on inflamma- tion, or even active congestion, seldom or never in any ordinary dose. Mild spasmodic affections will not unfrequently yield to it. It is much used in febrile diseases to calm restlessness, and general malaise, to obviate the nervous twitchings and startings so common in children, and to produce sleep, when the patient is wakeful. In the low or typhoid fevers, it is particularly indicated for the subsultus tendinum, and mild delirium so common in those affections. In all the slighter troubles of hysteria, in faintness, languor, lowness of spirits, palpita- tions, etc., and in analogous affections in the male sex, Hoffmann's ano- dyne is often an admirable aid to the physician, when more powerful remedies are not indicated. Flatulent colic, singultus, and gastric uneasiness, will frequently be relieved by it. It is often an efficient remedy in nervous headache. It might be employed, in very large doses, for obtaining those more powerful effects in spasmodic diseases for which ether itself is given; but the proportion of alcohol it contains must always be taken into account in such cases. When laudanum sickens the stomach or occasions headache, the effect may sometimes be obviated by giving Hoffmann's anodyne along with it. The dose is from half a fluidrachm to two fluidrachms. Sometimes it produces very pleasant effects in restlessness, in the dose of from thirty to sixty drops. It should be given in a wineglassful of water, sweet- ened or not as the patient may prefer. The dose may be repeated every hour or two if required. It is often usefully combined with solu- tion of sulplufte of morphia, or other preparation of opium, in affections in which both medicines are indicated. III. NITROUS OXIDE Syn. Protoxide of Nitrogen. Laughing Gas. Though not yet recognized by the Pharmacopoeias, nitrous oxide pos- sesses such valuable properties, and is at present so largely employed, VOL. i. 44 690 GENERAL STIMULANTS. [PART II. that it cannot be passed over in silence in a work, purporting to repre- sent the Materia Medica in its existing state. It was discovered by Dr. Priestly in 1776, but attracted little attention until, in 1800, Sir Humphrey Paw made known the remarkable exhilarating property which gave it the name of laughing gas. Even after this time, notwith- standing the excitant powers exhibited by it. and some futile attempts to take advantage of these powers therapeutic-ally, it was scarcely looked on in the light of a remedy until its application, in 1844, by Dr. Horace Wells, of Connecticut, to the purposes of an anaesthetic in dentistry. Since that period, though for a time neglected, it has risen into groat im- portance, partly as a therapeutic agent through the investigations of Pr. Geo. J. Ziegler, of Philadelphia, but chiefly as an anaesthetic, in which capacity, it is due to the dentists to say they have taken the lead in its practical use. Preparation. The most convenient method of preparing nitrous oxide is by the decomposition, by means of heat, of nitrate of ammonia, which for this purpose should be very pure. The salt is exposed in a glass re- tort, by means of a lamp or sand-bath, to a heat not exceeding 400 F.: and the gaseous product collected in a glass reservoir, over a saturated solution of common salt, as pure water absorbs a considerable propor- tion of the gas, and much loss might be incurred in using it. Warm water, however, absorbs much less than cold, and is often employed for the purpose. When nitrate of ammonia is heated, it is entirely decom- posed ; the hydrogen of the ammonia forming water with three equiva- lents of the oxygen of the acid, and the nitric oxide thus liberated, com- bining with the liberated nitrogen of the ammonia to generate nitrous oxide; so that this gas and water are the sole results of the decomposi- tion, if the process is properly conducted. But there are two sources of impurity which must 1><- guarded against. In the first place, if too much heat be employed, which will be known by the rising of white fumes in the retort, other products will be evolved, especially nitric oxide, uncombined ammonia, and possibly a little nitric acid; all highly injurious in their effects when inhaled. Secondly, nitrate of ammo- nia is apt to contain a portion of muriate of ammonia, or other impurity. in consequence of which chlorine may be among the products. To separate these impurities, which would unfit the gas for use, it should be passed, on leaving the retort, successively through a saturated solution of protosulphate of iron, and a solution of caustic potassa or soda, the former of which will remove the nitric oxide, and the latter. chlorine and whatever acid may be present. The gas thus purified may be kept in gasometers for use; or, as suggested by Dr. Ziegler, it may be forced into water, which can be made to take up five times its bulk, and, kept indefinitely in this state. When wanted for use, nothing iniv will be necessary than to heat the water thus impn-irnatrd. which will yield the gas with great rapidity. CHAP. I.] CEKEBRAL STIMULANTS. NITROUS OXIDE. 691 Properties. Nitrous oxide is a colourless gas, inodorous, slightly sweetish, and of the sp. gr. 1.527. Water at ordinary temperatures will absorb about three-fourths of its volume, and under pressure will take up much more ; and, thus impregnated, has a slightly sweetish taste, and a feeble not unpleasant odour. The gas supports combustion vigorously, and for a time will support respiration, having thus a great advantage over other anaesthetics, which have no power of sustaining life. By the combined influence of cold and pressure, it may be con- densed into a liquid, which is colourless, very mobile, and capable of retaining its form, without pressure, at about negative 9 of Fahr. Nitrous oxide consists of one eq. of nitrogen and one of oxygen, and its formula is NO. Medical Properties and Uses. Nitrous oxide has all the physiological properties which entitle a medicine to rank among the cerebral stimulants. In whatever mode introduced into the system, it especially stimulates the cerebral functions. But it has another important property, wholly independent of its powers over the nervous centres; that, namely, of directly oxygenizing the blood, which renders it highly useful in several morbid affections. Its exhilarating effect on the spirits, and the species of intoxication or delirium induced by it when inhaled, have been ren- dered familiar to every one through the public exhibition of its extraor- dinary powers in this respect. The most remarkable circumstance con- nected with its influence on the brain, is the exemption of those who have experienced its excitant effects from the subsequent depression, which, as an almost universal rule, follows stimulation. I know no other explanation which can be offered of this peculiarity, than that, in consequence of its chemical nature, the exhaustion of the cerebral cell? through the over-excitement it produces, is immediately repaired by the nutritive material, oxygen and nitrogen, which it offers to them; the carbonaceous and hydrogenous matter being always ready in the blood. Besides its general stimulating effects, nitrous oxide is said to have decided aphrodisiac properties, similar to those sometimes exhibited under the influence of other. Besides the exhilarating powers of nitrous oxide, Davy also discov- ered its anesthetic property, and even advanced so far as to suggest that advantage might be &ken of this property in obviating the pain of sur- gical operations. But no practical advantage was taken of this sug<:> -- tion until the year 1844, when Dr. Horace Wells, of Connecticut, who had been thinking of the means of rendering surgical operations pain- less, and especially the extraction of the teeth, having become acquainted with the anaesthetic property of nitrous oxide, immediately turned his knowledge to account by trying an experiment on himself. Having occasion for the extraction of a tooth in his own person, he put himself under the influence of nitrous oxide, while the operation for extraction 692 GENERAL STIMULANTS. [PART II. was performed, and was happy to find that the operation was entirely painless. Soon afterward, as the result of his experiment, t\vo import- ant surgical operations were performed, one by Dr. Marcy, and the other by Dr. Ellsworth, of Waterford, Connecticut, both of which con- firmed the expectations of Dr. Wells. (Med. and Surg. Reporter, Feb. 10, 1866, p. 117 ) For sixteen or eighteen years after this, the subject of nitrous oxide inhalation seems to have been forgotten by the profes- sion, probably under the excitement of the ether and chloroform discov- eries, until revived by Mr. G. L. Colton, of New York, in its application to dentistry, and by Dr. J: M. Carnochan, of the same place, in its appli- cation to higher surgery. In the former respect, it has now come into extensive use; and thousands, if not tens of thousands, every year expe- rience its benefits. In surgery, too, it is slowly making its way, but is as yet far from having superseded ether and chloroform. There are some objections to it as an anaesthetic in the more serious surgical oper- ations which are not applicable to dentistry. Though very speedily in- duced, its anaesthetic effect is as quickly over; so that, to maintain the insensibility long enough for most of the serious operations, it is neces- sary frequently to renew the inhalation; and as, in the case of nitrous oxide, this requires the co-operation of the patient, it can readily be per- ceived that there must generally be considerable difficulty, and sometimes an impossibility of sustaining the anaesthetic action of the medicine a sufficient length of time. One great advantage, however, which the nitrous oxide has over all the other known anaesthetics is, that it is itself a supporter of respiration, so that a temporary exclusion of the atmos- pheric air from the lungs would not endanger asphyxia, while its place was supplied by the nitrous oxide. The period at which the anaesthetic effect takes place after the administration of nitrous oxide, varies exceed- ingly. It may take place in a minute or two, or not till a great deal longer ; much depending upon the depth of the inhalation. One writer states that he has known anaesthesia to come on after only three deep and slow inhalations; while the process is often prolonged i<> twenty inhalations, in cases of superficial breathing from compressed or diseased lungs. (Boxt. Med. and Surg. Journ , Sept. 7, 1865, p. 118.) The dura- tion of the insensibility is short, generally, perhaps, not much exceeding the time required for inducing it. The use of nitrous oxide as an anaesthetic in surgery is gradually spreading. It has been employed in Philadelphia in several of the higher surgical operations; but the general conclusion thus far obtained is, I believe, that it is more especially adapted to dentistry, and to sur- gical operations which require little time ; but that for the more pro- tracted cases ether is preferable. The insensibility to pain is quite as complete, while it lasts, as that caused by the other anaesthetics; and the only objection, therefore, is its brevity. When some method shall CHAP. I.] CEREBRAL STIMULANTS. NITROUS OXIDE. 693 be contrived for continuing the effect, without the instrumentality of the patient, there is no reason, so far as is now known, why the nitrous oxide should not supersede all others ; being in its administration much less unpleasant than ether, in its effects vastly less dangerous than chlo- roform, and in its after-effects less disagreeable than either of the others, both of which are not unfrequently followed by nausea and depression. The danger from inhalation of nitrous oxide, when managed with due caution, may be considered as absolutely nothing. Of course if used in cases not adapted to it. harm may result as from any other remedy. If, for example, it were to be applied in cases of active congestion of the brain, acute inflammation, and general plethora, it would be likely to prove injurious, like alcoholic remedies under the same circumstances. But with ordinary caution in this respect, and care to use only a perfectly pure article, there is really no danger, unless from the existence of some latent predisposition, which might be called into action by this as by any other medicine. In a single dental establishment, out of 4,000 cases in which it was used, not the least injury resulted in a single case. (Boston Med. and Surg. Journ., Sept. 29, 1864.) Xor is it simply a~ an aiuvsthetic that nitrous oxide is likely to be employed. Its conjoined powers of general stimulation especially di- rected to the cerebral centres, and of directly oxidizing the blood, render it applicable to a great number of diseases, in which life is endangered by general prostration, loss of brain power, and insufficiently oxidized blood. The collapsed condition of cholera ; the vast prostration of the pernicious chill ; the cold stage of all other fevers in which reaction is feeble or insufficient, as in malignant cases of typhus, yellow fever, diph- theria, scarlet fever, erysipelas, etc. ; the debilitated states of these same fevers, and of others, as enteric for example, in their course, or towards their close ; cases of positive or threatened asphyxia, from strangula- tion, drowning, cold, and narcotic poisons; all these afford decided indi- cations for this remedy, to which the only objection, in such cases, is the inconvenience of its administration. Hitherto the remedy has made little headway in this direction ; but in an interesting report of Dr. Geo. (T. Shmuard, Medical Director in the U. S. Army, an account is given of eight cases of disease, of the character above mentioned, which were con- sidered hopeless under any ordinary treatment, in which the inhalation of this gas, even under circumstances not the most favourable for its effective exhibition, was followed in all by decided signs of improvement, and in three was believed to have saved life. (Boston Med. and Surg. Journ., Jan. 18, 1863, p. 446 ) Mode of Exhibition. The ordinary method of administration is by means of an air-tight bladder, with a tube and mouth-piece attached, through which the patient breathes, inhaling the contents of the bag, and returning into it the air from the lungs ; the nostrils being closed during the (394 GENERAL STIMULANTS. [PART II. process. Though the effects of the gas may be obtained in this way, yet it is liable to the objection, that the same air is constantly breathed over again ; and, as the carbonic acid from the lungs is steadily increasing, and the nitrous oxide as steadily diminishing, it must happen at length, if the process be long continued, that the air breathed will bo chiefly the former gas, and asphyxia may be endang-ered from this cause. To ob- viate the chance of this evil, the bag should be large enough to hold all the gas required to produce the anesthetic effect; and, instead of one or two gallons, which is often its capacity, should contain several gallons, not less, according to Dr. Spears, than six or eight, though this would probably, in general, be considered unnecessarily large. (Med. and Surg. Reporter, Feb. 10, 1866, p. 118.) But a still better plan is to use a bag with a valve in the tube opening outward, so as to permit the entrance of the air of the bag into the lungs, but to prevent the return of the ex- pired air into it. When the operation is carried on very largely, as in the office of a dentist, it will be convenient, in order to ensure at once a sufficient supply of the pure gas always on hand, and the greatest con- venience of administration, to be provided with an apparatus both for the preparation and preservation of the gas ; including the retort with the means of heating it, several bottles containing the purifying liquids through which the gas is to pass successively, and a larsre reservoir or gasometer of zinc, which may receive the gas as generated, and retain it for use. With this gasometer a tube may be connected, furnished with a valve opening outward, through which the patient may inhale the gas without returning a particle to the reservoir.* Nitrous Oxide Water. The aqueous solution of the gas without press- ure, containing from three-quarters to an equal bulk of the gas, was tried internally by Sir. H. Davy., who believed it to promote digestion, and to act as a diuretic. An oversaturated solution made under pi ure, and containing five volumes of the gas for one of water, was patented in England, where it was known as Searle's oxygenous aerated water, and has been used to some extent as an internal remedy. By Serullas it was thought to be useful in Asiatic cholera. In this country, the internal use of nitrous oxide water has been especially investigated by Dr. Geo. J. Ziegler, of Philadelphia, who made various experiments both on the human subject and the lower animals, and published the results of his researches. The solution taken into the stomach, or in- jected into the bowels, appears to exercise in some degree the stimulant and exhilarating effects of the gas inhaled, at the same time that it pro- duces a gently excitant effect on the mucous membrane, and by absorp- * For an account, with a figure, of an apparatus, contrived by Prof. V.tmler Weyde, and described by Dr. Sam. W. Francis, of New York, see the Medical and Surgical Reporter (May 19, 1866, p. 382). CHAP. I.] CEREBRAL STIMULANTS. NITROUS OXIDE. 695 tion to improve the blood, when deficiently oxygenated. Among other effects which it has in common with the inhaled gas, is that of obviating asphyxia from various causes, by at the same time oxidizing the blood and stimulating the nervous centres and the heart. The diseases in which the nitrous oxide water has been employed, with supposed advant- age, or may be used with hope of benefit, are dyspepsia ; depression of spirits; general torpor and debility ; neuralgia connected with debility; gastralgia; asthma; syncope ; threatened or existing asphyxia; the debility following the excitement of the stimulating narcotics, as opium, alcohol, ether, etc., and that attending the immediate action of the cerebral or nervous sedatives, as chloroform, hydrocyanic acid, digitalis, tobacco, aconite, etc.; and, finally, the low condition of all fevers requiring stimu- lation, in which this remedy is particularly indicated, as not being fol- lowed by depression. Dr. Chapelle, of Angouleme, in France, has found the remedy especially beneficial in lypemania, or that form of monomania in which the delusion is attended with depression of spirits or melancholy. (Arch. Gen., Juin, 1865, p. 739.) According to the observations of Dr. Ziegler, its long-continued use occasions emaciation, resulting from the too rapid oxidation and consequent excess of the vital changes of the tissues; but this condition is much less serious than that proceeding from an opposite cause, as it indicates no depreciation of the vital powers. Indeed, the remedy may be used, in case of morbid obesity, with a view to this very effect. Where it cannot be taken by the mouth, it may be administered with similar results by the rectum. From half a pint to a pint and a half of the nitrous oxide water may be taken, in wineglassful doses, less or more, through the day. Three times the quantity may be given by enema. Peroxide of Hydrogen. Some attention has recently been attracted to peroxide of hydrogen as an oxidizing agent in the system, and as a remedy of diversified powers, by the experiments and researches of Dr. Richardson, of London ; but it has not yet practically obtained such a position in therapeutics, as to authorize its adoption into the catalogue of remedies. Further trials may justify, or perhaps even exceed the hopes entertained in relation to it. At present I must content myself with referring to the U. S. Dispensatory (12th ed., p. 1579), where an abstract will be found of all that is at present known concerning it in a remediate capacity. 696 GENERAL STIMULANTS. [PART II. IV. CAMPHOR. CAMPHOR A. U. S., Br. Origin. Camphor is a concrete substance obtained from Camphora officinarum, an evergreen tree, of considerable size, growing in China and Japan, and other neighbouring countries, and occasionally kept in conservatories in temperate latitudes. The whole plant is impregnated with the camphor, which is separated either by sublimation, or by boil- ing, and, in the latter case, is sublimed before being sent into market. It comes to us either from the ports of China, or indirectly from Japan through Dutch commerce. As imported, it is not sufficiently pure for use, and is, therefore, submitted to another sublimation, along with a small proportion of quicklime. Thus prepared, it is in large circular cakes, an inch or two in thickness, slightly convex on one side and con- cave on the other, and perforated in the centre. Properties. As kept in the shops, camphor is usually in fragments of the cakes above mentioned, usually somewhat whitish on the surface, but beautifully clear and translucent within. It has a strong, fragrant, char- acteristic odour, and a warm, pungent, somewhat bitter taste, which leaves a sense of coolness ir he mouth, especially perceptible when the air passes over the tongue during inhalation. It is somewhat unctuous to the touch, and very brittle, yet of difficult pulverization, in conse- quence of a certain tenacity in its constituent granules, which causes them to flatten under the pestle, without breaking into powder. It may, however, be readily reduced to powder, by first adding a little alcohol, by grating and sifting, or by precipitation by water from its alcoholic solution. Camphor is lighter than water, and, when thrown upon it in small fragments, floats on the surface, and performs various gyratory movements, probably in consequence of the repulsion of its vapour. It is highly volatile, and if exposed to the air will in time wholly disappear. At a temperature somewhat above that of boiling water, it melts, at a higher temperature boils, and at a still higher takes fire, burning with a brilliant flame, but much smoke, and leaving no residue. In close ves- sels it may be sublimed unchanged. It is very slightly soluble in water, which, by simple agitation with it, takes up one-thousandth of its weight, and acquires the smell and taste of the camphor. By the intervention of an agent which enables it to be very minutely divided, as magnesia or its carbonate, it may be dissolved in water in much larger proportion. It is very soluble in alcohol, extremely so in chloroform, and to a con- siderable extent also in ether, the volatile and fixed oils, strong acetic acid, and the diluted mineral acids; even carbonic acid water dissolving CHAP. I.] CEREBRAL STIMULANTS. CAMPHOR. 697 it more largely than water itself. When rubbed with resinous substances, it often loses a part of its odour, becomes softened, and is thus rendered more readily suspensible in water. Composition. Camphor consists of carbon, hydrogen, and oxygen, which are thought to be combined in the form of oxide of camphene, a compound radical consisting of 10 equivalents of oxygen and 8 of hydrogen, and supposed to be identical with pure oil of turpentine. Another variety of camphor, denominated Borneo, or Sumatra, or Dryobalanops camphor, is obtained from the interstices of the wood of Dryobalanops C amphora, a large forest tree of Sumatra and Borneo. It is never, however, imported for use into America or Europe. 1. EFFECTS ON THE SYSTEM. Opinions the most opposite, and facts apparently the most contradictory, have been published in relation to the mode of operation and effects of camphor. Some consider it essen- tially sedative in its action, whether on the circulatory or nervous sys- tem; while others with equal positiveness determine that it is stimulant; and others again think that it may be the one .or the other; and facts not to be denied are adduced in support of each opinion. In the present state of our experimental knowledge on the subject, it is impossible to decide with certainty between these conflicting views and statements. More numerous observations, made under every variety of circumstances, and without influence from preconceived opinions, are necessary before any view of its mode of operation can be received as demonstrated. Nevertheless, it may be possible to find some clue through the labyrinth of seeming contradictions; and, after giving a succinct account of the effects produced by camphor, as deduced from the great multitude of published facts, and from my own personal observation, I shall endeav- our to explain them, as far as practicable, in accordance with the general principles maintained in this work. Local Effects. In the first place, when applied locally, and confined so as to prevent evaporation, camphor produces heat, more or less red- ness, and not unfrequently pain. These effects are not very obvious upon the skin protected by the cuticle ; but, when the medicine is applied in concentrated solution, they will, I think, be found to take place in some degree. In blistered and ulcerated surfaces, and in the mouth, they are incontestable. MM. Trousseau and Pidoux state, as the result of personal experiment, that pieces of camphor, held in the mouth for half an hour, had, at the end of that time, produced redness, heat, and painful swelling in the part with which they were in contact. (Mat. Mcd., 4e ed., ii. 235.) The experiments of Orfila on animals prove that the same effect is produced in the gastric mucous membrane. When camphor was given in small fragments, it was found, after the death of the animal, to have caused inflammation, and numerous small points of ulceration. It is well known that, in man, when swallowed 698 GENERAL STIMULANTS. [PART II. in the form of pill, it is apt to occasion uneasiness or pain in the stom- ach, and, if in considerable quantities, even nausea and vomiting. It would seem, therefore, that camphor is a local stimulant. But how are we to account for the coldness felt in the mouth when it is swallowed, and, as some assert, even in the stomach? Simply by its volatility. In its conversion from the solid state to that of vapour, it necessarily absorbs heat, and produces the sensation of cold ; and this is especially observed when the air is drawn through the mouth, thus favouring the evapora- tion. There can be no doubt that the same change goes on to some extent in the stomach, under the higher temperature to which the cam- phor is there exposed, and a necessary result there also is the production of more or less coolness. But excitement of the part is probably not the only effect of camphor. It is scarcely possible that the medicine should have been adhered to, as a local anodyne in rheumatism and other painful diseases, so universally, so pertinaciously, and through so long a series of years, if it really possessed no power of this kind. But nothing is more common, in our experience of the operation of medi- cines, than the succession of a stimulant and sedative effect. Chloro- form powerfully irritates a surface for a time, and afterwards as power- fully reduces its sensibility to painful impressions. Camphor operates in the same way ; but, whether its sedative effect on the nervous extrem- ities is direct, or consequent upon a previous stimulant effect upon them, there are no facts which enable us to determine. The question may perhaps be, in some degree, analogically settled, if we can determine how the medicine acts upon the nervous centres; for it is probable, though by no means certain, that it acts upon the same principle in both positions. General Effects. Our attention is next to be directed to the effects of camphor on the system at large. Omitting the impression it may pro- duce on the stomach, which will vary with the predominance of the refrig- erant influence of the evaporation, or the direct excitant influence of the camphor, and with the mode of its exhibition, whether in solution, finely divided, or in mass, I shall notice only the constitutional effects. From a very small dose, sufficient, however, to make a decided impression in certain morbid states of the system, no sensible effect whatever is expe- rienced in health. A somewhat larger dose will usually be followed by a slight increase in the frequency and perhaps fulness of the pulse, and in the warmth of the surface, and occasionally by some diaphoresis. In the course of about twenty minutes, there may be a slight exhilaration of spirits, or feeling of comfort induced, which, however, is much more observable in depression or uneasiness from nervous disorder than in health. This passes over in a short time, and no other discoverable effect may be produced. Thus far the medicine operates in exact accordance with the class of nervous stimulants. A larger dose will CHAP. I.] CEREBRAL STIMULANTS. CAMPHOR. 699 occasion obvious narcotic symptoms. With or without preliminary excitement of the circulation, there will now be a feeling of giddiness, perhaps also of languor or lassitude, with more or less mental confusion or unsteadiness ; and, if the impression be very decided, there may also be some disorder in vision and hearing. These symptoms are soon followed by heaviness, mental hebetude, and a disposition to sleep; during which the general sensibility is impaired, the pulse, whether at first excited or not, usually becomes slower, though perhaps still full, and the temperature of the surface is somewhat lowered. Very opposite statements have been made, in reference to the effects of the medicine upon the urinary and genital organs, by persons who equally speak from their own experience, and, so far as can be determ- ined, are equally deserving of confidence. While, according to one statement, camphor is apt to irritate the urinary passages and the organs of generation, producing even strangury in the one, and sensations of voluptuous excitement in reference to the other, the opposite statement affirms that the medicine, instead of causing, is admirably adapted to re- lieve strangury, and is a powerful antaphrodisiac, producing excellent effects in priapism, nymphomania, a disposition to onanism, etc. Now these assertions are not so contradictory as they seem. Allowing the camphor to act upon the nervous centres as a stimulant, the first stage of its action may be an excitation of the function over which the centres respectively preside, while, in the second stage, the congestion of the centre shall be such as to impair its power, and consequently depress the dependent function. Thus, camphor may excite, and may depress the generative organs, and whether it will do the one or the other, may depend upon the stage of its action, as well as on the quantity given, and on various circumstances which may hasten or retard, increase or diminish its influence. If it act promptly and powerfully on the centre, the first stage of excitation may pass over so rapidly that only the suc- ceeding sedative effect may be felt ; if, on the contrary, less rapidly and less powerfully, its congestive effect in the centre may not pass the boundary of pure excitation, and the function be stimulated accord- ingly. The different effects on the urinary passages may be explained on the same principles ; or we may suppose that, in producing one effect, the camphor may act through the system, and, in producing the other, locally. Poisonous Effects. In great excess, camphor sometimes occasions nausea and vomiting, by which it is discharged, and ill effects averted. If not speedily thrown off from the stomach, it gives rise to anxiety, vertigo, disordered or obtunded hearing and vision, delirium, insensi- bility, muscular twitchings, convulsions, and deep stupor. Along with these symptoms there are usually diminution in the frequency and force of the pulse, paleness of the face, and coolness of the skin, which is 700 GENERAL STIMULANTS. [PART II. sometimes bathed in cold sweat. The symptoms come on usually in less than half an hour, increase gradually in intensity, and in the course of an hour or two end in unconsciousness. If the poison is evacuated, they will go off quickly ; otherwise, they may continue several hours, and gradually decline, the patient returning to consciousness, but with some confusion of mind and feebleness of memory remaining for a longer or shorter time Except in the case of an infant, of about eighteen months, who died from the effects of the poison, after taking about ten grains, no instance of fatal result is on record; but in many instances the symptoms have been very alarming, and quite sufficient to suggest caution in the use of large doses. It is a singular fact that, in some of these cases of poisoning, there have been at first evidences of high circulatory excite- ment, with flushed face, and other symptoms of determination of blood to the head, followed by a state of depression ; while in other cases the depressed condition has first occurred, and the symptoms of excitement, amounting even to fever, have followed. It has been attempted to ex- plain the latter by the reaction following depression ; but we do not see the same phenomena succeeding the prostrating influence of real direct sedatives, such as conium, chloroform, digitalis, hydrocyanic acid, etc. It is more probable that they were the result of the direct action of the poison on the brain ; and the different states of excitement and prostra- tion were probably merely the results of different degrees of excitant or irritant influence on the cerebral centres, in one instance being only suffi- cient to stimulate them to excessive action, in the other overwhelming them with an active congestion, and thus preventing their due influence on the functions over which they preside, whether of the heart, lungs, or special senses. The occurrence of febrile symptoms, and obvious cerebral excitement, after the depressing effects have been for some time experienced, may be owing to a subsidence of the active congestion of the cerebral centres to a point, at which their operations are unembar- rassed, and at which, consequently, they are enabled to extend the direct effects of their irritation throughout the system. If any physician will ask himself the question, whether he would venture to give camphor, in large doses, in acute inflammation or active congestion of the brain, he will at least determine what is his own real belief of its action. If he agree with the author in thinking that it could do only injury under such circumstances, he will be disposed to rank camphor, as is here done, among the cerebral stimulants. Until he is prepared to administer it as an effectual remedy in such cases, he cannot be thoroughly convinced of its direct sedative properties. The quantity in which camphor is capable of producing poisonous effects varies exceedingly, according to individual peculiarity, or to cir- cumstances not well understood. Thus, while Mr. Alexander, of Edin- burgh, suffered the most threatening symptoms, including convulsions and CHAP. I.] CEREBRAL STIMULANTS. CAMPHOR. 701 stupor, from forty grains, and even twenty grains have produced alarm- ing effects, more than two drachms have been taken without serious consequences. The ten grains which proved fatal in the child of eighteen months, are probably equivalent to eight or ten times as much given to an adult. The main remedy in poisoning from camphor is to evacuate the stom- ach. The after treatment depends altogether on the symptoms pre- sented; but, in general, little else is required. 2. MODE OF OPERATION. Camphor probably acts on the system at large exclusively through the blood. That it is absorbed is proved by its odour in the breath and perspiration, and, as some have asserted, in the urine, and by the result of an experiment of Tiedemann and Gmelin, who distinctly perceived the smell of camphor in the portal blood of a horse, to which the drug had been given. From what has been stated above, it has been already inferred that 1 consider camphor as directly stimulant, both locally and generally, with very little comparative influence on the circulation, but a powerful ac- tion in large doses on the brain, and as indirectly sedative to all the functions, including of course that of the heart, through the over-stimu- lation or congestion of the nervous centres. 3. THERAPEUTIC APPLICATION. Camphor was probably unknown to the ancient Greek and Roman physicians, and was introduced into Eu- rope by the Arabians. In small doses of from one to three grains, re- peated at short intervals if required, it often answers an admirable pur- pose as a nervous stimulant, relieving slight pains, vague uneasiness, nervous headaches, muscular twitchings, restlessness, jactitation, etc., and often enabling the patient to sleep by removing the causes which keep him awake. It is much used for this purpose in various diseases, generally in the state of camphor water, or combined with opium in the officinal camphorated tincture of opium, or paregoric. In a full dose, calculated to act as a cerebral stimulant, it may be em- ployed to stimulate the brain in a depressed state of its functions, to relieve pain, and to allay spasm and other nervous disorder. It probably produces the two latter effects by rendering the cerebral centres, through its congestive influence upon them, insensible to the impressions sent from the affected part, and incapable of transmitting influence to the muscular or other dependent function. The following are the special diseases in which 'it has been most em- ployed ; but, whatever may be the name of the affection in which the indications above mentioned may be presented, it may be used to meet them, provided no contraindication exist. Idiopathic Fevers. Whenever, in any one of these complaints, what- ever may be the particular character of the fever, there may be general uneasiness, restlessness, jactitation, tremors, twitchings or starlings of 702 GENERAL STIMULANTS. [PART II. the muscles, slight delirium, wakefulncss, etc., and these symptoms may be in no degree dependent on, or connected with active congestion or inflammation of the brain, camphor may be employed as a nervous stim- ulant, and will often be found to act most happily in relieving them. The most convenient form for using it, under these circumstances, is that of the camphor water of the U. S. Pharmacopoeia, of which one or two tablespoonfuls may be given every hour or two, until the desired effect is produced. The symptoms referred to are peculiarly apt to occur in children, for whom, according to the age, the dose may vary from thirty minims to one or two fluidrachms, at the same intervals. Advantage will often accrue from combining or alternating it with compound spirit of ether (Hoffmann's anodyne), or with spirit of nitric ether (sweet spirit of nitre), under the same circumstances, and sometimes with one of the liquid preparations of opium, when that medicine may be simultaneously indicated. In enteric and typhus fevers, and in the low typhoid state of febrile diseases generally, camphor is particularly indicated ; and may some- times be employed with benefit, not only for the purposes above men- tioned, but also as a cerebral stimulant, in aid of wine-whey, carbonate of ammonia, etc., \viien the pulse is frequent and feeble, the tongue and skin dry, and the patient affected with low muttering delirium. The supposed diaphoretic property of the medicine comes here in aid of its stimulant action on the brain, which is in a depressed condition under the sedative influence of the depraved blood, or directly of some absorbed poison. Inflammation. Under the impression of its sedative powers, camphor has been recommended strongly in inflammatory diseases generally, and especially in acute rheumatism, in which it has been supposed to exer- cise peculiarly beneficial powers. Of course it may be used in these complaints when the nervous symptoms above referred to call for it ; but it is not in this capacity that its employment is now alluded to. It is supposed, in these complaints, to exercise a directly sedative influence over the inflammatory excitement, at the same time favouring perspira- tion. I have no doubt that it may act beneficially, but not precisely in the manner supposed. Whatever sedative influence it may exert is, I believe, secondary, and dependent on a direct stimulation and consequent congestion of the cerebral centres; and the inference from this view is, that it should not be employed in acute cerebral inflammation, or active cerebral congestion; nor, indeed, in any other inflammation with a full strong pulse and sthenic state ef system, until the vascular fulness and excitement have been subdued by depletory measures. In other words. I think that it acts upon the same principles precisely as opium in these cases, and, like it, should be associated with medicines calculated to give it a direction to the skin, and obviate any stimulation it may produce, CHAP. I.] CEREBRAL STIMULANTS. CAMPHOR. 703 such as tartar emetic, the neutral mixture, nitre, etc. It is probably the similarity and, at the same time, inferiority of its action to that of opium, that has led to its disuse in inflammations ; and advantage might some- time^ accrue, particularly in inflammatory rheumatism, from having re- course to it as a substitute for opium, when that medicine, from its pecu- liar properties, may act in some way disadvantageously. When on the subject of opium, I shall more fully discuss its mode of operation in in- flammations; and what maybe said there will apply in considerable degree to camphor. With a view to its antiphlogistic effects, it must be used in full doses. Painful Affections. Camphor has been occasionally used as an ano- dyne in neuralgia, but is much less efficient than several other medicines belonging to the class. In nervous headaches it may be useful, when they depend on cerebral depression ; and, in slight cases, when the head- ache is merely an expression of some trivial nervous disorder, a small dose of camphor, with a little opium, as in the common paregoric elixir, will often operate happily. It is, however, in dysmenorrhcea that cam- phor has been most used merely as an anodyne. To fulfil this indica- tion it must be given in the largest doses. Spasmodic and other Nervous Disorders. In the more violent of the painful spasms, the anodyne and relaxing powers of camphor, in any ordinary dose, are quite inadequate to the results desired. It is of little use. therefore, in spasm of the stomach, ureters, or bile-ducts, in the se- vere forms of colic, in tetanus, etc.; yet it has been employed, with sup- posed advantage, in the violent cramps attendant upon poisoning by strychnia; and, in conjunction with opium, is occasionally used in epi- demic cholera, and, in small doses, in the diarrhoea or cholerine prelimi- nary to that disease. In the convulsive affections produced through the cerebral centres, it has sometimes been employed with great asserted benefit, particularly in puerperal convulsions ; but, having no personal experience of it in this affection, I do not feel at liberty to recommend it. It has been used also in epilepsy, chorea, and hysterical convulsions with occasional advantage ; but cannot be depended on for more than temporary relief, and often fails to produce that. In pertussis, and other instances of spasmodic cough, it may be given as an adjuvant to more efficient medicines ; but is little used. In the cough attendant upon in- flammatory affections of the chest, in their advanced stages and chronic forms, it may sometimes be usefully associated with expectorants, when opium may be contraindicated, or in connection with that narcotic. In the form of camphorated tincture of opium, it very often enters into cough mixtures under the circumstances mentioned; but, in this form, should not be employed in the earlier stages. In the various slighter nervous disorders of hysteria, of the puerperal slate, of hypochondriasis, of feeble paralytic c.:se?. and of chronic debility in general, it may be used 70 1 GENERAL STIMULANTS. [PART II. with occasional benefit, in small doses, as a nervous stimulant, either alone, or associated with other medicines. It has been much used by some practitioners in insanity to produce sleep and quiet irritation ; and may be considered as indicated in that com- plaint under similar circumstances with opium, to which, however, it is greatly inferior. It has been particularly recommended in melancholy. In occasional attacks of apparently causeless mental depression, it some- times acts very happily. From its stimulant influence on the nervous centres, it has been used in cases of amaurosis, of a purely functional character, with asserted success ; but it has, under these circumstances, generally been prescribed with other medicines, such as valerian, arnica, etc. It has been used in delirium tremens to aid in procuring sleep, as well as in quieting the varied nervous disorders of that affection ; but, if used at all, it should be merely as an adjuvant of opium, or in conjunction with other narcotics when opium cannpt be used. One of the applications of camphor about which there has been the greatest difference of opinion, is to the alleviation of irritations of the urino-genital apparatus. The testimony, however, in favour of its occa- sional efficiency in morbid sexual excitement is too strong to be rejected. Sometimes in small, and sometimes in large doses, it has been given, with at least temporary advantage, in cases of nymphomania, priapism, and uncontrollable venereal propensities exhibited in other forms. Alone, or associated with lactucariurn or lupulin, it may always be given in such affections with hope of benefit. Many employ it habitually to prevent or relieve strangury from Span- ish flies used for blistering. For this purpose it is sprinkled on the sur- face of the plaster before application, and is given internally to relieve the affection when produced. I have never, however, found any very satisfactory influence from it, in the doses in which I have been willing to employ it; but have no doubt that, in large doses, whether by the mouth or rectum, it would sometimes have the desired effect; but the relief obtained, under such circumstances, by an anodyne enema of lauda- num is so prompt and certain, that I have seldom thought it worth while to resort to less efficient means. Camphor has also been employed in the retrocession of cutaneous eruptions, in order to relieve internal irritation by its calming influence, and to favour the return of the eruption by its diaphoretic action. Contraindications. It is scarcely necessary to repeat that camphor should not be given during the existence of active vascular irritation, congestion, or inflammation of the brain, nor in high febrile excitement with a strong pulse and sthenic state of system ; and that, in any case presenting these conditions, whatever otherwise may be the indication for its use, they should be subdued before it can with propriety be pre- scribed. Nor should it be administered when the stomach is inflamed. CHAP. I.] CEREBRAL STIMULANTS. CAMPHOR. 705 Local Use of Camphor. Few medicines are more frequently employed topically than camphor. In the form of vapour, it is sometimes inhaled in aslhma, spasmodic coughs, and chronic catarrh al affections; and there is no doubt that its constitutional impression may be obtained in the same way. It may be applied by means of an ordinary inhaler, placed in water more or less heated to favour the volatilization of the camphor. M. Raspail recommends that a small tube, a quill for example, should be filled with the coarsely powdered medicine, and loosely closed at each end so as to admit the passage of air, and that this should be used in the same manner as a cigar, but without burning. In the inha- lation of camphor, care must be taken to arrest the process, when signs are exhibited of its acting on the brain. Another mode of using the vapours of camphor is in the form of a vapour bath. For this purpose the patient may be seated naked on a stool, and covered with a blanket closely applied about his neck, and hanging down around him upon the floor. A plate of heated metal, holding half an ounce of camphor, should then be placed underneath the blanket, so that the vapours may completely surround the body. A similar arrangement may be made, by means of crossed hoops and the bedclothes, about the patient in bed, if unable to rise. The vapour thus applied is highly recommended by M. Dupasquier, in 'chronic rheumatism. A piece of camphor held before the nostrils, so that its vapour may be snuffed up into the nasal passages, is sometimes beneficial in coryza. Powdered camphor has been recommended to be used in the same way, and for the same purpose, as well as for the relief of various spasmodic and catarrhal affections of the air-passages. Dissolved in different liquids, camphor is injected into the urethra, vagina, and rectum, for the purpose of relieving irritations of those pas- sages, and is very much used as an application to the surface, chiefly with a view to its anodyne effect, in various painful affections, as gout, rheumatism, neuralgic pains, sprains, bruises, chilblains, etc. It is also used as a stimulant to gangrenous, flabby, and indolent ulcers. In the solid state, also, camphor is sometimes employed externally. Allusion has already been made to the use of the powder in the form of snuff, for which purpose it should be made very fine. In a similar state, it may be applied in cataplasms to painful parts; and half a drachm of it, thus applied to the perineum, will sometimes relieve the chordee at- tendant on gonorrhoea. ADMINISTRATION. Camphor may be used in pill or emulsion, but the latter form is greatly to be preferred ; as, in the former, it is more apt to irritate the stomach, probably by floating upon the gastric liquids, and thus coming in a concentrated state into contact with the mucous coat. ' The emulsion may be made by first pulverizing the camphor with a few VOL. i. 45 706 GENERAL STIMULANTS. [PART II. drops of alcohol, and then rubbing it up with powdered gum arable, loaf- sugar, and water, to which a little myrrh may be added, in order to favour the suspension of the camphor. Another mode of preparing the emulsion is first to dissolve the camphor in a little chloroform (see Chlo- roform), and then to incorporate the solution, by means of the yolk of an egg, with water. The medicine may also be given suspended in milk ; but an objection to this is its liability to undergo change in a short time. The officinal aqueous solution, and the tincture, are convenient forms for administration. The dose of camphor varies from one to twenty grains. As a simple nervous stimulant, it may be given in the dose of from one to three grains, repeated every hour or two, if required. For its full effect as a cerebral stimulant, or indirect sedative, the medium dose is from five to fifteen grains. When a powerful effect is required, as in certain painful neuralgic or spasmodic affections, the dose may be increased to a scruple. By enema, it may be given in twice or three times these quantities. The following preparations of camphor are officinal. 1. CAMPHOR WATER AQUA CAMPHORS. U. S., Br. This is made, according to the U. S. Pharmacopeia, by rubbing two drachmp of camphor, first with forty minims of alcohol, afterwards with four drachms of carbonate of magnesia, and lastly with two pints of dis- tilled water, and then filtering. The camphor is thus dissolved in water much more largely than by simple agitation. The carbonate of mag- nesia merely serves the purpose of dividing its particles minutely. Each fluidounce of the preparation, when well made, contains about three grains of camphor. The British preparation, which is made by exposing camphor, enclosed in a muslin bag, to the solvent power of water in a jar, is much feebler, and probably never used with us. Camphor water is an elegant preparation for obtaining the slighter effects of camphor as a nervous stimulant, in the nervous disorders of febrile diseases, slight hysterical affections, uterine after-pains, etc. It also frequently serves as a good vehicle of other medicines in bowel complaints, especially of nitric and nitromuriatic acids. It is not adapted for obtaining the more powerful effects of camphor. The dose of it is one or two tablespoon- fuls every hour or two. It was a favourite application of Scudamoiv in acute gout, mixed with alcohol, in the proportion of three parts of the former to one of the latter. The mixture was applied to the inflamed joint on linen compresses of six or eight folds, or by means of bread poul- tices saturated with it, 2. SPIRIT OF CAMPHOR. _ SPIRITUS CAMI-HOINE. U. S., Br. TINCTURA CAMPHOH.K U. S. 1850. Tincture of Camphor. This is simply a solution of camphor in officinal alcohol. A fluid rachm of it contains seven and a half grains. It is diidly used externally, a- CHAP. I.] CEREBRAL STIMULANTS. CAMPHOR. 707 an anodyne embrocation in rheumatic and gouty pains, chilblains, sprains, bruises, etc. I have sometimes used it mixed with five or six parts of milk, and applied on linen compresses, as an anodyne and emollient in acute gout. It is also frequently employed in nervous disorders, as lassitude, faintness, and slight hysterical affections, applied to the forehead, cheeks, etc., and held to the nostrils, so that its vapour may be inhaled. The tincture may also be used internally, whenever the alcoholic vehicle may not be contraindicated. The camphor is precipitated by water, but may be held in suspension by sugar or gum. The dose is from ten drops to a fluidrachm. first dropped upon loaf-sugar, and then mixed with water. 3. CAMPHOR LINIMENT. LIXIMENTUM CAMPHOR*. U. S., Br. This is a solution of camphor in olive oil, half an ounce of the former being employed to two fluidounces of the latter. It is used locally for the same purposes as the spirit, and as a discutient application to gland- ular swellings. It may also be used as an injection into the rectum in the tenesmus of ascarides and dysentery, and into the urethra for the re- lief of the ardor urinje of gonorrhoea. As an enema, not more than one or two fluidrachms of it should be thrown into the rectum at once, diluted with from two to four fluidounces of olive oil ; and a preparation of the same strength may be used for the urethra. The British Pharmacopoeia directs a Compound Camphor Liniment (LiMMENTUM CAMPHORS: COMPOSITUM,) consisting of camphor, solution of ammonia, and spirit of lavender ; but such mixtures might well be left to extemporaneous prescription. It is in fact a spirit of camphor, ren- dered more stimulating by the ammonia, and intended, therefore, to act both as a rubefacient and anodyne. It is employed externally for the same purposes as the tincture. 4. CAMPHORATED TINCTURE OP OPIUM TINCTURA OPII CAMPIIOUATA. U. S. Paregoric. This tincture will be treated of among the preparations of opium, to which the reader is referred. 5. SOAP LINIMENT. _LINIME\TUM SAPONIS. U. S.,Rr. TINC- TURA SAPONIS CAMPHORATA. U. S. 1850. Camphorated Tincture of Soap. This consists of Castile soap, camphor, and oil of rosemary, dissolved in alcohol diluted with one-eighth of its measure of water. It is a clear liquid, and is very much used as an anodyne and gently rubefacient lini- ment, in all the outward pains for which camphor is locally employed. (See pages 704-5.) To render it more anodyne, it may be mixed with an equal measure of laudanum, constituting the Anodyne Liniment or LINIMEXTUM OPII of the British Pharmacopoeia; and, if stronger rubefa- cient properties are required, stronger solution of ammonia may be in- corporated with it in the proportion of one-fourth by measure. The latter 708 GENERAL STIMULANTS. [PART II. preparation may be used as an effective rubefacient in pectoral inflam- mation, angina, laryngitis, and tonsillitis. 6. CAMPHORATED SOAP LINIMENT. LINTMEXTUM SAPO- NIS CAMPIIORATUM. U. S. 1850. Opodeldoc. The camphorated soap liniment is essentially the same as the soap liniment just described, differing in the kind of soap employed, which in this preparation is the common white soap, made with animal fat, in- stead of the Castile soap, made with olive oil. The effect of the substitu- tion is that the liniment is obtained of the consistence of a jelly, in con- sequence of the hot alcoholic solution of common soap gelatinizing when it cools. It is usually sold in broad-mouthed bottles, containing about four fluidounces. Though of the consistence of a soft solid at ordinary temperatures. it assumes the liquid state when applied to the surface of the body. It is much used popularly, under the name of opodeldoc, in rheumatic pains, bruises, sprains, etc. It was, however, discarded from the U. S. Pharmacopoeia at the late revision. V. OPIUM. U.S.,Br. This is a concrete juice obtained by incisions in the unripe capsules of Papaver somniferum, or the poppy, an annual plant, inhabiting Asia, in different parts of which, as well as in Egypt, it is abundantly culti- vated for the sake of the opium which it yields. There are two varie- ties of the plant, the white and black, both of which afford opium ; but it is said Jo be chiefly procured from the former. (See Poppy Cap- sules.) The juice, when collected, is put into convenient receptacles, and, after concreting into a proper consistence, is made up, either with or without addition, into masses of different shape, usually surrounded with leaves to prevent their adhering together, and then sent into market. Commerce is supplied with opium chiefly from Hindostan, Anatolia or Asia Minor, and Egypt. It is produced also in Persia; but little or none is exported. The opium of Hindostan is either consumed in India, or sent to China, and reaches Europe and this country only as an object of curiosity. It is the product of the Asiatic dominions of Turkey, and that of Egypt, with which the western world is supplied. The opium consumed in the United States is chiefly the variety produced in Anato- lia, and introduced into commerce through the ports of Smyrna and Constantinople. It is called Turkey opium, and is usually distinguished into two varieties, the Smyrna and Constantinople opium, so named from the ports from which they are respectively distributed. Of these, the Smyrna opium is the one most largely consumed in this country. Some Egyptian opium is occasionally imported ; but is seldom kept in the shops. CHAP. I.] CEREBRAL STIMULANTS. OPIUM. 709 1. Varieties of Opium. The only varieties which it is necessary to notice are, first, the Tur- key opium, including the Smyrna and Constantinople, and, secondly, the Egyptian. 1. TURKEY OPIUM. This comes in masses of irregular size and shape, from half a pound to two and a half pounds in weight, originally prob- ably spherical, but usually flattened, or irregularly angular, in conse- quence of the pressure to which they are subjected, while yet soft, in the cases containing them. On their outer surface are the remains of the leaves in which they were originally enveloped ; and adhering to it, in greater or less number, the light reddish-brown capsules of a species of Rumex, added, no doubt, with the object of absorbing moisture, and preventing the adhesion of the lumps. These are usually, as first im- ported, soft and tenacious in the interior, but hard upon the surface. When completely dried by time and exposure, they are brittle, and have a somewhat shining though uneven fracture. a. Smyrna Opium. Of the two varieties of Turkey opium, the Smyrna is most largely imported. It is, indeed, almost the only variety kept in our retail shops. Besides the characters above mentioned, it has the peculiarity, when cut into, and then torn, of exhibiting numerous minute shining tears, very obvious under the microscope, which some- what resemble small seeds, and are no doubt the concrete drops of juice formed on the capsules, upon exudation, after these have been incised. Along with the tears are numerous minute pieces of the outer covering of the capsule itself, scraped off with the juice. The best Smyrna opium consists of these ingredients exclusively ; but inferior specimens are often sent into market, variously and in different degrees adulterated, and frequently so much so as to unfit them for use in the shops. The adulterating matt-rials are an extract made from the leaves, grapes freed from their seeds and crushed, different gummy matters, liquorice, minute stones or pieces of metal, etc. Different samples of Smyrna opium vary in the quantity of morphia they contain from 3 to 13 per cent. The better kinds ought t yield at least 8 per cent, to a careful analysis. Good Smyrna opium is of a light reddish-brown colour in the interior. "When blackish, of a weak empyreumatic odour, a sweetish taste, a viscid or greasy consistence, an entirely dull fracture when dry, or containing obvious impurities, it should be regarded as inferior. If wholly without the Rumex capsules, or very scantily supplied with them, it may be looked on suspiciously, as probably of the kind which is said to be "made over again " in some of the Mediterranean ports. b. Constantinople Opium. This, so far as it is a distinct variety, is characterized by the entire want of the tears which distinguish the gen- 710 GENERAL STIMULANTS. [PART II. nine Smyrna opium. But the drug brought from Constantinople has probably been taken thither from all the different parts of the Turkish dominions where it is produced : and it is not, therefore, a matter of surprise that, under this name, Smyrna and Egyptian opium should have found their way into commerce. 2. EGYPTIAN OPIUM. This is in flat, roundish cakes, of different sizes, from half an ounce to a pound in weight, and often either wrapped in a poppy leaf, or presenting vestiges of the leaf, so applied that the midrib divides the cake into two equal parts. It has none of the Kumex capsules, and is always hard and brittle, breaking with a smooth frac- ture of a waxy lustre. It has usually much less morphia than good Smyrna opium, and should not be kept for use in the shops. It is important that only good opium, of a strength at least approach- ing to uniformity, should be kept for internal use, or for making those preparations, the strength of which depends on that of the opium u.-e keen enjoyments. After a length of time varying, according to the dose of the drug and CHAP. I.] CEKEB11AL STIMULANTS.^ OPIUM. 713 the susceptibility of the individual, from half an hour, to two, three, or four hours, or even longer, this exaltation sinks into a corporeal and mental calmness, which is scarcely less delicious than the previous excitement, and in a short time ends in sleep. Perhaps, in most instances, where a full dose has been taken, this result occurs within an hour. But, when the quantity of opium is insufficient for this effect, the individual will remain awake for hours, sometimes for many hours, even for the whole flight, supposing the drug to have been given at bedtime, lying calmly and placidly, without mental effort or uneasiness, and submitting himself to a current of vague, but generally pleasing fancies. Should the dose be sufficient only to induce a light sleep, there will be a constant succession of dreams, having the vividness almost of reality, usually pleasant in their character, but sometimes very much the reverse. I have repeatedly known patients to complain of excessively disagree- able effects from opium, and chiefly of horrible dreams with which they have been tormented during the night, and to declare that nothing would ever induce them to take the medicine again ; but I have almost inva- riably found, under such circumstances, that by increasing the dose on a subsequent occasion, or by giving an additional quantity when such symptoms may have presented themselves, that sound sleep is induced, and all discomfort vanishes. So real do these dreams appear, and so much like waking thoughts, that patients will often assert that they have not closed their e} 7 es all night, when the fact is that they have scarcely been awake during that time. The illusions of opium are so strong that one who uses the drug ha- bitually can sometimes scarcely distinguish them from realities; arid I have known intelligent, well educated men, having the ordinary regard for opinion, and perfectly free from any suspicion of insanity, to make statements, in the presence of numbers, as to occurrences which were known to every one present to be impossible, but were as fully believed by themselves as any other event of ordinary life ; and I have been able to explain such aberrations, only upon the supposition that the dreams produced by opium had been mistaken for realities. I have no doubt that perfectly truthful persons have thus got the credit of habitual men- dacity, when in fact their only immorality was the habitual use of opium, perhaps to relieve sufferings otherwise intolerable. When opium exercises its full soporific influence, the sleep is usually profound and dreamless, and continues for about eight or ten hours. Should the patient be awakened before the direct effect of the medicine has been exhausted, the feelings of comfort or bienaise before expe- rienced will often continue for hours in the following day ; and I have known the same thing to happen repeatedly even after a good night's rest. But generally, upon awaking from the full uninterrupted effects of opium, the patient experiences a state of greater or less depression, indi- 714 GENERAL STIMULANTS. [PART II. cated by languor and listlessness, a relaxed .surface, a rather feeble pulse, and not unfrequently loss of appetite, nausea, and even vomiting. This, however, gradually passes away, and the system returns to its ordinary condition, without having experienced any appreciable disadvantage. A remarkable diminution of sensibility attends the narcotic operation of opium, beginning even before the soporific effect, and continuing in a greater or less degree throughout the direct action of the medicine, and even into the secondary stage of depression. It is the general sensibility, or that to painful impressions, which is first and most prominently af- fected ; but the special senses are in some degree involved, especially under the influence of very large doses ; though I have met with no instance, even of opium poisoning, in which, until the advanced stage when profound coma had set in, the patient cquld not hear and see when roused. In this respect opium differs strikingly from some other narcotic medicines, and especially belladonna. 2. Action upon the Circulation. It was long an undecided point, whether opium was to be regarded as stimulant or sedative. The ex- periments of Dr. Crumpe, published in 1793, decided, what any one might have determined for himself by counting his own pulse under a dose of opium, that, in its first operation, it is stimulant at least to the circulation. Within ten or fifteen minutes after its administration, the pulse is, in general, moderately increased in frequency, fulness, and force, and at the same time the surface of the body becomes warmer, and the face somewhat flushed. When the period of general excitement is past, and that of calmness or drowsiness supervenes, the pulse either resumes its original condition as to frequency, or, under a large dose of the opium, becomes somewhat slower, retaining, however, its fulness and for a time its force. In this condition it continues for some time during the period of sleep ; but then gradually relaxes, and becomes soft with the relaxing surface, and in the end, participates in the general depression which attends the cessation of the direct influence of the medicine. With the increased frequency of the pulse, the respiration is also some- what quickened ; and, as the former becomes slower, the latter undergoes a similar change, and generally even in a greater degree. Under the full influence of opium, one of the most striking phenomena is the relative slowness of the breathing, which, is sometimes even stertorous, when the sleep is profound. Corresponding with the condition of the circulatory and respiratory movements is that of the blood itself. Retaining its florid colour for a time, it may give a bright tint to the complexion during the stage of ex- citement ; but, with the diminished influence from the respiratory cen- tres, the change from venous to arterial is less thoroughly effected, and the blood becomes darker-lined. This is not vn-y obvious from ordinary e,lo.<, etc.; and, in a less degree, in febrile diseases not malisrnant. In the chill of common intermittent feoer, the depression is often so great and so lasting as to call for the same treatment. In all these cases, the original depression is in the nervous centres. It i> through them that the cause of the fever first acts, and, prostrating them by its shock, produces the general prostration as a secondary result. Opium is obviously indicated by its highly stimulant action upon these centres ; and is preferable to alcohol, because the excitement of the cir- culation which it produces is sooner over, and does not, therefore, con- tinue forward into the stage of reaction, as the alcoholic stimulation does. Ardent spirits might equally excite the nervous centres, though even in this respect their operation is less favourable than that of opium : but they also endanger an increase of the fever to follo\v. which opium, properly used, does not. The latter medicine is. indeed, of the utmost importance in the condition now under consideration, and perhaps, on the whole, superior to all other remedies. It should always be given in full doses, being quite inadequate to the desired effect in small quantities. The only contraindication is an active congestion or inflammation of the brain ; but, happily, this is comparatively rare under the circumstances referred to. In doubtful cases, great contraction of the pupil might add some weight to that of other symptoms marking the contraindicating condition of the brain ; but alone it is of little value. Still another condition common in fevers, and indicating the use of opium, is sickness at the stomach. When this does not depend on acute gastric inflammation, it will often yield promptly to opium or its prepa- rations, administered by the mouth, the rectum, or endermically at the epigastrium. The special fevers occasionally offer special indications for opium be- sides those mentioned. Thus, it is often useful in the enteric or typhoid fever, by putting a check to exhausting diarrhu-a. and aiding in the sup- pression of hemorrhage from the bowels in the advanced stage. In smallpox it is very serviceable in the stage of maturation, and sub- sequently by modeling the irritative reaction of the disease .if the surface upon the system generally. This it does by diminishing the susceptibility of the nervous centres, ami consequently their power of receiving impressions from the surface, and transmitting them, in the form of irritation, to the heart, lungs, etc. The same remark is applica- ble to er>/x//>c!ax ; hut caution is more necessary in this affection, not to aggravate any existing disposition to cerebral congestion. in intermittent fevt99, opium will often effect cures, and may lie very beneficially resorted to in the absence of quinia. or as an adjuvant to that medicine. To he most efficient, it must be given in the intermission. and so that it shall be in full action at the time of the expected return of the paroxysm, its operation is strictly antiperiodic, ami has already been CHAP. I.] CEREBRAL STIMULANTS. OPIUM. 739 explained under the indications for the use of opium. (See page 732.) Somewhat more than the medium full dose may be given in this case. 2. Inflammations, Much apprehension has 'been entertained of the effects of opium in acute inflammations. The medicine is a stimulant : inflammation is essentially a state of over-excitement; and the two have consequently been by some considered as almost incompatible. But the fact is otherwise. Experience has shown that opium is a highly useful remedy, when properly administered, in acute inflammations. In cer- tain cases, given in full dose, at the very first approach of the dis- ease, it will often set it aside entirely, especially if taken with ipecac- uanha at bedtime, and aided in its operation by draughts of some warm tea, as the infusion of balm. It seems to preoccupy the nervous centres so as to arrest the irritant influence of the cause, while it carries off the morbid tendencies through the skin, by its diaphoretic action. The special inflammations in which opium is most efficient in this way are those of the respiratory passages, as coryza, angina, and bronchitis, and different forms of rheumatism, particularly the subacute. There is sometimes, however, danger, if it should fail of its effects, that it may somewhat aggravate the affection; and the method is not generally advisable. After the inflammation has become established, especially if it is severe, opium is at first, in general, contraindicated. Its stimulating properties are as yet in too strong contrast with the wants of the disease. Before commencing with it, the activity, both of the inflam- matory action and of the attendant fever, should, in general, be reduced by depletory methods, as by purgatives, the lancet, the antinionials, et<- ; but. at the end of two or three days, a sufficient reduction may ordina- rily be accomplished, sometimes even sooner, and the opiate be safely administered. It operates very usefully in various ways. In the first place, it alle- viates pain, thereby preventing the injurious reaction of that morbid condition on the system, as well as diminishing the sufferings of the patient. But the practitioner must take care not to mistake the relief thus obtained for a positive amendment, or he may be led into serious practical error. , He must learn to estimate the real state of the inflam- mation by other symptoms than the pain. In the second place, opium enables the patient to sleep, and obviates the exhausting effects of long wakefulness upon the resources of the system, and its direct injury to the brain. But, thirdly, it is still more influential for good, by reducing at once the inflammation and the febrile excitement, through its indirect sedative action. In the inflamed part, the nervous constituent suffer.- irritation as well as the vascular; and the former, reacting on the latter, aids in sustaining the excitement in the vessels, and the consequent in- flammatory phenomena. This property of the nerves, when irritated, to. 740 GENERAL STIMULANTS. [PART II. propagate irritation to the blood-vessels, is obvious even in pure neural- gia. In this affection, though the seat of pain may be at first colour- less, it soon evinces signs of vascular congestion, by redness, heat, etc. I fence, in cases of inflammation, if we can diminish the nervous irrita- tion in the part, we diminish also the inflammatory action. Opium pro- duces, this effect under the same circumstances as those in which it relieves pain, and through the same influence. Again, the local disease produces fever, partly at least, if not exclusively, by operating on the system at large through the nervous centres. If these are rendered ob- tuse or insensible, so as not to be susceptible to impression from the in- flamed part, the reaction on the system must be diminished, and more or less in the same proportion. In this way opium has a tendency to lessen the fever in inflammation, and, as the fever reacts again on the local dis- ease, to diminish that also. Bat, to do good in inflammation, the medicine must be given in full doses, so as to act energetically as an indirect sedative. The plan which I generally pursue in acute inflammation is, after sufficient deple- tion, which may usually be effected in two or three days, to give opium at bedtime, combined with ipecacuanha and calomel, in a dose large enough to put the patient to sleep. Two grains of opium, two of ipe- cacuanha, and from two to four of calomel may be made into four pills, two to be given at once, a third at the end of an hour, if sleep is not produced, and the fourth at the end of another hour, in a similar contin- gency. This plan may be continued regularly till no longer required; the bowels being opened daily. The basis of a mercurial treatment is thus laid, which, if deemed advisable from the threatening character of the inflammation, maybe carried into effect about the fifth or seventh day, by giving two of the pills every six or eight hours, or one at half the interval, till the gums are touched. The opiate should be gradually withdrawn when no longer needed; so that, when the patient has quite recovered, the want of it may not be felt. Inflammation occurring in different organs requires some modification of this treatment. In acute altogether unsuitable to the treatment of acute inflammation of the brain, and of very doubtful advantage even in the chronic; though cases some- times occur, in which, from the particular seat of the affection, as, for example, when confined exclusively to the meninges, the indications for its use more than balance the contraindications. To procure rest is sometimes, under these circumstances, all-important; and opium may be 742 GENERAL STIMULANTS. [PART II. cautiously used, when no symptoms of acuteness in the inflammation are present. In erysipelatous inflammation of the skin, opium may be given when not forbidden by stupor or coma. But of all the inflammatory affections there is no one to which it is better adapted than acute rheumatism. After two or three days given to depletory measures, opium and ipecacuanha, or the Dover's powder, may be used very freely : and, if associated with calomel, so as to affect the system in the course of the second week, will in general be found adequate to the cure. In subacute rheumatism, the remedy is indicated from the commencement ; and, in the chronic form, a Dover's powder at bedtime may enter into almost every plan of treatment adopted in that complaint. In acute gout, too, it is highly useful at bedtime, in relieving pain and enabling the patient to sleep, and, so far as I have seen, does no harm. It is, however, in this complaint better associated with colchicum ; mid the mercurial addition is not advisable unless merely to stimulate the liver when torpid. In the suppurative stage of inflammation, opium, in moderate stimu- lant doses, is of great use in supporting the system, and comforting the patient; and should generally be given with the tonics and stimulants employed. Ulceration, when painful, and indisposed to the healing process in con- sequence of an irritated condition, connected, it maybe, with an irrita- ble state of the system at large, may be advantageously treated with opium, both given internally, and applied topically. M. Ilodet has de- rived great advantage from it in the phagedenic serpiginous ulcerationx of syphilis, in which mercury is altogether contraindicated. (Med. Times andGaz., Aug. 1856, p. 170.) Mr. Skey, of St. Bartholomew's Hos- pital, London, considers no treatment equal to the opiate, in very old and obstinate ulcers of the limbs or other parts, in which it seems to act with a restorative power, wholly independent of its mere sedative influ- ence. (Banking's Abstract, No. xxiii. p. 120.) When inflammation is attended with gangrene, opium is an invaluable remedy, relieving the pain often attendant on that affection, and sup- porting the nervous centres under its prostrating influence. Indeed, opium is indicated in mortification under almost any circumstances; and, in the last stage of acute inflammation of the- alimentary canal, iriven in combination A\ ith oil of turpentine, it affords, in some instances, almost the only remaining chance lor the patient. After all that has been stated above, I wish not to be understood as recommending opium in all cases of Inflammation, when no positive con- traindication may exist. In slight or even moderate cases, and in the chronic (onus generally, it ,-hould lie employed with irreat caution, from the fear of leading the patient into its habitual and excessive use. CHAP. I.] CEREBRAL STIMULANTS. OPIUM. 743 3. Vascular Irritation. In this condition, opium is often of great ad- vantage, by diminishing the susceptibility of the nervous tissue of the part, and of the nervous centres, and thus obviating their injurious reac- tion upon the vascular tissue and the heart. In nausea and vomiting from this cause, it is an admirable remedy, applied either by the stomach, the rectum, or endermically to the epi- gastrium; the t\vo latter methods being resorted to, severally or con- jointly, upon failure with the first. The subcutaneous exhibition also of the medicine is strongly indicated under these circumstances. When any medicine has a tendency to irritate the stomach, this may generally be corrected by conjoining the medicine with a little opium, which is very much used for the purpose, and may always be employed unless when specially contraindicated. Thus, it may be given with nitrate of silver in chronic gastritis, and sulphate of copper in chronic enteritis; but should not generally be exhibited with cathartics, which it tends to counteract, nor with tonics in dyspepsia, because it rather weakens than invigorates the digestive function. In slight diarrhoeas, resulting from vascular irritation, opium is often the only remedy required, when there is no indication for evacuating the bowels; and, when such an indication is offered by the presence of irri- tating matters, no remedy is so promptly effectual as fifteen or twenty drops of laudanum with a full dose of castor oil. In acrid poisoning, after the evacuation of the irritating agent both from the stomach and bowels, opium is the chief remedy required; and it may often be used advantageously in connection with the special antidote of the poison. Emetics and acrid cathartics frequently leave an irritation behind them, which is promptly relieved by opiates either by the stomach or the rec- tum. In irritations of the urinary and genital organs they are no less promptly useful, and often afford almost instant relief to great distress, as, for example, in the strangury from blisters. In these affections, the opium is most effectual when given by injection, or used as a suppository. 4. Nervous irritation. This exhibits itself in a great diversity of forms, which require a separate consideration. Neuralgic pain is among the most frequent. Wherever this occurs, and under whatever name, opium is at least a most efficient palliative, sometimes absolutely indispensable from the suffering of the patient, Not unfrequently it will set the disease aside entirely for the time, espe- cially when occurring periodically. Given so as fully to affect the sys- tem, it will often wholly supersede the paroxysm, and by thus breaking the chain of morbid association, effect at least a temporary cure. The quantity necessary to produce relief varies greatly with the violence of the pain, and the constitutional susceptibility of the patient. Sometimes an ordinary full dose w* answer ; but it will often be found necessary to double, triple, or quadruple it, before relief can be procured. AY hen 744 GENERAL STIMULANTS. [PART II. local application will answer the purpose, it should be preferred, as inter- fering less with the functions of the stomach and bowels. With the skin unbroken, little effect can generally be obtained; but, by means of the eudermic method, or by injection into the subcutaneous areolar tissue, the medicine may generally be used with prompt and powerful effect, in the form of one of the salts of morphia. Not unfrequently a specially tender spot may be discovered in the track of the nervous trunk, sup- plying the painful part. In this case, the remedy should be applied to the point of tenderness ; the cuticle having been first removed by a blister. But a great objection to the use of opium in neuralgia is the increasing- dose in which it must be successively employed in order to procure relief, and the consequent danger of augmenting the quantity indefinitely, until the effects of the remedy become almost as pernicious as the disease it- self. This objection applies especially to oases in which the affection is incessant in its attacks, and probably incurable. Yet the patient will seldom submit to severe suffering, when an agent of present relief is at hand ; and the duty of the physician is so to regulate the remedy as to obviate its ill, and protract its beneficial effects as far as possible. This is to be done by allowing the dose to be increased only when absolutely necessary ; by varying the surface of application between the stomach, the rectum, the skin, and the areolar tissue; by occasionally intermitting the use of the medicine, and endeavouring to obtain a similar effect by anodynes acting on different principles, as by chloroform or conium ; and by correcting any resulting disorder of the functions by proper means, as constipation by laxatives, deficient action of the liver by mild mercurials or nitromuriatic acid, and enfeebled digestion by tonics, taking care not to do injury' by the excessive use of the counteracting measures. By this plan, in incurable cases, the patient may be rendered more comfortable, and his life prolonged ; whereas, if left to his own unrestrained propen- sities, he might soon exhaust the susceptibility of his system, and thus render the remedy almost useless. Even in occasional sit tacks of neuralgia, occurring at considerable in- tervals, the physician should always bear in mind the danger of laying the foundation of an evil habit, and should guard the use of opiates with such precautions as may tend to obviate this result. Sometimes, in per- sons of feeble intelligence, or deficient power of self-control, it may be proper to disguise the medicine, so that the patient may not know what lie is taking; and generally it is best to confine the use of opium, when the recurrence of the pain is frequent, to the severest attacks. Besides the external attacks of neuralgia, which may occur in any sensitive part of the body, from the crown of the head to the joints of the great toe, there are various internal Conns of it, which are sometimes even more imperious in their demands for reliefs angina pectoris, gas- tralgia, enleralgia, nephralgia, and dysmenorrhcea, the last of which CHAP. I.] CEREBRAL STIMULANTS. OPIUM. 745 is, I believe, often nothing but a neuralgic form of rheumatism, and may be most effectually relieved by this anodyne given by the rectum. In nervous toothache, and earache, opium may often be applied locally with effect; being introduced into a carious cavity, should a cavity exist. in the former case, and in a liquid form into the rneatus externus, in the latter. Neuralgia is often nothing more than a form of nervous gout or rheumatism, in which cases the opiate may be associated with the wine or extract of colchicura, and frequently also advantageously with a saline cathartic. Nervous headache, or sick-headache, will often yield happily to a full dose of opium or morphia, which is most effectual, however, in the latter affection, when it perseveres, after evacuation of the stomach. But care must be taken not to confound this complaint with headache from vas- cular irritation, or active congestion of the brain. In cancerous affections it is often necessary to have recourse to ano- dynes; and the observations above made, in relation to the precautions necessary to guard against the abuse of the medicine in incurable neu- ralgia, and to obtain the greatest amount of good from it, are equally applicable to this ca.-e. The same remark may be made of aneurisms and all other tumours. which, though not painful in themselves, often become extremely so by pressure on the trunks of neighbouring nerves, or in other modes inter- fering with the healthy structure near them. Painful spasms afford still stronger indications for the use of opium than simple neuralgia, because often more dangerous in their conse- quences, and because, also, being only occasional, and generally occurring at distant intervals, there is less danger of an abuse of the remedy. These spasms may be either external, affecting the voluntary muscles, or internal, affecting the muscles of organic life. Of the former we have examples in ordinary cramps of the limbs, in the intensely painful cramps of cholera, and in tetanus. It is in the two latter affections chiefly that opium is used; and in both it is certainly among the most efficient remedies. In tetanus, the insusceptibility of the cerebral centres U such, that much larger doses are required than under ordinary circum- stances. Two grains may be given at first every two hours, and, if neces- sary to bring about relief, the close may be increased to four, five, or six grains, or an equivalent proportion of morphia or one of the liquid pre- parations, repeated as often, until some degree of narcotic effect is expe- rienced; but the quantity of half a drachm of opium in twelve hours should in no case, I think, be exeeeded ; as, if the disease should sud- denly give way, poisonous effects might ensue from the portion remaining un absorbed in the stoi^)feh. The internal painful spasms are those of the stomach, of the bowels in the different forms of colic, of the ureters 7-46 GENERAL STIMULANTS. [PART II. and ducts of the liver from the passage of calculi, of the bladder, of the uterus, and finally of the diaphragm and the heart. In all these affec- tions the pain is often exquisitely severe, and in some of them life is endangered by the continuance of the spasm. All of them afford the clearest indications for the use of opium, which may in general be given unhesitatingly, and in quantities requisite to obtain relief, beginning with a full dose, and increasing until the pain is alleviated, or narcotic effects induced. The same insusceptibility to the influence of the anodyne ex- ists as in tetanus, though usually in a much less degree ; and it is seldom necessary to exceed two grains of opium, or an equivalent quantity of its preparations, at one dose. The liquid preparations are preferable to solid opium, as they operate more speedily. In these several affections, it is necessary to combine special modes of treatment with the anodyne, which, however, this is not the proper place to detail. As examples, it may be mentioned that, in gouty spasm of the stomach, colchicuin may be combined with the opiate ; in ordinary colic, castor oil ; in bilious colic, calomel ; in spasm of the heart or diaphragm, ether or chloroform ; in spasm of the hepatic ducts, ether and oil of turpentine ; in that of the ureters, the alkaline bicarbonates ; that in all of them sinapisms and the warm bath are efficient adjuvants ; and that, when not contraindicated by debility, the lancet may often be used with powerful effect in pro- ducing relaxation. The spasmodic pain attending enteritis, cholera, dys- entery, and peritonitis, affords an indication for the use of opium ; but those founded on other effects than the merely anodyne are much more important. Various spasmodic and convulsive affections, not painful in their character, or but slightly so, belong to the category of nervous irritations, and are more or less benefited by opium. Such is the paroxysm of spasmodic asthma, in which opium will often afford relief, though it is liable to the objection of checking bronchial secretion, and is, on the whole, much less efficient than some other narcotics and nervous stimu- lants or sedatives. In epilepsy it may sometimes be used as a pallia- tive ; but, on the whole, is better avoided, both from its liability to abuse, and from its congestive influence on the brain. In hooping-cough it is liable to the same objection as in asthma, and should be used only as a palliative of the cough, in connection with expectorants. To chorea it is scarcely appropriate, unless to obviate occasional intercurrent affec- tions. In the various spasmodic all'oefions of hysteria it is for a time an almost sovereign remedy; but, on moral grounds, requires to be pre- scribed with caution. In the convulsions of infa/x, depending on in- tesiinal spasm, opium is an excellent adjuvant of other remedies. To the list of nervous irritations relieved by opium may be added ohsfinale wakefulnesa, general uneasiness, rdQlfssness, Ian ut the dose should be more frequently repeated, as often as every half hour till relief is obtained ; and, when the pains are very severe, and the discharges exhausting, the opiate should be considerably increased, and administered by enema if rejected from the stomach ; calomel being at the same time moderately exhibited as before, to guard against a total suspension of the hepatic secretion. The discharges of bile in cholera morbus are no doubt intended to relieve a congestive irri- tation of the liver and whole portal circulation, which without this outlet might end in serious inflammation or fever. The use of calomel ensures a sufficient action of the liver to prevent, ultimate evil, while the opium prevents immediate mischief by arresting the excessive discharge. Epidemic cholera I believe to be a different affection from ordinary cholera morbus. and to depend on a different cause. Nevertheless, there is the same indication for the combined use of opium and calomel. In the stage of diarrhoea, or the joint discharge from the stomach and bowels called cholerine, which generally precedes the distinctive rice-water evac- uations of the fully formed disease, opium is the remedy mainly to be relied on. With or without camphor and the aromatics, and in small doses frequently repeated, it almost always arrests the discharges, and thus probably averts cholera itself. I have usually preferred the ordinary paregoric, or camphorated tincture of opium of the Pharmacopoeias, of which a lltiidrachm may be given three or four times a day if necessary. Should the evacuations from the bowels be destitute of bile, small d< of calomel and opium should be employed as above advised. Sometimes it may be necessary to give the opiate more largely, and to combine with it an anodyne enema, and a sinapism over the abdomen. When the 750 GENERAL STIMULANTS. [PART II. cholera is fully formed, opium is still, I think, the sheet-anchor in this disease. It should now be given in the dose of a grain or two at first, and afterwards repeated at intervals of half an hour or an hour, in one- quarter, or one-half the dose, till the discharges are arrested, and the pains relieved, or till some evidence of narcotism is produced. After this, it is of no use to push its effects further. Indeed, it can do only harm, by aggravating the general prostration through its secondary sed- ative effects. The great rule is not to allow it to render the patient stupid, or comatose; but. within this point, to continue its use, at longer or shorter intervals, so long as indicated by the spasms and the evacua- tions. But it should never be relied on exclusively. With the quantity of opium above mentioned, from two to four grains of acetate of lead, and a grain or two of calomel should be given, to be repeated afterwards along with it in proportionately diminished doses. At the same time, an anodyne enema should be exhibited, and a sinapism applied over the whole abdomen ; warmth and rubefaction to the extremities being addi- tionally used, if these should be cold and bloodless. In the collapse of cholera, opium is of little or no use. In the stage of reaction, its em- ployment must be governed by the same principles as in low fevers and inflammations. Cholera infantum does not offer equally strong indications for the use of opium. The head is so apt to suffer in infants, that anything which tends to congest the cerebral centres must be used with caution. Never- theless, if the vomiting cannot be otherwise restrained, this remedy may be cautiously administered, and should be preferably used by injection; great care being taken to proportion the dose to the age. In the subse- quent stages, when the affection has assumed rather the character of diarrhrea, and the indication exists for checking the evacuations, very small doses of opium, .or one of its preparations, may be added to the cretaceous, astringent, or alterative medicines employed. In excessive secretion of urine or diuresi*. especially when connected with nervous disorder, or an irritable state of the system, opium is one of the most efficient remedies. In diabetes, strictly so called, it is an excellent palliative, diminishing frequently the amount of excretion. moderating the wear of the system, and greatly comforting the patient : but it is wholly inadequate to the cure. It should be used in this com- plaint, in full doses, and preferably at night. In small doses, frequently repeated, so as to produce its stimulant effects, I have often known it greatly to increase the secretion of urine. In i-xcessive mercurial salivation, opium is very useful, not only by checking the discharge, but by relieving pain, and diminishing nervous irritability. In the rxi-r.-ixive mucous secretion from the stomach, bladder, and bronchial tubes, called respectively gaslrorrhcea, cystirrhcea, and bron- CHAP. I.] CEREBRAL STIMULANTS. OPIUM. 751 chorrhcea. opium may be usefully employed as an adjuvant or corrective of other medicines; but cannot be relied on exclusively, or even as the chief remedy. Under this head may be mentioned the use of opium in combination with other medicines, where it may be desirable to prevent their operation upon the bowels. For this purpose, it is almost con- stantly given with calomel, and frequently with the blue mass, when the object is to obtain the peculiar effects of mercury on the system. Hemorrhages constitute the second division of morbid discharges. In most of these opium is indicated, both from its effects upon the capilla- ries, and for its influence in quieting various attendant irritations, which often serve to aggravate the main affection. Thus, in hemorrhage from the lungs, or air-passages, it proves serviceable by allaying the irritative cough, which, by agitating the parts, tends to sustain the bleeding. In hemorrhage from the stomach, after the full evacuation of its contents, an irritated condition often remains, which provokes vomiting unneces- sarily, and prevents the retention of medicines that may be indicated. Opium by the mouth or rectum, or endermically to the epigastrium, is very useful in such a condition. So also in hemorrhage from the bowels, bladder, and uleru.f, it tends to control the irritative movements, which, beyond what may be necessary for the mere evacuation of the effused blood, can act only disadvantageous!}" on the affection. For these pur- poses, it is usually sufficient to employ small doses, in conjunction with the other medicines indicated. For the direct influence of the opium on the bleeding vessels, it should be given in full doses, and combined with ipecacuanha ; the patient being confined to bed, and well though not hotly covered, so as to favour the perspiration which is apt to be induced. But for this purpose, opium is not indicated in all the hemorrhages, nor in all conditions of any one of them. It should not be used when the pulse is full and strong, with a general febrile movement, and an active congestion of the bleeding organ. This condition should be removed by depletory and refrigerant methods, before recourse is had to opium. The remedy, in full do.lalline state. Medical Properties and Uses. Morphia is undoubtedly the main active principle of opium ; but that it is not the only one is proved by the fact, that a certain quantity of opium produces a much greater e fleet than all the morphia which can be obtained from it, though it may be entirely CHAP. I.] CEREBRAL STIMULANTS. OPIUM. 761 exhausted. Thus, opium must be very good which will yield one part in ten of pure morphia. If the latter, therefore, were the only active principle of opium, one part of morphia should produce an equal effect with ten parts of opium; while, in reality, it is equivalent to no more than six parts. Which of the principles of opium it is that supplies this deficiency in the power of morphia has not been decisively ascertained. Nor are the effects of morphia precisely the same in character as those of opium. So far as I have been able to decide from observation and trial, I believe that morphia has precisely the same anodyne and sopo- rific effects as opium, and closely resembles it in its stimulant influence on the brain. Like opium, also, it is apt to produce perspiration, though perhaps in a less degree ; and is quite as much disposed to cause itching of the surface. But it is less stimulant to the circulation, less disposed to constipate, has less restraining effect on the secretions, and cannot be so well relied on for the suppression of morbid discharges. I am confi- dent that it in general agrees better with the stomach, and is less apt to be followed by nausea, vomiting, and headache. It has appeared to me also to be less liable to provoke irregularities of mental action, and, with an equal excitant influence on the faculties and feelings, to derange them less frequently, and in a less degree. Morphia itself is perhaps less certain in its effects than its salts ; as, being insoluble or nearly so in water, it probably depends for its absorp- tion, and consequent effects on the system, in some degree at least, upon the presence of acid in the stomach, and might operate more slowly, and feebly in the absence of acids. Hence it is that the salts are alway% employed, and morphia itself never. The salts most used are the sulphate, acetate, and muriate. So far as can be inferred from observation, there is positively no difference in the remedial effects of these salts upon the system ; and one may be substituted for the other without disadvantage. All of them have one great advantage over opium, and those of its pre- parations the strength of which is determined by that of the opium, in their uniformity of dose. We know exactly how much of the narcotic principle we are giving when we prescribe a salt of morphia, while, in relation to opium, laudanum, etc., we are very far from this certainty, and may at one time give the medicine perhaps twice as strong as at another; for different parcels of opium, even bearing the same commer- cial name, not unfrequently have this diversity of strength. The salts of morphia may be given in all cases in which the indication i* to relieve pain, to procure sleep, or to quiet nervous irritation in any of its forms But they are less efficient as stimulants to the circulation in low forms of fever, and cannot be equally relied on for producing dia- phoresis, for checking diarrhoea, or arresting profuse secretion or hemor- rhage. They are preferable to opium in irritated states of the stomach, and in catarrhal affections, as they probably have less effect in producing 762 GENERAL STIMULANTS. [PART II. dryness of the mouth and air-passages, and consequently in impeding expectoration. They often agree well with individuals on whom opium produces disagreeable effects. Thus, I have had under my care a female patient, whom a full dose of opium always kept awake during the whole night, but with whom the salts of morphia, in equivalent quantities, had their usual soporific effect. I believe, moreover, that there is less danger of giving them in over-doses. Though undoubtedly capable of fatal poisoning, they appear to be less so relatively than opium. A case was related to me by Dr. Charles Foulke, of New Hope, Pennsylvania, in which a woman took by mistake eleven grains of morphia, equivalent to about sixty-six grains of opium in anodyne effect, and yet recovered without having discharged any of the poison from her stomach. She be- came profoundly insensible, and during this state was delivered of a child, of the birth of which she was quite unconscious, and which survived. A case was recorded, some years ago, in one of the London journals, of which I made a note at the time, though I neglected to make the precise reference, in which a young man was believed to have taken somewhere between twenty and thirty grains of one of the salts of morphia, and yet escaped with life without evacuating measures, though the symptoms were very alarming. Another advantage of the salts of morphia is the facility with which they can be applied endermically, and their great efficiency in this mode of application. They may be used in this way either for obtaining the general effects of opium, or to relieve some local affection, as neuralgic pain, and obstinate vomiting. Perhaps no remedy is more effectual, for the latter purpose, than one of the salts of morphia sprinkled upon a blistered surface in the epigastrium, denuded of the epidermis. The salts of morphia are also specially fitted for the hypodermic method of administration ; in other words, for injection into the subcu- taneous areolar tissue, as recommended by Dr. Alexander Wood. In this method, they not only more rapidly and effectually relieve neuralgic pains in the neighbourhood of their application than by any other mode of using them, but also, according to Mr. Charles Hunter, of London, more quickly affect the system, and through this, even though applied at a distance from the seat of disease, remove the pain quite as effect- ually as if injected in its immediate vicinity. Sleep is induced by morphia thus used in a very short time, sometimes so soon as five minutes. In this mode of exhibition it is said to constipate less than when given by the mouth. Another advantage is that it can be admin- istered, in some instances, where any other mode of exhibition is difficult or impossible. There are few affections in which opium is indicated, in which the salts of morphia have not been advantageously given in this way. Delirium tremens, violent adynamic delirium from whatever source, severe spasm of the diaphragm, stomach, and bowels, commencing te- CHAP. I.] CEREBRAL STIMULANTS. OPIUM. 763 tanus, violent hysterical convulsions, and the eclampsia of puerperal women, are among the severer forms of disease in which it is said to have proved effectual. For the mode of using this and other medicines by hypodermic injection, the reader is referred to the general remarks on the subject, at page 78 of this volume. Unless under urgent circum- stances, not more than about one-half of the dose should be given at first, which, under similar circumstances, would be required by the mouth for full effect ; and it may afterwards be increased if found necessary. This caution has been rendered advisable by unexpectedly violent effects, which have sometimes originated from narcotic medicines administered hypodermically in ordinary doses. Any of the salts of morphia maybe employed, and they should be given in solution ; each dose being dis- solved in from twenty minims to half a fluidrachm of water. Perhaps, on the whole, the acetate may be preferable, as least liable, when perfectly dissolved, to cause irritation. The dose of either of the salts of morphia, equivalent in anodyne effect to a grain of opium, is, as near as I have been able to determine, one-sixth of a grain. One-eighth of a grain, I am quite sure, is less powerful than a grain of good opium ; and one-fourth of a grain, I think, somewhat more so. Endermically, one-half of a grain may be used at first, and afterwards increased, if found necessary, to a grain or more. About one- third of a grain may be given, for a commencing dose, by enema, or as a suppository. Hypodermically, not more than a twelfth, or, at the out- side, an eighth of a grain, should be administered as a beginning dose, under ordinary circumstances. As a liniment, morphia may be em- ployed, dissolved in one of the fixed oils. The solution is most readily effected by first dissolving it in a little chloroform, and adding the solu- tion to olive or almond oil. SULPHATE OF MORPHIA. Morphias Sulphas. U. S. This salt is most used in the United States. It is prepare*! by mixing morphia with water, gradually dropping in diluted sulphuric acid till the powder is dissolved, and then evaporating and crystallizing. It is in beautifully white, minute, soft, feathery cr} r stals, very bitter, readily soluble in water, and slightly so in alcohol. It is known to be a sulphate by yielding with chloride of barium a white precipitate insoluble in nitric acid. It may be given in pill or solution, in the dose of from one-eighth to one-quarter of a grain. Solution of Sulphate of Morphia (LIQUOR MORPHINE SULPHATIS, U. S.) is directed by our officinal code to be prepared by dissolving eight grains of the sulphate in half a pint of distilled water. It of course contains one grain of the salt in each fluidounce. Though the solution becomes gradually coloured by time, I have found it perfectly efficient, upon trial, after having been kept a year or longer. It has the great advantage of easy divisibility, as regards the dose, to any desirable minuteness. For full anodyne and soporific effect, the dose is from one 764 GENERAL STIMULANTS. [PART II. to two fluidrachms. From one-quarter to one-half the quantity maybe inhaled in the form of spray, to relieve irritation of the air-passages. The solution is too feeble for subcutaneous exhibition; as from ten to twenty or at most thirty minims of the menstruum should contain the quantity of the salt to be injected. It is to be regretted that this solution, as kept in the shops, is not always of the officinal strength. In some parts of the country, a solu- tion containing 16 grains to the fluidounce has been habitually employed. This may readily lead to serious mistakes. The physician should always specially designate the stronger solution when he intends it; and the officinal solution should always be put up by the apothecary, when the simple officinal name is used. ACETATE OF MORPHIA. Morphias Acetas. TJ. S. To prepare this salt, the U S. Pharmacopoeia directs morphia, deprived of narcotina by mean> of ether, to be mixed with water, and acetic acid to be gradually dropped in till the morphia is dissolved. The solution is then evaporated, by means of a water-bath, to the consistence of syrup, dried by a gentle heat, and rubbed into powder. As thus obtained, it is amorphous, slightly coloured, and in general not wholly soluble in water. This is owing to the escape, during the drying, of a small portion of acetic acid, which leaves a corresponding portion of the morphia unsaturated, and of course, insoluble. All that is necessary to effect a perfect solution is to add a little distilled vinegar or diluted acetic acid. This salt is soluble in alcohol. It is known to be an acetate by giving forth an acetous odour on the addition of sulphuric acid. It may be given in pill or solu- tion, and in the same dose as the sulphate. It is sometimes preferred for endermic and hypodermic application, under the impression that it is less irritant, and more readily absorbed. MURIATE OF MORPHIA. Morphise Murias. U. S. Morphise Hydro- chlora*. Br. Hydrochlorate of ^Morphia. This is prepared, according to the U. S. Pharmacopoeia, in the same manner as the sulphate. In Great Britain it is usually prepared directly from opium, and is probably more used than any other of the salts of morphia. It is in fine, white- feathery, acicular crystals, inodorous, bitter, and soluble in water and alcohol. It may be distinguished from the sulphate by affording, with nitrate of silver, a precipitate insoluble in nitric or muriatic acid, but soluble in an excess of ammonia. The dose and mode of administration are the same as those of the sulphate. A Solution of Hydrochlorate of Morphia (Liquor Morphias Hijdro- chlora.ii!*, Br.) is directed in the British Pharmacopoeia to be prepared by dissolving four grains of the salt in six fluidrachms of distilled water, to which eight minims of diluted muriatic acid and two lluidrachms of rec- tified spirit have been added. The use of the acid is to ensure the complete solution of the salt ; that of the alcohol, to prevent spontaneous CHAP. I.] CEREBRAL STIMULANTS. OPIUM. 765 decomposition. It will be noticed that this solution is four times as strong as our officinal solution of the sulphate. Great care will be neces- sary to guard against the mistake of considering these two preparations, which have the same therapeutic properties and uses, as of the same strength. The full dose. of the British solution is from thirty minims to a fluidraehm. CODEIA. This is the only other opiate alkaloid, the effects of which, until very recently, have been investigated. For the method of procuring it, 'the reader is referred to the Dispensatories. It is white, crystal lizable in octohedra, much more soluble in water than the other alkaloids men- tioned, soluble also in alcohol and ether, but insoluble in alkaline so- lutions. It is distinguished from morphia by the difference of its solubilities, and by not becoming blood-red with nitric acid, or blue with sesquichloride of iron. It is contained in small proportion in opium, constituting almost always less than 1 per cent. Various accounts of its effects on the system have been given, among the most reliable of which is that of Dr. Gregory, of Edinburgh. From three grains of it he obtained no obvious effect: but when the dose was augmented to five or six grains, he found it to increase the frequency of the pnlse, to pro- duce a feeling of warmth in the head and face, and itching in the skin, and to exhilarate the spirits. This condition, after lasting for several hours, was followed by unpleasant depression, with nausea and some- times vomiting. This is so exactly the operation of morphia, in doses insufficient to produce sleep, as to suggest the inference that the codeia employed contained a small proportion of the stronger alkaloid ; and, from the statement of Pereira, that all the specimens he had tried of codeia produced an orange-yellow colour with nitric acid ( Mat. Med., 3d ed., p. 2099), it is highly probable that this impurity is very commonly present. M. Barbier, of Amiens, found codeia, in the dose of a grain or two, to relieve painful affections of the viscera supplied with nervous in- fluence from the sympathetic, while it produced no effect in pains of the back or extremities. Hence, he conceived it to act especially on the sympathetic system of nerves. It did not disturb the circulation or digestion, or produce constipation ; and, when taken largely enough to cause sleep, occasioned no signs of cerebral congestion. Dr. Miranda, of Havana, found it decidedly beneficial in dyspepsia. It has not, how- ever, been as yet proved to possess powers which are likely to render it a valuable article of the Materia Medica. Mauthner recommends it in the non-inflammatory spasms of the orbicular muscle of the eyelids occurring in infants. He applies a solution of one part in four of almond oil, by means of a hair pencil, three times daily to the lids. More recently, Professor Aran, of Paris, has made extensive use of 766 GENERAL STIMULANTS. [PART II. codeia, and says of it that it possesses the most valuable properties of opium, is inferior to morphia in the relief of pain only because it requires to be given in larger doses, and is superior to it in these respects, that it does not cause heavy and agitated sleep, does not induce perspiration or cutaneous eruptions, nor trouble digestion, and finally, that it does not cause nausea, vomiting, or obstinate constipation. It is specially valua- ble in procuring calm, relieving obstinate cough, and suppressing the pains of rheumatism, gout, and cancerous affections. (Am. Journ. of Med. Sci., Jan. 1863, p. 184.) The French Codex prepares a syrup of codeia by dissolving twenty centigrammes of the powdered alkaloid in thirty-four grammes of distilled water, and adding sixty-six grammes of pure sugar. A tablespoonful of the syrup contains only four centigrammes, or somewhat more than half a grain of codeia. In relation to the other peculiar principles of opium, paramorpliia or thebaina was found by Magendie to produce tetanic spasms in the quan- tity of a grain, when thrown into the jugular vein of one of the lower animals, and thus to resemble strychnia and brucia in its action ; opi- ania, according to Dr. Hinterberger, exercises powerful narcotic effects on the lower animals; and narcein or narceia has been thrown into the jugular vein of a dog, in the quantity of two grains, in several instances, without any observable effect. Not much is known of the operation of meconin or meconic acid ; but they are supposed to have little effect.* * Such was the extent of our knowledge on the subject of the active principles of opium, at ihe period of publication of the second edition of this work; and I have allowed the statements in the text to remain with little alteration, because, though most important investigations have been subsequently made, throwing much new light on the subject, yet the results have not assumed so definite a form, nor been so far confirmed by trial ou the human subject, as to justify their admission among the established facts of our science. I have, therefore, deemed it best to introduce a notice of these researches in the form of a note, to await the result of future inquiry. The author of the experiments referred to was M Cl. Bernard, of Paris. They were performed on several diiferent species of the lower animals, and great care was taken to avoid sources of error; so that the conclusions may be received with great confidence ; though it must be remembered that they cannot be relied on im- plicitly in relation to man. They relate to the relative powers of the several pe- culiar principles which have been extracted from opium ; and these powers were tested by injecting solutions of the alkaloids into the subcutaneous areolar tissue: the effects upon the same animals being noted and compared, and the comparison afterwards extended to the different species, in all of which the results obtained were remarkably uniform. M. Bernard tried six of these principles; morphia, narceia (narcein), codeia, nar- colina, papaverina, and thebaina (thebain). Of these, the first three alone, namely. morphia, narceia, and codeia, were found to possess soporific properties ; and these, CHAP. I.] CEREBRAL STIMULANTS. OPIUM. 767 NARCOTINA. For the mode of obtaining this substance from opium, the reader is referred to the U. S. Dispensatory. It exists uncombined in opium, which while agreeing in this respect, were severally distinguished by peculiar properties of their own. Morphia induced profound sleep, with sensibility blunted but not quite lost; as severe pinching caused obvious uneasiness, and sudden sounds occasioned move- ments of the animal, showing that they were heard. But there was a striking pecu- liarity in the mode of awaking. The animals exhibited an aspect as if startled or alarmed, and their hinder limbs were depressed as if partially paralyzed, so as to give to a dog the carriage of the hyena. The dog, too, under these circumstances, did not recognize his master, and sought to retire into some place where he could be hidden. Twelve hours elapsed before these effects had entirely disappeared. Godeia, in whatever dose exhibits .1, produced a less profound sleep. The animal could be easily aroused, and sensibility was much less blunted. On awaking from the sleep produced by it, the animal exhibited less disorder of his faculties, and had none of the semi-paralyzed condition of the hinder limbs, mentioned as result- ing from morphia. Narceia caused a sleep differing from that of either of the other alkaloids, yet partaking of the nature of both. It was in the same dose more soporific than either: the sleep produced being more profound than that of codeia, without the leaden torpor caused by morphia; and the sensibility, though blunted, being much le.^s so than by the latter alkaloid. The action of the narceia was characterized by calmness and want of excitability. The animal was not disturbed by any sudden noise, and on awaking, quickly returned to its normal state, with much less of the posterior weakness and mental confusion that marked the action of morphia. Narceia is peculiarly suited to the experimental physiologist; as the animal is per- fectly passive under his hands, and makes no resistance even though in pain. The same effects produced by narceia on the lower animals were found by Drs. Debout and Be"hier to be caused by it in man. In reference to the poisonous action of the several principles ; morphia is one of the least poisonous, thebaina the most so. Thus, a grain and a half of the muriate of thebaina, injected into the veins of a dog, killed the animal in five minutes: while thirty grains of the muriate of morphia, similarly exhibited, did not cause death. Next in poisoning power to thebaina was codeia. Much less of this then of morphia, injected into the veins, was required to cause death. Another point of comparison between the alkaloids was in regard to their convul- sive effect. M'liile they poison, they also occasion convulsions of a tetanic character, sometimes violent. The only exception is narceia, which occasions no convulsions even in a fatal dose ; the animal dying in a complete state of relaxation. On the whole, then, the conclusions were that three of the alkaloids are soporific; namely, in the order of their power, 1. narceia, 2. morphia, and 3. codeia; the three others, not soporific, are convulsive, and all six in the order of their power in this respect are 1. thebaina, 2. papaverina, 3. narcotina, 4. codeia, 5. morphia, and 6. narceia. In their tonic powers, they have the following order; 1. thebaina, "2. codeia, 3. papaverina, 4. narceia, 5. morphia, and 6. narcotina. (Archives Gen- f rales, Oe sdr., iv. 455.) Therapeutic effects of the opiate alkaloids. This subject has been practically inves- tigated by Dr. Ozanarie, who has published the following results of his observations. I'xeudo- morphia and mec :iin are destitute of action. 768 GENERAL STIMULANTS. [PART II. still retains it in considerable quantities after maceration in water. The portion which water dissolves is probably taken up through the agency of the free acid of the opium. Xarcotina is in white, silky, flexible, acicular crystals, without, smell or taste, insoluble in cold water and alkaline solutions, very slightly soluble in boiling water, slightly so in cold and much more freely in hot alcohol, and readily soluble in ether and the diluted acids. The volatile and fixed oils also dissolve it. Though capable of uniting with the acids to form definite compounds, and with the muriatic and sulphuric acids to form cry stallizabte salts, it does not affect the colour of litmus, and must be considered as pos- sessing but feeble alkaline powers. It is distinguished from morphia by its solubility in ether, by assuming a yellowish instead of red colour Morphia acts on the whole nervous system, first on the brain, then on the spinal cord, and lastly on the ganglionic system, as evinced by the expansion of the capil- laries. Opiania is little known in regard to its effects, but is thought to be calmative and stupefactive like morphia. Codeia is excitant, calmative, or stupefactive, according to the dose. Three or four grains stupefy like morphia, or prove anaesthetic like ether or chloroform. In very small doses, it calms, without exciting or but slightly. In moderate doses, it first excites and then calms. Its special influence appears to be exerted on the cerebellum and medulla oblongata. A disposition to retrogression iu the movements has been observed during its action, and, after death from it. the parts mentioned are found engorged with blood. Hence its usefulness in coughs and gastralgic affections, acting through the pneumogaslric nerve. Narcotina is always excitant in its influence on a debilitated system, an 1. even in the dying state, it will for a time revivify the vital actions. The dose of it required for this effect is from five to ten centigrammes (about three-quarters of a grain to a grain and a half). It excites the pulse and increases the warmth of the body, without in the least stupefying. Thebaina is more violent in its action than narcotic. In moderate doses, it agi- tates and even tetanizes, and occasions sleeplessness rather than the contrary. Its influence in producing tetanic spasm is exerted especially on the upper limbs, sug- gesting that it may perhaps prove useful in palsy of the parts. The author gave from three to six centigrammes (about half a grain to a grain) to a patient with paraplegia, but found the medicine to produce so much general uneasiness, and excitation, especially of the upper extremities, together with sleeplessness, that he was compelled to suspend it. Narceia is a valuable calmative. In the dose of one or two grains, though it may not produce sleep, it gives the patient a feeling of calmness and perfect com- fort; and produces these effects sometimes when morphia will not. It appear exercise a special influence on the lumbar portion of the spinal cord. (Kil. M^L Journ., Nov. 1864, p. 459; from Revue de Thfrap. Medico-chirurg., Oct. 1 ".. Of the same alkaloid we are told that, of all the alkaloids of opium, it produces physiological sleep in the smallest dose. In a child, 10 years old, with phthisis, given in the quantiiy of about one-seventh of a grain through the day, it produced sleep and relieved the cough beyond all other means employed. (Ibid., April, 1" p. 947; from Gaz. Med. de Paru, March 11, 18*35.) Note to the third edition. CHAP. I.] CEREBRAL STIMULANTS. OPIUM. 769 with nitric acid, and by the want of the other properties before men- tioned as characteristic of that alkaloid. If it be mixed with sulphuric acid, and then a piece of nitre be added, it becomes deep-red, while mor- phia, under similar circumstances, becomes brownish or olive-green. In this case, it is a mixture of the nitric and sulphuric acids that acts. Though tasteless, when pure, the compounds which it forms with the acids are very bitter. Very different opinions have been advanced as to its effects on the system. While some have found it very powerful, and have ascribed to it noxious properties, others have taken or given it largely, without any observable effect, whether it was taken in the solid state or in solution. Twenty, thirty, and, as asserted by M. Baily, even sixty grains have been given with entire impunity. The probability, therefore, is that, when pure, it has little narcotic influence upon the system, and that the effects at first ascribed to it have resulted from the use of an impure pre- paration, containing morphia, or some other active principle of opium. Dr. Roots, of England, was induced by the bitterness of its salts to em- ploy it in intermittent fever; and Dr. O'Shaughnessy, of Calcutta, gave it with the happiest results in a great number of cases, considering it superior even to quinia in antiperiodic powers. He gave it in the dose of three grains three times a day, and never found it to produce narcotic effects, headache, nausea, or constipation, but to act powerfully as a dia- phoretic. It is contained in opium in very varying proportions, from two to nine or ten per cent., and is generally most abundant when mor- phia is least so. Denarcotized Opium. Denarcotized Extract of Opium. Denar- cotized Laudanum. Under the impression that opium owed its unpleas- ant effects to narcotina, preparations were introduced into notice and extensive use, in which the medicine was deprived of this principle, retaining its other principles unchanged. Thus, opium or its extract was deprived of narcotina by ether, and a tincture was prepared from the denarcotized extract by treating it with diluted alcohol, so as to have about the strength of the ordinary tincture, and this has been called denarcotized laudanum. But, as before mentioned, it is ex- tremely doubtful whether pure narcotina exercises any obvious influence on the system ; and, if the preparations referred to have any advantage over the ordinary extract and tincture, the fact must be ascribed to some other modification of opium than the mere absence of this principle. The officinal deodorized tincture of opium (see page 757) renders unneces- sary all other preparations in which the object is to get rid of narcotina. VOL. i. 49 770 GENERAL STIMULANTS. [PART II. POPPY-HEADS. PAPAVER. U.S., Br. These arc tlio dried ripe capsules of the poppy. They owe all their medicinal virtues to the narcotic principles of opium they" contain, among which is morphia in variable, but always small proportion. Their seeds, which are white in the white variety of Papaver somnif- erum, and dark in the black variety, are perfectly free from narcotic properties, but yield by expression a bland fluid oil, much used on the continent of Europe, and for which the poppy is largely cultivated in France and Germany. The capsules are used for obtaining the slighter effects of opium, particularly in children. The preparations are the decoction, extract, and syrup. The Decoction (DECOCTUM PAPAVERIS, Br.) is made by boiling four ounces of the capsules, deprived of their seeds, in three Imperial pints of water, for ten minutes. It is used as a fomentation, or mixed with emollient cataplasms, in painful tumours and superficial inflammations. The Syrup (SYRUPUS PAPAVERIS, Br.) is made by adding sugar to a concentrated decoction, and a little spirit to enable it to keep better. It is considerably used in England to allay cough, quiet restlessness, relieve pain, and produce sleep, in infantile cases. But a syrup made with one of the salts of morphia is much to be preferred, as of a more definite strength. The dose is from half a fluidrachm to a fiuidrachm for an infant, and from half a fluidounce to a fluidounce for an adult. The preparation is very little used in the U. States, but is often referred to by British writers on medicine. VI. HEMP OF INDIA. CAXNABIS INDICA. Br. I prefer the designation above given to that of Indian Hemp, ordina. rily applied to the medicine, because the latter name is habitually used in this country for the Apocynum cannabinum, which is totally differ- ent, both in its botanical relations and medicinal properties, from the sub- stance now under consideration. Hemp of India, considered as a medicine, consists of the dried flower- ing tops of Gannabis saliva, which is a native of the interior of Asia, but cultivated in many parts of the world, and to a considerable extent in our own Western States. It is only, however, the product of the plant grown in the East Indies that is used medicinally. Its virtues reside mainly in a resinous exudation, which is thrown out in hot weather, upon the surface of the plant, rendering it clammy and adhesive to the fingers. This is produced much more largely in the Indian than in the CHAP. I.] CEREBRAL STIMULANTS. HEMP OF INDIA. 771 European plant, probably owing simply to the difference of climate. The hemp of this country, if we are to judge from the odour it exhales when growing as a crop in the fields, and its viscidity to the touch, ought to be efficacious ; and it would be an object worthy of attention to investigate this point experimentally. In Hindostan the tops are cut after flowering, and when dried are tied together in bundles, two feet in length, each containing about twcuiy- four plants. These bundles are called ganjah or gunjah by the natives; and are essentially the same as the hashish of the Arabs. Bang is a name given to a mixture of the leaves and capsules, without the stem. The resinous exudation is collected in various methods from the grow- ing plants in the flowering period, and formed into small masses which are called char r us. It is an alcoholic extract from the dried tops, or gunjah, that is recognized in the U. S. Pharmacopoeia, under the name of Extract of Hemp or EXTRACTUM CANNABIS. In the British Phar- macopeia the preparation is recognized by the name of EXTRACTUM CANNABIS INDICT. Properties. The tops of hemp, when fresh, have a characteristic odour, which, in the growing plant, is said sometimes to produce narcotic effects ; and, in passing by fields of hemp, I have myself either felt, or imagined that I have felt, something of the kind. This odour is diminished in drying, and in the tops, as imported, is relatively very faint. Their taste is feeble and bitterish. The churrus, as described by Dr. Royle, is of a blackish-gray, blackish-green, or dirty olive colour, a fragrant and narcotic odour, and a slightly warm, bitter, and acrid taste. The best extract, as sold in our shops, is soft, of a blackish-green colour, a feeble narcotic odour, and a taste which is very slight at first, but becomes bitterish and herbaceous, and leaves a slight sense of acrimony for some time in the mouth. Active Principles. So far as is known, the active principles of hemp are a volatile oil and a peculiar resin called cannabin. That the for- mer has narcotic properties is to be inferred from the effects of the odour of the plant. The latter is a neuter substance, having a somewhat fragrant odour, especially when heated, and a warm, bitterish, subacrid, and balsamic taste. It is insoluble in water, but soluble in alcohol and ether, and from its alcoholic solution is precipitated white by water. M. Jacques Personne has made an experimental investigation into the chem- ical composition of hemp, from which it may be inferred that this nar- cotic owes its powers of affecting the system wholly to its volatile oil, and that the resin, when entirely freed from the oil, is inert. M. Per- sonne found the oil to be complex, consisting of two carburetted- hydro- gens, one of which he proposes to name cannabene, the other hydrate of cannabene. (Journ. de Pharm. et de Chim., 3e ser., xxxi. 50.) Effects upon the System. The effects of hemp have a certain analogy 772 GENERAL STIMULANTS. [PART II. with those of opium, and, so far as regards the brain, with those of alcohol ; showing that all three belong to the same class of agents. But there are also decided peculiarities in the operation of hem p. which dis- tinguish it in a marked degree, from all other cerebral stimulants. It is feeble in its local influence, and but moderately stimulant to the circu- lation ; producing a slight increase in the force of the pulse, with little or none in its frequency. Upon the brain, however, it acts with great energy. Like all stimulants to the cerebral centres, it first exalts, then deranges, and finally diminishes their functions. Hence, as a first effect, there is generally a remarkable exhilaration of the spirits, with a con- dition of mental reverie, in which a new state of existence seems to open, the most pleasing fancies present themselves, and 'the thoughts rush along in rapid succession, with little guidance or government from the will. In this state, there is often a disposition to laugh, sing, shout. or dance, or to do some other extravagant act ; but, in other instances, the excitement betrays itself in a quarrelsome temper or deeds of violence ; and in others, again, there is a quiet internal enjoyment which does not seek any outward expression. The sense of hearing is said, in some in- stances, to be greatly exalted. A not unfrequent peculiarity of this mental state is that objects seem further off than they really are, and sounds seem to come from a distance. The individual affected often speaks, after recovery, as having felt himself buoyed up, and rising above the surface of the earth. There is, too, a feeling of spiritual or intellectual exaltation, and of superiority to ordinary men. Sometimes there are impressions of duality, as if the patient were at the same time himself and another. Occasionally a species of intoxication is induced. with hallucinations or complete delirium. These effects come on within an hour or two, and are attended with a sense of giddiness, and, as writers generally assert, with aphrodisiac excitement. They gradually subside into a pleasing calm, a feeling of luxurious repose and indolence, during which the senses, particularly that of touch, become more or less obtuse, and general sensibility is so much impaired, that pinching, or other act ordinarily attended with pain is scarcely felt, and causes no uneasiness. Drowsiness soon follows, and, in three or four hours from the taking of the medicine, the person falls into a sleep or stupor, which continues about six or eight hours. During this condition, the pupils are generally dilated, and a state of the muscles is sometimes induced analo- gous to catalepsy, in which the limbs are perfectly flexible, and may be moved in every direction, but have a tendency to retain any position in which they may be placed. This latter affection, however, has not been noticed by those who have used the medicine in this country and Europe. Dr. O'Shaugl messy observed it in several instances among the Hindoos. Upon awaking, it is said that, instead of the nausea which is apt to follow the influence of opium, there is often a strong desire for food ; CHAP. I.] CEREBRAL STIMULANTS. HEMP OF INDIA. 773 and the medicine is believed to have the property of exciting the ap- petite. Though thus analogous in its course of action, and in many of its effects to opium, it yet differs from that narcotic remarkably, in one respect, in its operation on the brain. While opium elevates and for a time appears to invigorate the intellectual faculties, hemp, on the con- trary, tends to confuse the mind, and induces a purposeless succession of ideas, which, though generally pleasing and even exciting, have no es- sential connection, and lead to no special result. It does not aid the student in acquiring or the writer or speaker in dispensing knowledge. It is the imagination and feelings which appear to be most highly stimu- lated, and altogether without the control of reason. The wildest vaga- ries, the most fantastic images, and the most gorgeous scenes, rapturous to every sense, and often voluptuous under the aphrodisiac influence of the drug, rush in throngs through the fancy, and seem to carry the soul along with them through long -periods of passive, but diversified and thrilling adventure. In its operation on the organic functions, also, hemp differs greatly from opium in several important points. Though, like it, sometimes diaphoretic, it is so in a much less degree ; and has none of that tend- ency to produce constipation of the bowels and dryness of the mouth, or to check the mucous or biliary secretion which so often interferes with the beneficial influence of opium, and so much limits its use. It is, more- over, much less apt to induce nausea, and to leave headache or other disorder behind it. From alcohol hemp differs in being much less excitant to the vascular system, less brutifying in its effects on the mind and temper, and indis- posed to produce that thickness of speech, and staggering movement, so characteristic of the former stimulant. There can be little doubt that, in over-doses, it is capable, like the other cerebral stimulants, of proving poisonous ; but its effects in this respect have not been fully investigated. A case is reported by Prof. Schroff in which ten grains of an Indian preparation, after giving rise, in an exaggerated degree, to the characteristic effects of the medicine, produced an alarming prostration of the circulation ; but the case ended in recovery. (Dublin Quarterly Journ., xxvi. 231.) Alcohol is said to be the most efficient antagonist. (Ann. de Therap., 1865, p. 81.) Among those who use it habitually, it is said ultimately to impair the mental faculties. The remedies, both in its acute and chronic poisoning, would lie the same as those required by opium. Hemp probably operates, like opium and alcohol, through absorption. Drs. Ballard and Garrocl, in their Elements of Materia Medico, state that it imparts an odour to the urine, like that produced by mixing the tincture with water, and somewhat resembling that of the Tonquin bean. 774 GENERAL STIMULANTS. [PART II. Therapeutic Application. Hemp was known to the ancient Greeks and Romans, who seem to have had some confused notion of its narcotic powers, though there is no reason to suppose that they ever employed it as a medicine. From time immemorial it has been used in India and Persia as a luxury, both internally and by smoking, in the same manner as opium. Its intoxicating and stupefying powers are spoken of by Linnaeus, Murray in his Apparatus Medicaminum, and other early modern writers on Materia Medica ; but it was not employed as a rem- edy, to any extent at least, in Europe or America, until introduced to the notice of the profession, not many years since, by Dr. O'Shaughnessy, of Calcutta, in the treatment of rheumatism, tetanus, cholera, etc. The indications for the use of hemp, founded upon a knowledge of its physiological effects, are, 1. to allay pain, 2. to relieve spasm and various other nervous disorders, and 3. to promote sleep. In producing these effects, it probably operates in the same manner as opium ; and it may be substituted for that medicine, for any of the purposes above men- tioned, when opium has failed to act as desired, or is contraindicated by some idiosyncrasy of the patient, or when it is specially desirable to avoid its occasional nauseating influence on the stomach, its constipating effect on the bowels, and its tendency to restrain the secretions. Another indication, derived from a supposed property of hemp not yet particularly noticed, is to produce uterine contraction. Attention, I believe, was first called to this property by Dr. Alexander Christison, of Edinburgh, who observed that, in several cases in which he had employed it during labor, it very much increased the intensity of the contrac- tions.* The effect usually occurred, if at all, in two or three minutes after its administration, ceased after a few pains, and was not followed by any of the ordinary physiological results of its exhibition, as mental excitement, intoxication, or sleep ; nor does the sense of pain appear to have been blunted. Indeed, the action took place much sooner than is required for its usual effects, and its powers seem to have been ex- hausted in the effort. Dr. Christison thinks the action of hemp more energetic, and perhaps more certain, than that of ergot. (See Am. Journ. of Med. Sci., N. S., xxiii. 200.) Notwithstanding this supposed action of hemp, it has been found, in large doses, very promptly to suppress ute- rine pains in delivery. (Ed. Med. Journ., ii. 6G7.) With a view to the first indication, that, namely, of allaying pain, hemp has been used in different forms of neuralgia, in acute and sub- acute rheumatism, and in gout,- and may be employed in these affections under the same circumstances as opium. * Sir J. Y. Simpson informed me. when in Edinburgh, Unit the idea of using hemp of India for its cfl'eots in causing uterine contraction:-; oi-^inuted wiiii himself. (Mile to the third edition.) CHAP. I.] CEREBRAL STIMULANTS. HEMP OF INDIA. 775 To relieve pain and relax spasm jointly, it has been considerably used in tetanus, and with variable results. Dr. O'Shaughnessy found it effect- ual on several occasions ; a few successful cases have been reported by others ; and, in some instances, where it has failed to cure, it has afforded relief. But the general result has not, I think, been favourable. As in the use of opium in this disease, it is necessary to increase the ordinary dose six or tenfold, or more, and to repeat the dose frequently. The medicine has been tried also in hydrophobia, but has proved quite pow- erless. In epidemic cholera it is said to have been found useful ; but the property of checking alvine discharges, which renders opium so ben- eficial in that disease, is wanting in hemp, and it can act only by relieving pain and resolving spasm. Hemp has also been used in various painless spasmodic affections, and nervous disorders, usually treated with the nervous Stimulants and narco- tics. In convulsions not connected with cerebral congestion, in chorea, hys- teria, languid or depressed spirits, and insanity, it has been found more or less beneficial. For allaying cough, whether spasmodic, as in per- tussis and hysteria, or dependent on bronchial irritation, as in different pulmonary affections, it may be resorted to as a substitute for opium, when this is contraindicated by its property of checking mucous se- cretion. To promote sleep, it may be employed in any case of wakefulness, not associated with vascular irritation of the cerebral centres, and is said to have been used with special advantage in relieving the sleeplessness of drunkards. In reference to "its supposed property of promoting uterine contraction, it may be employed in protracted cases of delivery, in which it is pref- erable to ergot, if it be true, as may be inferred from the observations of Dr. Alexander Christison, that its operation is soon over, and not pro- tracted like that of the medicine alluded to. It is thus free from the greatest objection to ergot, that, namely, of endangering the life of the foetus by the steady and prolonged contraction of the uterus. The same property of hemp would render it useful in expelling the retained pla- centa, and in checking uterine hemorrhage, when sustained by a relaxed condition of the organ. But, if preferable to opium under the circumstances above mentioned, in which that medicine, though indicated by certain symptoms, is con- traindicated by others, hemp cannot be brought into competition with it in any of the cases to which they are both applicable. It is not only less efficient than opium, but is much more uncertain on account of the ine- quality of strength in the preparations used, and probably also in conse- quence of the inequality of its operation upon different individuals, even when it may be of the due strength Dr. Fronniuller, who speaks of the practical use of hemp, with an au- 776 GENERAL STIMULANTS. [PART II. thority based on the experience of a thousand cases, says that it pro- duces sleep more like the natural than any other narcotic, causes consid- erable vascular excitement, does not disturb the secretory functions, and leaves behind no unpleasant sequelae, and, finally, that it may be em- ployed as a substitute for opium in all the phlegmasias, and all the typhous affections, without apprehension of evil result. It is, however, at the same time, less energetic and less certain than opium. (Arch. Gen., 5e ser., xv. 745.) Preparations. The forms in which hemp is ordinarily used in Europe and this country are the extract and tincture. Extract of Hemp (EXTRACTUM CANNABIS), as recognized in the IT. S. Pharmacopeia, is prepared by treating the dried tops with alcohol, and evaporating the tincture thus obtained. But it may also be procured by purifying the crude cfrurrus of the Hindoos, by dissolving what is solu- ble of it in alcohol, allowing the undissolved impurities to subside, and then decanting and evaporating. In this way is prepared the Purified Extract of Hemp (EXTRACTUM CANNABIS PURIFICATTJM) of the U. S. Pharmacopoeia. A still purer form of it is prepared by a somewhat complicated process, for an account of which the Dispensatories may be consulted. One of the best tests of its strength, independently of actual trial, is its possession, in the highest degree, of the characteristic prop- erties of smell and taste. Prof. Procter, who has specially investigated the subject, gives as its characteristic properties, its peculiar smell when slightly heated, its indifference to the alkalies, and its solubility in alco- hol, ether, chloroform, benzole, and oil of turpentine ; but the best test, he thinks, is nitric acid, which acts on it slowly when' cold, but rapidly with heat, giving out red fumes, and converting the resin into an orange- red substance, which, when washed and dried, closely resembles gam- boge in colour. (U. S. Dispensatory, 12th ed.) The dose of the extract varies extremely, in consequence of the vari- able strength of the preparation. When of the best quality, half a grain of it will produce obvious effects, while ten or twelve grains are oTtcn required, and sometimes the drug is quite inert. It is best, as a general rule, to begin with one grain or less, which may be repeated every two, three, or four hours, until its effects are produced; and, if none can be obtained from this dose, gradually to increase it, until the amount is ascertained in which the parcel employed will act. In tetanus, ten grains may be given every half hour till it operates, and the quantity increased. if necessary. It may be administered in pill or emulsion. The latter is the preferable form, where speedy effect is required. It may be made by rubbing the extract up with a little olive oil, and then suspending it in water, or one of the aromatic waters, by means of gum arabic and sugar. Tincture of Hemp (TINCTURA CANNABIS, U. S.; TINCTURA CANNA- CHAP. I.] CEREBRAL STIMULANTS. HENBANE. 777 BIS INDICT, Br.) is made by dissolving six drachms of the extract in a pint of officinal alcohol (sp. gr. 0.835). The dose, equivalent to one grain of the extract, is about 20 minims or 40 drops. Dr. O'Shaugh- nessy gave 10 drops of the tincture every half hour in cholera, and a fluidrachm as often in tetanus, until the desired effects were produced, or the medicine showed decided signs of acting on the brain. This is among the substances which have been used in the form of spray, as made by the atomizer ; from five to ten minims being mixed for the purpose with a fluidounce of water. It has been inhaled for the relief of nervous or spasmodic cough, and that attendant on phthisis. It has also been used hypodermically for the general effects of the medicine, in the dose of from ten to twenty drops. VII. HENBANE. HYOSCYAMUS. Br. This is the Hyoscyamvs nigerof botanists, an annual or biennial herba- ceous plant, indigenous in Europe, where it is also cultivated for medical usr. It has been introduced into this country, and grows wild in some of our Northern States, especially in Michigan, where it abounds in the neighbourhood of Detroit, The whole plant is possessed of medicinal virtue. The IT. S. Pharmacopoeia recognizes the leaves and seeds. HENBANE LEAF. Hyoscyami Folium. U.S. Hyoscyamus. Br. The leaves of henbane, in their recent state, are somewhat hairy, viscid to the touch, of a sea-green colour, of a strong, disagreeable, narcotic odour when bruised, and of a mucilaginous, somewhat acrid taste. By drying they become nearly or quite inodorous and tasteless. They im- part their virtues to alcohol and water. By destructive distillation, th% yield a very poisonous empyreunmtic oil. HENBANE SEED. Hyoscyami Semen. U. S. The seeds are very small, roundish, compressed, of a grayish or yel- lowish-gray colour, in odour like that of the plant, and a bitter, oily taste. They are stronger than the leaves, but less used. Active Principle. There is little or no doubt that the virtues of hen- bane reside in a peculiar alkaloid, denominated hyotciamia, which, how- ever, though it has been isolated and accurately described, and its effects upon the system investigated, has scarcely been introduced into use as a medicine. It exists most largely in the seeds, but in small proportion even in these. Experiment has proved that both it and its salts are very poisonous. M. Gustave Lemattre, who has carefully investigated the physiological action of this and other alkaloids of the solanacese., with 778 GENERAL STIMULANTS. [PART II. the view of determining their relations to one another, was unable to discover any appreciable difference, in this respect, between hyoscyamia and the two better known alkaloids, atropia and daturia. (Archives Generates, Aoiit, 1865, p. 186.) Dr. A. B. Garrod, of London, has sat- isfactorily determined that the caustic alkalies, potassa and soda, entirely destroy the activity of hyoscyamia, and render hyoscyamus inert, in reference both to its local and general effects. It is not, however, inju- riously affected by the carbonates of the same alkalies. (Med. Times and Gaz., Dec. 1857, p. 589.) Effects on (he System. In doses scarcely sufficient to make themselves felt in health, hyoscyarnus appears to act as a nervous stimulant in dis- ease, calming restlessness, and other forms of slight nervous disorder, and, in cases of morbid wakefulness, producing sleep indirectly by re- moving the cause which prevents it. In full medicinal doses, it often produces, along with some increase in the frequency of pulse and general warmth, or with no observable effect of the kind, an agreeable and diffu- sive feeling of comfort, followed perhaps by slight vertigo, or other un- easy sensations in the head, and after a time by an easy natural sleep. Sometimes, however, it occasions headache, and, instead of sound sleep, gives rise to uneasy dreams, spectral illusions, or delirium. In not a few instances, nothing like sleep can be obtained from any ordinary dose ; and, in such cases, some degree of seasonal or mental aberration is apt to occur, if the medicine is pushed. Dr. Pereira says that it is least apt to produce sleep in persons accustomed to the use of opium. A characteristic effect of it, as of other solanacese, especially belladonna and stramonium, when the system is fully under their influence, is dila- tation of the pupil. Besides these effects, it often occasions heat or irri- tation in the fauces, sometimes increases the perspiration or urine, and, in rare instances, has caused a pustular eruption upon the surface. In- stead of constipating like opium, it either produces no effect on the bowels, or acts as a laxative ; the latter result being not uncommon. In some persons, or in certain states of the system, it occasions general febrile heat and irritation. After the subsidence of its full direct effects, a state of greater or less depression occurs, which, when the quantity taken has been very large, may amount even to prostration. Hyoscyamus has not unfrequently been swallowed in poisonous quan- tities. This has happened most frequently with the root, which has been taken by mistake for that of some other plant, as parsnep or chiccory. The effects are usually giddiness, more or less stupor, extreme dilatation of the pupils, disordered vision, spectral illusions, diminution or loss of the power of speech, accelerated pulse, delirium, sometimes violent and maniacal, sometimes low and muttering, often attended with laughter, tonic spasms, convulsions, coma, paralysis, and at length irivat prostra- tion, with small and irregular pulse, difficult breathing, and cohlne.-s. of CHAP. I.] CEREBRAL STIMULANTS. HENBANE. 779 the extremities. From this extreme condition, however, reaction gener- ally takes place, and comparatively few cases terminate fatally. Yet death has occurred in several recorded instances. Sometimes, with these narcotic effects, symptoms of severe gastro-intestinal irritation are exhib- ited, as nausea, vomiting;, abdominal pains, and purging. The adminis- tration of the medicine by enema, and its external application over the abdomen, have been known to produce severe symptoms, though never. I believe, fatal. The operation of the poison usually continues for about twelve hours before abating spontaneously. The remedies are the same as those for opium ; full vomiting being the most important. From the experiments of Dr. Garrod, it appears that animal charcoal is an efficient antidote to hyoscyamia, completely destroying its powers, even in small quantities. This, therefore, should be used, along with the other means employed, in the treatment of its poisonous effects. Of course it can exert no in- fluence on the poison after absorption. (Hed. Times and Gaz., Dec. 1857, p. 590.) The lower animals are affected very differently by the herb. Some, as horses, cows, sheep, goats, and hogs, eat it with impunity; while birds and dogs are affected like man. It is not impossible that injury may have accrued, particularly to children, from the use of the milk of cows and goats which have been feeding on henbane. The effects of hyoscyamia have been carefully investigated by Prof. Schroff, of A'ienna. In a moderate dose it produced dryness of the mouth and throat, dilatation of the pupils, diminution followed by increased frequency of pulse, vertigo, hebetude of mind, general feelings of languor, and finally quiet sleep. By larger doses these effects were produced in a greater degree. The dryness of throat was very great, there was diffi- culty of deglutition, the sense of taste and smell were impaired, head- ache came on, and a deep and quiet sleep closed the series. A solution of it dropped into the eye caused a dilatation of the pupil more rapidly, intensely, and for a longer time than any other agent. Given to rabbits in poisonous doses it produced deep sleep, followed by death, without any convulsive movements, or apparent delirium. It appeared to occa- sion inflammation of the lungs. This result is somewhat singular ; as the same animals can eat the herb freely with impunity. (Wochenblatt der Gesellschafl der Aertze zu Wien, June 16, 1855.)* Reisinger states * A solution of this difficulty will be found under belladonna, the peculiar alka- loid of which so closely resembles hyoscyamia, as to have led to the supposition that the two might be identical. It appears that the reason why certain animals can feed with impunity on the leaves of the solanaceae is that, in consequence of the mass of matter in their stomachs undergoing digestion, the proportion of the poison- ous principle absorbed, within a given time, is insufficient to cause a poisoned state 780 GENERAL STIMULANTS. [PART II. that a single drop of an aqueous solution containing one part of it to ten of water, introduced into the eye caused dilatation of the pupil with- out irritation of the conjunctiva. Mode of Action. Though it would be difficult to prove that hyoscya- mus operates upon the system through absorption, analogy leads almost necessarily to this conclusion. Its local action is that of a very moderate irritant, as shown by its occasional effects on the stomach, and its not unfrequent action upon the bowels. As a direct" circulatory stimulant it is very feeble, being, in this respect, greatly inferior to opium ; and, in many instances, the pulse is not affected, at least in frequency. The de- pression of the circulation which attends its full narcotic action is a secondary result, depending probably on the condition of the nervous centres. Its influence upon the cerebral centres is, I have no doubt, essentially stimulant; sleep resulting from a mild congestive action upon them, while, in a higher degree of the same operation, delirious excite- ment is produced, and, when the centres are quite overwhelmed, coma. The effect upon the pupil may be considered as a kind of sleep of the nervous centre, which causes contraction of the iris; or it may result from an excitant influence upon the sympathetic centres, producing a strong contraction of the dilating fibres. Therapeutic Application. Henbane was known as a medicine to the ancients, but received little notice, until attention was attracted to it by Baron Storck, of Vienna, so famous for his experiments with this and other narcotics, and for the enthusiastic estimate he placed upon their therapeutic powers. Though this medicine has not realized all that was hoped from it, in consequence of his representations, it is, however, of no little value, and assuredly does not deserve the sentence of banishment from the Materia Medica pronounced upon it by M. Fouquier. (Arch. Gen., \. 297 and 312.) The indications which hyoscyamus is calculated to fulfil are to allay pain, produce sleep, relax spasm, and quiet nervous disturbance gen- erally. These are, among others, the therapeutic effects of opium, which hyoscyamus probably as nearly resembles, in its soporific influ- ence, as any other medicine. It is, however, in these respects, much in- ferior to opium, and incomparably less to be relied on ; but there arc certain circumstances under which, in consequence of its want of prop- erties which sometimes interfere with the beneficial operation of that medi- cine, it may be used when opium cannot, arid is admirably calculated to supply its place. In the first place, it is much less stimulant to the cir- of the blood, which throws out the noxious matter before time hns been allow> 1 for it to accumulate HO as to be destructive. But if one of the solanaceou.s alkaloids be injected into the veins, or even into the subcutaneous tissue, it acts on these ani- mals poisonously, just as it acts on man. (Note to the third edition.) CHAP. I.] CEREBRAL STIMULANTS. HENBANE. 781 dilation than opium, and though, from this deficiency, it is of little use in supporting the system in certain conditions of debility where opium is highly valuable, it is more safely used in others, in which the anodyne and soporific properties of opium are wanted, but its stimulant prop- erty contraindicates it. Again, it does not constipate like opium, but is rather laxative, and cannot, therefore, be substituted for it in diarrhoea; but thei'e are frequent occasions in which this dissimilarity gives it great advantages. Thirdly, it has no such effect in restraining the secretion of mucus, bile, and urine as opium has ; and may on this account be sometimes preferably employed, where it is desirable rather to promote than to impede those secretions, as sometimes in the early stages of in- flammation of the bronchial tubes, liver, and kidneys. Lastly, from in- dividual idiosyncrasy, or peculiarity in disease, opium not unfrequently occasions so much nausea, headache, delirium, or other disagreeable effect, that it cannot be given, however strongly called for as an anodyne or soporific. In such cases, hyoscyamus may sometimes be substituted with great advantage. In fevers, hyoscyamus may often be usefully employed to quiet nervous disturbance and produce sleep, where the excitement may be too high for opium, or that medicine may be objectionable upon some one or more of the grounds just mentioned. This remark is especially applicable to the febrile affections of infants, in which a little hyoscya- mus may often be advantageously conjoined with the refrigerant or laxative medicines, when there is considerable nervous disturbance, in- quietude, and wakef ulness; while opium might do more harm than good. In the different phlegmasise, also, the medicine may be used to fulfil its proper indications, with no little benefit. This is particularly the case in bronchial inflammation, whether original, or connected with other diseases, as measles, pneumonia, etc., in the earlier stages, before secretion has taken place, and in any stage, whether acute or chronic, if the prominent indication is to promote secretion, and to allay cough. Opium might fulfil the latter indication at the expense of the former. Hyoscyamus, if it do not fulfil both, has certainly no effect in restrain- ing the secretion. It should be combined with the expectorants em- ployed. The same may be said of its use in hepatitis, especially when the substance of the gland is affected. In the peritoneal form of hepa- titis, opium would be incomparably superior. In nephritis, when there is a great deficiency of secretion, hyoscyamus may sometimes be pref- able ; and for the same reason, applying, however, in this instance to the mucous and not the urinary secretion, there may be instances in which this narcotic would be more appropriate than opium in inflamma- tion of the bladder and urinary passages. To the relief of the more violent forms of neuralgia, or indeed of ex- cessive pain from any cause, the anodyne powers of hyoscyamus are 782 GENERAL STIMULANTS. [PART II. generally inadequate; though it may be tried in any case of the kind where opium cannot be given. There is, however, one condition of things in which it is peculiarly indicated; I refer to attacks of excessive sensitiveness of the retina. A case of this kind occurred to me, many years since, which will illustrate my meaning. A gentleman of highly nervous temperament, in the state of general depression following an acute disease, and after considerable depletion, was seized with an ex- quisite irritability and sensitiveness of the eye, which occasioned the most severe suffering. Light was torture to him; and it was neeessary to close the outer shutters of the apartment, and to draw the curtains closely around his bed. so as to prevent the least particle from reaching him. Notwithstanding, however, this precaution, he complained of the intolerable brightness, the intense and insufferable glow, as of incandes- cent metal held immediately before his face, or of a concentration of the whole blazing light of the sun directed upon his vision ; and language, in one who knew its resources well, and knew how to wield them pow- erfully under the impulse of a brilliant imagination, was exhausted to find expressions strong enough to convey an idea of his sufferings. Under the impression that he was affected with inflammation of the < he refused opiates altogether, though urged upon him. At last I pre- vailed on him to take a single grain of extract of hyoscyamus every hour. He had not taken more than three or four doses, when he expe- rienced a sensible amelioration of his sufferings, along with the first narcotic impression of the medicine ; and they continued to abate so long as the hyoscyamus was used. Convinced now of the nature of tin affection, he consented to take an opiate enema, which immediately put an end to the symptoms. I have no doubt that a full dose of the hyoscyamus would have had the same effect. It is especially imlir; in neuralgic affections of the eyeball, through its influence over the nerv- ous centre of vision. In carcinomatous and other painful organic affections, hyoscyamus may lie alternated with opium, in the hope of protracting longer the period of susceptibility to the anodyne effect of the latter remedy. Spasmodic and convulsive diseases, and other forms of nervous irri- tation, afford frequent occasion for the use of this narcotic. It can do little good in the more violent cases of painful spasm, such as spasm of the stomach, severe colic, the cramps of cholera, tetanus, etc.: yet in the milder conditions of the affection it may often be usefully combined with other medicines, as in slight colicky pains with cathartics, in the milder forms or stages of colica piclonum with alum, in similar conditions of the biliary and urinary passages with calomel in the former case, and bicarbonate of soda in the latter. In asthmatic affections. pi>rtu.~ and the convulsive attacks of infants dependent on teething or intes- tinal irritation, it may sometimes be advisable. Though inadequate to CHAP. I.] CEREBRAL STIMULANTS. HENBANE. 783 the cure of epilepsy or chorea, it may be usefully combined, in some in- stances, with the metallic tonics and nervous stimulants used in those complaints. In the multiplied nervous disorders of hysteria, hyoscy- amus may now and then be had recourse to, with great benefit, for reliev- ing distressing sensations, soothing inquietudes, and procuring sleep. It is a favourite practice with many to combine hyoscyamus with the more irritating purgatives, under the impression that it tends to pre- vent their griping, without diminishing their purgative effects. For this purpose it is frequently used with the compound extract of colo- cynth, or with scammony, colocynth, and aloes severally. Contraindications to the use of hyoscyamus are active congestion or inflammation of the brain, a very high degree of febrile or inflammatory excitement generally, and inflammation of the stomach or bowels. Topical Use. Fresh henbane is sometimes used in the form of a cata- plasm, or infused in hot water as a lotion or fomentation, to relieve pain and irritation, as in hemorrhoidal or carcinomatous tumours, painful glandular swellings, gouty or rheumatic affections, scrofulous and cancerous ulcers, nervous headache, etc. The extract is also employed for the same purposes. The remedy is sometimes used in the way of enema, to relieve irritation of the rectum, bladder, urinary passages, or genital organs. Oculists sometimes use it to dilate the pupil before the operation for cataract ; a solution of the extract, or an infusion of the leaves being drppped into the eye, or the extract with lard, rubbed upon the lids and around them. The effect is usually produced within four hours, and continues twelve. The same application has been recom- mended after the operation for cataract, when there is danger of iritis, to prevent the pupil from closing. Used in this way, it does not affect the vision. Administration. Neither generally nor locally should henbane be administered with one of the fixed caustic alkalies; and, when it is de- sirable to combine an alkaline action with that of the medicine, the car- bonates should be used. The medicine may be given in substance, extract, or tincture. The dried leaves are so uncertain that they are very seldom used. The dose to begin with is from five to ten grains. The seeds should not be employed at first in more than half the smaller dose mentioned. The extract is much more frequently used. Two extracts of henbane are directed by our national Pharmacopoeia, one made by inspissating the expressed juice of the fresh leaves, the other by evaporating an alcoholic tincture of the dried leaves The former is called simply Extract of Henbane (EXTRACTUM HYOSCYAMI, U. S.), the latter Alcoholic Extract of Henbane (EXTRACTUM HYOSCYAMI ALCO- HOLICUM, U. S.). As, in many parts of our country, the fresh leaves cannot be obtained, it is necessary either to use the imported extract, or to prepare the alcoholic. Unhappily, in either case, the preparation is of 784 GENERAL STIMULANTS. [PART II. very uncertain strength, and often extremely feeble. The proper method of proceeding, in this uncertainty, is to give from one to three grains of the extract, and gradually increase the dose until it produces the desired effect, or at least evinces some narcotic power; and, having thus ascer- tained the strength of the parcel, to be guided afterwards accordingly. The dose will often be raised to ten grains before acting, sometimes even to twenty or thirty grains, or indeed much higher; for occasionally the extract is quite inert. A Fluid Extract (EXTRACTUM HYOSCYAMI FLUIDUM, U. S.) was in- troduced into the U. S. Pharmacopoeia at the late revision. It is a con- centrated tincture, and may be given in the commencing dose of from five to ten minims. The Tincture of Henbane (TINCTURA HYOSCYAMI, U. S., Br.) is also officinal. It is prepared from the leaves by percolation with diluted alcohol, and is of such a strength that a fluidrachm represents rather less than eight grains. The same ru^e holds as to the commencing dose in this as in the extract; for the preparation is almost equally uncer- tain. From thirty minims to a fluidrachrn and a half may be given at first. Should hyoscyamia be used, not more than one-sixteenth of a grain should be given at once. As water dissolves it in small proportion, its aqueous solution may be used for dilating the pupil, being for that pur- pose dropped into the eye. VIII. BELLADONNA. BELLADONNA LEAF. BELLADONNA FOLIUM. U.S. BELLA- DONNA. Br. BELLADONNA ROOT. BELLADONNA RADIX. U. S., Br. Origin. Under the name of Belladonna, the British Pharmacopoeia recognizes the leaves of Alropa Belladonna, or deadly nightshade, which in our own are designated as Belladonnae Folium ; while in both, the root of the plant is officinal, with the title of Belladonna Radix. The plant is herbaceous, but perennial, indigenous in Europe, and cultivated in this country, but to no great extent, for medicinal purposes. Though all parts of the plant are active, the leaves only were officinally recognized until the recent revision of the Pharmacopoeias, when the root, which is said to be much more active than the leaves, was adopted.* The * Hirtz states that the roots are stronger than the leaves in the proportion of five to one. (Ann. de Thfrap., 1862, p. 22.) CHAP. I.] CEREBRAL STIMULANTS. BELLADONNA. 785 fruit, though not specially used in medicine, merits a particular notice, as it is highly poisonous, and has frequently been eaten with fatal effect. Properties. The root is a foot or more in length, round, an inch or more in thickness, branched, grayish or brownish-white when fresh, be- coming reddish-brown by drying, internally whitish and fleshy, of a faint peculiar odour, and sweetish, slightly bitter, mawkish taste. The leaves, which are often in unequal pairs, upon short footstalks, are from four to six inches long, ovate, pointed, entire upon their edges, of a deep-green colour above and paler below when fresh, of a dusky or brownish-green when dried, and, in the latter state, almost destitute of odour, and of a feeble subacrid taste. The fruit is a berry, at first green, then red, and, when ripe, of a fine glossy blackish-purple colour, about as large as a cherry, with a longitudinal furrow on each side, having the adhering calyx at the base, and containing numerous seeds in a juicy pulp. Its taste is sweetish, but mawkish, and not agreeable. All parts of the plant impart their medicinal properties to water and alcohol. Active Principle. The ingredient to which belladonna chiefly if not exclusively owes its virtues is a peculiar alkaloid, denominated alropia, which will be specially treated of at the close of this article. Brandes obtained also a peculiar substance called pseudotoxin, and Lubekind supposed that he had detected another alkaloid which he named bella- donnin; but little is known of their properties; and the ordinary exist- ence of the latter may be looked on as doubtful. In relation to the in- compatibility between atropia and caustic potassa and soda, even in very weak solution, the same remarks are applicable as were made upon hyoscyamia. (See page 777.) 1. Effects on the System. Belladonna produces its characteristic effects upon the system, to what- ever part it may be applied, whether to the stomach, the skin, the rectum, the cellular tissue, or the blood. When it is given in small doses, re- peated two or three times daily, so as to bring the system gradually under its influence, the first effect usually noticed is a feeling of dryness and stricture in the fauces, soon followed, if the medicine be continued or increased, with slight uneasiness or pain in the forehead, vertiginous sensations, some dimness of vision, and occasionally dilatation of the pupil. The system maybe kept long under its influence, with little other observable effect, by a careful management of the dose. In some very susceptible persons, however, the quantity usually given will act more powerfully ; in one, producing blindness with large dilatation of the pupil ; in another, decided pain in the head, flushed face, perhaps slight delirium, and an excited pulse. From larger quantities, the effects are more quickly induced and more VOL. i. 50 786 GENERAL STIMULANTS. [PART II. severe. A dose sufficient to bring the system at once decidedly under its influence, generally begins to show its effects in about half an hour. Pryness of the mouth and fauces, a feeling of stricture of the throat, difficult deglutition, thirst, dimness of vision sometimes amounting to blindness, dilated pupil, vertigo or headache, flushed face, suffused eyes, morbid sounds, irregular muscular contractions, and hallucination or de- lirium, sometimes followed by a disposition to sleep, sometimes attended throughout with wakefulness, are symptoms which most frequently ap- pear, though not all generally in the same case, and which, having con- tinued for twelve hours or more, gradually subside, without leaving any ill consequences behind. Along with more or less of the effects men- tioned, there is generally some frequency of pulse and febrile excitement : but sometimes the circulation is at first little affected ; and, when the cer- ebral phenomena are at their height, it is in a greater or less degree depressed. According to Lemattre. even when most excited, the pulse is diminished in tension or force. Not unfrequently there is an increase either of perspiration or urine, sometimes an eruption of scarlet rash on the surface, or irritation of the urinary passages. Occasionally, also, there is some nausea or griping pain with diarrhoea, intimating an irri- tating influence on the alimentary mucous membrane. A curious fact in relation to the tolerance of belladonna by children has been made known by Dr. H. W. Fuller, of London. Having pre- scribed the extract in a case of chorea, and observing no effect to follow, he gradually increased the dose, and was surprised to find that very large quantities were borne without effect. He tried the medicine in other cases of chorea with the same result. In one girl of ten years, seventy grains were given daily with little effect. It was satisfactorily ascertained that the extract used was active ; and, in one instance, atro- pia escaped copiously with the urine. He then tried the medicine in healthy children from five to twelve years old, and found the same tol- erance evinced ; and hence came to the conclusion that this singular phe- nomenon was ascribable to peculiarity in'the systems of children. The quantity which was quite harmless in a child could net be borne by an adult. (Med. Times and Gaz., July, 1859, p. 95.) Nevertheless, this ex- perience of Pr. Fuller should not be hastily acted on ; as peculiar un- known circumstances may possibly have influenced the result, and a similar tolerance might not be found in other instances. Poisonous Effects. When poisonous quantities are taken, the effects described are experienced in a still greater degree. The circulation is accelerated and the heat of skin increased. The lips, tongue, and fauces are very dry, with a burning sensation in the throat and stomach, a sense of severe constriction of the throat, great difficulty of swallowing, and intense thirst. Not unfrequently there is nausea with ineffectual retch- ings ; and sometimes strangury and bloody urine. The dimness of vision CHAP. I.] CEREBRAL STIMULANTS. BELLADONNA. 787 is extreme, and total blindness not uncommon, with the pupil greatly dilated, immovable and quite insensible to the brightest light. The hear- ing is also defective, and not unfrequently there is great difficulty of speaking, amounting sometimes to aphonia. General sensibility, which is at first somewhat exaggerated, after a time becomes blunted, and at last disappears. (Lemaltre.) The face is red and swollen, and the eyes suffused with blood, sometimes as it were projecting, sometimes with a fixed meaningless stare, sometimes haggard, or wild and fierce. Vertigo soon comes on with .visual deceptions, and the patient fancies that he sees objects in his vicinity which have no real existence, and makes mo- tions accordingly. There are occasionally illusions of hearing, but they are much rarer than those of sight. In one case, complete somnambul- ism was observed ; the patient imagining that he was a tailor, and for twenty-four hours making gestures as if working at his trade. The de- lirium is generally cheerful or gay ; agreeable or ludicrous ideas present themselves; and the patient smiles or bursts out into laughter, or makes whimsical gesticulations. Sometimes, however, he is wild or even fu- rious. The intoxication is not unlike that of alcohol. Stupor or coma at length supervenes, sometimes alternating or mingling with delirium, and even in sleep the dreams are occasionally ludicrous, producing bursts of laughter. Partial spasmodic contractions take place ; the jaws being closed, the muscles of the face working, and those of the hands moving irregularly ; but convulsions, though they sometimes occur, are very rare. On attempting to rise, the patient is unable to maintain the erect position, staggers, or moves with his body bent forward. Sometimes dysury has been noticed ; but no increase of urine unless when the pa- tient has indulged his great thirst. The pulse is now very feeble, the ex- tremities cold, a disposition to syncope evinced ; and, if the case is to terminate fatally, death is preceded by great prostration, subsultus ten- dinum, and profound coma. If, on the contrary, recovery takes place, which happens in the great majority of cases, even without medical in- terference, the symptoms gradually disappear, and, in two or three days, the patient is restored, usually remembering nothing of what had passed. * The poisonous effects have been experienced from belladonna injected into the rectum, applied to blistered surfaces, and even employed in * The symptoms above given, as characteristic of poisoning by belladonna, must not be considered as all occurring in every case, nor at the same time in the same case ; but the affection of the pupil and of vision is probably uniform. Many of the symptoms have been drawn from an account, by M. Gamier de Claubry, of one hundred and fifty French soldiers, who, in one of the campaigns in Germany, ate the berries of the belladonna plant by mistake, and all suffered in greater or less degree. Many of them perished. (Journ. Gfnfral de Mid., xlviii. 335.) 788 GENERAL STIMULANTS. [PART II. the form of a large cataplasm over the abdomen, with the cuticle unbroken. Its influence extends to the contents of the womb in pregnancy ; and it is said that the aqueous humor, taken from the foetus of one of the lower animals poisoned with it, will expand the pupils in another animal, if dropped into the eye. The quantity necessary to destroy life varies so much, according to the constitution of the patient, and the strength of the preparation, that it is impossible to fix the poisonous dose, with an approach to precision Two grains of the extract have produced alarming symptoms ; six grains administered by enema have had a similar effect; while it is asserted that a pound of the berries were eaten by a man on one occasion, who nevertheless recovered under treatment. (Christison on Poisons.) Accurate accounts are wanted of the appearances left behind by the poisoning of belladonna. In general the stomach exhibits signs of some irritant action, and, in a case recorded by Gmelin, the vessels of the head were found engorged, and the blood was fluid. According to Lemattre, no lesions are found in the larynx or pharynx, or in the proper nervous tissues ; and the only ascertained signs of disorder are offered in conges- tion. Hyperasmia of the pulmonary tissue is generally presented, but always in small foci, which sometimes unite, and are more frequent on the surface than in the depths of the lungs. There is also congestion of the meninges, especially at the base of the brain, and in the choroid plexus of the lateral ventricles. The pia mater is strongly congested ; and the same is the case with the retina in chronic poisoning. The con- gestion, however, is not inflammatory, but rather hemorrhagic. No signs of exudation are discoverable. (Arch. Gen., Aout, 1865, p. 173.) The treatment of this poisoning is exactly the same as that for opium, to which the reader is referred. As the insensibility of the stomach and bowels is often great, though not equal to that from opium, the same measures must be had recourse to, in order to favour the operation of emetics, including the loss of blood if the symptoms of cerebral conges- tion should be very prominent. The stomach-pump should never be trusted to, when the berries have been taken. In the state of coma, the electro- magnetic machine may be employed. In addition to the other measures, it may be advisable to use animal charcoal as an antidote, as in poisoning by hyoscyamus. (See page 779.) Much has been said of an antagonistic relation between opium and belladonna, in their effects on the system, which is supposed to render them, to a certain extent, mutually antidotal in cases of poisoning from either; opium being considered as an antidote in poisoning by bella- donna, and belladonna in poisoning by opium. The idea seems to have originated in the marked difference in their action on the pupil, which is CHAP. I.] CEREBRAL STIMULANTS. BELLADONNA. 789 dilated by belladonna, while it is often contracted by opium in large doses. It was supposed that there might be a similar opposition in other respects. Indeed, opium had been long previously employed, and advantageously, in the treatment of belladonna poisoning. But the ap- plication of belladonna to opium poisoning seems to have originated with Dr. Thomas Anderson, who, in a paper offered to the Physio- logical Society of Edinburgh, in 1854, gave the details of two success- ful cases in which he had used belladonna. Afterwards, Mr. Benjamin Bell, of Edinburgh, derived advantage, in a case of excessive action of atropia, from injecting a solution of morphia into the subcutaneous areo- lar tissue. (Ed. Month. Journ., July, 1858, p. 6.) A few other cases of similar significance had been published in the journals of Europe and this country ; but it was not till 1862, that the attention of the profes- sion was generally aroused to the subject, by a paper of Dr. Wm. F. Norris, of Philadelphia, published in the American Journal of the Medical Sciences (Oct. 1862, p 395), describing two cases of opium poisoning, in which belladonna was employed with other measures, and giving a brief account of what was known on the subject up to the time at which he wrote. Since then, numerous cases have been published in which these medicines have been employed with apparent success as antidotes, the one of the poisonous effects of the other ; and the general sentiment of the profession is probably favourably inclined to the idea of their mutual corrective powers. I have examined many of these reported cases, and have come to the conclusion, that we should not be justified, by anything which has yet been published, in relying practically upon the entire adequacy of either of these narcotics to the prevention of the poisonous effects of the other, and especially upon that of belladonna to obviate the danger from excessive doses of opium. In the first place, very many of the cases of poisoning from these narcotics, even from large quantities, end favourably, without any aid from the physician, sometimes in con- sequence of the spontaneous occurrence of vomiting, sometimes from a remarkable insusceptibility of the patient, but still more frequently from the dose taken having been sufficient to produce very alarming symptoms, and yet not large enough to destroy life ; and it is very obvious, from a perusal of the published cases, that many of them belonged to this cate- gory. Secondly, in a large proportion of the cases recorded, measures had been successfully used for the evacuation of the poison, even at an early period ; and this measure alone, if complete, is often sufficient to save life Thirdly, in almost all instances, other remedies were em- ployed in connection with belladonna, in opium poisoning, such as had often before proved efficient ; so that it would be impossible to deter- mine to which one, or to what combination of them, the favourable result was really ascribable. Besides, cases of failure have been re- 790 GENERAL STIMULANTS. [PART II. corded as well as successes ;* and experiments have been performed, which, if confirmed, must, as appears to me, be decisive against the opinion of a mutual antidotal power. Dr. Bois has published, in the Gazette des Hopitaux, an account of experiments, in which large doses of morphia and atropia were injected successively into animals, with conse- quences which induced him to conclude that, so far from neutralizing each other, they produced conjointly more powerful poisonous effects than could proceed from either acting separately. (Arch. Gen., Aout, 1865, p. 203.) Nor is this otherwise than might be reasonably ex- pected a priori. Both poisons operate with a powerfully congestive influence on the brain ; and both destroy life in the same way ; that is, either by suspending respiration, or by the vast secondary prostration consequent on their primary excitant action. It is true that in some points they actually are antagonistic. Thus one contracts, the other ex- pands the pupils ; one agitates and greatly disturbs the cerebral functions, the other has a composing influence on these functions. This probably happens in consequence of a special direction of each poison to separate nervous centres ; while, in regard to their fatal effects, they operate upon the same. Therefore, though belladonna may expand a pupil contracted by opium, and partially rouse a patient from the torpor produced by the latter; yet, in their fatal action on the respiratory centres, and in the sec- ondary prostration, they coincide, and augment each other's effects ; and at least in one of the fatal cases on record, it seems to me highly probable that death, which was caused by great debility, was really the result of the conjoint prostration from excessive doses of the two narc6tics. To produce a decided impression in opium poisoning, large doses of bella- donna are considered needful, and the quantity sometimes exhibited has been such as under other circumstances might endanger life. This fact has been advanced in support of the idea of antagonism ; but the fact is that, when the nerve centres are under any powerful impression, much larger doses of one of the narcotics is required to produce a given effect than under ordinary circumstances. The enormous doses of opium tol- erated and required in tetanus, delirium tremens, and some cases of neuralgia are familiar to every one. So, when the system is under a * A case is recorded in the Bost. Med. and Surg. Journ. (Ix. 468), in which over- doses of sulphite of morphia and extract of belladonna were by accident taken simul- taneously, and in which, instead of any material counteraction, there was an exag- geration of effect, which could scarcely have arisen from any other cause than the conjoint influence of both. In the Med. Times and Gaz. (Nov. 18!>6, p. 473), there is an account of a casein which the two poisons were taken in connection; a liniment intended for external use, containing extract of belladonna and laudanum, having been swallowed by mistake. The symptoms of the two narcotics were. jointly pro- duced; and, though there was scarcely enough of either or both together to cai!-*o death, yet the symptoms were alarming. (Note to the third edition.) CHAP. I.] CEREBKAL STIMULANTS. BELLADONNA. 791 strong influence from opium, much more belladonna is required for the production of its own peculiar phenomena than in ordinary health. From all this it results, that it would be very hazardous to trust a case of poisoning from belladonna or opium exclusively to the supposed anti- dotal powers of either. Still, both of these narcotics may be. advan- tageously used, with due attention to their special influences. Thus, the excessive agitation of belladonna poisoning, and the prostration of its advanced stage, may be relieved by the composing and stimulant influ- ence of opium ; while the stupor and depression which mark the later stage of the effects of opium, may be counteracted by the agitating and supporting action of belladonna ; but care should be taken that the two should not coincide in their poisonous effects; that is, that neither the early nor the advanced stages of their action should come together. As has been before mentioned, one of the great dangers of opium poison- ing is the secondary prostration. Here belladonna may be used as a stimulant, in like manner as brandy, carbonate of ammonia, etc. In the similar stage of belladonna, when the great danger is debility, opium may sometimes perhaps save life by its stimulant action, in the same manner as the alcoholic stimulants. On the lower animals the effects of belladonna vary greatly. The herbivorous eat the plant with apparent impunity, while the carnivorous are affected like man. Instances are mentioned in which the horse, the ass, and rabbits have eaten of it freely, with no observable symptoms, while dogs are poisoned. A rabbit was fed on it for eight days, and was not observed to suffer. (Journ. de Pharm., x. 85.)* 2. Mode of Operation. Belladonna is a feeble local irritant, has upon the circulation either a moderately excitant effect, or no direct effect whatever, and powerfully stimulates the brain. It undoubtedly operates on the system through absorption. The proofs of this fact are that it produces the same effect to whatever surface it may be applied, even when introduced into the * The generally admitted fact, that plants poisonous to man are taken with im- punity by certain of the lower animals, does not, according to M. Lemattre, imply that the active principles are not poisonous to these animals, if absorbed into the circulation. M. Lemattre found that all animals, upon whioh the trial was made, were susceptible of the poisonous action of atropia, and the other solanaceous alka- loids. The impunity, therefore, with which rabbits, goats, etc., may eat the leaves of the belladonna and stramonium plants must be attributed to the non-absorption of the alkaloids from the stomach, or so slow an absorption that sufficient does not enter the circulation at one time to produce deleterious effects. This may be ex- plained in part by the fulness of the stomach with various fresh vegetable matters, which interfere with the rapid digestion of the poison. (Archives Gen., Juillet, 1865, p. 89; also Lancet, Sept. 2, 1865, p. 269.) Note to the third edition. 792 GENERAL STIMULANTS. [PART II. blood, and that its active principle has been detected in the urine. It is asserted that the urine of a rabbit which had been fed upon it, caused dilatation in the pupil of a cat to which it was applied. According to M. Runge, of Berlin, belladonna, stramonium, and henbane, are the only substances which have this effect on cats. (Orfila, Toxicologie.) The circumstance that this plant, as well as others of the same natural family of Solanaceae, is eaten by some animals with impunity, while it kills others, proves that the medicine acts on the susceptibility of the tissues, and not by a chemical reagency upon their organization. From the suc- cession of phenomena produced, it may be inferred that belladonna acts with a powerful irritant influence, primarily on the centres of conscious perception in the brain and annular protuberance, and subsequently on the spinal marrow ; as sensibility to pain is lost, while yet reflex action continues, showing a persistent sensitiveness of the gray matter of the cord. The congestion of the cerebral membranes and those of the upper part of the spinal cord, observed after death, confirms this view of the operation of the poison. (Lemaltre.) One of the most curious effects of this medicine, and of other Solana- ceae, is that which they exert on vision and the pupil. The dilatation of the puj.il i.s probably owing to an irritant influence upon the centres of the sympathetic nerve, a branch from which governs the action of the dilating fibres of the iris. Its influence on vision may be ascribed, when complete amaurosis exists, to a constriction of the blood-vessels of the retina, depriving it for a time of blood, and, of course, of sensibility. but a less degree of visual disturbance, such as presbyopia, or an ina- bility to see near objects, while the distant are visible, is probably refer- able to the action of the sympathetic on the ciliary muscles, thereby disturbing the accommodating powers of the eye. When belladonna is locally applied to the eye, the effect is much more prompt than from its internal use, and quite as great if not more so. But, under these circum- stances, the vision is not affected, and the nervous centres of the retina, therefore, not acted on. Generally only the eye to which the application is made is affected ; but it is asserted that the other eye sometimes par- ticipates ; in which case it is possible that the medicine may have been absorbed, and reached the cerebral centres. The dilatation of the pupil and dimness of vision appear to be direct, without any preceding excita- tion of the organ. 3. Therapeutic Application. It is uncertain whether belladonna was used by the ancients as a medicine. The earliest account we have of its employment in modern times was about the close of the seventeenth century, when it appear- to have passed from empirical use into the hands of the regular profes- CHAP. I.] CEREBRAL STIMULANTS. BELLADONNA. 793 sion. At first it was chiefly valued as a remedy in cancerous tumours and ulcers, of which it was supposed sometimes to effect cures; and cases were recorded which would go far to confirm this opinion of its powers, did we not know how frequently erroneous diagnosis has led to false estimates of the efficacy of medicines in these affections. At present there are very few who would maintain that belladonna could do more than palliate in true cancer. But, though now little employed in those complaints for the cure of which it was first brought into notice, it has been found, by abundant experience, to possess powers which render it highly useful for various other purposes. Indications. The chief indications which belladonna is calculated to fulfil are, 1. to subdue pain, 2. to relax muscular spasm and rigidity, - 3. to stimulate the nervous centres, and 4. in reference specially to the eye, to lessen the sensibility of the retina, and dilate the pupil. As a soporific, it cannot be relied on, and is, I believe, never employed. One mode in which it operates, in answering these purposes, is by rendering the nervous centres insusceptible of irritative impressions, and incapable of transmitting irritative action ; but there can be no doubt that it is capable also of operating directly on the peripheral sensibility of the nerves, and of producing the same insusceptibility at their extrem- ities as at their centres. Whether it acts in this way by an immediate or by an indirect sedative agency it would not be easy to determine; but, as the evidence is irresistible that it occasionally does stimulate the nervous centres, it is safest to admit that in this respect its action is uni- form, and that the depression evinced is an indirect result of an active congestion in all instances. What tends to confirm this view is, that tht- medicine has not been found applicable to cases, in which the nerv- ous centres were already in a state of active congestion or inflammation; the very condition in which it would seem to be specially indicated, were it directly sedative. In the relief of painful and spasmodic affections, belladonna seems to be capable of something more than a mere temporary influence. Not only does it give ease ; but, by a perseverance in its use, we not unfre- quently obtain positive cures from it, which opium itself, though more powerful as a mere anodyne, is unable to effect. It would appear, there- fore, to produce some permanent modification in the nervous tissue, in- compatible with that which existed in its morbid condition, in other words, 1<> art as an alterative as well as an anodyne. Another advantage which it possesses over opium, in the treatment of chronic or frequently repeated painful affections, is its entire exemption from the liability of abuse as an exhilarating agent, which constitutes one of the greatest objections to the use of that most fascinating drug. Contraindications. The contraindications to the use of belladonna are, as in this class of medicines generally, active congestion or inflam- 794 GENERAL STIMULANTS. [PART II. mation of the brain, inflammation of the stomach, high inflammatory or febrile excitement, and a plethoric state of system ; in all which condi- tions, should any special symptom call for this remedy, its use should be preceded by depleting measures. I shall treat of the special complaints in which belladonna is used, under the several indications above mentioned. 1. For the Relief of Pain. a Neuralgic Affections. In these belladonna displays its most useful powers ; and I know few remedies more effectual in their cure. No matter where the pain is seated, provided it be purely functional, that ' is, connected with no inflammatory or other organic disease affecting the nerve or its centre, the medicine may be employed. It may be used both internally and locally ; and, when the pain is near the surface, or in any position to which near access can be obtained, it is generally advisable either to depend on the topical use of the remedy, or to em- ploy it in the two methods jointly. The general rule is to administer it in quantities sufficient to produce obvious effects, without going so far as to cause delirium, stupor, or dimness of vision approaching blindness. Though these latter phenomena have seldom if ever proved really dangerous, when proceeding from medicinal doses, yet they are not necessary to the anodyne effect, and are, therefore, better avoided. I am in the habit, in neuralgic cases, of giving half a grain of the extract three times a day, and, if no effect is experienced from this dose, of gradually increasing it, until dryness of the throat, dimness of vision, dilatation of the pupil, slight frontal uneasiness, or feelings of fulness or giddiness in the head are produced ; and of afterwards so managing the dose that these effects should not be exceeded. Sometimes the first dose will act with unexpected energy; in which case it should be reduced to one-third or one-quarter of a grain, and afterwards increased again if necessary. More frequent repetition than three times a day is unneces- sary to maintain a continued operation of the medicine, and might lead to cumulative effects. Both in the neuralgic and spasmodic diseases belladonna may often be very advantageously associated with those tonics which have the effect of strengthening the nervous centres, as quinia, the chalybeates, and the preparations of silver, copper, and zinc; the narcotic and tonic being administered conjointly in the same pill, or separately, as may be most convenient. Modes of Application in Neuralgia. Some remarks in relation to 'the method of using the remedy locally in these cases m:iy l>r advisable here. A decoction of the leaves maybe employed, or tin- extract ; and one or the other of these may be used in the form of lotion, cataplasm, liniment, ointment, or plaster. Of the use of atropia 1 shall treat under * CHAP. I.] CEREBRAL STIMULANTS. BELLADONNA. 795 a separate head. The extract may be brought into the state of liniment by simply rubbing it with a little water; and of an ointment by incor- porating it with lard. The plaster is officinal. Usually it will be suffi- cient to make the application upon the unbroken skin ; but the effect is more speedy and much more powerful when the remedy is used ender- mically, the cuticle having been removed by a blister. In this case, the extract should be used mixed with water or lard, and never at first in quantities exceeding two or three grains, which may be increased if neces- sary. As it occasions some pain if brought into direct contact with the denuded surface, it may be applied, as recommended by MM. Trousseau and Pidoux, spread on a piece of linen with the uncovered surface next the skin, and protected by means of adhesive plaster. The effect is thus gradually produced, and without pain. To the writers just named I am also indebted for some of the following observations in relation to the local use of the medicine in special cases. In neuralgia of the scalp, a decoction of the leaves made in the pro- portion of half an ounce to the pint of water may be used locally. With this the hair may be saturated ; and a thick linen compress thor- oughly moistened with it, having been applied over the head, the whole should be covered with a cap of oiled or waxed linen, or silk. A solu- tion of the extract in the proportion of a drachm to the pint, or the officinal tincture diluted with four parts of water, may be similarly em- ployed. In supra-orbital neuralgia, or that of the eyeball, from five to ten grains of the extract, mixed with a little water, may be rubbed upon the lids and around the eye, with gentle friction, for ten or fifteen minutes; and the process may be repeated every two or three hours, the part being in the mean time covered with a light compress, until the pain is relieved. Or a cataplasm made with a solution of the extract and flax- seed meal may be applied over the whole eye. The same method may be employed in other forms of facial neuralgia; but in the infra- orbital and submaxillary forms, the authors above mentioned prefer the friction to be made upon the gums or inside of the cheeks. Of course, care must be taken that the patient do not swallow the medi- cine. In painful affections of the ear, a solution of the extract may be injected into the meatus, and cotton afterwards introduced impregnated with the same. In toothache, the extract itself may be introduced into the carious cavity. In neuralgia of the limbs or trunk, the application should be made as near to the seat of pain as possible; and in these, the endermic method will often be advisable. In sciatica, which is one of the most obstinate forms of the affection, the blistered surface should be made in the course of the nerve as it passes out of the pelvis. MM. Trousseau and Pidoux have met with great success, in very obstinate cases of this affection, by 796 GENERAL STIMULANTS. [PART II. making an incision through the skin, between the great trochantor and ischium, and inserting a ball in the form of a pea, containing from one to five grains of the extract with a little opium ; thus gaining the effects of an i>suc> with those of the narcotic. In angina pectoris the medicine has been used locally with advant- age. Dr. Davies relates a case in which a plaster of belladonna was applied to the chest after tartar emetic, and before the ulcers from this had healed. Alarming symptoms were induced; but, on their subsi- dence, it was found that the angina had ceased. (Led. on Dis. of Lungs and Heart, p. 496.) In the internal neuralgic affections of the abdomen, as gastralgia, enteralgia, nephralgia, etc., the external use of the medicine should be resorted to when the complaint is complicated with vomiting or purging, while opium is used internally. But, in the contrary condition of con- stipation, it would be better to try the effects of extract of belladonna internally. Lead colic and nervous colic, which are really forms of intestinal neuralgia, may be advantageously treated in their milder and more chronic conditions, with belladonna combined with alum or iodide of potassium internally, and frictions with an ointment of the extract ex- ternally over the surface of the abdomen. b. Rheumatic and Gouty Disease. Among the painful affections which, in like manner with neuralgia, may be treated with the internal and ex- ternal use of belladonna, are rheumatism and gout. The medicine has been employed even in acute rheumatism, and is asserted to have proved very successful. After a proper use of the lancet, and in connection with purgatives and arterial sedatives, I have no doubt that it would prove serviceable, given so as to maintain a constant and decided impression ; and, in cases where some 'idiosyncrasy may forbid the use of opium, might be had recourse to with great propriety. But it is in the nervous or neuralgic forms of these diseases that belladonna is especially indj- cated ; and here it is among the most efficacious remedies. It is also frequently serviceable in the shifting forms of subacule rheumatism without fever; and, in the chronic forms of the same disease, is a standard remedy, given in connection with one or more of the various alteratives used. In this form of the disease it may also be advanta- geously employed locally, in the shape of poultice or plaster; the former being most conveniently applied to the joints, the latter over muscular parts, as to the small of the back in lumbago, and to the side in pleurodynia. c. Other Painful Affections. There is a number of painful affections, local in their character, in which the topical use of belladonna has been resorted to with more or less benefit. In dijsmenorrhcea it has been in- ' troduced into the vagina, either by injecting a decoction of the leaves or CHAP. I.] CEREBRAL STIMULANTS. BELLADONNA. 797 solution of the extract, or in the form of a pill containing half a grain or a "Train of the latter preparation. Fissures of the anus, painful piles, and excessive sensitiveness of the rectum, may often be usefully treated with an ointment made by mixing the extract with lard ; not more than from half a grain to a grain and a half of the former being used at the first application, especially if introduced within the sphincter. Phymosis and paraph ymosis, sivelled testicle, inflamed urethra, and various pain- ful tumours and ulcers, cancerous, scrofulous, or simply phlegmonous, are additional affections in which the extract has been recommended, in the shape of cataplasm or ointment, with the view of relieving pain. 2. For the Relief of Spasm or Muscular Rigidity. Singular as it may seem, the painful spasmodic affections are less benefited in general by belladonna than either pure neuralgic pain, or spasmodic affections without pain. Thus, spasms of the stomach, bowels, ureters, hepatic ducts, etc., and those of tetanus, do not yield readily to belladonna, perhaps because the centres of irritation in these cases are in the spinal marrow, upon which that narcotic may exercise less power than on the cerebral centres. Still, the medicine has been used in tetanus, and in certain colicky affections, and not without favourable results. Cases are on record of its successful employment in spasmodic constriction of the bowels, with obstinate constipation, and even in ileus. As a remedy iu colica pictonum, it has already been spoken of; bat this is rather a neuralgic affection of the bowels, than simply spas- modic, and, moreover, probably depends more on the local influence of the lead upon the nervous tissue of the bowel itself, than upon the nervous centres. In cholera it is said to have been advantageously employed in large doses; and, independently of its use in relieving the spasms of that disease, it may possibly act favourably, by its stimu- lant influence over the sympathetic centres, causing a contraction everywhere of the relaxed capillaries, and thus restraining the excessive discharges. In painless spasms, the medicine is often highly beneficial. In these affections, it not only yields relief, but serves, as in neuralgia, to make a permanent impression on the nervous centres, which sometimes proves curative; and, in like manner, may be usefully combined with the anti- spasmodic tonics, as quinia and various metallic salts. It will very seldom cure epilesy; but, in some purely functional cases, it is said to have had this effect, and it will often ameliorate the symptoms. The patient should be kept under its very moderate influence for a long time, with oc- casional intermissions ; and, about the period of the expected paroxysms, it should be given more freely. In the non-epileptic convulsions of puerperal women and children it has been highly recommended ; but should not be given when in these 798 GENERAL STIMULANTS. [PART II. cases there is active cerebral congestion, or any suspicion of inflamma- tion. In infantile cases, it should be confined to the convulsions which depend on some extra-cranial irritation, such as teething or spasm of the bowels. In both instances, it is best adapted to those attacks in which there is a frequent recurrence of the paroxysms, and should be given in the interval, in order to prevent the convulsions, and not during their continuance. On the continent of Europe, belladonna was long since used in hooping-cough, but was neglected until the practice was at a recent period revived by Bretonneau. In this country, it has been employed and highly recommended by Dr. Samuel Jackson, late of Northumber- land, who gave to children two years old from the twelfth to the sixth of a grain of the extract, twice or three times a day, increasing the dose until the pupil became dilated. Dr. Hiram Corson, of Montgomery County, Pennsylvania, also used it with great success. My own ex- perience with it is confined to a single case. This occurred in an infant, to the chest of which I applied a belladonna plaster. The child was soon afterwards attacked with convulsions, which were frequently re- peated, and very alarming. It recovered, however ; and the hooping- cough ceased with the convulsions. It is possible that the medicine may have cured the disease, and may not have caused the convulsions, which are not uncommon in hooping-cough ; and I am disposed to think that this was really the case ; for belladonna very rarely produces this effect, even in poisonous doses. The occurrence, however, deterred me from afterwards having recourse to the remedy in that disease. It is thought by some to be more efficacious in hooping-cough, when associ- ated with sulphate of zinc. In asthma it has been strongly commended. It has been used in- ternally in this complaint, being given during the intervals of the par- oxysms, so as to sustain a steady impression ; but the most efficient method of employing it is by the inhalation of its fumes. For this pur- pose, the dried leaves may be smoked in a pipe, or in the form of cigars, made like those of tobacco. Great care, however, must be taken that too great a narcotic effect is not produced. This use of the remedy no doubt originated in a similar employment of stramonium, which very closely resembles belladonna in its medical properties. Another mode of using the remedy, in the same complaint, is by inhaling the vapour from a decoction either of the leaves or extract ; two drachms of the former, or fifteen grains of the latter, being boiled with a pint of water. The smoking of the leaves, steeped when fresh in a strong infusion of opium and then dried, is said to have afforded relief in phthisis. As the breathing of the fumes arising from the combustion of paper, impreg- nated with nitre, often affords great relief in the asthmatic paroxysm, the idea occurred to M. Dauncey, an apothecary of Bordeaux, that advantage CHAP. I.] CEREBRAL STIMULANTS. BELLADONNA. 799 might accrue from a similar impregnation of the leaves of belladonna before being smoked. Accordingly he prepared cigars from leaves thus treated, and found them to answer the purpose intended. A solution of nitre containing three ounces is sprinkled on three avoirdupois pounds of the leaves, spread out after drying. The nitre thus penetrates the tissues of the leaves, and is left after the dissipation of the moisture. Another advantage of the preparation is that the carbonaceous matter of the smoke is consumed in the combustion. (Am. Journ. of Pharni., xxx. 404.) In muscular rigidity, the local application of belladonna has been found very useful in a number of different affections. In constriction of the sphincters of the anus and neck of the bladder, and in spasm of the urethra, it has been employed in poultice, or in the way of friction to the perineum, with the extract mixed with lard ; and, in the urethral affection, it has been introduced into the passage by means of a bougie smeared with the ointment. Rigidity of the os uteri in delivery is said sometimes to yield to the local application of the extract. It has been employed externally in strangulated hernia, to produce relaxation of the abdominal muscles. M. Chrestien, of Montpellier, in France, speaks very strongly of the favourable influence of the extract of belladonna, rubbed over the surface of the tumour, in reducing the strangulated bowel. (Arch. Gen., Dec. 1865, p. 743.) Under the impression that vomiting in pregnancy is sometimes caused by irritation from a spasmodic contraction of the uterine fibres, resisting the expanding growth of the foetus, Bretonneau was induced to employ friction with the extract over the hypogastric region, and met with great success. It is unnecessary to admit his theory of the influence of the medicine, which may relieve other disorders of the uterus besides con- striction of its fibres, and thus obviate sympathetic irritation elsewhere ; but the fact is important. Its accuracy is confirmed by the experience of MM. Trousseau and Pidoux ; and the late Dr. R. L. Scruggs, of Louisiana, employed the remedy repeatedly, with uniform success. He also succeeded, by the same method, in relieving an obstinate and dis- iiv-sing cough, apparently dependent on irritation from the impregnated uterus. (South. Journ. of Med. and Phys. Sci., i. 318.) 3. To Stimulate the Nervous Centres. In reference to this indication, belladonna has been used in certain conditions of paralysis with asserted success, particularly in paraplegic cases. It is quite obvious that it should never be employed in cases de- pendent on congestion, inflammation, or organic lesion of the nervous centres, until this condition shall have ceased entirely, and nothing is left but mere inertness. In paralysis combined with neuralgic pains, as in lead palsy, we may readily conceive that the medicine may act fa- 800 GENERAL STIMULANTS. [PART IT. vourably. In amaurosis, moreover, it is said to have proved useful ; but here also the affection should be purely functional to justify its employ- ment. Belladonna has been used in insanity, particularly in its melancholy forms ; and it is probably useful in cases similar to those in which opium proves advantageous, but it is so much inferior to that narcotic, that unless some special objection to opium may exist, it would scarcely be worth while to employ it. When complicated, however, with neuralgic pains, the disease would present a much stronger indication. In delirium tremens it has been used like most other narcotics ; but, as it has little tendency to produce sleep, which is the great object aimed at here, it would not seem to be specially called for. In this complaint the pupils are often very much contracted ; and belladonna has been suggested as an appropriate remedy, because one of its most constant effects is to dilate the pupil. Dr. James Grieve, of Dumfries, Scotland, has used it locally to expand the pupil, and thus to obviate spectral illusions which he supposed might be connected with this condition of the iris. I tried it in one instance, with no satisfactory result. Besides, one of the characteristic effects of belladonna, when given largely, is to produce illusions. Under this head we may introduce a notice of the use of belladonna in the nocturnal incontinence of urine of children. There can be no doubt of its frequent usefulness in this affection. It should be given at bedtime, and continued for a week or two before being relinquished if unsuccessful. If it prove efficacious, it should be persevered with for some time after apparent cure, in order to break up the habit. It prob- ably acts either by giving greater energy to the sphincter through the nervous centre which regulates its action, or by rendering it, through a congestive influence on the centre, insensible to irritant impressions. A similar efficacy has been claimed for the remedy in fecal incontinence occurring in children. (Bulletin Gen. de Therap , Aout 15, 1855.) Upon the same principle of its action on the nervous centres, must be explained its asserted influence in preventing the very serious reflex in- juries following extensive burns. 4. In Reference to its Influence upon the Eye. Belladonna is employed in affections of the eye with two objects ; one to diminish the sensibility of the retina or optic nervous tvntre, and the other to dilate the pupil. With the first object, it may be employed in that not uncommon condition of the eye, in which, altogether independ- ently of inflammation, light in extremely painful to it, and, though the vision is in no degree impaired, the use of the organ for any length of time is impossible, in consequence of the pain induced. It has also been advised in the similar sensitiveness which attends ophthalmia; though its appropriateness, in the latter condition, is more equivocal. CHAP. I.] CEREBRAL STIMULANTS. BELLADONNA. 801 For the dilatation of the pupil belladonna is much used by the sur- geons. It is the local application of it that is resorted to for this pur- pose. The infusion of the leaves, or solution of the extract may be dropped into the eye, or the extract itself, mixed with a little water or lard, may be rubbed upon the eyelids and around them. By many atropia is preferred for the purpose on account of cleanliness. The dila- tation usually begins in about half an hour, is at its height in three or four hours, and may continue one or two days or longer. The objects in producing dilatation with it are manifold. Before the operation for cataract, it is useful by removing the iris out of the way : and, after the operation, has been recommended, in order to prevent the adhesion of the iris and obliteration of the pupil, which might result from inflammation of that membrane. In operations which involve a wound of the iris, it is supposed to be indicated upon the same score. It is said that even in partial or complete obliteration of the pupil al- ready produced, if recent, the remedy will obviate the evil by causing a separation of the adhesions while still soft. In iritis, either exclusive, or attendant upon conjunctivitis, it has been recommended with the same view of obviating obliteration of the pupil. In cases of commencing cataract, it is sometimes temporarily serviceable by bringing within reach of the light the yet unaffected portions of the lens nearest the cir- cumference. In opacity of the cornea., moreover, in which vision is ob- structed by the position of the opacity immediately before the pupil, it occasionally restores sight for a time by dilating that orifice, so that the light passing the transparent parts of the cornea may enter it. Belladonna has been used for other purposes besides those mentioned. It has been recommended in scarlet fever, both as a remedy and pro- phylactic. I have no confidence in its efficiency in either capacity. Its use was suggested by the originator of the homoeopathic delusion, upon the basis of one of his dogmas, that diseases are cured by remedies the effects of which resemble the disease itself. Belladonna causes dryness and irritation of the fauces, and sometimes a rash like that of scarlet fever; therefore it is the appropriate remedy for that complaint. If it be capable of acting rernedially, it is probably capable also of preventing the disease. Such is the rationale of its use. Though I would accept a useful fact from the homceopathists, or any other class of men what- ever, or from any source whatever, I should be disposed to subject it to a close scrutiny before admitting its claims to be a fact. I think that many in our profession have been somewhat too hasty in adopting this scion of a false hypothesis. It is true that, in many instances, numlx-rs of children to whom belladonna has been administered, have escaped scarlatina though exposed to the cause ; but nothing is more common VOL. i. 51 802 GENERAL STIMULANTS. [PART II. than a similar result where belladonna has not been given. Every one knows, who has seen much of this disease, that it is extremely capricious in its choice of subjects, sometimes attacking all the children of a family, and not unfrequently seizing upon one only of a large number equally exposed to the cause ; so that the exemption, under the circumstances referred to, might well have taken place, though no preventive had been used. Besides, numerous trials have been made by persons quite as de- serving of credit, in which the use of belladonna has entirely failed in securing the desired exemption, which could not have happened were it possessed of the power ascribed to it. The mistake might be a very fatal one, if, in reliance upon the prophylactic virtues of belladonna, other means of securing exemption, such as common sense would sug- gest, should be neglected. The medicine is asserted to possess antaphrodisiac properties, and to be useful in priapism, chordee, and other irritated conditions of the sexual organs. It probably operates here, like other narcotics in the secondary stage of their action, by diminishing the sensibility of the nervous centres. Another application made of belladonna is to arrest the secretion of milk, when the infant is from any cause withdrawn from the breast. For this purpose a solution of the extract, or an ointment made by rub- bing it with lard, may be applied to the areola and around it. The dis- tended and painful breast is said to be thus greatly relieved, and the practice has been extensively adopted But the remedy is by no means uniformly efficient (Bost. Med. and Surg. Journ., Iviii. 487, and lix. 80); and a case has been recorded in which serious poisoning was produced by the application made to an abraded breast (Lancet, Nov. 11, 1865, p 536). Care, therefore, must be taken that the extract should be used in this way only when the cuticle is unbroken. The local application of belladonna in the form of tincture, or of lini- ment made with the extract and lard, has been recommended by Mr. Cooke, of Scarborough, England, as affording great relief in erysipelas, inflamed chilblains, boils, and carbuncles. (Med. Times and Gaz., July, 1858, p. 126.) Another local application of belladonna which has been recommended is for the relief of the tenesmus of dysentery. For this purpose the ex- tract or atropia may be used, in the form of a suppository made by incor- porating it with cacao butter. 4. Administration. After what has been stated above, little remains to be said on this point. Belladonna may be given in substance, infusion, extract, or tinc- ture; and there are two officinal preparations intended exclusively for external use, namely, the plaster and ointment. Atropia is also among the officinal preparations. CHAP. I.] CEREBRAL STIMULANTS. BELLADONNA. 803 The commencing dose of the powdered leaves is one or two grains, to be repeated two or three times daily, and to be gradually increased until the effects of the medicine are produced. When the leaves have not been injured by time, ten or twelve grains daily can rarely be ex- ceeded without inconvenient effects. The Infusion may be prepared by macerating a scruple of the dried leaves in ten fluidounces of boiling water. The dose at first is one or two fluidounces two or three times daily, to be increased as in the case of the powder. The medicine, however, in this county, is much more used in the form of extract than in any other way. The U. S. Pharmacopoeia directs two extracts, one of which is the inspissated juice, and the other is pre- pared by means of diluted alcohol. EXTRACT OP BELLADONNA. EXTRACTUM BELLADONNA. U. S., Br. This is prepared by bruising the fresh leaves, expressing the juice, heating this to the boiling point so as to coagulate the albumen, then straining, and evaporating the clear liquor to the proper consistence. It has a dark-brown colour, a narcotic not disagreeable odour, a bitterish taste, and a soft consistence. As used in this country it is generally imported, and is of unequal strength, sometimes very powerful, some- times feeble, and therefore requiring to be administered with much cau- tion. Special care must be taken that, in increasing the dose, the same parcel should be employed ; and if a new one is to be used, the dose should be reduced so as to test its strength. This is the preparation most employed in the United States. The commencing dose is from one-quarter to one-half a grain, twice or three times a day, gradually in- creased, if necessary, until some sign of its action is produced, as dry- ness of the throat, dimness of vision with dilatation of the pupil, or uneasy sensation in the head. I have often known half a grain to act decidedly. In the way of enema not more than three times as much should be given as by the mouth. For endermic use, three or four grains may be employed, but its effects should be watched. If no effect is produced, the quantity may be increased. For friction on the sound skin, from ton to thirty grains or more may be used, with sufficient water to bring it to the consistence of thick cream, or with twice its weight of lard. ALCOHOLIC EXTRACT OP BELLADONNA. EXTRACTUM BELLADONNA AI.COHOLICUM. U. S. The alcoholic extract is prepared by evaporating a tincture of the leaves made with diluted alcohol. The dose is half a grain to begin with. TINCTURE OP BELLADONNA. TINCTURA BELLADONNA. U. S., Br. This is made in the proportion of four ounces of the dried leaves to 80 i GENERAL STIMULANTS. [PART II. two pints of diluted alcohol. It is an efficient preparation, if made from recently dried leaves. The dose is fifteen or thirty drops, or half the number of minims, to be increased as the other preparations. Not more than one- sixth or one-eighth of the doses above mentioned should be given at first to a child two years old. PLASTER OP BELLADONNA. EMPLASTRUM BELLADONNA. U. S., Br. This is prepared by incorporating the extract (alcoholic extract, U. S.) with melted resin plaster. It is used, spread upon coarse linen or leather, in rheumatic pains, neuralgia, dysmenorrhoea, etc. I have known the system to be affected by it; and a case is on record in which even alarming symptoms resulted from the application of this plaster to a surface covered with an eruption, and partially ulcerated. OINTMENT OP BELLADONNA. UNGUEXTUM BELLADONNA. U. S., Br. This consists of one part of the extract and eight of lard mixed. It is used for friction upon the skin, or as a dressing to blistered surfaces. For the latter purpose, not more than half a drachm or two scruples should be applied at first. LINIMENT OP BELLADONNA. LINIMENTUM BELLADONNA. Br. This is a very concentrated tincture of the root of belladonna, intended exclusively for external use. It may be applied by means of a camel's- hair pencil, or may be diluted with two or more measures of soap lini- ment, and rubbed upon the part. It is peculiar to the British Pharma- copoeia. ATROPIA. U. S., Br. This is thought to exist in belladonna, combined with malic acid in excess. For an account of the different somewhat complex processes by which it is extracted, the reader is referred to the U. S. Dispensatory. Mr. W. T. Luxton, of London, proposes the following simple method. To a decoction of the leaves he adds a little concentrated sulphuric acid, which precipitates the albumen and forms sulphate of atropia; then, having drawn off the clear liquor, he precipitates the atropia either by solution of ammonia, or tin- Beaquicarbonste of that alkali. After a day or two the clear liquid is drawn off, and the crystals which have formed, having been thrown on a filter to dry, are washed with a little spirit of ammonia, which deprives them of most of their colouring matter, leaving them " moderately" white. He has thus generally obtained about 5.5 parts from 1000 of the leaves, while the process usually employed yields only 3 parts for 1000. (See Am. Journ. of Pharm., xxvii. 156.) Atropia is in white, translucent, silky, acicular crystals, inodorous, of a bitter acrid taste, sliirlitly soluble in cold water, considerably more so in ether, very soluble in alcohol, and dissolved by all these liquids in CHAP. I.] CEREBRAL STIMULANTS. BELLADONNA. 805 larger proportion when hot than cold. It melts with heat, and at a higher temperature is dissipated; part being volatilized without change, and the remainder decomposed. It has an alkaline reaction with litmus- paper, and neutralizes the acids, forming crystallizable salts with the sul- phuric, muriatic, and acetic. Nitric acid dissolves it, forming a yellow solution ; sulphuric acid dissolves it without change of colour if cold, but when hot reddens it. Like the other organic bases, it is precipitated by the alkalies from its saline solutions, unless very feeble ; and from the same solutions tannic acid throws down the tannate of atropia. Like most of these, too, it consists of carbon, hydrogen, oxygen, and nitrogen. The effects produced upon the system by atropia are exactly those of belladonna, only that they occur more promptly, and are relatively much more powerful. Thus, the alkaloid gives evidence of its operation in twenty minutes, while the powdered leaves or extract usually require half an hour. Its action continues from twelve to twenty-four hours or longer. One-sixth of a grain, taken into the stomach, generally pro- duces symptoms of a somewhat violent character, as accelerated pulse, dryness and stricture of the throat, dimness of vision with dilated pupil, giddiness, abnormal sounds, phantasms, delirium, and sometimes numb- ness and tingling of the extremities, and strangury, with depression of the circulation and temperature of the surface. Two-thirds of a grain have occasioned the most alarming symptoms, from which, however, recovery took place. For internal use it has little advantage over the other preparations, while, from its small bulk, it might be more liable to be taken in poison- ous quantities. Nevertheless, if pure, it may be more certainly depended on in a given dose, and danger may be avoided with care. It is appli- cable to the same diseases precisely as belladonna itself. The dose at first should never exceed the twelfth of a grain ; and it would be best to commence with the twenty-fourth or thirtieth, which may be repeated two or three times daily, and increased if requisite. Externally, especially for application to the eye, it is preferred by some to the extract, in consequence of the less quantity required, and its greater cleanliness. It may also be used with great effect endermically. It is chiefly employed to dilate the pupil, which it does very promptly, in exceedingly minute quantity. One drop of a solution, containing only a grain in a fluidounce of the menstruum, will produce the effect. M. Steafield recommends for this purpose the use of atropia paper, which may be made by saturating paper with the solution just men- tioned, in such a way, that a little piece, about one-fifth of an inch square, shall be wet with exactly one drop of the solution. The paper is then dried, and, when wanted, may be applied by drawing down the lower lid, and placing the piece of paper upon the ball beneath the cornea. (Ann. de Therap., 1864, p. 33.) 806 GENERAL STIMULANTS. [PART II. Atropia has also been used hypodermicaUy for the relief of neuralgic affections. Its use in this way has greatly extended of late ; and it has been employed in most other complaints in which belladonna has been thought to be useful. It seems to have been peculiarly efficacious in severe rheu- matic pains of a subacute character, but of considerable duration, espe- cially sciatica. One-twenty-fourth or one-sixteenth of a grain, dissolved in from fifteen to thirty minims of water, may be injected into the sub- cutaneous areolar tissue at one operation; but some cases of unexpected violence from its use in this way have led to peculiar caution in regard to the hypodermic dose ; and it is now recommended not to administer by in- jection, at the first operation, more than one- half the quantity administered by the mouth. It is not improbable that, in the cases where alarming effects have been suddenly produced, the solution may have been injected directly into a punctured vein. To avoid such a result, the point of the instrument may be very slightly drawn back before the liquid is injected. A case is on record in which the -,-^-g- of a graiu produced apparently serious effects. The British Pharmacopoeia directs a Solution of Atropia (LIQUOR ATROPI/I:, Br.\ made by dissolving four grains of the alkaloid in a fluid- ounce of a menstruum consisting of seven fluidrachms of distilled water and one of rectified spirit. Four minims, equivalent to one-thirtieth of a grain of atropia, may be given as a commencing dose, and increased if necessary to ten or twelve minims. Half the quantity may be used for subcutaneous injection. Diluted with four measures of distilled water, it may be used for dilating the pupil. An Ointment of Atropia (UNGUENTUM ATROPIA, Br.) is also officinal in the British Pharmacopoeia, made by first dissolving eight grains of atropia in half a fluidrachm of rectified spirit, and afterwards mixing the solution with one ounce (avoirdupois) of prepared lard. In the appli- cation of this ointment, care must be taken that it do not come in con- tact with wounded, abraded, or ulcerated surfaces. The U. S. Pharmacopoeia directs the Sulphate of Atropia (ATROPIJE SULPHAS, U. S.) ; but it has little advantage over the pure alkaloid, which may be dissolved in water with the utmost facility by means of a little acetic acid. Valerianate of atropia has also been recommended as peculiarly efficacious in asthma; but the dose of valerianic acid is so controlled by that of atropia that it can scarcely exercise any observable influence. The following preparations may be made for use. Dissolve one grain of atropia in a fluidrachm of alcohol, and add seven fluidrachms of distilled water to the solution; or mix a grain with a fluidounce of pure water, and drop in diluted acetic acid till the solution is effected. Of either of these preparations, fifteen minims may be given for a com- mencing dose, and a drop or two may be introduced into the eye in order to dilate the pupil. An ointment may be made by rubbing up five CHAP. I.] CEREBRAL STIMULANTS. BELLADONNA. 807 grains thoroughly with three drachms of lard; of which a portion about as large as a pea may be used in friction to the eyelids and face, to dilate the pupil, or relieve neuralgia. Another method is to paint the eyelid with a solution of atropia in a chloroformic solution of gutta percha. When atropia is applied to a blistered surface, or that of an ulcer,, not more than the dose given by the mouth should be used at first, in consequence of its very rapid absorption. It causes when thus em- ployed a slight pain, which soon ceases. A case of fatal poisoning is said to have occurred from the application to a blister on the neck of an ointment composed of 15.5 parts of sulphate of atropia and 700 parts of lard. (Pharm. Journ. and Trans., June, 1865, p. 664.)* * Atropia and Morphia. Some interesting results have been recently obtained in regard to the physiological action of atropia, and of its relation with the alkaloid of opium. A series of observations on these points were undertaken, under favour- able circumstances, jointly by Drs. S. Weir Mitchell. Win. W. Keen, and Geo. R. Morehouse, of Philadelphia, which eventuated in the following conclusions: and these correspond very closely with the results of similar inquiries made about the same time by Dr. Da Costa, of this city, and subsequently by Dr. Erlenmeyer, of Bendorf, in Germany. In the experiments of Dr. Mitchell and his coadjutors, the alkaloids in solution were injected into the subcutaneous areolar tissue ; the mor- phia, in the form of sulphate, in doses varying from one-third to one-fourth of a grain; the atropia, from one-fifteenth to one-thirtieth. 1. Circulation and Respiration. On the circulation, the first effect of atropia was for a few minutes either nothing, or a slight diminution in the frequency of the pulse; but uniformly tlii. short period of quiescence or diminution (from 4 to 10 minutes) was followed by excitement; the pulse rising from 15 to 40 beats in a minute, con- tinuing thus about an hour, then gradually subsiding till, after about 4 hours, it fell considerably below the natural standard. The greatest depression was in the tenth or eleventh hour, after which it rose again, and became normal in 24 hours. The respiration did not increase in frequency with the pulse, but either remained unaltered, or was slightly depressed. After the injection of morphia, the pulse was not strikingly affected. In a few cases it rose slightly, in a larger number it was unchanged, and in a still larger number fell an average of 8 beats only ; but the fulness was increased with the general influence of the morphia. The respiration was little affected. The general conclu- sion was that morphia subcutaneously administered, in ordinary remedial doses, has no conspicuous influence on the heart and lungs. When the two alkaloids were administered conjointly, the result was precisely the same on the pulse and respiration as when the atropia was given alone; that is, its action was in no degree modified by the morphia. The inference is that, in relation to the functions of circulation and respiration, there is no antagonism between atropia and morphia. 2. Action on the Eye. In their action on the eye, the alkaloids appeared, to a cer- tain extent at least, to neutralize each other. When the pupil was dilated with atro- pia, the injection of morphia caused it, within half an hour, either to return to the normal standard, or to contract still further. So also with the power of accommo- dation, which, however, oftener remained paralyzed for an hour or more after the pupils began to show the influence of morphia; so that in this respect the opiate 808 GENERAL STIMULANTS. [PART II. IX. STRAMONIUM. Datura Stramonium, thornapple, or Jamestown weed, is an annual plant from two to six feet high, growing in all quarters of the world, and flourishing especially in rank soil, as on dung-heaps, and on the road-sides and commons near towns and villages, whore refuse matter is apt to be collected. Its original native country is uncertain. It is often clustered in patches, and scents the air of the neighbourhood with its disagreeable odour. All parts of it are active. The U. S. Pharmacopoeia recognizes the leaves, seeds, and root. 1. STRAMONIUM LEAF. Stramonii Folium. U. S. Stramonii Folia. Br. These have short footstalks, are five or six inches long, unequal at the base, irregularly sinuated and notched at the border, dark green above, and pale beneath. When fresh and bruised, they have a fetid, narcotic odour, which they lose by drying; retaining, however, a bitter and nauseous taste. 2. STRAMONIUM SEED. Stramonii Semen. U. S. Stramonii Semi- na. Br. These are small, kidney-shaped, flattened on the sides, of a blackish-brown colour, without smell, and of a bitter, nauseous, some- alkaloid seemed to be less powerfully antagonistic than in reference to the pupil. The general conclusion, however, was that the two alkaloids neutralized each other in their action both on the retina and the ciliary muscle. 8. Cerebral functions. Here there was found to be a decided antagonism in some points. Thus the headache, phantasms, visual disorder, and deafness caused by atropia were lessened or disappeared under the influence of morphia; while the drowsiness and stupor of the latter alkaloid were controlled by the former. The pallor of morphia and the flush of atropia were also mutually modified. 4. Other actions. The nausea often caused by morphia was not diminished by iitropia. The effects of the two alkaloids on the mucous membrane coincided ; but the property of inducing dryness in the throat was greater in atropia. In producing dysury, they appeared to concur. The influence of morphia in the relief of pain was not disturbed by atropia. According to the same experimenters, neither atropia, daturia, nor conia, has any power of lessening pain when administered hypodermically. In this respect, how- ever, the conclusion of the authors does not coincide with that of many others, who have found great relief to painful affections from the subcutaneous injection of atropia. Dr. Erlenmeyer states that the atropia and morphia given jointly, will, in many cases of neuralgia, succeed perfectly, after entire failure with both adminis- tered separately. (Arch. Gen., Mars, 1866, p. 362.) From all these results it may be inferred that, while a certain degree of antago- nism exists between atropia and morphia on some points, in others they coincide or are indifferent ; and therefore that it would be unsafe to rely upon either exclu- sively in poisoning by the other; though they may be employed to meet certain indications. (See Am. Journ. of Metl. .S'ci., July. 1865, p. 67.) A'ote to the third flit ion. CHAP. I.] CEREBRAL STIMULANTS* STRAMONIUM. 809 what acrid taste. They are stronger in medicinal qualities than any other part of the plant. 3. STRAMONIUM ROOT. Stratnonii Radix. U.S. 1850. This is large, whitish, branched, with numerous fibres, fleshy when fresh, light and spongy when dry, and of very little smell or taste, though it leaves a slightly acrid impression in the mouth when chewed. All these parts yield their virtues to water and alcohol. Active Principle The odour of the plant would suggest that the vol- atile principle might possess narcotic properties ; but it is asserted that water distilled from the fresh leaves, though it has their odour in some degree, is without effect on the system ; and the seeds, which are inodor- ous, are stronger than the leaves. It is probable that the virtues of the plant reside exclusively in an organic alkali, which has been extracted from the seeds, and received the name of daturia. In its sensible, chem- ical, and physiological properties, this bears so close a resemblance to atropia as to have led to the supposition that the two principles are identical ; and if their composition be, as stated by Von Planta, precisely the same, the supposition must be considered as correct. Upon this ground we can explain the extraordinary resemblance of stramonium and belladonna in their effects upon the system, and their remedial appli- cation. Daturia, like hyoscyamia and atropia, is rendered inert by admixture with even a weak solution of caustic potassa or soda, but is not affected by their carbonates. Effects on the System. The operation of stramonium on the system so closely resembles that of belladonna, that it is necessary to do little more than refer to the account of the latter medicine. (See page 785.) It is sufficient to say, in reference to the effects of stramonium in full medicinal doses, that it produces dryness and uneasy sensations in the throat, dim- ness or perversion of vision, sometimes dilatation of the pupil, not unfre- quently vertigo, headache, mental confusion or slight delirium, and, in some rare instances, sleep; and that its operation on the brain is at- tended with little or no disturbance of the circulation, and no tendency to constipation, but with an occasional increase of perspiration or urine. In poisonous quantities, it causes great uneasiness of the throat with a feeling as of strangulation, anxiety and faintness, partial or complete blindness, great dilatation of the pupil, sometimes deafness, flushing X)f the face, vertigo, headache, hallucinations, delirium of a whimsical, ludi- crous, or more rarely furious character, tremors, paralysis, and at last stupor, with convulsions in rare instances. There is usually, in the ad- vanced stage, great prostration, as indicated by the very feeble pulse, and cool skin; and sometimes the local irritant influence of the poison is evinced by a burning pain at the stomach, nausea, and vomiting. From the worst symptoms mentioned, recovery has often taken place ; but not unfrequently they have ended fatally, in a period varying from six 810 GENERAL STIMULANTS. [PART II. to twenty-four hours. In case of recovery, the poisonous symptoms are of variable duration, but generally begin to disappear within twenty-four hours ; and the patient, upon rising out of his lethargy, has no recollec- tion of what has passed. Little definite is known, as to the smallest quantity that may cause death. A child two years old was killed by 100 seeds, which were swallowed whole, and were afterwards found in the stomach and bowels. Dr. Young states that a single capsule with its contents proved fatal to a child. It is the seeds which are most fre- quently taken in poisonous quantities, and generally by children, who gather them from the plant. Stupor in a child, with extraordinarily dilated pupil, should lead to the suspicion of this kind of poisoning, if access to the cause was possible. The late Dr. Dorsey used, in his lec- tures, to relate a case in which this symptom induced him to suspect narcotic poisoning, and, upon this suspicion, to administer an emetic, which caused the discharge of numerous stramonium seeds, with the effect apparently of saving life. Alarming symptoms have followed the external application of the leaves to a burn. Herbivorous animals are less affected than man. Five ounces of the fresh juice produced only slight drowsiness in a horse ; and two pounds and a half of the seeds, given to another horse, though they proved fatal, did not destroy life until after fifty-two hours. (Pereira's Mat. Med.) Upon dogs the poison acts as in the human subject. The treatment of poisoning by stramonium is the same as that for opium. Animal charcoal may be given at the same time, as an antidote to the poison remaining in the stomach. Like belladonna, stramonium produces its peculiar effects, no matter to what part of the body it may be applied; and, in like manner, the expressed juice, an infusion of the leaves, or the extract dilates the pupil, when introduced into the eye, or rubbed upon the eyelids and neighbour- ing parts. There is little doubt that it acts on the brain exclusively through the blood. Therapeutic Application. This medicine is not known to have been employed, before it was introduced to the notice of the profession by the famous Storck, who used it in insanity, chorea, and epilepsy. It is capable of fulfilling the same indications as belladonna; that is, to iv- liftve pain, relax spasm and muscular rigidity, stimulate the depressed cerebral centres, diminish the susceptibility of the retina, and dilate the pupil. There is not, perhaps, one of the therapeutic uses of belladonna, in reference to which stramonium might not be substituted for it, with the same or very similar results. The following, however, are the dis- eases in which it has actually been employed, with more or less sup- posed success; namely, neuralgia, syphilitic pains, rheumatism and gout, dysmenorrhoea, painful tumours and ulcers, tetanus, epilepsy, hooping-cough, spasmodic asthma, puerperal convulsions, mania, de- CHAP. I.] CEREBRAL STIMULANTS. STRAMONIUM. 811 lirium tremens, and nymphomania It is also occasionally used by American oculists to dilate the pupil. To enter into a minute account of its uses in each of these affections, would be merely to repeat what has been said under the head of belladonna; and I must content myself with referring the reader to the article on that subject. But the use of stramonium in asthma deserves a more particular consideration. The smoking of the root of Datura ferox, in the paroxysms of asthma, has long been a common practice among the natives in the East Indies. An English general officer, having derived great benefit in his own case from the remedy, was induced, on his return to England, to try the ef- fects of the common stramonium, which he found to answer the same purpose. The remedy, having been made known, was soon extensively employed, and received the highest commendation from various respect- able sources. Objection, however, was afterwards made to it, on the score that it endangered disease of the brain, and had frequently caused mischievous results. The same nia} r be said of every active remedy. In its application to asthma, stramonium requires to be judiciously em- ployed; but, with proper precautions, there is little or no danger; and the greatest benefit may often be obtained. In dyspnoea arising from organic disease of the heart or lungs, it can generally be productive of little good, and should not be employed unless to alleviate the affection, when 'dependent, not on congestion of the pulmonary organs, but on mere nervous irritation connected with the disease. Neither is it adapted to cases of gouty asthma, in which there is a disposition to translation from one organ to another, and especially, when experience has shown that there is any tendency of the disease to the brain. In such cases, by stimulating the cerebral centres, the medicine renders them a point of afflux for the gouty irritation, which may fix upon them with great vio- lence ; and, though the patient may be relieved of the dyspnoea, he is liable to die of coma. But in the pure spasmodic asthma, unconnected with any other organic disease than such as has been induced by the asthma itself, as emphysema of the lungs, for example, the smoking of stramonium is often extremely useful, and, if care be taken not to carry it too far, is perfectly safe. It is applicable only to the paroxysms, and should be confined to these, lest its influence should wear out too rapidly. The relief afforded by it is sometimes immediate and entire; the patient falling quietly to sleep, not because of the soporific effect of the remedy, but in consequence of the removal of the cause of his wakefulness. It does not prevent subsequent paroxysms, and will not cure the complaint, which, after being completely established, is seldom cured by any means that can be employed ; but it is an object of great importance to miti- gate the sufferings of the patient, and prolong his life, as probably may be done by preventing the rapid increase of emphysema, which is the inevitable result of the excessive dyspnoea. Unfortunately the remedy 812 GENERAL STIMULANTS. [PART II. has not been found equally effectual in all cases of the disease ; and, even in those in which it at first operates most effectually, though it may continue to yield relief for years, yet its influence gradually diminishes ; so that at length it sometimes ceases to be felt. It is said that General Gent, who was most instrumental in introducing the remedy into Eng- land, at last suddenly died with coma from the effects of it, probably owing to his over-confidence. Either the root or the dried leaves may be used. The former should be quickly dried, cut in pieces, and beaten so as to render its texture loose. Fifteen grains may be smoked at once, and the pipe may be renewed several times a day, if necessary, care being taken to stop when any decided narcotic effect is produced. The leaves may also be used in the form of a cigar ; and, as in the case of belladonna, they may sometimes be advantageously impregnated with nitre previously to being rolled into the required shape. (See page 799.) The smoke is said to cause a feeling of warmth in the lungs, which is soon followed by copious expectoration, and often by some temporary vertigo and drowsiness, and sometimes nausea. In the intervals between the paroxysms, the extract may be taken internally in such doses as moderately to affect the system. As an external remedy also, stramonium is susceptible of the same applications as belladonna, and may be used in the same way. In the form of cataplasm, or of ointment made with the extract, it has been used in inflamed or painful tumours, irritable ulcers, rheumatism in the joints or muscles, swelled mamma, painful hemorrhoids, and irritating cuta- neous affections. Administration. The dose of the powdered leaves is two or three grains, twice or thrice daily. That of the powdered seeds is one grain, repeated as often. Should this dose produce no effect in a day or two, it should be gradually increased until it gives rise to some evidence of its action, as dimness of vision, dryness and stricture of the throat, etc. Fifteen or twenty grains of the leaves have often been given without unpleasant effects. The medicine, however, is more frequently administered in ex- tract. The U. S. Pharmacopoeia directs two extracts, one of which is the inspissated juice of the leaves, and the other is prepared by evapo- rating a tincture of the seeds. The Extract of the Leaves (EXTRACTUM STRAMONII, U. S.) is made by expressing the juice of the leaves, heating to coagulate the iilbumen, then filtering, and evaporating. The preparation is of unequal strength. The commencing dose is one grain, to be repeated and increased in the same manner as the powder. An Alcoholic Extract (EXTRACTUM STRAMONII ALCOHOLICUM, U. S.) is prepared from the leaves, by the U. S. Pharmacopoeia, by first forming a tincture by percolation, and then evaporating. The dose is a grain. The Extract of the Seeds (EXTRACTUM STRAMONII SEMINIS, U. S.; CHAP. I.] CEREBRAL STIMULANTS. STRAMONIUM. 813 EXTRACTUM STRAMONII, Br.) is prepared by evaporating a tincture of the seeds. It is a stronger and more equable preparation than the pre- ceding, and may be given in the dose of one-quarter or one-half a grain, to be repeated and increased in the same manner. The Tincture of Stramonium (TINCTURA STRAMONII, U. S., Br.) is made from four ounces of the seeds and two pints of diluted alcohol. It is an excellent preparation, and may be administered in the commencing dose of ten minims or twenty drops. The Ointment (UNGUENTUM STRAMONII, U. S.) is prepared by simply mixing a drachm of the extract with an ounce of lard; the extract having been first rubbed with half a fluidrachrn of water. It may be used for frictions over painful surfaces, as an application to hemorrhoidal tumours, and as a dressing to irritable ulcers. Daturia, the alkaloid of stramonium, upon which its virtues probably depend, has been used in a few instances for obtaining the effects of the medicine; but its action is so precisely that of atropia that sufficient in- ducement is not offered for its preparation, and it is comparatively little employed. 814 GENERAL STIMULANTS. [PART II. C3L.A.SS I'V. SPINAL STIMULANTS. OF all the medicines in common use, only the products of the genus Strychnos belong properly to this class. Some others have a stimulant influence over the spinal functions, but they have also properties which class them elsewhere, and there is no one which approaches in power those here referred to. The products of the two species, Strychnos Nux vomica and S. Ignatia, are so similar, I might say identical in character, that it is scarcely advisable to consider them distinctly. They are, therefore, united in the following article. NUX VOMICA AND BEAN OF ST. IGNATIUS. I. NUX VOMICA. U. S., Br. Origin. This name has been given to the seeds of Strychnos Nux vomica, a middling-sized tree, growing in various parts of the East Indies. The bark is intensely bitter, containing the same alkaloids which characterize the seeds, and is thought to be identical with a product which at one time attracted considerable attention, under the name of False Angmlura bark. The seeds are embedded in the juicy pulp of the fruit, which is a round berry, about the size of an orange, arid covered with a -inooth, yellowish, or orange-coloured rind. Properties. The seeds are circular, about three-quarters of an inch in diameter and two lines thick, somewhat concave on one side and convex on the other, externally presenting a thin coat closely invested with very short, silky, ash-coloured hairs, internally whitish, translucent, very hard and tough, and difficult to pulverize. They are inodorous and intensely bitter, and yield their bitterness and medical virtues to water, but more readily to diluted alcohol. CHAP. I.] SPINAL STIMULANTS. NUX VOMICA. 815 II. BEAN OF ST. IGNATIUS. FABA SANCTI IGNATII. IGNATIA. U.S. Origin. This is the seed of Slrychnos Ignatia, the Ignatia amara of the younger Linnaeus, a tree of moderate size, growing in the Philippine Islands. The seeds are embedded in the dry pulp of a fruit resembling a pear in size and shape. Properties. The bean of St. Ignatius is about an inch long, of less thickness, convex on one side, obscurely angular on the other, of a pale- brown colour, externally covered with a very short down, internally translucent, hard, and horny. In its sensible properties of odour and taste, and its relations to water and alcohol, it is closely analogous to nux vomica. Active Principles. Both nux vomica and the bean of St. Ignatius owe their medicinal virtues mainly to two alkaloids, denominated strych- nia and brucia ; and claims have been advanced to the discovery of a third, to which the name of igasuria has been given. These bases are supposed to exist naturally in combination with a peculiar acid, called igasuric or strychnic. The alkaloids differ greatly in strength, strych- nia being estimated as having at least twelve? times the strength of brucia, and igasuria being intermediate. For practical purposes, strych- nia may be considered as the active principle, and is the only one much used in an isolated state. Though similar in virtues, nux vomica and bean of St. Ignatius probably differ greatly in power ; at least, the latter contains a much larger proportion of strychnia than the former; the per- centage of that alkaloid being given at 0.4 in nux vomica, and 1.2 in the bean of St. Ignatius. Incompatible^. Alkalies, their carbonates, and alkaline earths, and the vegetable astringents, throw down precipitates from watery solutions of these medicines, the former separating the insoluble alkaloids, the latter forming insoluble tannates ; but, if the precipitated matter is swallowed, it is capable of acting energetically, though probably somewhat more slowly than the solution. 1. Effects on the System. The effects of nux vomica, in small doses, are those of a bitter tonic, roinbiin'd, when the quantity taken is sufficient to affect the system, with an influence on the nervous functions which is quite peculiar, and which, in its higher degrees, is so violent and dangerous as to give the medicine a place among the poisons. From very small doses no effects are at first experienced ; but, if re- peated every six or eight hours, they will be found in the course of a day or two to increase the appetite, hasten the digestion, and act gen- 816 GENERAL STIMULANTS. [PART II. erally the part of a simple tonic; and, by carefully managing the dose, diminishing it, or suspending the medicine for a time when the slightest sign of its peculiar action upon the nervous system is evinced, the effects may be confined within the tonic limits. Often, however, there will be some increase of the urinary secretion, with more frequent micturition ; and it is said that the medicine sometimes proves diaphoretic or laxa- tive. In large doses, its operation upon the stomach becomes irritant, causing loss of appetite, epigastric uneasiness, cardialgia, and sometimes vomiting or purging. When it is taken more largely than requisite for the tonic effect, an entirely new series of phenomena are developed. The first observable effect in this series is generally a feeling of stiffness or stricture in the muscles of the jaw, or at the back of the neck, or of weight or weak- ness with trembling of the limbs. Some resistance is apparently felt in opening the mouth widely; there is difficulty in taking a full inspiration; and after a time the feeling of stiffness may be experienced more or less * elsewhere, upon any attempt at movement. Along with this symptom, there is an increased sensitiveness to external impressions, especially of the touch ; so that a slight tap upon the skin will produce sudden and involuntary startings of the muscles ; and twitchings or catching move- ments in the limbs are not unfrequcntly the first symptom which attracts particular notice. If, under these circumstances, the individual try to walk, there will be a sense of tottering or staggering, not from vertigi- nous feelings, but as if from want of power to regulate the action of the muscles. After some days there is often a feeling of formication, ting- ling, or itching on different parts of the surface, such as is commonly felt when the foot is said to be asleep. Sometimes this sensation is among the earliest phenomena ; and it is occasionally so severe as to constitute the most prominent symptom. An eruption upon the skin has been noticed in some instances. Under a somewhat more energetic influence of the medicine, the spas- modic startings become more frequent and severe ; horripilations and shiverings, with darting sensations like electric shocks, are not unfrc- quently experienced ; and the muscular stiffness increases and extends, so that the patient complains not only of rigidity of the limbs, but also of tightness about his throat, difficulty of deglutition, stricture of the chest and abdomen, and even involuntary erections of tin: penis; those muscles now becoming affected which belong but partially to the volun- tary class. With the powerful effects upon the nervous system above referred to, the circulation is little affected; the pulse being often slo\v and calm; and, when accelerated, as sometimes happens, it is so, in all probability, secondarily. The brain, too, i.s usually undisturbed ; (lie mental functions being quite sound ; though occasionally there may be temporary attacks CHAP. I.] SPINAL STIMULANTS. NUX VOMICA. 817 of pain in the head, vertigo, tinnitus aurium. contraction or dilatation of the pupils, and sparkling or dimness of vision. A tendency to drowsi- ness or stupor has also been observed in some rare instances.* Poisonous Effects. Beyond the condition above described, the effects of the medicine become poisonous. The spasms are more frequent, ex- tensive, and severe, sometimes involving almost the whole frame, and are attended with a tetanic rigidity which is probably the most charac- teristic symptom. The attacks come on suddenly, like electric shocks, last usually from a quarter of a minute to two or three minutes, and, after a longer or shorter interval, seldom exceeding ten minutes, recur with increased violence, and at last, if not relieved, with fatal effect. If the patient is seized with them when attempting to walk, he staggers and falls. During the spasms, the muscles affected feel hard like a board, and different parts of the body are drawn fixedly into various ab- normal positions, from which they cannot be removed. Thus, the head may be thrown backward, the jaws firmly closed, the face distorted, the arms or lower limbs extended outward, the hands clenched, the toes flexed, and the trunk bent backward, forward, or to either side, or stifly erect. The respiratory muscles become involved, and the breathing is hurried or imperfect, and temporarily suspended, with a purple hue of the face, lips, and extremities, coolness of the surface, and a pulse which is sometimes slow, sometimes quickened, but always feeble, and occa- sionally almost or quite imperceptible. In some instances, there are in- voluntary discharges of urine or feces. The attacks are often brought on by very slight causes affecting the surface, as by a fresh contact of the bedclothes, or a gentle touch with the finger. As in tetanus and hydrophobia, an attempt to swallow, or even the idea of swallowing, will sometimes induce spasms of the respiratory muscles f The spasms are often attended with a violent shivering or tremulous movement through the body; and the muscles may be felt vibrating as it were under the hand. Sometimes the patient, when asked if he has suffered pain in the spasms, answers in the negative; in other instances, they are more or less painful, and in others, again, extremely so. In the inter- vals, there is often a feeling of trepidation, alarm, or anxiety strongly expressed on the countenance ; the stomach is sometimes nauseated ; the pulse is feeble and often agitated, or even fluttering ; and the patient complains of thirst, sweats profusely, and, after a severe attack, has a feeling of fatigue and exhaustion. At length, in one of the spasmodic attacks, respiration is quite arrested, the pulse ceases to beat, and the * See remarks by W. G. Thomas, M.D., in the 3 r . Jersey Med. and Surg. Reporter, Jan. 1857, p. 3. f See the account of a case by Mr. Hennel in the Lond. Med. Times and Gaz., April, 1855, p. 414. VOL. i. 52 818 GENERAL STIMULANTS. [PART II. patient dies with asphyxia. The mind is usually clear throughout the case, until near the fatal issue, which is preceded for a short period by insensibility and unconsciousness. When the poisoning has resulted from one large dose, the characteristic symptoms make their appear- ance from ten minutes to half an hour after it has been taken, and death generally occurs very quickly, sometimes in the course of a few minutes, after the third, fourth, or fifth paroxysm. One instance is on record, in which death followed in fourteen minutes after the poison was swallowed ; and from half an hour to an hour and a half is not an uncommon period. Under other circumstances, the poisonous phenomena ID ay be developed much later, and the termination be much longer postponed. When the case is to end favourably, which not unfrequently happens, there is a gradual subsidence of the violent symptoms; but more or less rigidity may linger for a day or longer; and soreness of the muscles, as if they had been bruised, is felt after other symptoms have ceased. After death, the muscles often remain in a state of tetanic rigidity, and there is frequently more or less blueness or lividity about the face, hands. and feet. Internally the ordinary signs of venous congestion are pre- sented, as of persons dying from asphyxia. This is especially observa- ble in the lungs ; and the bronchial mucous membrane, as well as that of the stomach and bowels, sometimes exhibits hemorrhagic spots or patches. The heart has in some instances been found firmly contracted, in others quite relaxed, and either empty, or distended with blood. The blood itself has by some examiners been seen coagulated; while In others no clot could be anywhere discovered. Congestion of the brain and its vessels, redness and increased vascularity of the membranes of the spinal cord, patches of extravasated blood in these membranes, and effusion into the spinal sheath have been noticed: and both the brain and the spinal marrow are said to have been found in a softened state ; but nothing has yet been discovered by post-mortem examination which can throw a very clear light on the action of the poison. Though evi- dences of inflammation of the stomach are stated to have been exhibited in several cases, yet in the great majority nothing of the kind has been noticed ; and the poisonous effects must, therefore, be quite independent of gastric irritation. The bulk of the spleen has been observed to be strikingly diminished, after death from strychnia in the lower animals. Strychnia may usually be detected in the stomach and bowels if not evacuated or absorbed during life, in the urine if it has had time to pass off by the kidneys, in the blood, and in some of the tissues, especially in the liver; but the absence of any discoverable chemical evidences of strychnia in these positions, though a presumption, should not be con- sidered as a positive proof that the death did not result from the poison Quantity requisite for Poisoning. The quantity of nux vomica or of ita preparations requisite to destroy life is very uncertain. The suscep- CHAP. I.] SPINAL STIMULANTS. NUX VOMICA. 819 tibility to its influence is extremely different in different persons. A case is on record in which fifteen grains of the powder are stated to have proved fatal; another in which the same effect was produced by thirty grains in two dose* ; and in two others, which occurred in 1839 in Lon- don, death resulted from fifty grains (Taylor on Poisons, p. 775) ; yet the last-mentioned quantity has been repeatedly administered without inconvenience; and, as a general rule, the poisonous dose would proba- bly much exceed a drachm. Recoveries have frequently taken place, under proper treatment, after quantities had been swallowed varying from half an ounce to an ounce. As the bean of St. Ignatius contains probably three times as much strychnia as mix vomica, it may be con- sidered as in an equal degree more poisonous. The extract of nux .vomica is said to have proved fatal in the quantity of three grains (Ibid.) ; and as M. Recluz obtained from the seeds an average product of about one-twelfth of extract, this would be equivalent to somewhat more than half a drachm of the powder. The .smallest quantity of strychnia, known to have caused death in an adult, is half a grain ; which is much larger relatively than the smallest fatal doses above mentioned of the powder and extract. Treatment of Poisoning. The most important point of treatment in poisoning from nux vomica, bean of St. Ignatius, or any of their prepa- rations, is to empty the stomach as speedily and as thoroughly as possi- ble. An active and prompt emetic should be administered immediately. Sulphate of zinc, tartar emetic, or ipecacuanha may be given severally or combined ; and their influence may be aided, if necessary, by pow- dered mustard. During the spasmodic paroxysms, it is usually impos- sible for the patient to swallow, and the jaws are often so firmly closed that medicines cannot be readily introduced into the mouth ; but relaxa- tion in general takes place in a short time, and the opportunity thus afforded should be instantly seized for the exhibition of the emetic. Should it be impracticable to introduce the medicine into the mouth, it might possibly be injected through a catheter or other small tube inserted into one of the nostrils. When the stomach pump can be employed, it should be brought in aid of the emetic, so as thoroughly to wash out the poison ; but it should not be relied on to the exclusion of the latter rem- edy, which has often proved efficient. I have been informed of a case in which, after the strongest emetics had been taken without effect, a cur- rent of electricity directed through the body at the epigastrium wa.- quickly followed by vomiting, probably in consequence of the suscepti- bility of the stomach being aroused by the measure. The patient wa> saved. Unfortunately there is no antidote to strychnia which has thus far been sufficiently tried to be confidently relied on ; yet the experiments of Dr. Garrod with animal charcoal would seem to prove, that the power which this substance has of absorbing the vegetable alkaloids, and even GENERAL STIMULANTS. [PART II. of separating them from their combinations, may be made available in obviating the poisonous effects of strychnia, if brought into contact with it in the stomach before enough has been absorbed to cause death. In these experiments of Dr. Garrod, when strychnia previously mixed with animal charcoal was administered to animals, they were not in the least affected by it ; and a case is recorded by Mr. W. Chippendale, in which, an hour after four grains of strychnia had been taken, three or four ounces of animal charcoal, mixed with water, were injected by means of the stomach-pump, and the stomach thoroughly washed out, with the effect of saving the life of the patient, which appeared to be in imminent danger. (Lond. Med. Times and Gaz., April, 1855, p. 423.) Other sub- stances have been proposed as antidotes, on the ground that they render strychnia insoluble; but none has sufficient experience in its favour to, justify a reliance on it. For an account of them the reader is referred to the U. S. Dispensatory (12th ed., p. 1356.) Among them is tannic acid, which Prof. Kurzak infers, from experiments on dogs, to be an excellent antidote, requiring, however, to be given in very large proportion, at least from 20 to 25 times as much as of the poison taken. ( Am. J. of Med. Sci., Jan. 1863, p. 258.) Perhaps the best emetic would be sul- phate of zinc or tartar emetic, in connection with ipecacuanha. But the evacuation of the stomach will not obviate the effects of the portion of the poison absorbed. For this purpose medicines must be resorted to calculated to diminish irritation of the spinal nervous centres. Opium, conium, camphor, chloroform, ether, and alcohol have been em- ployed, and each with asserted advantage. Considerable doses are required; as the susceptibility to the narcotic influence seems to be di- minished, as in tetanus, by the violence of the nervous derangement. One of these medicines, or some combination of them should be exhib- ited after the stomach has been emptied; and they may even be exhib- ited by the rectum during the use of emetic measures, with the exception perhaps of opium, which might tend to retard or prevent vomiting. In the Boston Medical and Surgical Journal (li. 476), Dr. J. II. Tewks- bury, of Portland, Maine, records two cases in which camphor appears to have been employed successfully without other measures, two flui- drachms of the saturated tincture having been given by the stomach in one ease; while in the other, in which the patient could not swallow, the same preparation was injected into the rectum, and the patient at the same lime immersed in a warm camphor bath. It is probable, however, that, in these cases, the camphor merely moderated symptoms which would not have proved fatal ; for Dr. J. E. Thompson, in repeated ex- periments with dogs, found that the tincture of camphor was quite una- vailing to obviate the fatal effects of the poison. (Ibid., liii. 163.) Sub- sequently, however, Prof. Rochester, of Buffalo, N. Y., has reported two successful cases, in which he ascribes the result to the camphor used. CHAP. I.] SPINAL STIMULANTS. NUX VOMICA. 821 (Buffalo Med. Journ., March, 185G.) In the Medical and Surgical Re- porter (Nov. 18, 1865, p. 339), a case is recorded in which severe poison- ing from strychnia yielded to half a pint of strong gin, exhibited in di- vided, but quickly repeated doses. Dr. Dresbach, of Tiffin, Ohio, relates a case in the Western Lancet for February, 1850, in which the most alarming symptoms, caused by swallowing three grains of strychnia, were completely relieved in fifteen minutes by two drachms of chloroform ad- ministered by the mouth Within a few years, inhalation of chloroform has been much used in poisoning by this alkaloid, and with encouraging success; many cases having recovered under its use. It very much re- lieves the pain and spasm, and to a considerable extent counteracts the effects of the poison, often preventing a fatal issue, until time has been allowed for the elimination of the strychnia by the kidneys. It should never be permitted to supersede the evacuation of the stomach by emetics or the stomach-pump, or the use of any substance which may be supposed to act as a proper antidote to the strychnia. The inhalation of ether, however, would be preferable, if found to produce the same effect, as it is not liable, like chloroform, to act as a fatal poison. To- bacco has also been employed with supposed success. The infusion should be given by enema. One instance, however, is recorded, in which it was exhibited by the stomach, so as to produce excessive vomiting, and with complete success. (Brailh waiters Retrospect, No. 46, p. 185.) M. Cl. Bernard recommends the use of woorari, which, besides contributing to relieve the spasms, favours the elimination of the poison by its stimu- lant influence on the various emunctories, especially the kidneys. (Arch. Gen., A out, 1865, p. 203.) Aconite also is thought to be antagonistic to strychnia, and has acted successfully as an antidote in experiments on dogs. (Dr. Woaks, British Med. Journ., Oct. 26, 1861, quoted in Am. J. of Ned. Sci., Jan. 1862, p. 276.) 2. Mode of Operating. Nux vomica and its preparations are locally somewhat irritant ; but not powerfully so. There can be no doubt that the active matter is absorbed, and oper- ates through the circulation. This is proved by an experiment of Ver- nierc, who found that, when a ligature was applied around the leg of an animal so as to check the flow of blood in the veins, but not in the ar- teries, and extract of nux vomica was introduced into a wound in the foot, blood taken from the vein proceeding from the wound towards the liga- ture, and injected into the veins of another animal, caused the death of the latter with the characteristic symptoms of poisoning by this drug. The same inference may be drawn from the facts, that strychnia pro- duces its peculiar constitutional effects, to whatever part capable of ab- sorption it may be applied, and that the rapidity with which these eflVct> occur is proportionate to the facility of absorption in the part. Thus, in 822 GENERAL STIMULANTS. [PART II. contact with the lungs, it operates more quickly than when swallowed, and in the stomach more quickly than when applied to the skin. Dr. Christison killed a dog in two minutes by the injection of one-sixth of a grain in alcoholic solution into the cavity of the chest. Inserted into a wound it operates still more quickly; and, when injected into the veins, its effects are almost instantaneous. In all these instances, too, the effects are identical ; proving that, in all, the blood is the vehicle by which the poison is conveyed to the part affected. Besides, Dr. A. I. Spence, of Edinburgh, has proved by experiment that strychnia is wholly unable to act by means simply of nervous communication. (Ed. Med. Journ., July, 1866, p. 45.) The medicine, when absorbed, has not been found to produce any change in the blood itself; and the phenomena of its action evince that its influence is exerted mainly at least upon the solid tissues. Upon these it seems to operate, in very small doses, as a moderate stimulus of the tonic character, closely resembling the simple bitters in the modifica- tion of the functions it induces. But it may be inferred, from its effects in larger doses, that even this tonic influence is exerted specially upon the nervous centres ; and important therapeutic inferences may be de- duced from this view of its action. When given so as to produce the peculiar effects above enumerated, all the phenomena go to show that it is mainly upon the nervous centres of the spinal marrow, including the medulla oblongata, that the medicine operates. The functions of the brain are often wholly unimpaired, even when the spasms are frightfully violent ; and the division of the spinal marrow near the occiput, or even the decapitation of the animal, does not prevent them. That it is not upon the muscles directly that the medicine acts may be inferred from their simultaneous contraction, and simultane- ous relaxation, showing that the influence modifying their condition flows from a common source; and this can only be in the nervous centres which preside over them. Besides, Matteucci observed that, after death from strychnia, the muscles could be made to contract by the direct ap- plication to them of an electric current, but refused to respond to the same stimulus applied to their nerves; the latter having been exhausted of their excitability by the stimulus of the poison, while that of the former remained unimpaired. Another fact confirmatory of the special spinal influence of nux vomica, is the almost exact resemblance of its poisonous phenomena to those of tetanus, which i- generally admitted to have its essential seat in the spinal marrow. ilui what is the nature of the action thus shown' to have its seat in the medulla spinalis? It appears to me oliviously to be merely an ex- . c- excitement, or, in other words, irritation of the nervous centres of this structure, extended no doubt thence to the nerves proceeding firott them. The first effect is to exalt the sensitiveness of these centres. Hence, even before the spasmodic movements commence spontaneously, CHAP. I.] SPINAL STIMULANTS. NUX VOMICA. 823 they may often be induced by the slightest impressions upon the surface, such as would ordinarily produce no effect. An increase of the stim- ulus irritates the centres into excessive action, without the aid of any additional exciting cause ; and the characteristic spasms now occur with a violence proportioned to the central irritation. But in this, as in all other cases of over-excitement, the excitability itself is more or less rapidly exhausted; and, if death be not produced by the interference of the spasms with some vital function, there follows a condition of greater or less prostration of the spinal power, and consequently of depression in the functions dependent upon it. There is reason to believe that death is not always induced by the rigid immovability of the respiratory muscles, rendering breathing impossible, and thereby inducing asphyxia; for it has been found that respiration, artificially sustained, does not pre- vent the fatal consequences of poisoning with nux vomica. The exhaus- tion of the whole medulla oblongata by its over- excitement will explain the result. It has been conjectured that among the causes of death may be a direct influence of the poison on the heart, either causing a spas- modic contraction of that organ, or exhausting its excitability through previous stimulation. In support of this opinion, an experiment of M. Briquet may be adduced, who, having injected extract of nux vomica into the veins of a dog, observed the first effect to be considerably to elevate the haemadynameter of Poiseuille, which subsequently fell lower and lower until death, indicating first an augmentation of the heart's force, and afterwards a reduction with exhaustion of its excitability. After death, the heart could not be excited to contraction. (Briquet, Trait. Therap. du Quinquina, p. 87.) It may be that there is a conjoint ex- citant action upon the respiratory nervous centres and the heart, fol- lowed by a conjoint failure of power in both. It has been supposed that the sympathetic nervous centres are affected in like manner with those of the spinal marrow ; but we have no sufficient evidence upon this point. That the nerves conveying the spinal influence to the muscles participate in the irritation and subsequent depression or exhaustion of the centres, would seem to be shown by the experiment of Matteucci before referred to, which proves that at least they lose the susceptibility to galvanic influence, while the muscles themselves remain sensible to it. It is probable that the influence of nux vomica extends to the whole spinal marrow, including the medulla oblongata; for there is no muscle in the body, supplied from that source, which is not liable to be thrown by it into spasm. Some suppose that the medicine acts on the cerebellum; and it has been noticed, by several observers, that this structure occasionally ex- hibits post-mortem evidences of having suffered in cases of poisoning. With those who believe that the cerebellum is the special seat of the sexual propensities, the excitation of the genital organs which has been 824 GENERAL STIMULANTS. [PART II. occasionally noticed under the influence of nux vomica, will afford further proof of the correctness of this supposition. Though the cerebral lobes are seldom affected by this agent, and per- hup-i never by a direct influence, yet thesensorial region at its base often participates in the irritation, as shown by the frequent itching and tin- gling sensations experienced, and the occasional occurrence of irregu- larities of sight and hearing, contraction or dilatation of the pupil, etc. These may be owing either to a direct action of the medicine, or, what is quite as probable, to a radiation of the original and direct spinal irri- tation from the medulla oblongata to the contiguous parts of the cerebrum. 3. Therapeutic Application. Nux vomica has long been used as a medicine in India, and was de- scribed by the early Arabian writers, by whom it was made known to modern Europe. The name is not appropriate: for in ordinary doses the medicine is not apt to irritate the stomach, and, when given largely, sel- dom vomits, and could never be given with propriety in reference to an -nit 'tic effect. The bean of St. Ignatius, though supposed by some to be the nux vomica of Serapion, was probably first made known in Europe after the discovery and settlement of the Philippine Islands, where the tree pro- ducing it is indigenous, and the seeds were used as a medicine by the natives. It was from their supposed value in the treatment of intermit- tent fever, and various other complaints, that the Jesuit missionaries to those islands were induced to honour the medicine with the name of the founder of their order. Both nux vomica and the bean of St. Ignatius have, at various times, been used in numerous complaints, but, it must be confessed, rather em- pirically. Intermittent fever, the plague, gout, rheumatism, cholera, diarrhoea, dysentery, colic, constipation, worms in the bowels, the pois- onous effects of snake-bites, scorbutic ulcers, insanity, hypochondriasis, hysteria, epilepsy, chorea, hydrophobia, neuralgia, hemicrauia, palsy, and impotence are among the affections in which one or the other, or both of these medicines have been recommended. Better acquainted than our predecessors with their mode of operating, we can now prescribe them more intelligently, and with more accurate discrimination. It will be remembered that the medicine is in Hnall doses simply tonic, though probably with a special ti-ndency to the nervous centres, and, more hirgely given, acts with great energy upon the spinal marrow, and to a certain extent also on the buse of tin- brain, stimulating both the -msitive and motor functions. Hence arise two distinct indications for its use, one as a tonic in local or gem-nil debility, particularly when the nervous functions are involved: and the other as a dirrct siiiimlant of the nervous centres in cases of loss of sensation or the power of motion. CHAP. I.] SPINAL STIMULANTS. NUX VOMICA. 825 or of both, in other words, in paralytic affections. Under these two heads will be arranged the practical remarks which are to follow. 1. Use as a Tonic. As a mere stimulant to the stomach, in ordinary dyspepsia, though probably equally efficient with the simple bitters, nux vomica has no advantage over them, while any accidental abuse of it would be attended with inconveniences to which they are not liable. Hence they should, as a general rule, be preferably employed in this complaint. But, when there is reason to think that, from want of due nervous influ- ence, the muscular coat of the stomach is unable to perform efficiently its share in the process of digestion, nux vomica may be resorted to with the hope of special benefit. In nervous disorder of the gastric sensibil- ity, connected with debility of stomach, it is decidedly indicated, and has been found highly beneficial. Hence its use in pyrosis, and that most painful affection denominated gastralgia or gastrodynia. Upon the same principles exactly it may be employed in bowel com- plaints. In constipation dependent on torpor of the peristaltic muscles, it proves often of great service, especially in connection with tonic laxa- tives, such as rhubarb or aloes. In obstinate flatulence from the same cause, it would probably be among our most efficient remedies. We now and then meet with cases of excessive accumulation of flatus, amounting to tympanites, especially in debilitated states of the system, and in nervous persons, and wholly independent of any discoverable lesion, which resist all ordinary remedies. Some of these may depend on a certain laxity or torpor of the muscular coat, and would be very likely to yield to nux vomica. When the flatulence is attended with copious discharge of air, whether from the stomach or bowels, it may possibly arise from an extrication of gas from the mucous tissue itself, owing to insufficient innervation ; and here too the remedy is indicated. In en- teralgia or neuralgic pains of the bowels, connected as this often is with debility of the parts, nux vomica has been used advantageously ; as also in colica piclonum, and in pure nervous colic independent of the poison of lead. The remedy has been recommended in diarrhoea and in dys- entery, having been employed in the latter complaint particularly by the German physicians, some of whom speak highly in its favour. These complaints are sometimes connected with a relaxation of the bowels, in which a defect of innervation is probably concerned, permitting an excess of secretion from the flaccid vessels, or deranging the due relation be- tween the contents of the bowels and the expulsive power. In such cases tin- medicine may sometimes prove useful; but, as a general rule, little good can be expected from it in these complaints, and it would probably often do harm by adding to the existing irritation of the mu- cous membrane. The medicine has been little used in complaints of the chest; but M. Homolle has recently recommended it in the asthmatic paroxysm, and 826 GENERAL STIMULANTS. [PART II. in suffocative catarrh, believing that, in both these affections, the diffi- culty lies in a want of proper contractility of the bronchial tubes and perhaps the air-vesicles, and that mix vomica operates by restoring- this contractility. (Ann. de Therap. par Bouchardat, 1854, p. 18.) Though not disposed to admit the pathological view of M. Homolle, I am quite willing to hope that the therapeutic advantages claimed for the remedy may prove well founded on future trial. If nux vomica does good in these complaints, it is probably, in asthma, by so affecting the nervous centres as to overcome the existing spasm of the tubes, and in the suf- focative catarrh, by giving increased tone to the mucous membrane, and thereby checking the excess of secretion poured out from the relaxed vessels. In defect of the generative function, M. Trousseau was inclined to make a trial of nux vomica, from having observed its effects in produc- ing erections, and exciting the venereal propensity. He has found it useful in impotence in both sexes. (Trait, de Therap., 4e ed., i. 714.) It has also been employed with supposed advantage in spermatorrhoea. In general nervous debility, manifested by tremulousness, and uncon- nected with positive cerebral lesion, and particularly when dependent on previous excesses, as from intemperate drinking, abuse of opium, or excess in sexual indulgences, good may be expected from nux vomica in supporting the nervous functions, while the patient is endeavouring to regain health by abstinence from the cause. Any apparent good which might arise from it, without an abandonment of the indulgences referred to, must be merely temporary, and might indeed do harm by still further exhausting the excitability of tne centres. In chronic states of debility connected with the various cachexiae, as in atonic gout, scrofula, atonic dropsy, etc., good may result from the use of nux vomica as of most other tonics ; but, unless a special indica- tion exist in some functional defect of nervous power, it would be better to trust the case to medicines less liable to produce serious injury if abused. It has been recommended in albuminuria. (Ann. de Therap., 1863, p. 65.) The asserted efficacy of the medicine in different forms of nervous dis- ease, not paralytic, must be referred to the same tonic influence over the nervous centres, either directly stimulating them to a more energetic exer- cise of their function, or strengthening them against irritating iniliieners calculated to throw them into disorder. Spasmodic asthma has already been referred to. The remedy is asserted to have proved ell'ertual in neu- ralgia in the face, and may be employed against this alleetion wherever d. whether externally or internally, with some hope of henelit. In hysteria, c/i<>ri:a, and f/^Vry/s// it was long since used, but attracted little attention until recently revived as a remedy in the two latter of these complaints. M. Trousseau, and MM. Fouilhoux and Kougier, about the CHAP. I.] SPINAL STIMULANTS. NUX VOMICA. 827 year 1841, simultaneously announced the great efficiency of this medicine in chorea; and since that period it has come to be one of the remedies most relied on in this affection among the French physicians. (Trousseau et Pidoux, Traite de Therap., 4e ed., i. 715.) In chorea, the involun- tary movements are not dependent on excess of action in the nervous centres, but upon irregularity of action, which is often connected with debility. It may, therefore, be readily understood how a medicine may prove efficient in its cure, by elevating the powers and actions of these centres. But it is not so easy to explain the asserted usefulness of nux vomica in epilepsy. Bayle speaks of it as having been used advantage- ously in this disease; and in the N. Y. Medical Times for April, 1855 (iv. 229), Dr. Elisha Harris has reported several cases, in which it ap- pears to have acted very favourably. As the epileptic irritation is in the brain, while nux vomica acts specially on the spinal marrow, we can con- ceive that the remedy may prove useful by a revulsive influence from the former to the latter; but great care should be taken, before using it, to ascertain that the system is not plethoric, and, as a cerebral irritation superadded to that already existing might result in serious consequences, to begin with it very cautiously, lest it might, as it sometimes excep- tionally does, act upon the brain. A case of epilepsy is recorded in which paralysis and death followed the use of strychnia. (Pereira, Mat. .Med , 3d ed., p. 1492.) Headache, mental dejection, hypochondriacal feelings and notions, and general or local uneasiness of a nervous character, when connected with general debility, may be treated with nux vomica with a reasonable hope of benefit. Perhaps the asserted usefulness of the medicine in bronchocele, may be traced to its action on the nerve-centres. 2. Use as a Spinal and Sensorial Stimulant. M. Fouquier, a French physician, was the first who regularly employed nux vomica in the treat- ment of palxy. He was very naturally led to this application of the medicine by the consideration of its physiological operation, as shown by its effects as a poison, and fully developed and established by the ex- periments of Magendie and others on inferior animals. In palsy there is a loss of the power of voluntary motion. One of the most striking effects of nux vomica is muscular contraction. It seemed a very fair inference that the medicine would prove useful in the disease. On trial it was found to be so in many instances, and nux vomica is now an established remedy in paralytic affections. A curious circumstance in the treatment of paralysis by nux vomica is, that the first, effects of the medicine are felt in the paralyzed part. It is in tiiis that the muscular twitclfmgs, the electric-like shocks, the for- mication, tingling, t'tc., characteristic of its action, are in general first experienced, especially in cases which are to end favourably. I know not how better to explain this curious fact than by supposing that each 828 GENERAL STIMULANTS. [PART II. portion of the system, when under its ordinary healthful influences, is best able to resist disturbing causes ; and that consequently the nervous centres which preside over the unparalyzed parts, being in the healthy .state, arc less readily thrown into disorder by contact with the medicine circulating with the blood, than the diseased nervous centres corre- sponding with the external seat of paralysis. Of course, this explanation implies that the diseased centres are only functionally affected; for, if disorganized, they become either insensible, or sensible only in an ab- normal way, to the action of the medicine; and the fact is that, in cases of the latter kind, that is, when the nervous centres are organically affected, the paralyzed limb is not apt to exhibit this peculiarity, and the disease is not likely to yield to the remedy. It may, therefore, be re- garded as an unfavourable sign, in reference to the remedial influence of nux vomica in palsy, when the effects referred to are displayed first in the sound parts, and little or not at all in the diseased. But, though nux vomica was found to possess unquestionable powers over many cases of palsy, experience soon demonstrated that there were also many which were in no degree benefited by it, and that it some- times proved positively injurious. This is what might have been antici- pated from a consideration of the ordinary causes of palsy, and the mode of action of the medicine. In most paralytic affections the real seat of disease is in the nervous centres of the paralyzed part, or in the course of the connecting nerves ; and this disease is very often of an organic character, that is, such as deranges or destroys the structure of the part affected. Most frequently it is hemorrhagic or inflammatory. Now to expect to restore to its healthy function, by the stimulant influence of nux vomica, a nerve or a nervous centre, already actively congested, or positively inflamed, or lacerated by effused blood, would be in the highest degree unreasonable. What might rationally be expected, under such circumstances, would be an increase of the inflammation or of the hem- orrhage, and consequently a confirmation of the paralysis. When palsy, therefore, follows hemorrhage within the encephalon or spinal column, or attends inflammation of the cerebral substance or the medulla spinalis. nux vomica and its preparations should be scrupulously avoided, until the immediate effects of the injury shall have been remedied, and the nervous tissue have been restored ;is nearly as possible to its normal organic condition. Being now merely enfeebled, and unable to perform its function in consequence of this feebleness, all that is needed is a stimulus calculated to rouse it into action ; and such a stimulus is happily afforded in the nux vomica. In the pal-ies, whether hemiplegic. para- plegic, or local, which are believe.! to originate in inllamnution or hem- orrhage, or other organic mischief, ample time should be allowed for the subsidence of the inflammation under suitable appliances, or for the ab- >orption or isolation of the effused blood, and the repair of the injury in- CHAP I.] SPINAL STIMULANTS. NUX VOMICA. 829 dieted by it, or for the removal of whatever other disorganizing condition may exist, before recourse is had to mix vomica. There can be no doubt that injury has often accrued from a neglect of this caution. Weeks or months, and sometimes many months, must be allowed to pass before the remedy is used. Hemorrhage generally requires a longer delay than acute inflammation, because a longer time is requisite to repair the mischief done. In hemiplegia following hemorrhagic apoplexy, it will in most cases be prudent to wait from four to six months, or even longer. When, moreover, under these circumstances, the medicine is begun with, the smallest doses should be first prescribed, and a careful watch kept so as to note the first sign of injury, and when it is presented, to suspend the remedy for a time. How far a complete restoration of the palsied part is to be accomplished in these cases of organic affection, depends upon the degree of permanent injury which the nervous tissue has suffered. When it recovers without injury, but merely debilitated, the palsy may be cured; but in very many instances there is only a partial restoration, and consequently only a par- tial relief of the paralyzed part. Hemiplegia yields much less frequently and less completely to nux vomica than paraplegia; chiefly, in all probability, because the former, connected as it generally is with disease of the brain, is much more fre- quently dependent on a destructive, and often irreparable hemorrhage, than the latter, which, proceeding usually from disease of the spinal marrow, where hemorrhage is less common, is more apt to be a result of inflammation, or other curable affection. There is, however, another reason why cerebral palsy yields less readily to nux vomica than spinal. It is upon the spinal medulla that the remedy specially acts; and, even when the cerebral centres are sound, though debilitated, they may be without the circle of its influence, and thus remain unaffected by it. But even in paraplegia, though, when suitably employed, it often does much good, it often also fails altogether, in consequence of the disorganized condition of the spinal marrow, from inflammation, degeneration, soft- ening, etc., or irremovable pressure upon it, as by displaced bone, aneu- risms, organized tumours, etc. Though nux vomica acts most powerfully as a stimulus to the motor power, it is by no means without influence over the sensibility or im- pressibility of the nervous centres, and therefore proves useful in palsy of sensation as well as in that of motion, though perhaps in an inferior degree. When the loss of sensibility depends upon a want of due power of action in the conducting fibres of the spinal marrow, it is highly probable that these are stimulated in like manner with the spinal cen- tres by the direct influence of the medicine. Hence in paraplegia there is very generally a restoration jointly of sensibility and the power of motion. When the cause of the palsy of sensation is in the seasonal cen- tres at the base of the brain, there is still hope of benefit from the rem- edy, which, as before stated, acts often with considerable energy on these 830 GENERAL STIMULANTS. [PART II. centres, either directly or through emanation from the medulla oblongata. Hence, mix vomica may be used, with reasonable prospect of advant- age, in exclusive palsy of sensation, whether the general sensibility i> affected, or only the special senses, as of tact, taste, smell, hearing, and sight. But the kind of palsies to which mix vomica is most appropriate are those of function merely, without organic injury of the nervous fibrils or centres. It may be very difficult to decide during life upon the nature of such cases ; but when, upon the most careful examination, no source of organic mischief can be discovered or reasonably suspected, the prac- titioner will be quite justifiable in presuming upon its absence, and in giving at least a trial to nux vomica. Palsy commencing with hysteri- cal phenomena, or of rheumatic origin, if persistent, may be treated in this way; and in the various forms of lead-palsy nux vomica is among the most efficient agents. It has also proved especially useful in diph- theric paralysis. Of the varieties of palsy, as connected with the seat of the affection, little need be said. Of hemiplegia and paraplegia enough has been said in the preceding general remarks. General palsy too often fails to yield to any remedy; but it is among those in which nux vomica is particu- larly indicated; for, if obscure in its origin, it would obviously call for a trial of means calculated to stimulate the defective function ; and if traceable, as it often is, to degeneration of the nervous tissue under depressing influences, it is to be remedied, if at all, by the joint influence of a tonic and of a stimulant to the enfeebled tissue, such as is exerted by the medicine under examination. In local palsies, such as those dependent on injuries, the use of the remedy is to be governed by the same principles as in the other forms. There are a few of these local affections which require particular notice. Retention of urine from palsy of the bladder, and incontinence of urine from a similar condition of the sphincter muscles, are frequently treated with advantage by nux vomica or its preparations; and it is among the most efficacious remedies in the nocturnal incontinence of children, which frequently depends upon debility of these muscles. In prolapsus ani in children, depending on debility of the sphincter ani, it would seem to be indicated. M. Duchanssoj reports a very obstinate c:ise, in a child of eleven years, in which a complete cure was ejected, in le-s than a week, by the daily application of about one-fourth of a grain of strychnia upon blistered surfaces near the anus ( Ardi Qt'-n. de Mtrychnia. upon blistered surfaces upon the temples, as near the seat of the complaint as possible. Experience has not fully confirmed the san- guine hopes that were at one time entertained of its efficacy; but, with the caution above given, in relation to any possibly existing organic dis- order, it may be used with great propriety either endermically, or by the stomach. Used hypodermically, by injection into the supra-orbital areo- lar tissue, the solution has proved successful in a case under the care of M. Freminau. (Med. T. and Gaz., Jan. 21, 1865.) 4. Administration. In reference to the administration of nux vomica and its prepara- tions, a few preliminary observations regarding certain peculiarities in the operation of the remedy are necessary, in order properly to regulate its exhibition. In the first place, it has been often noticed that the system becomes less rapidly habituated to this remedy than to most others, and that con- sequently it is not requisite, in order to maintain a given impression, to go on increasing the dose, as is necessary with the narcotics. After it 1ms been ascertained how much is required to produce the characteristic effects, the dose may often be continued without augmentation for a long time. I have had patients for several weeks, if not for months, under the use of strychnia, without being able to increase the dose, unless at the risk of inducing troublesome muscular contractions. Nevertheless, it is probably only in degree that nux vomica differs from other medicines in this respect ; and if, after having given evidence of its action, it should at length cease to do so, the dose should be cautiously increased up to the amount requisite for sensible effect. It occasionally happens that, instead of becoming less susceptible to the influence of the medicine with its continued use, the system is ap- parently more so, and the same doses cannot be borne as at first This can be explained, v. '.tli<"it the necessity of considering nux vomica as an 832 GENERAL STIMULANTS. [PART II. absolute exception to the otherwise almost universal rule. In the event referred to, the medicine may be conceived to have induced a positive irritation of the spinal mamnv, perhaps in consequence of an existing predisposition, which irritation, having thus been set on foot by it, will continue altogether independently of its further influence, just as if it had been induced by cold, which does sometimes give rise to a similar condi- tion, as in idiopathic tetanus. This irritation may continue for several days, giving rise to phenomena similar to those produced by the medi- cine, which seems therefore to sustain its action for a long period, though really at the time quite inoperative. In this condition, a further dose would aggravate the irritation, and seem, therefore, to be operating on an increased susceptibility; whereas the susceptibility might remain un- altered, or possibly even be lessened. The occasional result, therefore, above referred to, must be considered as exceptional, and by no means authorizing the conclusion, as a law of the action of mix vomica, that the longer it is given the greater is the susceptibility to its action. A second very important consideration is the vast difference of sus- ceptibility to its influence in different individuals. In this respect, though not quite peculiar, for there are several substances of which the same fact holds true, and some even to a greater extent than nux vomica, yet it differs so much from ordinary medicines that the greatest caution is requisite in regulating the dose. I have known a lady to be thrown into violent and even alarming spasms, almost threatening suffocation, by one- twelfth of a grain of strychnia ; and instances have already been referred to of death from fifteen grains of the powder, and three grains of the extract of nux vomica; while Pereira once gave to a patient a grain and a half of the alkaloid, which w;is repeated several times, before the symptoms indicating that the system was affected came on. Though he began with smaller quantities, and gradually increased to that mentioned, and although no serious consequences ensued in the case, yet he slates that subsequent experience had convinced him that so large a dose was dangerous. With our present knowledge of the action of this medicine, I do not think that a practitioner would be justifiable in administering such quantities, however cautiously they may have been readied. 1 have noticed the extreme susceptibility, above referred to, most frequently in nervous females. A third point worthy of attention is the question whether nux vomica is cumulative ; that is, whether, after having been given for some time in repeated doses, at the ordinary intervals, without any apparent effect, it can ever break forth suddenly with the full influence of the accumulated doses, and with danger to life. It has generally been thought not to be so; and no danger has been apprehended upon this score. But a case has been recorded by Dr. Pereira, which shows that the use of it is not so exempt from this danger as had been supposed. Strychnia was given CHAP. I.] SPINAL STIMULANTS. NUX VOMICA. 833 to a man first in the dose of one-eighth of a grain, then of one-quarter, and finally of half a grain, in each instance being repeated three times a day, and the last dose was continued many days without perceptible effect. At length he was seized suddenly with violent spasms, and died with asphyxia in a very short time. (Mat. Med., 3d ed., p. 149t.) Un- combined strychnia is of extremely slight solubility in cold water, while in acidulated water it is readily dissolved. It might happen that acid in the primse vise should be wanting for a time, and the strychnia thus re- main undissolved and accumulating; but at length the gastric juice, reacquiring its normal acidity, might dissolve the whole at once, and enable it to be absorbed. The effects in the above case may thus be conjecturally explained. The lesson deducible from it is never to ven- ture upon so large a dose ; as present impunity, even though lasting for many days during the administration of the medicine, affords no certain guarantee against ultimate danger. From all that has been stated above it is to be inferred that, in using any of the forms of nux vomica, we should begin with a very small dose, especially in persons of great nervous irritability, as nervous females and young children, and increase by minute increments, and at intervals not shorter than a day or two, until we have ascertained the active dose, and then increase no further, but rather fall back somewhat, or suspend for a time, especially if the symptoms should be of a rather decided charac- ter. If the first dose produce observable effect, it should not be repeated till these effects have ceased, and then in diminished amount. In no case should the quantity be increased, however cautiously the augmentation may be conducted, to an amount adequate to the destruction of life in ordinary persons. When the medicine is administered as a tonic simply, it may be pushed, with the precautions just mentioned, to the point of observable effect on the system, and then diminished, so as to be maintained just within that point. The following are the different forms which may be resorted to for exhibition. The Powder. Nux vomica is not readily reduced to fine powder, and from this cause, as well as from its extremely bitter taste, and its uncer- tainty as regards strength, is seldom administered in that form. The dose is five grains three times a day, to be gradually increased till its effects are produced ; but in no case should it be pushed beyond fifty grains ; and it would be better to stop short at twenty or thirty graius. The dose of the bean of St. Ignatius should not be more than one-third that of nux vomica. Either of these may be given in pill if deemed advisable. ALCOHOLIC EXTRACT. Extraction Nucis Vomicse. U. S. 1850, Br. Extractum Nucis Vomicx Alcoholicum. U. S. This contains all the VOL. i. 53 834 GENERAL STIMULANTS. [PART II. virtues of the seeds. It is more convenient and efficacious than the powder, but like it is liable to the objection of inequality of strength. If the estimate of M. Recluz as to the average product obtained from the seeds is to be relied on, it is about twelve times as strong; as the powder. The dose is from half a grain to two grains, and in no case should exceed four or five grains. In persons of an irritable nervous constitution, it would be best to begin with the smallest quantity men- tioned. For a child from four to eight years old, the commencing dose may be one-eighth or one-sixth of a grain, which should not be increased beyond one, or at the furthest, two grains. At first, one or two doses may be given daily, which should be increased to three or four doses, before augmenting the size of each. The extract is most conveniently given in the form of pill. ALCOHOLIC EXTRACT OF IGXATIA. Extractum Tgnatise Alcoholi- cum, IT. S. Under the name of ignatia amara, an extract of the bean of St. Ignatius was a few years since used empirically or popularly to a considerable extent. It is needless to say that so powerful a medicine should never be tampered with, and never employed unless under proper medical supervision. The revisers of the U. S. Pharmacopeia for the present edition, sensible of this inconvenience, have introduced a formula for the extract under the name at the head of this paragraph. It is pre- pared by first forming a tincture by percolation and then evaporating the tincture to dryness. The dose is stated at from half a grain to a grain and a half, three times a day ; but, considering the relative rich- ness in strychnia of the nux vomica and the bean of St. Ignatius, it would probably be safer to commence with a dose not exceeding at most one-half of that of the extract of the former medicine. TINCTURE. Tinctura Nucis Vomicse. U.S. This is seldom used internally, on account of its excessive bitterness, while it has no advant- age in relation to equability of strength over the powder or extract. If the nux vomica be completely exhausted by the alcohol, the quantity equivalent to five grains of the powder will be twenty minims. This, therefore, may be considered as the proper commencing dose for an adult. As hitherto stated in most books, the dose is too small for effect, unless it may be as a tonic. The tincture is chiefly employed externally, by friction or as an embrocation to paralyzed parts. It may be conveniently diluted with the camphorated tincture of soap, or used as an addition to the liniment of ammonia. STRYCHNIA. U. S., Br. All that has been said of the effects of mix vomica on the system, and of its uses as a medicine, may be consid- ered as applying also to strychnia. When pure it has the advanta^- over the powder, extract, or tincture, of perfect uniformity of strength. The only objection to it is the extreme danger from over-doses, which therefore should be avoided with the greatest -care. CHAP. I.] SPINAL STIMULANTS. NUX VOMICA. 835 Strychnia is usually procured from the bean of St. Ignatius, in conse- quence of its greater richness in this principle than nux vornica. The seeds, properly comminuted, are treated with acidulated water till ex- hausted; the liquid thus obtained is precipitated by means of lime; the precipitate is treated with alcohol, which dissolves out the alkaloid ; the alcohol is distilled off from the tincture; the residue is dissolved with sulphuric acid; the solution having been purified by animal charcoal, is filtered, evaporated, and crystallized; and the resulting sulphate is redie- solved and precipitated by ammonia. As thus obtained, the strychnia contains some brucia; from which it may be freed by repeated crystal- lization from its alcoholic solution; the brucia being left behind in the mother liquor, in consequence of its greater solubility in cold alcohol. The only disadvantage of brucia is that it renders the preparation weaker in proportion to the quantity present. A little of it does no harm. Though crystallizable from its alcoholic solution, and sometimes crys- talline as sold in the shops, strychnia is more frequently in the form of a white powder, inodorous, excessively bitter, fusible by heat, but not vol- atilizable without decomposition, entirely dissipated when thrown on red- hot iron, almost insoluble in cold water, soluble in 2000 parts of boiling water, freely soluble in officinal alcohol when hot, but much less so when cold, and very sparingly soluble in ether. It may be known, in connec- tion with the above properties, by yielding a violet colour, when a minute proportion of solution of bichromate of potassa is added to a solution of the strychnia in concentrated sulphuric acid. If reddened by nitric acid, it may be assumed to contain brucia. With the acids it forms salts, most of which are soluble in water and crystallizable. The watery solu- tion of salt of strychnia is precipitated by the alkalies and their carbon- ates, and by tannic acid; but the precipitated matter is medicinally active. Perhaps, however, the most delicate test of strychnia is the phy- siological test of Dr. Marshall Hall ; its powerful effect, namely, in pro- ducing tetanic spasms in the frog. One of these animals, put into a liquid containing but an extremely small proportion of strychnia, say one-fiftieth of a grain in the fluidounce, speedily becomes affected with violent tetanic spasms, and perishes. (See Med. and Surg. Reporter, June 24, 1865, p. 85.) To a very considerable degree, strychnia has superseded nux voniica and its other preparations. Being one of the most violent poisons known, it requires to be prescribed and administered with the greatest caution. Many instances of death are upon record, arising from carelessness in the dispensing or use of it. The commencing dose of strychnia, when quite pure, should not ex- ceed the sixteenth or twelfth of a grain; and, in patients of irritable nervous systems, it would be best to commence with the twenty-fourth of a grain. This dose may be repeated twice or three times a day, aad 836 GENERAL STIMULANTS. [PA11T II. gradually increased, if necessary, in order to obtain its sensible effects. As death has resulted from half a grain, repeated two or three times a day for several days, it would be best never to allow the augmentation of the dose to reach this point. But, as the strychnia of the shops is often impure, larger doses than those mentioned are often necessary for effect. Less than one-sixth of a grain of commercial .strychnia will often produce no effect; but, as the strength is generally known only by trial, the dose of any untried parcel should not at first exceed that of the pure alkaloid. A very important caution, in prescribing strychnia, arises out of its variable degree of purity as kept in the shops. When the parcel is changed, unless the one first used is of known purity, the dose should be diminished to a point at which no possible injury could accrue, whatever might be the strength of the new parcel. For children from four to eight years old, the commencing dose should not exceed the thirtieth or fortieth of a grain. The best form of administration is in pill, which may be made with the crumb of bread, or the conserve of roses. Should no effect proceed from ordinary doses, the patient should take a little acidulated drink, as diluted acetic acid, in order to favour its solubility in the stomach ; or, should the bitterness not be objectionable, the strychnia may be exhibited in solution, made by slowly dropping into the water in which it is suspended enough acetic, diluted sulphuric, or muriatic acid, to render the liquid clear. For children, the solution may sometimes be advantageously incorporated with syrup, so as to make the dose a teaspoonful. One of the salts of strychnia, as the muriate, sulphate, acetate, or nitrate, may be substituted for the uncombined alkaloid. The only advantage of the salts is their solubility, so that they may be used in the pilular form, without the necessity, in any case, of following them with an acid. The dose is the same as that of strychnia. The Sulphate of Strychnia (STRYCHNINE SULPHAS, U. S.) is directed, in the U. S. Pharmacopoeia, to be prepared by mixing the alkaloid with distilled water, gently heating the mixture, and gradually adding diluted sulphuric acid until the strychnia is neutralized and dissolved. The liquid, now filtered and evaporated, yields the sulphate in crystals. The salt is in prismatic crystals, colourless and inodorous, but extremely bit- ter, readily dissolved by water, sparingly by alcohol, and not at all by ether. It melts with heat, and at a high heat is completely dissipated. The dose is the same as that of uncombined strychnia. Strychnia, or one of its salts, may be used externally by sprinkling it, in the form of powder, upon a surface denuded of the cuticle. The solubility of the salts here gives them an advantage. The quantity first used, if the preparation be pure, should not exceed half a grain of the strychnia, or a quarter of a grain of one of the salts. It may be applied also to the sound skin in the vicinity of the palsied part, in the way of CHAP. I.] SPIXAL STIMULANT?. NUX VOMICM. 837 embrocation ; the strychnia or one of its salts being incorporated pre- viously with glycerin or oleic acid. One part of strychnia, with a minute quantity of diluted sulphuric acid (a drop or two for each grain), may be rubbed up with fifty parts of glycerin, and a teaspoonful of the mixture rubbed over the paralyzed limb, or along the spine in chorea. (Journ, de Pharm. et de Chim., xxvi. 65, 91, and 303.) Dr. I. Hays, of Philadel- phia, has used, with advantage, a solution of acetate of strychnia, dropped into the eye, in order to produce contraction of the pupil, and to excite the muscle of accommodation. (Am. Journ. of Med. Sci., July, 1863, p. 266 ) Strychnia has been used hypodermically in amaurosis and prolapsus ani, and might be similarly employed in other local para- lytic affections ; the quantity injected at first not exceeding one-half the commencing dose by the mouth. BRUCIA. This alkaloid is extracted in the same manner as strych- nia, and accompanies it in the first steps of the process, but is in great measure separated on the crystallization of the latter from the alcoholic solution, remaining behind in the mother liquors in consequence of its much greater solubility in alcohol when cold. Still, it is with difficulty entirely separated from strychnia, and is very apt to contain it as exist- ing in commerce. It should be procured in the state of crystals. It is bitter, but less so than strychnia, and much more soluble in water and cold alcohol. It is reddened by nitric acid. Its claims to be considered as a distinct principle have been denied ; and Dr. Fuss supposes it to be a compound of strychnia and resin. It forms, however, distinct salts with the acids, which are for the most part soluble and crystallizable. From experiments of Magendie, Andral, and others, brucia is believed to be identical in its effects with strychnia, only much weaker. M. Le- pelletier, however, who had ample opportunities of noting its effects in the hospital practice of M. Bricheteau, though he considers its physio- logical action analogous to that of the stronger alkaloid, has yet found it to be in some respects peculiar. Thus, the fingers and great toe are rapidly extended and flexed, sometimes even producing a friction sound in the articular surfaces, but are never affected with that tetanic rigidity so characteristic of the action of strychnia. Moreover, the muscles of the jaws, pharynx, and oesophagus, which participate in the spasmodic effects of the latter principle, remain almost always unaffected under the influence of brucia. On the organs of generation, however, brucia acts with considerable energy. But, according to M. Lepelletier, the great advantage of brucia is its comparative safety; and, if it be true that it does not produce the tetanic rigidity, as he asserts, the danger of as- . phyxia, at least from the immovability of the respiratory muscles, is avoided. M. Bricheteau, though he has employed brucia for a very long time, has never known serious consequences to result. It may be used for the same purposes as strychnia, its great advantage being, ac- 838 GENERAL STIMULANTS. [PART II. cording to the author just cited, its comparative safety. He considers its influence over the generative organs, in connection with its entire harmlosm-ss, a peculiar recommendation. But, as it is often combined with strychnia, it is indispensable, in order to obtain due results, that attention should be paid to its purity, and that it should be employed only when iu the crystalline state. (Ann, de Therap., 1852, p. 50, etc.) Statements vary as to the comparative strength of brucia. Andral considers it as having only one-twenty-fourth of the strength of pure strychnia, Magendie the one-twelfth. M. Lepelletier gives the com- mencing dose of it, when quite pure, at two centigrammes (about one- third of a troy grain), to be increased progressively to five, ten, twenty centigrammes (about three grains troy), or even more, if necessary to obtain its physiological effect. (Ibid., p. 62.) DATE DUE J6' - iim Tin -i ^ JUL 2 J t!76 ' JUL 8 MSU (LEB-jii ^ 1 > -LCI : MARO' j 1070 SEP: I p REC'D CAYLORD PRINTED IN U S A t ; oy u 1867 v.l on therapeutic pharmacology and Wood, George B QV 1 W8?5t 186? v.l colo^ 186 n thera P eutics and pharma- MEDICAL SCIENCES LIBRARY UNIVERSITY OF CALIFORNIA, IRVINE IRVINE, CALIFORNIA 92664 9BH