,-^,-„,,HEBHBESIONAL,

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Bought of

THE LIBRARY

THE UNIVERSITY

OF CALIFORNIA

LOS ANGELES

Gift of
ur. \'i. L. Grant

■ L. GRiifiir, iw. a

FARGO, N. DAK.

G>C^

A HANDBOOK

THERAPEUTICS

SYDNEY RINGER, M.D.

PROFESSOR OF THE PRINCIPLES AND PRACTICE OF MEDICINE IN UNIVERSITY COLLEGE,
PHYSICIAN TO UNIVERSITY COLLEGE HOSPITAL

^iwiftix '^amon

NEW YORK

WILLIAM WOOD AND COMPANY

56 & 58 LAFAYETTE PLACE

1889

Bismedical
libiaiy

300

PEEFACE TO THE TWELFTH EDITIOK

As ill previous editions, so with this, I dwell much more on the
indications for the use of drugs in disease than on their physiological
action. The book is, in fact, a work on clinical therapeutics.

In preparing this edition, I have carefully revised every portion,
and added much fresh information, not only on new drugs, but also
on old.

I am anxious again to express my great obligation to my friend,
Dr. George Bird, who has assisted in revising this and several previous
editions of this Handbook, and who has increased its usefulness by
many suggestions.

Octobei', 1888.

6n.^rt.^4

INTEODUCTIO:^'.

I HAVE thought it might prove useful to the student and to the young
practitioner to insert in this edition a brief account of the symptoms of
disease. Of late years, since attention has been more drawn to the signifi-
cance of physical signs, too little heed seems to me to be paid to the detec-
tion and appreciation of symptoms, objective and subjective. This is a
marked defect among students. One often meets with a student,
thoroughly equipped with all the resources pertaining to physical diagnosis,
who yet is sorely puzzled with the indications afforded by the pulse or
tongue. The reason is obvious. Physical signs are soon learned, whilst
it requires a longer time, more patience, and a more discriminating obser-
vation to appreciate the meaning and to estimate the value of symptoms.

The indications of disease are divided into symptoms and " physical
signs." The direct information to be obtained from the pulse, the skin,
the tongue, the breathing, the evacuations, etc. , are for convenience, termed
objective symptoms. The indirect information we gather from the
patient's description of his own feelings and sensations, which are detected
only by the patient himself; these, likewise for the purjiose of convenience,
are termed subjective symptoms. Important though physical signs un-
doubtedly are, yet symptoms, especially objective symptoms, are far more
valuable. Physical signs, as a rule, help us to detect only coarse and de-
cided changes, and are chiefly useful in diagnosis, whilst symptoms are far
more useful guides in prognosis and in treatment.

It may be said, that before we can efficiently treat a patient, we must
first form a correct diagnosis; hence physical signs, by greatly assisting us
in this respect, must likewise greatly aid in the treatment. In some measure,
this proposition is no doubt true; but when we have accurately diagnosed
the disease, we treat, in most cases, the secondary effects rather than the
primary disease; and these secondary effects generally make themselves
apparent solely as symptoms. Only in a few instances, as ague and syphi-
lis, can we directly cure the disease itself; but in other instances we must
be content to combat the secondary and often fatal effects. A disease
often neither endangers nor destroys life by its direct effect on the organ
attacked, but through a secondary effect manifested on another organ or
organs. Thus to take the case of pneumonia; here, by no means unfre-
quently, the dangers depend, not on the condition of the lung, but on
nervous or cardiac depression. The fever depresses the nervous system,

VI INTRODUCTIOJ^.

shown in sleeplessness and delirium, and this depressed state of the
nervous system causes cardiac weakness and so endangers and destroys
life; or the fever may directly depress the heart and so weaken it that the
patient dies. Xow in both these instances, the effects on the nervous
system and on the heart are manifested solely by symptoms, and without
due appreciation of, and proper attention to these symptoms, so much
the worse for the patient.

Instances like this might be multiplied to any extent. Moreover,
there is the wide range of diseases in which physical diagnosis is unavail-
ing and when there are only symptoms to guide our treatment; and unless
trained in the recognition and estimation of symptoms, these are just the
cases in which the young practitioner is more likely to find himself at sea.

CONTENTS.

PAGE

Introduction, v

The Tongue, 1

The Pulse, 4

The Skin, 15

Tlie Temperature of Health, 18

Temperature in Disease, 18

Abnormal Elevation of Temperature, or Fever, etc 19

Chronic Fever, 24

On Dropsy, 32

The Effects of Cold on the Body, 35

The Cold Bath, including Sea-Bathing, . 38

The Sitz-Bath, 43

On Packing with the Wet Sheet, 44

Cold Baths in Fevers, 45

The Warm Bath and the Hot Bath, 50

Hot- Air and Vapor-Baths, 53

Shower, Douche, and Sponge Baths, 54

The Turkish Bath, 58

Poultices and Fomentations, G2

The Medicinal Uses of Ice, G7

On the Spinal Ice-Bag and the Spinal Hot-water Bag, .... 69

The Spinal Hot-water Bag, 71

The Internal Use of Water, 71

On Enemata, 74

On Acupuncture, 77

Irritation and Counter- Irritation, 81

Carbon, Animal Charcoal, Wood Charcoal, 86

Carbonic Acid, 88

Sulphur, 88

The Sulphide of Potassium, Sodium, Ammonium, and Calcium, . . 92
Chlorine Gas, Chlorine Water, Chlorinated Soda, Chlorinated Lime,

and their Solutions, 98

Iodine, 100

Vlll CONTENTS.

PAGE

A few Introductory Remarks regarding the Relative Effects of Potas-
sium and Sodium Salts, 104

Iodide of Potassium, Iodide of Sodium, Iodide of Ainiuoniuiii, . . 107
Bromide of Potassium, Sodium, Ammonium, and Lithium, . . .114
A Theory concerning the " Topical " Action of Acids and Alkalies on

Secretion, 123

Sulphuric, Hydrochloric, Nitric, Phosphoric, and Acetic Acid, . 123

Sulphurous Acid, Sulphites, Hyposulphites 130

Chromic Acid, 132

Boric or Boracic Acid, 133

Group embracing Caustic Potash, Solution of Potash, Carbonate and
Bicarbonate of Potash, Acetate of Potash, Citrate of Potash, and
the corresponding Preparations of Soda, Potash Soap, Soda Soap,

Borax, 133

Ammonia, Carbonate of Ammonia, Spirits of Ammonia, .... 146
Magnesia, Light Magnesia, Carbonate of Magnesia, Light Carbonate of

Magnesia, Solution of Carbonate of Magnesia, 150

Lime, Caustic Lime, Lime-water, Liniment of Lime, Saccharated Solu-
tion of Lime, Carbonate of Lime, 151

Phosphate of Lime, 155

Hypophosphite of Lime, Hypophosphite of Soda, 158

Chloride of Potassium, Chloride of Sodium, Chloride of Ammonium, . 158
Group containing Sulphate of Potash, Sulphate of Soda, Sulphate of

Magnesia, Phosphate of Soda, Tartrate of Potash, Bitartrate of •

Potash, Tartrate of Potash and Soda, IGO

Nitrate of Potash, Nitrate of Soda, 165

Chlorate of Potash, 168

Alum, Dried Alum, Acetate of Alumina, 169

Preparations of Iron, 172

Salts of Manganese, 178

Nitrate of Bismuth, Carbonate of Bismuth, 180

Lead Salts, 181

Nitrate of Silver, Oxide of Silver, 187

Mercury and its Preparations, 191

Preparations of Copper, 206

Preparations of Zinc, 207

Preparations of Antimony, 210

Preparations of Arsenic, 215

Phosphorus, 232

Collodion, . . . • 236

Cod-Liver Oil, Almond Oil, Poppy Oil, Hemp-seed Oil, Linseed Oil,

Cocoa-Nut Oil, Dugong Oil, Palm Oil, Lard, Suet, Wax, etc., . 237

CONTENTS. IX

PAGE

Castor Oil, Croton Oil, 244

Glycerine, 247

Tannin and its Compounds, on Gallic Acid, 248

Hanianielis Virginica, 252

Coto Bark, 253

Petrolevini, Vaseline, etc., 253

Tar, Creosote, etc., 253

Carbolic Acid and Sulpho-Carbolates, 256

Musk, Castoreum 260

Alcohol, 261

Chloroform, 2G9

Ether, 278

Iodoform, 279

lodol 281

Hydrate of Chloral, 281

Paraldehyde, 287

Urethan 288

Hydrate of Croton-Chloral, 288

Nitrite of Amyl, 292

Nitro-Glycerine, 298

Nitrite of Sodium, 300

Camphor, 301

Turpentine, Oil of Turpenthie, 303

Group containing : — Nutmegs, Cloves, Canella Bark, Cinnamon Bark,
Cajeput Oil, Oil of Anise, Fennel Fruit, Caraway Fruit, Coriander
Fruit, Dill Fruit, Elder Flowei's, Lavender Oil, Oil of Rosemary,
Oil of Sandal Wood, Menthol, Oil of Peppermint, Oil of Spearmint,
Oil of Rue, Oil of Lemons, Cubebs, Buchu Leaves, Balsam of Tolu,
Balsam of Peru, Copaiba, Mezereon, Sassafras, Storax, Juniper,

Benzoin, etc., 306

Eucalyptus, 309

Valerian, Valerianate of Zinc, Valerianate of Quinia, Valerianate of

Ammonia, 310

Assafoetida, Ammoniacum, Galbanum, 310

Cantharides, 311

Mustard, 313

Capsicum, 315

Ipecacuanha and its Preparations, 316

Apomorphia ^ 327

Veratrum Viride. . . . . . _ . ^ 327

Veratria, . . . . ^ . . . . 328

Colchicum, ... ..... ^ . . . _ 330

X CONTENTS.

PAGE

Poilopliyllum, '^'•^■^

Guaiacuiii, ^'^6

Actaea (Ciiuicifuga) Racemosa, 337

Aconite, 338

Digitalis and its Preparations, 345

Convallaria Majalis, 357

Strophanthus (Kombi Arrow Poison), 357

Spai'teine, 358

Adonidin, 359

Tobacco, 360

Coniuni, 361

Calabar Bean, 365

Muscarin, 368

Jaborandi, 373

Gelseniium Sempervirens, 375

Grindelia Robusta, 382

Belladonna, 383

Ethyl- Atropium, Methyl- Atropium, 400

Hyoscyauius, 401

Hyoscine, 402

Stramonium, 403

Duboisia Myoporoides, 403

Hydrocyanic Acid, Cyanide of Potassium, 404

Opium, 405

Nux Vomica, Strychnia, Brucia, Thebaia, 419

Lobelia Inflata, 426

Cannabis Indica, 427

Ergot, 429

Coffee, Caffeine, 432

Cocaine, 435

Cinchona and its Alkaloids, 441

Salicine, Salicylic Acid, SaUcylates, 448

Salol, 452

Antipyrine, 453

Phenacetin, 455

Quassia, 456

Chamomile, 456

Pareira Brava, 456

Elaterium, 457

Colocynth, 457

Aloes, 457

Squill, 460

CONTENTS. XI

PAQE

Jalap, Scammony, 460

Rhubarb, 461

Senna 462

Cascara Sagrada, 462

Euonyiuus, 462

Senega, 463

Anthelmintics : — Filix Mas, Kousso, Kamela, Santonin, Turpentine,
Areea ]N^ut, Bark of the Pomegranate Root, Powdered Tin,

Mueuna, etc 463

Dietary for Invalids, 467

Index to Therapeutic Agents, 479

Index to Diseases,

A HAND-BOOK OF THERAPEUTICS.

THE TONGUE.

"We examine the tongue to ascertain whether it is clean or furred; dry

or moist; its color, etc.

What is the meaning of a furred tongue ?

A tongue may he furred from febrile disease; from local causes; or
from sympathy with the stomach, intestincB, or liver.

The condition of the tongue in fever is, perhaps, more a help in prog-
nosis than in treatment. In most fevers the tongue at first is covered
with a moist fur; but in some cases the tongue, strange to say, remains
quite clean. Sometimes this is the case in typhoid fever. Now the coated
tongue in fever does not give us much suggestion with regard to treatment,
for whether the tongue is clean or foul, if there is constipation the bowels
must be relieved; and if the tongue is very foul, that is, thickly coated, a
mercurial purge is best, though whilst the fever continues some fur usually
remains.

Local causes often foul the tongue. Enlarged tonsils often coat the
back of the tongue. Decayed teeth often fur a portion of the tongue.
If one tonsil only is enlarged, or if the decayed teeth are situated on one
side, then only one longitudinal portion of the tongue is furred. In neu-
ralgia of the fifth, when the lower branches are affected, the tongue on
the neuralgic side is apt to become furred.

Excessive smoking almost always furs the tongue.

The tongue very frequently indicates derangement of the stomach,
bowels, or liver. For instance, if there is no fever, and no local cause, as en-
larged tonsils, bad teeth, etc., then a coated tongue indicates some dis-
turbance of the primge via?.

What does a coated tongue under these circumstances indicate ? We
shall rarely go wrong in taking this furred tongue as an indication for
giving one of four medicines, or some of them combined : namely, mercury,
podo})hyllin, tincture of nux vomica, or nitric acid.

How are we to determine which to give and its dose ? If there is con-
stipation then give a mercurial preparation or resin of podophyllin in pur-
gative doses. Any purgative, it is true, will here be useful, especially the
natural purgative waters, as Pullna, Friedrichshall, or Carlsbad; but these,
though valuable remedies, are in many instances inferior, in the cases in
question, to mercurial and podophyllin purges.

As regards mercury, our choice falls either on calomel or blue pill for
adults, or calomel or grey powder for children. The calomel or blue pill
should be combined with extract of belladonna or of hyoscyamus, since
this addition obviates the griping and certainly seems to enhance the ac-
tion of these drugs. An effective dose is half a grain of calomel with

iJ THE TOXGUE.

three grains of extract of liyoscyamus, for tlireo consecutive nights; tlie
first pill generally purges pretty freely, the second much less freely, and
the tliird scarcely at all, though it helps to clean the tongue.

Which should we choose — mercurial purges or podophylli.n resin ?
The answer to this question depends on the color of the stool. If the
motions are too light-colored mercurial purges are best. If, on the other
hand, the motions are too dark then podophyllin is needed. For this clin-
ical fac^t I can give no explanation.

What is to bo done when the l)owels are freely open, or have been re-
laxed by medicine, but where the tongue still continues furred ? Such
cases Ave often meet with in gastric, biliary, or intestinal disturbance,
and sometimes in the early convalescence from acute illness the tongue
does not clean so quickly as it should — a sure sign of impaired digestion.
Here again a mercurial preparation or podophyllin is useful, given with
tincture of nux vomica and nitric acid. If the motions are too light then
give a third or half a grain of grey powder, night and morning or three
times a day; if the motions are too dark then give a small dose, say a
thirtieth to twentieth of a grain of podophyllin resin, night and morning.
Five drops each of tincture of nux vomica and dilute nitric aid thrice
daily, will much promote the action of the mercury and the podophyllin.
Sometimes the fur is dirty or brown, and the patient complains of a dis-
agreeable bitter taste, especially in the morning, and this symptom is an
additional indication for the foregoing treatment. Sometimes, however,
in spite of this treatment, the disagreeable bitter taste persists in the
morning, or even during the greater part of the day. Einsing the mouth
with a weak solution of permanganate of potash will generally temporarily
remove the annoyance.

As the tongue cleans the fur recedes from the tip and edges and grad-
ually becomes thinner, especially at its margin. With a little practice
we can generally detect when the cleaning process is going on.

After an acute illness, like typhoid fever, the tongue sometimes parts
w^ith its fur in flakes, leaving clear smooth patches, especially at its back.
This tongue denotes a slow convalescence. In typhoid fever this tongue
may a second time become dry, with a return of the abdominal symp-
toms. In a case like this turpentine is indicated in 10 to '^*0-minim doses
every two or three hours.

A dry tongue occurs most frequently in fever. The dryness first
invades the tip and extends up the centre, spreading meanwhile lat-
erally, till the whole tongue becomes dry. It grows moist in the inverse
order of its invasion. A dry tongue generally indicates nervous depres-
sion, often shown by delirium, usually of a low muttering kind. This
nervous prostration is often dependent on want of sleep. Narcotics there-
fore, like choral, bromide of potassium, or opium, by inducing sleep,
soothe and strengthen the nervous system, and indirectly moisten the
tongue. Opium is often more useful than bromide of potassium, or
choral, for opium appears to have a greater effect on the tongue than
either of the other drugs, probably inducing a moist condition by its direct
action on the tongue and stomach as well as through its sleep-producing
effect on the nervous system.

Being frequently a sign of nervous depression, the dr}' tongue becomes
also an indication for giving alcoholic stimulants. If, liowever, the
nervous depression is due to wakefulness it is better, if possible, to secure
refreshing sleep by a soporific, which, by soothing and strengthening the

THE TONGUE. 3

nervous system, renders the tongue moist, promotes digestion and assim-
ilation, and incites the patient to take more food.

The two chief uses of alcohol are to assist digestion and to sustain the
nervous system. Now sleep is the best restorative; hence fever patients
who sleep well do not as a rule require stimulants.

If sleep cannot be secured, or if in spite of sleep the tongue remains
dry and the delirium persists, then alcohol is indicated, though the ]Hilse
is a better guide. Usually, however, a patient with a dry tongue has a
frequent, quick and compressible pulse calling for alcoholic stimulation.

Whilst the tongue often affords evidence of the necessity for alcohol,
sometimes it shows when it does harm, for if the tongue grows coated or
drier, it is evident that the stimulant is doing mischief.

The tongue in an aged person often readily becomes dry even in non-
febrile illnesses; hence a dry tongue has not quite the same serious import
as a dry tongue in a younger person. If with the dry tongue there is
sleeplessness we must be careful how to give soporifics; for though in
many cases a soporific is very beneficial, yet in old people sometimes it
produces great excitement. If the dry tongue is associated with depression
or exhaustion we not at all rarely find that alcohol increases the dryness
and destroys the appetite; hence, at first, stimulants must be given to
aged patients in a small quantity, the effect of which must be carefully
Avatched.

The color of the tongue is a useful sign. A broad, pale, flabby teeth-
indented tongue, indicates anfemia with a relaxed condition of the tissues.

It is met with in simple antemia, and chlorosis, and in some chronic
diseases, as in Bright's disease, in which, in addition to anaemia, there is
hydremia — an excess of water in the blood. This tongue always signifies
the need for iron; and the astringent preparations in large doses, are, as a
rule, far the best. A swollen teeth-indented tongue during a course of
mercury, is one of the earliest signs of salivation.

In diabetes, in severe and advanced cases, the tongue is often charac-
teristic. It becomes smooth, glazed, shiny, beefy-looking, abnormally
clean, often with a tendency to become dry, and sometimes quite dry.

The tongue may be red, with prominent red papilla? most marked at
the tip; and this red tongue too clean, too smooth, or, slighty furred
points to ' ' the irritable tongue " and a coi-responding state of the stomach.
It is met with in certain dyspeptic cases, sometimes in drunkards, and
especially in phthisis when the intestines are ulcerated or there is tuljer-
cular peritonitis. Small doses of arsenic, say one minim of the liquor,
given shortly before food, will generally improve this tongue aiid the as-
sociated conditions. It should be borne in mind that great irritation of
the stomach or intestines or tubercular peritonitis may exist, unaccom-
panied with this irritaljle tongue.

In scarlet fever, a few days after its commencement and before the
fever declines, this tongue is met with, and it continues during the eiwly
part of convalescence. It is the very characteristic " strawberry tongue,"
always suggestive of scarlet fever. Its appearance arises from desquama-
tion of the tongue, for the cuticle of the tongue being moist is more easily
separated than the cuticle of the skin, hence the tongue desquamates some
days before the skin. I need hardly say, that whilst the fever lasts, we
should not treat the tongue with arsenic, though, if convalescence is te-
dious and the tongue retains its strawberry cliaracter, arsenic and nitric
acid will be found useful.

THE PULSE.

The " nervous tongue " is also very noteworthy: generally it is very
slightly coated and covered with a slight froth, most marked close to the
edge. We meet with it in persojis of nervous temperament, especially
during the period of excitement, and in cases where the nervous system
has been depressed by overwork, and worry.

THE PULSE.

With each contraction of the heart, a wave is sent through the
arterial system, which, in its journey along the vessels, distends them,
and this periodical distention, readily felt when the fingers are placed on
an artery, is the pulse. Dr. Broadbent. however, denies that the pulse
is due to distention of the artery, and ascribes it to the wave forcing or
trying to force the vessel flattened by pressure of the finger back to its
cylindrical form. The pulse, therefore, depends on the heart; and varies
with the condition of the heart. It is influenced also by the condition
of the vessels, the pulse varying according to the contracted or dilated
condition of the arteries; moreover, it is also modified when the walls of
the vessels become fibrous or calcareous. The pulse is an accurate index
of the condition of the heart, and is therefore the most valuable guide in
disease.

The importance of the pulse is manifest when we consider that disease
kills by arresting the heart. Whilst tlie heart beats there is life and hope.
In many instances, the pulse gives the promptest signs of danger and the
earliest indications for treatment. To illustrate this by an example, take the
case of pneumonia, in which disease so long as the pulse continues good
we have fair hopes of our patient. In some patients the heart fails early
and the pulse soon reveals this condition; the patient fails, Ave say, at the
heart. In other instances, the nervous system first gives way, shown by
sleeplessness and muttering deli' :um: but though these symptoms cause
anxiety, yet so long as the pulse remains good, we hope to save our patient.
The anxiety we feel with regard to this nervous perturbation arises from
its depressing effect on the heart; for if the patient does not sleep, this
unrest, with the consequent dehrium, rapidly depresses and weakens the
patient, and at last arrests the heart. The disease, therefore, may directly
tell on the heart, or it may indirectly affect this organ by its depressing
effect on another system. In any case it is the ultimate effect of the dis-
ease on the heart that destroys life. It is hardly possible, therefore, to over-
estimate the cardinal importance of the ptilse. The pulse-beats may be
frequent or infrequent; slow or quick; small or large; compressible or
incompressible; regular or irregular; or intermittent.

By the frequency of the pulse we mean the number of beats in a given
time.

In a quick pulse each beat occupies less than the usual time, that is,
each wave is of short duration relatively to the pause between the waves.

When the volume of the pulse is greater than usttal. it is said to be
large; or the volume may be less than usual, when it is said to be small.

THE PULSE. 5

When the fingers can easily stop the pulse it is said to be compress-
ible; when, on the other hand, it can be arrested only with difficulty or
not at all, the pulse is said to be incompressible.

The pulse may be irregular or intermittent. In an irregular pulse,
succeeding beats differ in length, force, and character. In an intermit-
tent pulse a beat is from time to time lost.

The frequency of the healthy pulse varies; thus in some persons the
normal pulse is 100, in others as low as 50 a minute, but these extremes
are rare.

Five conditions produce a frequent pulse: Fever, debility, excitement,
hysteria, and cardiac disease, as in some cases of mitral disease; and the
pulse in exophthalmic goitre is greatly accelerated. We seldom experi-
ence difficulty in determining the cause of the accelerated pulse. In ex-
citement the acceleration is not persistent and lasts only whilst the excit-
ment continues. Hysteria may greatly and permanently accelerate the
pulse to even 150 or 160 beats per minute. But in a grave illness, whether
febrile or not, liysteria, if present before, generally passes away at unce, so
that we may safely attribute the frequent pulse to the invasion of another
and more serious disease.

In fevers the pulse is generally accelerated in proportion to the eleva-
tion of temperature, though the proportion between the pulse and tem-
perature varies in different fevers. In scarlet fever, the pulse is more
frequent than in typhoid fever with the same temperature, hence a fre-
qvTent pulse is of less serious import in scarlet than in typhoid fever.
The same elevation of temperature accelerates the pulse relatively much
more in children than in adults.

When a pulse is more frequent than the temperature will explain, it in-
dicates cardiac weakness — the weakness being proportionate to the want of
ratio between the temperature and pulse. In this way the pulse affords
important information in prognosis and treatment.

A pulse that day by day progressively increases in frequency, the tem-
perature remaining the same, shows increasing cardiac weakness.

In all febrile diseases, a pulse in adults over 120 is serious and indi-
cates cardiac weakness, a pulse of 130 or 140 indicates great danger, and
with a pulse at 160 the patient almost always dies. There is, however,
a notable exception to this rule, in rheumatic fever. In estimating the
value of the pulse in this disease, we must carefully ascertain whether
rheumatic fever itself or pericarditis occasions the increased frequency.
A pulse of 120, if due to the rheumatic fever, indicates great danger. In
such a case the temperatu.re is high, 104 to 105, the patient is prostrate,
the tongue pro1)ably dry, and sordes collect on the lips: a case like this
often ends fatally, and when the pulse rises above 120, say to 130 or
higher, the patient will pretty surely die.

If pericarditis causes the frequent pulse, it becomes then of far less
serious import, though the pulse may rise to 150 to 100 per minute.
Not unfrequently we meet with such cases where, with but slight rheu-
matic fever, severe pericarditis with perhaps extensive effusion sets in.
The temperature is not greatly raised, rising only to 101° or 102" Fah.,
the tongue remains clean or but slightly coated. Now in a case of this
kind, though the beats rise even to ICO and the pulse becomes very bad
in other qualities, being very compressible or even small and compressible,
yet we may reasonably expect the patient to recover. The heart's sub-
stance too is generally inflamed; and this weakening of the heart's sub-

b THE PULSE.

stance, coupled with the mechunical embarrassment arising from the peri-
cardial effusion, excites very hurried, even panting breathing. Thus
attacked, the patient often looks very ghastly, the face l)ecomes dusky
and distorted with the hideous risus sardonicus; yet if these symptoms
can be clearly traced to the cardiac mischief, we may hold a well-grounded
hope of the patient's recovery, even without the aid of large doses of alco-
holic stimulants. In fact, acute pericarditis is rarely immediately fatal;
it remotely destroys life only by leading to dilatation with valvular incom-
petency, or to fatty degeneration of tne heart.

Rheumatic fever with other complications generally ends favorably, no
matter how serious the aspect of the patient. Pneumonia, even Avhen
double and further complicated with extensive pericarditis, seldom de-
stroys a patient.

Again, an irregular pulse from mitral disease may be very frequent,
120, 130 or more, without indicating extreme danger. Sometimes in acute
fever, as typhoid fever, though the temperature is high, the pulse remains
normal throughout the attack; such a pulse certainly shows absence of
cardiac weakness, and is of course a favorable sign.

In chronic diseases a frequent pulse very generally indicates cardiac
weakness.

With increased frequency other signs of cardiac weakness are associated.
The weakened heart propelling the blood less energetically than in health
diminishes arterial tension and the pulse becomes soft and compressible.
Relaxation of the arteries plays a part still more important in producing
a compressible pulse; this condition permits the blood to pass with greater
readiness into the veins, and so to lessen arterial tension. This relaxed
condition of the arterioles, unless the heart is very weak, causes the pulse
to be large and voluminous. At first one might erroneously suppose that
this pulse indicated an energetic arterial circulation and a well-beating
heart, but the compressibility soon corrects this error. It is therefore
highly important always to test the compressibility of the pulse. If the
heart becomes still more weak, and the arterioles still more relaxed, then
each beat propels little blood into the arteries, and these allowing the
blood to pass readily into the veins, the pulse becomes small as well as
quick and compressible. Smallness of the pulse, therefore, indicates still
greater weakness. When the pulse is very small it is said to be thready.
When the heart is weakened its contraction often becomes sudden and
sharp, rapidly reaching a maximum and rapidly declining, giving rise to
a quick pulse, which thus often gives evidence of cardiac weakness, es-
pecially when combined with the other and surer indications of this state.

Therefore, in estimating the condition of the heart, we pay regard to
the frequency, especially with reference to the temperature, to the com-
pressibility, and to the size of the pulse. The more frequent, the more
compressible, the smaller the pulse, the greater the cardiac weakness, and
the more imminent the patient's danger, and the greater the need of car-
diac stimulants.

These pulse signs, therefore, both in febrile and non-febrile disease,
are indications for giving cardiac stimulants, especially alcohol. These
pidse signs, moreover, afford an accurate index of the effects of alcohol
and of the amount required; for alcohol strengthens the debilitated heart,
reduces the frequency of its beats, and contracts the vessels, and so
heightens arterial tension and lessens the compressibility of the pulse.

ISoth in acute and chronic affections cardiac weakness is, as a rule, ac-

THE PULSE. T

companied by evidence of general weakness, though this by no means
is always the ease. We may be called to a patient with an acute
illness who at first shows no evidence of Aveakness; his temperature
is found to be from 102° to 103°; he easily turns over or sits up in
bed; his voice is strong; his tongue moist and but little furred, per-
haps even clean ; he takes his food and apparently digests it well.
He sleeps well at night and is free from delirium; in fact the general
appearance of the jjatient indicates no danger; but the pulse beats
say 130 per minute, and it is small, compressible, and quick; and
not due to excitement, as we ascertain by repeated observations; in
fact this patient is in considerable danger. Are we to pay regard to the
pulse or to the general condition ? Certainly to the warning pulse, for in
a case like this, just described, serious symptoms will set in in a few days,
and the patient will sink. The pulse here is a much prompter and surer
danger-signal than the other symptoms. To take another instance: — A
febrile patient when first seen presents no serious symptoms, but as the
case goes on, and whilst the patient's general state remains apparently
satisfactory, the pulse gradually increases in frequency and loses in force.
Here again the pulse is the better guide, giving early indications of ap-
proaching general prostration.

We must, however, bear in mind that owing to individual joeculiarity,
the pulse in some persons is easily made very frequent, and a moderate
amount of fever may accelerate the pulse and make it 130 to over 150,
without this frequency indicating any danger. Our previous knowledge
of the patient will alone enable us to rightly estimate the frequency of the
pulse in these cases. Again, we meet with cases of this kind: a patient
suffers from a moderately severe attack of fever, and the j)ulse is by no
means frequent in proportion to the fever, but it is very small and very
compressible. In forming our prognosis are we to be guided by the small-
ness and compressibility, or the frequency of the pulse ? In most cases
certaiidy by the frequency. The size and compressibility of the pulse
varies in health very considerably in different persons. In some persons
in perfect health and capable of vigoi'ous exertion, we find a very small
and compressible pulse — that might even be called thready. Such a pulse
often occurs in various members of the same family. Now if such a person
becomes febrile the pulse becomes more frequent, and without any cardiac
weakness is of course small and compressible — and it is obvious if we dis-
regarded frequency and paid attention only to the size and compressibility,
we should be misled, both as regards prognosis and treatment. Of course
our previous knowledge concerning the patient will, in many instances,
save us from falling into error; but should we see the patient for the first
time in a febrile attack, if we regarded the size and compressibility rather
than the frequency, we should probably be misled. Of course if a pre-
viously good pulse becomes small and compressible this change is significant,
but it rarely happens that this change occurs without a corresponding
increase in the pulse's frequency. ^

It is true that sometimes signs oi danger arise first in other organs,
perhaps in the nervous system, in the form of sleeplessness and delirium,
yet, as I have pointed out, so long as the pulse remains good we feel that
our patient is comparatively safe. If the nervous perturbation neither
spontaneously declines nor yields to treatment, the pulse will ultimately
fail and the patient will sink.

An infrequent pulse occurs in some cases of blood-poisoning, as in
jaundice, uraemia, and in these cases the temperature is often subnormal.

8 THE PULSE.

In some cases of pericarditis at its commencement the pulse jjreatly
falls in frequency; and in rheumatic fever if the pulse changes suddenly
and greatly in frequency, especially without corresponding cliange of
temperature, we should expect the onset of pericarditis or other cardiac
complications.

An infrequent pulse is met with sometimes in fatty degeneration of the
heart, and in aortic obstruction, in irritation of the vagus or its root, as
in meningitis, cerebral tumors or compression. In defervescence, the
frequency of the pulse may be much diminished.

'I'he size of the pulse varies in disease. It is often large at the com-
mencement of fever, the ventricle acting strongly whilst the arterioles are
relaxed. It is rendered larger too from arterial excitement. In aortic
regurgitation, the pulse is very large during systole, but during diastole
becomes very small from the great emptying of the arteries.

The pulse is small in inanition owing to the small quantity of blood.
It is small too in mitral obstruction, mitral regurgitant disease, and in
aortic stenosis, also with cardiac debility.

In an intennitfent pulse, an occasional beat is missed, the rhythm being
otherwise regular. The omitted beat may occur frequently or unfre-
quently, at an equal or irregular interval. It must be clearly understood
that an bdenniUent pnlse is very different from an irregular jmlse, and
has an altogether different significance. Some persons have a life-long
intermittent pulse, but ordinarily, it does not occur till after middle age. It
may be persistent or occasional; and when occasional only it is often due to
an idiosyncrasy, and is caused by some article of food, as tea, perhaps green
tea, smoking, or indigestion. Certain patients are unconscious of the inter-
mission, and as Dr. Broadbent points out, this is especially the case when
the intermission is habitual. Other persons are made very uncomfortable
and nervous by a sensation as if the heart stopped or rolled over. The
intermission often occurs in the artery only simultaneously with a weak
beat of the heart.

In most cases an intermittent heart is of no significance, and does not
appear in any way to imperil life, though Dr. Broadbent states that a patient
so affected succumbs more readily to any illness; when, however, associated
with unequivocal evidence of heart disease intermittency is of more serious
import.

An irregular is of far more serious significance than an intermittent
pulse. The pulse is irregular both in force and rhythm, succeeding beats
differing in length, force, and character. It is generally due to mitral
and rarely occurs in other forms of heart disease, though sometimes met
with in great cardiac prostration, as in an acute febrile illness a few hours
before death. It occurs too in fatty degeneration of the heart and in
the first and second stage of meningitis. It may be called the mitral
pulse, and generally indicates the need of digitalis, which in most instances
lessens or removes the irregularity.

Whilst an irregular pulse alm(^t always indicates mitral disease, it
must be borne in mind that a perfectly regular pulse may accompany ex-
tensive mitral disease; either obstructive or regurgitant, or both combined.

Some hold that the occurrence of irregularity in mitral disease is a sign of deficient
compensation, the compensation being insufficient to meet the obstruction to tlie cir-
culation offered by the initnil disease. But were this view correct, how does it hap-
pen that a few doses of digitalis will in many cases restore regidarity, and that with
the discontinuance of the digitalis the irrregularity does not return V

The irregular pulse is very rare in children under twelve, though the

THE PULSE. y

conditions which produce it in adults are well marked. If, say, between
six and seven, mitral disease is established, and the child, though suffering
from its effects lives till it is over twelve, the intermittency then becomes
gradually developed.

Though irregularity from mitral disease is rare in children, yet I have
seen aconite, in half-drop doses repeated hourly, several times produce
marked irregularity of the pulse. Irregularity of the pulse in children is
common in the first and second stages of tubercular meningitis; in fact
its existence is often a valuable diagnostic guide. In some cases of cere-
bral disease, with Cheyne-Stokes breathing, the pulse is affected by the
respirations; as these grow more and more shallow the pulse grows slower
and slower, and then becomes frequent when the patient takes a deep sigh-
ing breath.

An irregular pulse may be due to much smoking, to venereal excess,
and to tea-drinking.

Hitherto I have referred to the dependence of the pulse exclusively or
mainly on the condition of the heart. But the condition of the blood-
vessels themselves also influences the pulse.

Through the action of the vaso-motor nerves on the muscular coat of
the arteries, the small blood-vessels undergo relaxation or contraction.
When the vessels are relaxed the blood passes easily from the arteries to
the veins, hence arterial tension is slight, and the pulse is soft and com-
pressible, but owing to the relaxed state of the vessels it is also large. A
relaxed condition of the arteries, therefore, produces a large, soft, com-
pressible pulse.

In most diseases, a relaxed condition of the arteries is associated with
a weak heart. Sometimes, however, we have arterial relaxation with a
normal heart, in which case the pulse is soft and compressible, but large.
This pulse is met with in the early stage of some fevers.

Arterial relaxation, or, in other words, diminished arterial tension, pro-
duces dicrotism. In this pulse one of the normal secondary waves of oscil-
lation becomes greatly exaggerated, so that it can be easily felt by the fin-
ger. Indeed it may be so distinct that an inexperienced person mistaking
it for the primary wave, might easily be led erroneously to think it indi-
cated a cardiac contraction. Indeed a nurse has been known to make this
mistake and thus to double the number of true pulsations. Dicrotism
always indicates marked arterial relaxation, and often coincides with car-
diac weakness. Some writers insist that this pulse indicates the use of
alcohol, which should be pushed till the dicrotism ceases. JSTow, in this
opinion I cannot concur, feeling convinced that in many cases with marked
dicrotism no alcohol is needed. We must look rather to the frequency of
the pulse, and if this shows the need for stimulation, then no doubt dicro-
tism affords additional evidence in favor of giving alcohol.

A dicrotous pulse is frequently met with in typhoid fever.

I now come to the pulse of liigh arterial tension; here the vessels are
much contracted, and then as the blood escapes with greater difficulty from
the arteries into the veins, the arterial tension becomes high. In some of
the following remarks, I largely borrow from Dr. Broadbent's valuable lec-
tures on the pulse; and the pulse in question cannot be better described
than in his own words: —

"The artery, usually rather small but sometimes large, is hard and
cord-like; it can be rolled under the finger and is easily traced in its course
up the forearm, where it feels like another tendon lying amidst those in

10 THE PULSE.

front of the wrist. It reminds one, as I have often said, of the vas defer-
ens. "

With the vessels in this condition the pulsation is often so slight that
it might readily be mistaken for a weak pulse, but that its incompressi-
bility prevents our falling into this error. It can be compressed only by
using considerable foi'ce. It is, in fact, a sligbtly pulsatile pulse, for
owing to the high arterial tension the vessel with each beat of the heart
undergoes but little dilatation, hence the pulsation is indistinct. In addi-
tion to being small the pulse is slow and hard.

The following conditions give rise to arterial tension —

1. Degeneration of vessels.

2. Bri gilt's disease, especially the contracted kidney.

3. Gout, jaundice; lead-j)oisoning; ergot; gallic acid.

4. Affections of the nervous system.

5. The rigor of fevers.

High arterial tension accompanies some forms of Bright's disease, oc-
curring in the fatty, but especially in the acutely-inllamed and contracted
kidney; in fact high arterial tension, and hypertrophy of the heart, asso-
ciated with an increased quantity of urinary water containing a small quan-
tity of albumen, enable us to diagnose the contracted form of Bright's
disease. The albuminoid kidney is not associated with high arterial ten-
sion.

Although it is quite true that, in general, a soft compressible pulse of
low tension accompanies a weakly acting heart, we meet with exceptions
to this rule. For a patient prostrate, nay, even moribund, and conse-
quently with a very feebly acting heart, may have a high tension pulse,
the radial artery feeling hard and remaining to the touch like a firm cord,
and is distinctly traceable some way up the forearm, even during diastole;
whilst the temporal artery is also firm and resistant. This combination of
a high tension, and therefore small and resistant pulse, with great cardiac
and general weakness is, I think, more commonly seen in children, and is
sometimes strongly marked in tubercular meningitis and capillary bron-
chitis or broncho-pneumonia.

It is obvious from these facts that we must not be led to give a too
favorable opinion because of the high tension pulse. "When the frequency
and the tension point in opposite directions we must rely on the frequency
rather than the tension. In those cases where the heart is feeble, though
the pulse shows high tension of the vessels, we can, from the feel of the
pulse sometimes detect the condition of the heart, and thus estimate the
true state of the patient, without having regard to the frequency of the
pulse. The jiulse, even during diastole, feels hard and resistant, and we
can trace it a long distance beyond the point where it is usually felt, but
each systolic distention feels smaller than usually, even with high tension
of the vessels; moreover, with slight jiressure, Ave can easily arrest the
pulse-wave along the vessel.

Here, perhaps, I may profitably introduce, though at the risk of some
repetition, an account of the modifications the pulse undergoes in the
stages of an acute illness. First I will refer to the characters of the pulse
of a man previously -vngorous and robust smitten with an acute disease.
The pulse differs in the separate stages of the fever, in the chill, the acme,
and the decline. During the rigor or chill the arteries contract, and pro-
duce a pulse of high arterial tension. The pulse is fi*equent. small, often
verv small, hard, incompressible, and long, or as it is otherwise ternietl.

THE PULSE. 11

slow. The chill over and the fever established, the arterioles relax and
the pulse becomes larger; but as the heart is not yet weakened the pulse
is large, full, and not easily compressed, — bounding as it is called. When
the fever persists during many days and the patient grows weak, the pulse
becomes softer, and more compressible, short (or quick) and often dicro-
tous.

In the case of a fever with great prostration the pulse is very frequent,
small, short, very compressible, these characters becoming still more
marked if the illness terminates fatrdly. If in the supposed case the
patient, previously in weak health, is suddenly attacked with an acute ill-
ness, the pulse from the first would assume this character. During the
decline of the fever, especially when it ends abruptly, and accompanied
by free sweating, the pulse, unless the patient has been greatly weakened,
is large, very soft, easily compressed, dicrotous,and short — all the characters,
indeed, of extreme arterial relaxation. Indeed in febrile diseases, even dur-
ing their height, and in non-febrile diseases too, when tlie skin perspires
freely, this is generally the character of the pulse. And this also is the
pulse of acute rheumatism, because this disease is usually accompanied by
sweating. Again, in a febrile disease, when by means of a drug we con-
vert the dry into a moist skin, we find the pulse becomes soft, large, but
compressible.

In well-marked aortic regurgitation, the pulse is often characteristic.
It is a pulse of extreme low tension. In this afl^ection the blood during
diastole flows back into the ventricle, so that the arteries become more
or less emptied of blood. The ventricle being hypertrophied and dilated,
propels a larger quantity of blood with greater force than usual into the
partially emptied arteries, and suddenly distends them. This explains
most of the phenomena of the aortic regurgitant pulse. The pulse in
great arterial relaxation (low tension) may simulate the pulse of aortic
regurgitation, for great arterial relaxation by unduly facilitating the
passage of blood from the arteries into the veins empties the arteries more
than usual, and these unfilled vessels becoming suddenly distended by the
normal contraction of the ventricle, especially during excitement, give to
the finger some of the characters of an aortic regurgitant pulse, but in
a much less marked degree. The pulse is somewhat sudden, and this
quality, as is the case with aortic regurgitation, is accentuated by raising
the arm above the level of the heart. Further, if the radial is at all
visible with the limb dependent, this visibility becomes much more
marked on raising the arm. Indeed it may become visible only on raising
the arm.

The pulse of aortic regurgitation is of two kinds, depending on the
amount of regurgitation and the strength of the heart. The pulse in
early cases gradually rises as usual till it reaches its acme, and suddenly
collapses, the collapse being due to the regurgitation of the blood into
the ventricle.

In more advanced cases the pulse gives to the finger a sharp, quick
stroke. The extreme suddenness in the commencement of the pulse, as
Dr. Galabin observes, gives to the finger in marked cases the impression
of a sudden blow or jar. This is the diagnostic quality of the pulse. In
some cases, especially when the heart is weak, if several fingers are placed
on the artery, and the pressure is graduated, the pulse feels at a certain
degree of pressure as if a small ball or shot was puffed under each finger.
This is the shotty pulse.

12 THE pulsp:.

This cbiiractor of pulse can often be felt best by gT'asping the wrist with
the Avhole hand, so as to feel both nlna and radial arteries; and these
characters are also increased by raising the wrist high above the level of
the heart, thereby enal)ling gravitation to assist the aortic regurgitation
to empty the arteries. This quality of pulse is often oidy felt when a cer-
tain degree of pressure is made on the artery, becoming much less by
diminishing or increasing this pressure.

In aortic regurgitation, as Dr. Corrigan points out, the pulse is often
yisible in the more conspicuous arteries. In fairly nourished persons the
radial pulse is not visible in health, but is often distinctly visible in
healthy thin ]iersons. In aortic regurgitation it becomes far more visible
at the wrist when the arm is raised over the head. This visible pulsation is
probably due, as Corrigan points out, to the empty condition of the artery
during diastole. The blood flows easily into the veins, and much is poured
back by the aorta through the patent aortic orifice into the ventricle,
hence the imperfectly filled arteries, on receiving the impact of the blood
from each contraction, become widely dilated.

Is visible pulsation diagnostic of aortic regurgitation ? Certainly not.
Yisible arterial pulsatioi\ of the neck and head accompanies not only aortic
regurgitation, but also fibroid degeneration of the vessels, great arterial
relaxation, and high arterial tension. Mere excitement, by increasing the
force of the heart's contraction, often in nervous persons produces visible
carotid pulsation, and this phenomenon is more frequent in women. But
this nervous pulsation rarely extends more than half way up the neck,
and hence can generally be at once detected from the visible carotid pul-
sation due to more serious causes. Visible pulsation of the whole length
of the carotid to the lobe of the ear and of the temporal, and perhaps of
the facial artery, is far more frequently due to aortic regurgitation than
to high arterial tension or to the opposite condition, low arterial tension,
or to degeneration of the arteries. Therefore extensive visible arterial
j)ulsation in the neck, that is, when the pulsation can be distinctly seen
as far as the back of the lobe of the ear, is strongly suggestive of aortic
regurgitation; though I should mention that visible pulsation is well
marked in pericarditis accompanied by carditis or pericardial effusion, con-
ditions generally associated with marked arterial relaxation.

Aortic regurgitation, degeneration of the arteries, and high arterial
tension, will produce distinct visible pulsation not only of the carotid, but
likewise of the brachial, radial, ulna, etc.

These three conditions— aortic regurgitation, arterial degeneration,
and high arterial tension — may be combined. Aortic regurgitation is es-
pecially a disease of middle or advanced life; the endo-arteritis and endo-
carditis producing aortic and arterial degeneration being due to age and
strain from some laborious occupation. Ulie chronic inflammation often
afl'ects the entire arterial system even to the smallest vessels, and by ren-
dering them inelastic, and by narrowing the lumen of the smaller vessels
friction is increased — a greater hindrance is ofliered to the passage of the
blood, and the tension of the vessels rises.

How can we distinguish between the visible brachial pulsation due to
some simple arterial degeneration, and that due to simple aortic regurgita-
tion ? In arterial degeneration the arteries become elongated and tortuous,
easily visible in the brachial Just above the elbow. A tortuous pulse,
therefore, always suggests arterial degeneration. Moreover, in arterial
degeneration the arteries feel hard and cordy even when all blood is

THE PULSE. 13

pressed out of them, and sometimes calcareous plates or atheromatous
hardenings can be distinctly felt. A tortuous condition of the arteries,
as of the bracliial, does not, however, always point to degeneration, for
as Dr. Broadbent tells me in confirmation of my own experience, this
tortuosity may be produced by high arterial tension, but says it occurs
only when high arterial tension has endured for some time, and is not
seen in the cases of high arterial tension accompanying acute Bright's
disease.

Long ago. Dr. Corrigan pointed out that raising the arm increased
the visibility of the radial pulse in aortic regurgitation, and he used this
fact to support his theory of the production of visible arterial pulsation
in aortic regurgitation. This increased visibility of the radial pulse on
raising the arm will not, however, enable us to diagnose aortic regurgita-
tion, for in arterial degenei'ation the visible radial jDulse becomes decidedly
more obvious in this position, though perliaps not so great in a degree
as in well-marked aortic regurgitation. I may mention, that in children
even with considerable aortic regurgitation the pulse is rarely visible.

In many cases of advanced aortic regurgitation, when the observers
ear is placed in the palm of the patient, raised above the level of the
heart, each beat of the pulse is distinctly audible. Extreme arterial re-
laxation without aortic regurgitation will produce this thud-like sound.
It is probably due to the sudden distension of the relaxed arterial walls.
In advanced cases a double murmur, too, may be produced by pressing
the stethoscope on a large artery. This double murmur is heard best
over the femoral, just at Poupart's ligament. The diastolic murmur is
only audible with a certain degree of pressure, and is often quickly lost
by any increase or diminution of it. The systolic murmur can, of course,
be produced in health by pressure. It is the diastolic murmur which
points to aortic regurgitation.

In aortic regurgitation we often meet with the capillary pulse, first
noticed by Quincke, who points out that it also sometimes occurs in
health, and is best seen under the finger nails. It is not visible, I believe,
in the skin of the forehead in healthy jiersons, but a slight pulsation some-
times occurs in cases of very low arterial tension. I have seen it after a
copious ha3morrhage. It is much more marked in aortic regurgitation,
if the regurgitation itself is marked. "When the skin is reddened by
irritation, the blush pulsates synchronously with the heart's beat. It is
observed best in parts situated on a higher level than the heart, as the
forehead and temporal region. With each diastole the skin becomes pale
and reddens again with the systole. The explanation of these changes
is obvious. During diastole the blood flows back into the ventricle, and
the arteries become comparatively empty, those especially situated above
*the cardiac level; hence during diastole the irritated skin grows pale, but
the systole again fills the dilated vessels, and a blush diffuses itself over
the skin. The capillary pulse is also visible in the extremities, but is
much more marked when hand or foot is raised above the heart's level.
This capillary pulse is well exemplified in the sole after reddening the
skin by putting the foot in hot water or mustard and water. It is well
brought out by wrinkling the skin, by strongly extending the foot and
flexing the toes. The skin along the wrinkles becomes pale, but reddens
with each systole. The pulsation is well marked even Avhen the foot rests
below the heart's level, for the wrinkles in the skin press on the capilla-
ries and empty them; but the systole is strong enough to refill them and

14 THE ruLSE.

to redden the previously pale skin. As would be expected, pressure on
the artery supplying the surface under observation arrests the visible
capillary pulsation.

Brunton describes a capillary pulsation synchronous with respiration
as Avell as the heart's beats. He also suggests that there may be a third
cause of the increased redness, namely, the peristaltic contraction of the
arteries, and certainly one sees blanching and redness which are not de-
j)endent on the heart or breathing occurring less frequently than the res-
pirations and lasting longer than a respiration.

The pulse of aortic obstruction, so long as the left ventricle remains
imdegenerated, is slow, generally small, infrequent, and often hard. It
is slow" and small, because even the hypertrophied ventricle can force the
blood but slowly through the narrowed aortic orifice. It is infrequent
because of the great length of each systole. If there is co-existing in-
sufficiency, of coiirse the character of the pulse is much modified. When
compensation fails, the pulse becomes small and compressible.

In marked mitral obstructive disease, the pulse, when not irregular,
is small and compressible.

In arterial degeneration the vessels become elongated, tortuous, and
the pulse-beats become very visible. The artery feels hard and like a
cord, or like the vas deferens, and sometimes the calcareous plates may
be felt even in the radial ratery at the wrist. This is a very significant
condition, being evidence of senile decay of the arteries, a condition which
leads to atrophy and degeneration of the organs. Many j^ersons are con-
stitutionally much older than their years will warrant — they are, in fact,
jH'ematurely old; while, on the other hand, many old people show few
signs of old age. In individuals prematurely old the arteries are found
in a state of degeneration, while in hale old peoi^le their arteries show
few or no signs of degeneration; it has been well said that a man is as
old as his arteries.

The pulse in this condition is weak, and if the artery is rigid there
may be no pulse. In a sphygmogram the line of ascent is slow, and less
than normal. The top of the trace is rounded, and the line of descent
is more gradual with less distinct secondary waves.

The pulse may be delayed at a distance from the heart. This occurs
in arterio-sclerosis (fibroid). If this condition is more marked on one
side, or if the origin of the vessel as it arises from its trunk is narrowed,
then the pulse beats later on this than on the opposite side. Aneurism
of the aorta, too, often delays the pulse, and it may do this on one side
more than the other, or on one side alone. In aneurism of the aorta in-
fluencing the arteries of one arm only, the artery on this side can be felt
to fill more slowly, and sometimes the distension of the artery is dis-
tinctly divided into two parts, by two impulses almost continuous, the
second being the less considerable. These effects are still better seen in a
sphygmogram, where the line of ascent is delayed (and it may consist of
two parts), the top of the trace is rounded and the waves in the line of
descent are much less distinct.

Dr. Augustus AValler describes a " recurrent pulsation in the radial
artery." After compressing the radial pulse and completely obliterating
it, he points out that in many cases the pulse still beats at the distal side
of the fingers. The arterial wave Avhich produces the pulsation, he ex-
jilains, comes from the ulna artery and travels through the radio-ulna
inosculating arteries, and so reaches the radial artery. If the ulna artery

THE SKIN". 15

likewise is compressed this pulsation at .the distal side of the fingers
ceases. -This " recurrent pulsation " is found generally in persons with
relaxed arteries, in wiioni the heart beats fairly well; for a weak heart is
unable to propel a wave from the ulnar to the radial artery. Dr. Wal-
ler finds this recurrent pulse* twice as often in women as in men.

THE SKIN.

The condition of the skin affords us a series of instructive symp-
toms; but in this j)lace I must restrict myself to speak only of a dr}', a
moist, and a profusely wet and sodden skin.

In most fevers with persistently high temperature the skin is hot,
often pungently hot. Now, if we make the jDatient's skin comfortably
moist, we shall considerably promote his comfort and well-being. Small
often-repeated doses of tincture of aconite, or tartar emetic, or full doses
re})eated every three hours of spirit of mindererus, will induce perspi-
ration. Aconite and tart:ir emetic are the most efficient; in fevers with-
out lung implication aconite is best, but in catarrh, bronchitis, or pneu-
monia, tartar emetic is preferable.

In many cases of diabetes and Bright's disease, it is very difficult to
make the very dry skin perspire.

The occurrence of sweating often suggests hints for treatment or
assists the prognosis.

The two chief causes of sweating are weakness and a fall in a febrile
temperature, two causes often combined in the same person in exhaust-
ing febrile disease, as in phthisis.

In a non-febrile patient, the readiness to perspire often indicates
weakness, and even measures its amount; thus, in depressed health, a
person finds that exertion, even slight exertion, or any excitement, causes
too free sweating. A trainer knows well that a trainee is in bad condition
when he perspires too freely.

Again, in exhausting diseases, and during the weakness of convales-
cence, slight exertion, or even sleep, produces sweating, often profuse. It
must, however, be borne in mind, that in sound health great differences
in respect to the amount of sweating are met with in different individuals.
A person returning from a residence in a hot climate where his skin has
habitually acted very freely, finds on his return to a colder climate that,
under slight exertion, he still continues to perspire very readily.

Profuse sweating occurs during the sudden fall of a febrile tempera-
ture, as in the sweating stage of ague, or during the fall of temperature
after a rigor in pygemia. Phthisical jiatients, too, in whom there occurs
a great diurnal variation of temperature, rising to 102° or higher at night
and falling in the early morning hours, commonly undergo with this fall a
drenching perspiration. The amount of sweating in febrile cases depends
on the extent of the fall of temperature and the weakness of the patient;
where the weakness is great, the sweating is often profuse, though the fall
in the temperature may measure only two degrees or less.

These two forms of perspiration when uncombined can be easily dis-
criminated. Except in the case of pyaemia, there occurs in febrile dis-
eases only once daily, a rise and a fall pf temperature, and consequently

16 THE SKIN.

sweating when due to a fall in a febrile temperatnrc occurs only once
daily, and chiefly early in the morning. In weakness, on the other hand,
sweating breaks out at any hour, and many times a day, Ijeing occasioned
by exertion, sleei), or excitement.

In my experience, profuse sweating as a rule is more common and
lasts longer in the convalescence from scarlet fever than in other acute
febrile disease; hence during the recovery from scarlet fever, sudamin a in
large crops often occur, greatly hastening desquamation, the skin some-
times coming off in large patches.

AVith the exception of rheumatic fever, profuse sweating at the com-
mencement of an acute febrile disease, when the temperature remains
permanently high, indicates great weakness and adds to the gravity of the
prognosis; when besides profuse sweating, there is duskiness of the face,
ears, and under the nails, showing weak circulation from enfeeblement
of the heart, the serious aspect of the case is strengthened. Again, the
feel of the skin shows the condition of a patient. With much perspira-
tion, the skin soft and sodden, points to general weakness, a state accom-
panied with a soft, perhaps large compressible pulse. These signs often
indicate the need of alcoholic stimulants.

TEMPERATURE OF HEALTH.

t-l

H
:^

fed

18 TEMPERATURE IN DISEASE.

THE TEMPERATURE OF HEALTH.

Within" certain narrow limits tlio body maintains its temperature in
health, hut within these limits the temperature varies in a definite daily
cycle. During the day the temperature remains about *.yS% but towards
evening it begins to fall, and generally reaches its minimum at midnight.
At this point it remains steady during a few hours, and then begins to
rise, reaching its maxmium about 9 a.m. The diagram of the tempera-
ture of a lad twelve years of age illustrates the daily course of the tempera-
ture in health.

The chart shows at once, that a temperature normal during the day
would be abnormal at night, and vice ver.su.

During the day, between 9 a.m. and 4 p.m., the healthy temperature
is usually about 99°; thus it may not be higher than 98°, or it may rise
to 99*5° Fall. Any rise above 99*5° constitutes fever. About four in
the afternoon the evening fall begins, and at midnight the temperature
is about 97°or even 96° Fah.

Whilst in many robust adults the temiieratnro runs the same course as in children,
yet with others the course is scmiewhat modified from that just described; thus the
daily cycles are not so considerable, the maximum temperature and the evening fall
being less.

In persons under 25 the daily variation is 2° Fah. ; whilst the varia-
tion in persons over 40 is more restricted, being often only 1° or even less.

Jaeger finds that the daily variation is greater in persons whilst labor-
ing than when at rest At rest he finds the average daily variation to be
2.2, whilst during hard physical work the daily variation amounts to 4.7.
His experiments were made on soldiers, the observation being taken in
the rectum.

TEMPERATURE IN DISEASE.

"Whilst any elevation of temperature above 99.5° indicates disease, it
need hardly be pointed out that a normal temperature does not necessarily
indicate health. Many diseases, both acute and chronic, during their
whole courses are unattended with fever. Indeed, in some diseases, the
temperature is depressed below the health standard.

The daily course of fever varies Avitli the severity of the disease. In a
mild attack there is a considerable diurnal variation, the temperature
rising toward night and falling in the early morning hours; but in a severe
attack of febrile illness the diurnal variation may be very slight or even
absent, the temperature remaining persistently high.

In private practice, as a rule, it is convenient to make but two daily
observations, and these should be taken at such times as to obtain the
highest and lowest temperature of the day. The likeliest times to give
these minimum and maximum temperatures are 8 to 9 A. M. and 8 to 9 p.
M. Though as a rule the morning temperature is lower than the evening,
in rare cases the reverse happens. In some, especially in chronic cases, as
in phthisis and sometimes in subacute rheumatism, the fever may last only
for a few hours betAveen 8 a.m. and 8 p.m., and thus observations taken at
these times, though the temperature is then normal, do not absolutely

TEMPERATURE OF FEVER. 19

prove that the patient is fever-free. If only one observation daily is made
it should be taken in the evening, as, even in the diseases so severe as
scarlet fever, the morning temperature may be nearly normal through-
out the attack, while the evening temperature may rise to 103°; hence a
morning observation only would lead to a great mistake concerning the
severity, and possibly the nature, of the illness.

ABNORMAL ELEVATION OF TEMPERATURE, OR FEVER.

Many diseases, contagious and inflammatory, are accompanied by a
rise of temperature. It must be borne in mind that the same amount
of disease produces in children a relatively higher temperature than in
adults, and that there are, moreover, probably individual or family pecu-
liarities apt to raise the temperature in disease beyond the ordinary
standard.

Some chronic diseases modify the fever, for in Bright's disease and
diabetes an inflammation may produce little or no rise of temperature.

The derangement of function in a febrile disease is largely often
mainly due to the rise of temperature, which depresses the functions of
the body, and if of much intensity or duration induces parenchymatous
degeneration of the tissues, which likewise depresses function. The dan-
gers, therefore, in a febrile disease are mainly dependent on the high
temperature, and are in proportion to the amount of elevation; so that
we take the degree of fever as a measure of the depressive effect of the
disease. The danger from a high temperature may, of course, be aug-
mented by other circumstances as the diarrhoea of typhoid fever.

It may be said, perhaps, that the symptoms — the general weakness,
the frequent, feeble pulse, the loss of appetite, and the delirium, are due
to the elevation of the temperature; and this remark no doubt is true,
for by treatment which tends to reduce the temperature to the normal
standard we can abate or remove all these symptoms; and the abnormal
elevation of temperature not only immediately depresses and weakens all
the bodily functions, but in proportion to the height and duration of the
fever it likewise produces degeneration of all the organs, and this degen-
eration greatly weakens the activity of the organs. If the symptoms are
till referable to the direct depressing effect of the fever temperature, and
indirectly through the degeneration it produces, it would seem a plausible
supposition that the height of the temperature should be an exact measure
of the patient's danger. A little reflection will soon show that this is but
partially true, for though, no doubt, most of the symptoms arise from the
high temperature, it must be recollected that its depressing effect must
greatly depend on the previous condition of an invaded organ; thus, if
previous illness, excesses of any kind, or unhygienic conditions have al-
ready depressed the organs, high temperature will inflict on them much
graver mischief. If, for example, rheumatic fever has slightly damaged
the heart, a febrile attack will considerably increase the dangers to the
patient through failure by the heart. If intemperance has injured the
nervous system a febrile disease will intensify the danger of delirium and

20 TEMPERATURE OF FEVER.

depression of tlio nervous system. AVe estimate tlie resistive power of
ouch organ by the severity of its symptoms in comparison with tlie lieight
of the fever. Thus, if delirium is excessive, while the temperature is but
slightly elevated, it shows that the nervous system has but little power to
resist; and if the pulse becomes very frequent, small and compressible, it
shows that the heart's resistance is but slight. If, on the other hand,
with the fever severe nervous symptoms are slight, and the pulse, not very
frequfent, is full, and not very comjiressible, then we conclude that the
condition of the nervous centres and the heart is satisfactory and our
prognosis is good.

Therefore, in estimating the dangers of a febrile attack, we must re-
gard not only the severity of the disease, as measured by the temperature
and other depressing causes, but the resisting forces of the body. 'J he
temperature largely measures the severity, but the power to resist fever is
estimated only by careful attention to the condition of the different
organs, especially the heart, the brain, and the stomach.

To illustrate these remarks take two ordinary cases of typhoid fever.
One patient with high temperature takes and digests his food fairly
well ; he sleeps well, his heart is not much weakened, and yet, in spite of
the high fever, or, in otlier words, the severity of the attack, he makes a
good recovery. Another patient, with decidedly less fever, is troubled
with sickness, sleeplessness, delirium, and weak heart, and so, though
his attack as indicated by the temperature is not severe, yet he dies worn
out. Again, take two cases of phthisis. One patient, in spite of consid-
erable daily fever, eats, digests, and assimilates fairly well, and for the
most part maintains his ground. Another patient, though his fever may
be slight, and indeed sometimes even after it has become normal or below
normal, the appetite, digestion, or assimilation being greatly impaired,
slowly but surely wastes away. In certain rare cases, though the appetite
is good and the digestion is apparently well performed, yet if assimilation
is at fault the patient, in spite of plenty of food, wastes away, even in
cases when the temperature has become normal. Hence in a case of
phthisis, in addition to the fever and the appetite, we must note the
weight, for in a case where plenty of food is ingested but assimilation is
defective, the patient's weight is the sole measure of his progress.

Does the course the temj)erature runs give evidence of the nature of
the disease ? While, on the whole, this question must be answered in
the negative, still it must be remembered that certain diseases generally
have a somewhat characteristic temperature; indeed, in many cases of
ague and pyaemia the temperature itself is diagnostic.

The thermometer assists us in diagnosis in cases of the following kind :
— A patient becomes ill, and the temperature is found raised above the
healthy standard. This fact, especially if the temperature is high, makes
it incumbent on the doctor to search carefully to discover its cause. To
narrow the range of our instances, let us restrict our attention to the com-
moner causes of fever. The fever may be due only to the acute contagious
diseases, acute inflammation of some organ, rheumatism, gout, or to the
diseases causing chronic fever. The doctor, we will suppose, has been
called in on the first day of the attack, and his duty is carefully to inves-
tigate whether the fever is due to inflammation of any organ. In most
instances the symptoms and physical signs will enable him to arrive at a
diagnosis, an attack of rheumatism or gout being so characteristic that he
will detect either at once. If the fever cannot be thus accounted for.

TEMPERATUKE OF FEVER. 21

then lie probalDly has to deal with one of the acute specific diseases; its
nature, however, cannot ordinarily he diagnosed with certainty till the
characteristic rash appears. Still, even before the advent of the rash he
may give a shrewd guess as to the nature of the illness. Thus, the
patient may have been in the company of an infected person, or an acute
contagious disease may prevail. Moreover, even before the appearance of
the characteristic rash, the symptoms may suggest one of the acute specific
diseases. Thus, sore-throat would point to scarlet fever; severe backache,
headache and sore- throat to small-pox; coryza with cough to measles. Severe
fever, ushered in by a severe rigoi*, with severe headache, and pain in the
limbs, would suggest typhus; whilst dull frontal headache with diarrhoea,
would strongly point to typhoid fever. The mode of onset of the fever,
that is the more or less rapidity with which the temperature mounts, and
the more or less elevation which it reaches, also assists the diagnosis; but
this point will be more dwelt an presently. Having then in many cases
a strong suspicion as to the nature of the attack, he must Avait for the rash
to confirm or to correct his impression. If the second day passes with
out the occurrence of a rash, the case in all probability is not one of scarlet
fever; for the rash of this disease appears on the second day, being very
rarely delayed longer, more frequently, indeed, occurring before the sec-
ond day, sometimes even in twelve hours. If the third day lapses with-
out a rash, he is not dealing with a case of small-pox, for this rash usually
appears punctually on the third day. In measles, it is commonly said that
the rash appears on the fourth day, but in many cases this statement is
certainly erroneous, for the rash often appears on the first day of the
fever, and I have seen it even precede the fever. In many instances,
however, though there is no fever, the patient suffers from coryza and
cough for three or four days; but these symptoms may not occur till the
rash appears on the very day the temperature rises. This being so, it
may, however, be fairly taken that if the fourth day passes without a rash,
the case is not one of measles. If the fifth day passes without a rash, the
case is not typhus, for typhus rash appears punctually on this day. The
foregoing diseases being excluded, there is then left only typhoid fever,
and one of the diseases producing chronic fever; and the diagnostic diffi-
culty will lie between typhoid fever and acute tuberculosis, the other dis-
eases causing chronic feve^ being, in many cases, easily detected.

As the eruption of typhoid throughout the attack may be either alto-
gether absent or be manifested by only a very few spots, which may possi-
bly escape detection, we must in some cases diagnose this disease irre-
spective of the rash. The rash, however, appears between the eighth and
twelfth day, which makes the diagnosis certain. If we are led to exclude
typhoid, then, as I have just said, we have probably to deal with a disease
which causes chronic fever. The diagnosis of the disease referable to this
head will be treated of when we speak of chronic fevers.

I now give another instance of the diagnostic value of temperature.
A patient is suddenly seized with severe pain on tlie side of the chest.
The pain, shooting or stabbing in character, is intensified on coughing or
deep breathing. This is the characteristic pain of pleurisy and of pleuro-
dynia; — one an inflammatory disease, the other a non-inflammatory dis-
ease — which is it ? A physical examination, it may be said, will at once
discriminate one from the other. But suppose the doctor has been sum-
moned at the very onset of the attack, when the signs are undeveloped,
the pain on moving the chest is a symptom common to both diseases;

22 TEMPERATURE OF FEVER.

no doubt con2,-li, present in pleuris}^ may be absent in pleurodynia; but
pleurodynia may occur in a patient with slijjht catarrh of the bronchial
tubes, and* one would not venture to base his distinction, Ijetween these
diseases, simply on the presence or absence of cough. The thermometer
alone solves the difficulty. If the attack is pleurisy, an inflammatory
disease, there is fever (elevation of temperature), whereas if the attack is
pleurodynia, a non-inflammatory disease, fever is absent.

In studying the temperature of fever, we must notice the mode of
its rise (initial period), its character whilst at its height, and in a lesser
degree, as of less importance, its declination to the standard of health.
The character of the rise often helps us to form an opinion of the nature
of the illness. In most febrile diseases the temperature rapidly rises,
reaches its acme in twelve to twenty-four hours. This rapid rise occurs
in the fever of most inflammations, and of typhus, scarlet fever, measles,
erysipelas, etc. Where the rise is sudden and rapid, the onset of the
symptoms is equally sudden and accentuated, and the rise in the tempera-
ture is generally accomjianied by chills or rigors; or, as in typhus and
pneumonia, by a single severe rigor. This sudden and rapid rise, being
common to so many attacks, is of little diagnostic use beyond serving to
exclude those diseases in which the invasion is more gradual.

On the other hand, in some diseases, the temperature rises more grad-
ually and takes three or more days before it attains its maximum. This
happens in most cases of tuberculosis and in almost all cases of typhoid
fever, and sometimes in rheumatism and pleurisy. This gradual rise of
temperature is therefore suggestive of the invasion of these diseases, and
if there is no joint pain, the case is likely to prove either typhoid fever or
tuberculosis, diseases which often closely simulate each other so closely
at the commencement as to baffle the discrimination of the most experi-
enced. As in diseases with slow invasion of the fever, the doctor is seldom
summoned till the temperature has become well developed, he has not
often the opportunity of ascertaining how it has comported itself at the
beginning of the attack. Hence, at this stage, the temperature is seldom
a serviceable guide; the mode of its rise must be estimated from the slow
or quick onset of the symptoms.

From the course the temperature runs during the time the fever is at
its height, we learn much more than from the mode of its onset. At
this juncture we must regard the height of the thermometer, the extent
of the daily variations, and the duration of the fever. The height of the
temperature with its daily variations measures the severity of the attack.
The greater the daily variations the more favoraljle»tlie case. The high
temperature, as we have seen, immediately and directly depresses all the
functions, and further indirectly lowers them by producing degeneration
of all the tissues; these effects of course being manifested in proportion to
the height of the temperature. Hence they are far more marked in cases
when the temperature all day keeps high, than in cases when, during
many hours, the temperature is but little or not at all raised above the
limits of. health. A temperature of 105° always marks a severe attack of
any disease, especially if the diurnal variation is very slight, A tempera-
ture above 105° threatens considerable danger; and from a temperature of
107° patients, unless treated by cold baths, very seldom recover. A tem-
perature of 110° to 112°, unless it yields to the application of cold, is very
quickly fatal.

In the early days of the clinical thermometer it was taught that in

TEMPERATURE OF FEVER. 23

some diseases, as in typhoid, tlie temperature always readied a charac-
teristic heiglit, so that in a given case, if by the fourth day the temperature
failed to reach 103.5° Fall, the case was said to be not one of typhoid
fever. This absolute rule a more extended experience has shown to be
erroneous. Typhoid and other fevers may run their course with any tem-
perature above the normal standard. Some writers, indeed, go so far as to
maintain that typhoid fever may exist without any abnormal tempera-
ture, and if typhoid, they say, why not other "fevers"? Still it must
be admitted that the temperature is a serviceable guide in the discrimina-
tion of diseases. For example, in the majority of cases of typhus and
typhoid fever, measles and inflammations, the temperature reaches 103'^,
and certainly if the temperature never exceeds lOl"" then probably the case
is not typhoid, typhus, scarlet fever, measles, nor any important acute
inflammation. Sometimes the thermometer greatly assists us in discrimi-
nating measles and scarlet fever from German measles (rotheln). Thus,
in German measles, the patient often complains of sore throat, and some-
times its rash is so like the rash of scarlet fever, and sometimes so like
the rash of measles, that simply by the aspect it is difficult or impossible
to distinguish them. In this dilemma the temperature, though not an
absolute proof, affords strong presumptive evidence; thus in German
measles the temperature generally is scarcely or very slightly raised, not
higher than 100° or 101°, Avhilst in measles and in scarlet fever, in the
great majority of cases, the temperature runs higher than this.

The course of the temperature wdien at its height indicates, as I have
said, not only the severity of the attack, but also helps us likcAvise to dis-
tinguish its duration. If the te^uperature is high, and the daily variations
are slight or non-existent, a severe attack threatens, sure to persist longer
than a case with considerable daily falls in the temperature. The infor-
mation thus obtained is especially instructive in typhoid fever, for if dur-
ing the second week there are daily great variations, we have reason to
hope that the disease may terminate, possibly on the fifteenth, though
more probably on the twentieth day; but if during the second week the
daily variations are but slight, then the fever will probably last twenty-
five or thirty days.

When the temperature has remained persistently high, the occurrence
of morning falls shows the beginning of the decline of the disease.

The duration of tlie fever helps us to detect the nature of the disease;
and indeed in obscure cases it often greatly aids the diagnosis. In most
inflammations, in scarlet fever, in measles, the fever usually passes away
by the fifth or tenth day, and in typhus on the fourteenth or fifteenth
day. If the fever persists beyond this time it is fair to conclude that we
have not to deal with one of these diseases; but as, in the majority of
instances, they are easily diagnosed early in their course, it is evident that
in such cases the duration oi^ the fever is of little practical use; but by
enabling us to discriminate between typhoid and tuberculosis and Ijetween
the diseases causing chronic fever, the duration of the fever does give us
very trustworthy and important evidence.

In some cases of typhoid fever, the symptoms are not sufficiently
marked to enable the doctor to decide whether the case is one of typhoid
fever, tuberculosis, or phthisis. If the fever goes on beyond thirty days
then probably the patient sutlers from consumption; and each additional
day of fever strengthens this conclusion. In most cases of phthisis,
before the thirtieth day, the lungs or other organs will, it is true, gener-

CHRONIC FEVER.

ally manifest the nature of the ilhiess; hut not unfrequently the fever of
consumption may persist thirty days or more without the concurrence of
any characteristic physical signs or symptoms of its existence, AVhen I
come to speak of chronic fever I shall point out with more particularity
that sometimes the thermometer will enable us to detect consum})tion
earlier than by the combined aid of the symptoms and the physical signs.

Any sudden and considerable temperature variation generally fore-
bodes some complication; and a sudden and considerable rise, always.
A sudden and considerable fall may, of course, indicate the natural ter-
mination of the attack, for in many diseases the temperature falls very
rapidly; in pneumonia notably, it is not uncommon for the temperature
in twelve hours to suljside from 105° to the normal standard.

A sudden and marked rise in the course of a disease foretells the onset
of some inflammatory complication. On the other hand, it is important
to bear in mind that an inflammatory onset, interposed in the course of
a febrile disease, may not heighten the existing temperature; hence the
fact of the temperature running the ordinary course pertaining to the
original attack, does not preclude the necessity for close watching, lest an
inflammatory complication should supervene. Thus, an attack of pneu-
monia or of pleurisy may leave the temperature of pre-existing fever un-
affected. It is important to recollect that, as a rule, the onset of pericar-
ditis in acute rheumatism does not increase the fever. This is hardly to
be wondered at, seeing that when a fresh joint becomes implicated the
temperature does not alter, and inflammation of the pericardium may be
regarded as analogous to inflammation of a joint.

A sudden and considerable fall, if not due to the natural termination
of the illness, means sudden collapse. It is oftenest met with in typhoid
fever, and it means haemorrhage into the bowels, or perforation of the
intestine. It must, however, be recollect(3d that each week in typhoid
fever a great morning fall often occurs. A fall equal to that due to
ligemorrhage or perforation, may occu-r at any time, but the fall with these
accidents is more persistent, and is always accompanied by the symptoms
of collapse. A sudden great fall with collapse and without tenderness of
the abdomen, is always very ominous of haemorrhage into the bowel.
This ligemorrhage, though considerable, may yet be retained for some
hours in the intestines.

CHEOXIC FEVEK.

In some diseases fever may persist for weeks or months, and by its
very duration helj) the diagnosis. It is true that in most cases, whilst the
fever has lasted only a short time, perhaps only a few days, the other
symptoms reveal the nature of the disease; but not unfrequently the
nature of the malady remains for a long time obscure, and then the per-
sistence of the fever is an important help to the diagnosis.

Between acute and chronic fever there is no sharp line of demarcation.
Certain acute diseases, for instance, typhoid fever and pleurisy, may each
run more than thirty days; whilst, on the other hand, febrile diseases, like
deep-seated abscesses and consumption, which often continue several Aveeks
or months, or even longer, may run a short course of only a fortnight or
three weeks.

CHRONIC FEVER. 25

Since most acute illnesses, even typhoid fever and pleurisy, which
persist longer than others, come to an end, in the great majority of cases,
before the thirtieth day, we may take that as the limit of acute fever.

Chronic fever occurs in jjhthisis, abscess, syphilis, ague, rheumatism,
in most cases of leucocythfemia, lymphadinosis, pernicious ansmia and
chronic pyaemia, including malignant endocarditis.

As in acute diseases, so in acute and subacute phthisis, the tem-
perature is a fairly accurate measure of the activity of the disease. In
other words, there occurs a daily elevation of temperature of the body,
in most cases in which a formation of tubercle is taking place in any of
its organs. This elevation is an index of the activity of the disease;
the fluctuations of temperature indicating corresponding fluctuations
in the rate of the disease.

One exception, however, I must mention to the above general rule.
In tubercular meningitis, it is by no means uncommon, though certainly
it is not the rule, for the temperature to remain normal throughout the
course of the attack ; or at all events during most of its later stages. In
some cases, for a short period, the temperature is slightly elevated, and
then becomes natural, or falls even below the normal point. In by far
the greater number of instances the temperature is elevated, sometimes,
indeed, mounting to 105° to 108° Fall.

It has been asserted that, during acute miliary tuberculosis of the
lungs, the temperature, in rare instances, may remain normal. AYith
regard to this statement, I believe that the deposit of tubercle has gone
on by very slight and scarcely appreciable increments; or has become
obsolescent at the time the temperature was first taken, so that the fever
stage was overlooked. It must be admitted that, in some very chronic
cases of phthisis, pneumonia, the disease advances too slowly, and the
deposit, at any one time, is too slight to be adequate to elevate the tem-
jDcrature unless to a very small extent.

Thus, we meet with cases in which, some time before death, the tem-
perature was always natural, yet the post-mortem examination reveals
much fibroid degeneration from old standing tubercle or catarrhal pneu-
monia; and adjacent to the fibroid portions, in the otherwise healthy
lung tissue, we see a few recent miliary tubercles easily counted, or a
few small patches of recent tubercular pneumonia. Indeed, in these
diseases, we meet with every degree of activity to which the temperature
corresponds. In some cases the disease advances so slowly that the tem-
perature is scarcely raised, and we should naturally expect so very slight
an amount of morbid action would be insufficient to raise the tempera-
ture appreciably. Where there is no elevation of the temperature, we
may conclude that the progress of the disease is almost insignificant;
although the patient is exposed to the lurking danger that, from some
slight cause, this comparatively harmless condition may be aggravated
into a severe and dangerous attack.

The apparent exceptions to this statement can, I think, be ex^jlained
in this way : —

With phthisis, as with other causes of chronic fever where the disease
goes on but slowly, it must be borne in mind that the fever may last only
a few hours in the day, sometimes not more than three or four, sometimes
only in the middle of the day, so that a morning and evening observation
may miss the fever, and may lead to the erroneous conclusion that the
patient was fever-free.

26 CIIEONIC FEVER.

Another source of error arises from the mode of taking the tempera-
ture. Phthisical patients are often very thin, and hence the bnlh of the
thermometer, when pLaced in the axilla, instead of being embraced all
round by the tissues, lies half exposed in a hollow cavity, and never ac-
quires the temperature of the body. This source of error is, moreover,
often coupled with another. When the patient is perhaps dressed, or has
had his arms out of bed, and his axilla has become cooled, it would take
half an hour or an hour before the skin of the exposed parts would recover
its lost heat so as to mark the temperature of the body. Over and over
again, in hospital practice, I have been told that the temperature was
normal, or even below normal, but on taking the temperature under the
tongue, or in the rectum, have found the patient suffering from several
degrees of fever.

In some cases, it must be admitted, there ajopears to be a dispropor-
tion between the progress of the disease and the temperature. This dis-
proportion occurs, I believe, only in cases of long standing, and when
the disease has lasted a considerable time, perhaps it produces less eleva-
tion than at first, the patient becoming accustomed to the disease, and,
as in the case of medicines, it produces less constitutional effect. As
the result of my experience, I am inclined to think that the same amount
of disease in middle-aged and in elderly people produces less fever than
in the young, and that less fever is produced toward the end of the dis-
ease, when the patient's powers are greatly depressed.

The temperature is a more accurate indication of the activity of tuber-
culosis or of catarrhal pneumonia, than either the physical signs or the
symptoms. Thus, only a considerable increase in the amount of disease
can be detected by physical signs; and in disseminated tuberculosis,
where the granulations are pretty equally scattered throughout the lungs,
and, indeed, often through most of the organs of the body, there may
be entire absence of physical signs. Thus, it is apparent that the physi-
cal signs, even in very acute cases, only give ns evidence of the continu-
ance of the disease after the lapse of a considerable interval: while it has
been shown that in almost all cases there is an elevation of temperature
during the formation of tubercle, and that this elevation being propor-
tionate to the activity of the disease, the thermometer will, unerringly
at any time, point out the continuance and the amount of disease, except
indeed, in those very chronic cases where the amount of tuberculization
or of catarrhal pneumonia is slight and almost insignificant. When it
is thus borne in mind that only considerable deposits in the lungs can
be detected by physical signs, while even a small amount will raise the
temperature even considerably for some time, it becomes evident that
the thermometer will give a far better estimate of the amount of mis-
chief than the physical signs. Moreover, after the cessation of tubercu-
losis or catarrhal pneumonia, consolidation from the fibroid lung remains,
and from the physical signs it is impossible to tell the condition of such
a lung, to tell whether disease is progressing or not; the temperature
will answer the question for us. If the temperature is natural at all
joeriods of the day, we may safely conclude after a few days that active
disease has very nearly or entirely ceased.

It must be recollected that the fever is a measure of the increase of
the tuberculization, not of the damage already done. Thus the disease
may cease to extend and the tem})erature become normal; but the ex-
tensive consolidation of the lung may begin, and continue to soften and

CHRONIC FEVER. 27

lead to cavities. Hence, because the fever ceases, and the formation of
fresh tubercle of catarrhal pneumonia ceases, we must not conclude that
the patient is free from danger, for the softening and suppuration may
lead to fatal exhaustion.

Observation of the temperature often saves us from error, and ena-
bles us to form a correct judgment of the true condition of the patient.
A patient with only a moderate amount of fever, say 102° to 108°, last-
ing only a part of the day, has been losing weight and growing weaker.
She goes to the country, her appetite and assimilative powers increase,
she grows much heavier and stronger, and regains much of her lost color.
On a physical examination of the chest, we detect no increase in the
physical signs, but during the whole time the temperature has risen to
its accustomed height, 102° to 103°, showing that the disease still pro-
gresses, but that the improved appetite has more than obviated the waste
from the fever. In other words, nutrition is in excess of waste.

On the other hand, we must be careful not to pay too much heed to
the temperature, nor to build our prognosis entirely on it. For it often
happens that there is a marked disproportion between the general symp-
toms and the degree of tuberculization, or the rate of formation of the
products of catarrhal pneumonia. A patient, with very slow progressive
phthisis and moderate fever, associated with the very slight physical
signs which develop slowly, has a flagging appetite and he quickly
wastes; or sometimes a good appetite, but assimilation is at fault, and
so, in spite of plenty of nourishment, he progressively grows thinner
and thijiner. Therefore, we must regard not only the temperature as a
measure of the progress of the tuberculization, but must likewise take
into consideration the patient's appetite and weight, the occurrence of
complication, as diarrhoea from ulceration of the intestines, the presence
of albumen in the urine from fatty kidiiey, and whether albuminoid de-
generation has implicated the liver, spleen, or kidneys.

Fibroid phthisis remains now to be considered. Tubercle, behaving
as an irritant, induces increase of the connective tissue with formation
of fibroid bands, which cause the lung to become tough and fibrous.
This condition of lung often co-exists with progressive formation of
tubercle. When the further progress of these two diseases is stayed this
fibroid condition is left. This is the most common cause of a fibroid
lung, but it may originate in a different way. The temperature in fibroid
phtliisis varies. In some cases it is quite natural, or if the health is much
depressed, it is even below normal. In those cases which go on to cure it
is natural. The walls k.^ the cavities become dry, rhonchus and expecto-
ration cease, the cavities slowly contract, and the patient recovers health
and strength; but the induration, very obvious on a physical examina-
tion, still remains. Now in a case like this, the temperature often be-
comes of the greatest importance. A patient presents himself with a
history of a previous attack of phthisis. We find marked evidences of
consolidation of the apices of the lungs. The jDatient's health is good,
his appetite and digestion vigorous. Are these physical signs simply
due to his jirevious illness, or is the phthisis progressing? If his tem-
perature remains for several days quite normal, we may conclude either
that there is no progressive tuberculization, or that it is very small in
amount ; as we shall shortly see, there may be probably a slight amount
of catarrhal pneumonia, without a rise of temperature.

In other cases of fibroid phthisis, even when the formation of tuber-

28 CHRONIC FEVER.

cle hiis ceased, we may have a slight daily rise in the temperature to 100°
or even 101°, due to the suppuration in the cavities. This suppuration
can, of course, raise the temperature just like suppuration in an open
discharging psoas, or other discharging abscess.

Thepersistence of a slight amount of fever does not, therefore, con-
clusively prove the continuance of the tuberculization. Nor, on the
other hand, I think, can we possibly say that while the temperature is
normal the tuberculization may not be in a very slow degree extending.
Clinical experience shows us that a very small formation of tubercle or
of catarrhal pneumonia may occur without a rise of temperature.

We very often meet with mixed cases, where the upper part of the
lung has become fibroid, while active disease goes on in the lower part.
In cases like this the temperature is raised in proportion to the activity
of the acute disease. If the disease progresses slowly, and raises the
temperature to only 100° to 101° Fall., it is difficult to determine whether
the fever indicates an extension of the tuberculization, or of catarrhal
pneumonia, or is due to suppuration in the cavities.

As in acute phthisis, so in chronic, with fibroid lung, we must be
careful not to pay sole regard to the temperature. Thus the formation
of tubercle ceases, and the temi^erature becomes normal; but before this
comes to pass the health may become damaged beyond recovery, or the
kidneys may become seriously implicated, or through lack of appetite
and digestive power, the patient may wastef away and die; or the uncer-
tain weather incidental to this country may irritate the cavities and keep
up continuous suppuration, which drains away, exhausts the strength,
and destroys the patient by j^roducing wide-spread albuminoid degen-
eration.

Therefore, in a case of fever-free phthisis, we must take into consider-
ation the general condition as well as the temperature. When appetite,
digestion, and assimilation are good, then the patient quickly regains
strength and health. Therefore, in forming an ojDinion of a case, we
must regard the temperature, the appetite, and the weight.

The temperature in phthisis affords us still further guidance. A
patient throws up a large quantity of blood from the lungs, and the
grave questions arise, — is the haemorrhage due to the congestion which
accompanies acute phthisis ? or is it independent of phthisis ? If the
temperature is normal we may at once exclude acute phthisis; and if the
temperature remains normal we conclude that the hemoptysis has not
excited catarrhal pneumonia. Again, a patient having recovered from a
previous attack of phthisis, which has left well-marked physical signs,
spits a little blood. Does this show that he is again the subject of pro-
gressive phthisis, or is the bleeding due to ulceration of the avails of an
old cavity? Here the temperature, if normal, and continuing normal,
enables us to conclude that the lia3moptysis does not depend on another
attack of phthisis.

The thermometer in many cases is of still more signal service in giv-
ing early and significant warning. By its aid we can often diagnose
phthisis, before we can detect any physical signs, and at a period when
symptoms themselves are insufficient to justify a grave diagnosis. A
patient suffers from chronic fever. What is the cause of it ? So far as
we at present know chronic fever occurs only in tuberculosis, cat-arrhal
pneumonia, large abscesses, rheumatism, ague, occasionally in syphilis,
in some cases of leucocythgemia, in lymphadenoma, and in pernicious

CHRONIC FP^VER. 29

anasmia and chronic pyaemia. The diagnosis of ague and rheumatism is
rarely difficult, the characteristic symptoms in most cases rendering their
identification quite easy. Large superficial abscesses j^resent no diffi-
culty, but it may not be so easy to detect deep-seated abscesses; and in
some cases the diagnosis is for a considerable time impossible. As a rule,
however, they give more or less jDain, often to a considerable degree, in
the neighborhood of the abscess or over the spine-, moreover, a tumor is
generally detectable after the fever, if at all high, has lasted a few weeks.
Local symptoms, too, as pain on movement, stiffness, lameness, etc., will,
in most cases, point out the nature of the disease. Sometimes, however,
deep-seated abdominal abscesses run a much more chronic course, the
temperature assuming then the character so common in fibroid lung;
thus the temperature rises to 101°, even perhaps to 102°, and daily
mounts to this height for a few days, then becomes natural for a varia-
ble time, but some cause, as over-exercise, once mor^ excites the fever,
and the temperature again stands high for a week, a fortnight, or longer.
It is very often difficult to determine the nature of the disease, so as to
exclude phthisis. True, there are no pulmonary physical signs, but
these may be absent in phthisis, whilst the local symptoms may be too
few to justify the diagnosis of abscess. Having but a limited experience
of deep-seated subacute abscesses I would wish the following remarks
to be accepted with caution. In general there is pain in the abdomen,
not constant, but brought on by slight walking; sometimes there are
marked dyspeptic symptoms, amongst Avhich flatulence predominates. A
slight daily rise of temperature continued for a considerable time, or
running the irregular course just described, if accompanied by deep pain
and tenderness in the abdomen, the lungs being free from evidences of
disease, will, I am inclined to believe, justify the suspicion of a deep-seated
subacute abscess. These rules at all events have enabled me to diagnose
doubtful abscesses, when, unaided by the thermometer, their detection
seemed impossible. I lean to the belief that, with these abdominal ab-
scesses, the fever-free periods not unusually ]3ersist longer than in suba-
cute phthisis ; moreover, the rise can sometimes be traced distinctly and
repeatedly to exercise, a bout of fever, accompanied by an increase in the
other symptoms, occurring after each undue exertion. When an abdomi-
nal tumor is detectable by the hand, or when there are evidences of dis-
eased spine, then, of course, the diagnosis is far more easy.

Again, a large discharging sore, or a discharging psoas or iliac abscess,
frequently produces a course of fever like that described under subacute
and chronic phthisis. In some cases there is a slight daily elevation
lasting for months, in other cases the abnormal temperature continues
for only a few days, or lasts one or two weeks, and then for a short time
falls again, and this alternation may be repeated for a considerable time.
Here the diagnosis is easy, for there is a discharging sore with absence
of pectoral physical signs or symptoms.

In cases of constitutional syphilis with chronic fever, the diagnosis in
many cases is more difficult, and, unfortunatch^ little of this subject is
known at present. The temperature may be high, rising to 103° and
104° Fall, daily; the morning remissions are usually great, the tempera-
ture often falling to 98°. In these respects sy2:)hilitic fever corresponds
to moderately severe cases of phthisical fever, but distinct and easily
recognizable constitutional symptoms generally set in concurrently with
the fever. The disease may assume the rheumatic form; and thus the

30 CHRONIC fp:ver.

diagnostic difficulty Avill lie. not between i)lithisis and syphilis, but be-
tween simple acute rheumatism and syphilis. In some cases the diagno-
sis has seemed impossible until, on the administration of iodide of potas-
sium, the temperature at once became normal, or declined gradually,
reaching the temperature of health in one or two weeks. Very large
doses may be required.

In syphilitic affection of the lung, the diagnosis may be impossible,
though other manifestations of syphilis may suggest the correct diagno-
sis, which becomes confirmed on the rapid improvement produced by
large doses of potassium (iodide).

Assuming the exclusion of the foregoing causes of fever, the question
arises — How long must the elevation of temperature persist before we
can w4th probability suspect j^hthisis, in cases free from physical signs
or characteristic symptoms, as, for instance, haemoptysis ? From ten to
twenty days, I think, each day facilitating and strengthening the diagno-
sis. In the first few days the diagnosis is well-nigh impossible, but each
successive day serves to exclude sources of error. Thus, on the second
day, if the rise is due to scarlet fever, its characteristic rash ought to
appear; if due to small-pox, the rash should apjiear on the tliird day; if
in measles, about the fourth; and in typhus, on the fifth day. Before
this time, if the rise is due to acute inflammation of the brain, lungs,
kidney, etc., characteristic symptoms and physical signs will have set in.
In most cases of typhoid fever the rose spots w^ill appear between the
eighth and tenth day; and at this stage we may exclude most cases of
simple inflammation, which usually decline before the tenth day, when
the fever ceases. Thus, on the tenth day, or thereabouts, assuming, as
we have said, the exclusion of the other causes of chronic fever, the
diagnosis lies between tuberculosis and t^qihoid fever. In the early
stages the discrimination of one from the other is difficult, and may in-
deed be impossible. Each begins gradiially, and is not usually ushered
in with chills, convulsions, or rigors; nor have we ordinarily to assist
our judgment, distinctive symptoms, like the back and headache of small-
]30x, the sore-throat of scarlet fever, the coryza and cough in measles,
before the advent of the characteristic rashes. It is true that in the be-
ginning of many cases of typhoid fever, before the appearance of the
rash, there is diarrhoea and headache; but though these symptoms point
strongly to typhoid fever, yet they m;iy be present at the commencement
of acute tuberculosis. Moreover, diarrhoea and even headache may be
absent in typhoid fever. But by the tenth or the fifteenth day the diag-
nosis in most cases becomes easy; still it must be admitted that now and
then we encounter perplexing cases of typhoid fever, which render the
diagnosis between it and tuberculosis or catarrhal pneumonia doubtful
for a much longer time; the thirtieth day once passed, should the disease
have remained so long undetermined, it is in all probability not typhoid
fever, for this usually ceases either before or at this time. Yet it is well
knoAvn that typhoid fever occasionally lasts six wrecks, or longer. In
children, the diagnosis between typhoid fever and acute miliary tuber-
culosis is often extremely difficult, the symptoms of typhoid being in
some cases so ill-defined that many good observers refuse to consider
them to denote typhoid fever, and call them simple continued fever of
children. Many of these cases are probably acute tuberculosis, the de-
posit ceasing, and the tubercles becoming obsolescent and harmless. Of
course the diagnosis is difficult only when, in acute miliary tuberculosis

CHRONIC FEVER. 31

and cutarrhal pneumonia, there are neither physical signs nor charac-
teristic symptoms.

Again, after typhoid fever, a period of fever may set in lasting six
"weeks or two months, the temperature becoming almost natural, then
daily rising higher and higher to 101'', 102°, even 103°, and after about
four or five days again gradually falling, this course being often re-
peated. Occurring after typhoid fever, such a temperature does not
show lung disease. This condition may co-exist with a clean tongue, in-
crease of appetite and weight, and a steady amendment of the health.

It thus appears that the temperature alone may enable us to diagnose
tubercle phthisis, in cases where the physical signs and symptoms are
absent, or are too indefinite to assist the diagnosis.

The following typical instances illustrate the usefulness of tlie ther-
mometer in doubtful cases of phthisis :

A patient is taken rather suddenly ill. His face is flushed, eyes bright,
pulse quick. The temperature is very high. There is no headache, no
delirium, no diarrhoea. So weak is he that he stays in bed. At the end
of ten or fifteen days he remains much in the same plight, but has
grown weaker. His tongue has become dry. There are no typhoid spots,
no diarrhoea, and the stomach is not distended. He has neither cough
nor expectoration, and there are no physical signs in the chest. For a
month or five weeks he continues in the same state, when distinct physi-
cal signs at the apices of the lungs appear, accompanied by expectoration,
and possibly slight hasmoptysis. Soon he begins to improve, the fever
grows daily less severe, his tongue becomes clean, appetite slowly returns,
cough diminishes, and at last both cough and expectoration cease. All
moist chest sounds disappear, and at the expiration of about two months
the temperature becomes natural, strength returns, his weight increases,
although he will always carry evidences of consolidation at the apices
of his lungs.

A woman, between 30 and 35 years of age, fails slightly in health,
complains of slight weakness, is soon tired, but is never ill enough to be
confined to bed. Her appetite is rather bad.

There is a trifling cough, and perhai:)S on one or two occasions the ex-
pectoration of a slight streak of bright-colored blood, so slight and so
seldom repeated that it is hoped the blood may have come from the mouth
or throat. There may be a strong family predisposition to phthisis.
!No physical signs are apparent; yet the temperature, rising nightly to
101° or 102° Fall., declares the true nature of the disease, which, perhaps,
in the course of some months, decided physical signs render too evident.
How important is it to detect this early and slight stage of the disease!

By means of the temperature we can diagnose tuberculosis, even
when during the whole course of the disease there are no physical signs
indicative of tubercular deposit in any of the organs of the body, and
when the symptoms are quite inadequate to enable us to form such a di-
agnosis. Thus, we commonly meet with cases of acute miliary tuberculo-
sis in children, where, throughout the whole course of the disease, the
only guiding symptom is iDreternatural heat of the body, except, perhaps,
a small amount of sonorous or sub-mucous rhonchus, and yet after death
most of the organs of the body are found studded with miliary tubercles.
Again, we occasionally meet with patients, generally among children ten
or twelve years old, who complain of pain in the head, and whose man-
ner is peculiar, being semi-idiotic, in whom the temperature daily rises

32 DROPSY.

considerably for weeks or months, and after death small masses of yellow
tubercle, the size of a large pea or bean, are found embedded in the sub-
stance of the brain, with sometimes miliary tubercles scattered through
the thoracic and abdominal organs.

ON DROPSY.

Ix health, nutritive plasma escapes from the blood-vessels into the
adjacent tissues, and is afterwards absorbed by the lymphatics and veins.
This transfusion and absorption counterbalance each othei*, and hence
only a moderate amount of fluid is found in the parenchymatous tis-
sues. But if a disturbance arises in the balance between these two pro-
cesses, the parenchymatous fluid increases, producing dropsy, or ana-
sarca, a condition due either to too large a quantity of fluid transfusing
through the blood-vessels, or to deficient absorption. Nutritive plasma
passes from the blood-vessels by filtration, difl'usion, or secretive attrac-
tion of the tissues for the fluids in the blood. Dropsy never probably
happens through increased attraction of the tissues for the jDlasma, but
generally on filtration. The amount of fluid escaping from the tissues
by filtration depends on the difference between the pressure of fluid in
the blood-vessels and in the parenchymatous tissues. In health the
pressure of the fluid in the blood-vessels is higher than that of the fluid
outside the capillaries, and hence a constant current of nutritive plasma
flows through the blood-vessels to the tissues outside them.

Most cases of general dropsy depend on hydremia, and this is pro-
duced by diminished action of the kidneys, whereby the urine is greatly
diminished in quantity, while the patient takes the same quantity of
liquid into the system ; hence the excess of ingestion over that eliminated
through the kidneys accumulates in the blood, and produces hydremia,
and, as Bartels has pointed out, the amount of dropsy is for the most part
in projDortion to the diminution of urine. The inaction of the kidneys
may be j)roduced in three ways — by disease of the kidneys, as Bright's
disease, especially the acute and fatty kind; by diminished arterial pres-
sure in the glomeruli from general diminution of arterial pressure depend-
ing on heart disease; and on retardation of the circulation through the
kidneys from venous congestion due to tricuspid regurgitation.

In those forms of Bright's disease, the fibroid or the albuminoid,
where the quantity of urine is normal or even excessive, there is no dropsy,
while in the acutely inflamed or fatty kidney, in both of which diseases
the quantity of urine is often greatly lessened, the dropsy is often marked,
and almost always occurs when the quantity of urine is notably dimin-
ished, while it is absent in those cases where the secretion of urine is free.

In all valvular affections of the heart, and in a weak heart, less blood
is propelled into the arterial system, and consequently arterial tension is
lowered. This is the result of emphysema, which hinders the passage
of blood through the lungs. It is the result of mitral and of aortic affec-
tions. To overcome the obstruction the heart undergoes compensatory
hypertrophy, and if this is perfect then arterial tension is kept up, but if
this is imperfect, or if the left ventricle after hypertrophy undergoes de-
generation, then arterial tension immediately falls in the glomeruli as

DROPSY. 83

well as in the body generally. Now the amount of water that filters
through the walls of the vessels in the glomeruli depends on the differ-
ence of lateral pressure inside and outside the blood-vessels. If arterial
tension is much reduced, then less water filters through the vessels, and
the water accumulates in the blood.

But the quantity of urine dej^ends not only on the degree of arterial
tension in the vessels of the glomeruli, but also on the rapidity of the
circulation through the kidneys. If arterial tension is lowered then the
rate of circulation is reduced. But general venous congestion from tri-
cuspid regurgitation also lessens the rate of the circulation ; hence tricus-
pid regurgitation in this way tends to lessen the secretion of urine and
so to produce hydrasmia. How does hydra3mia produce dropsy ? The ques-
tion canuot at present be satisfactorily answered, but it is often assumed
that the volume of the blood being increased arterial pressure is aug-
mented, hence more serous fluid filters into the parenchyma, and filtration
is easier from watery than normal blood.

Cohnheim finds that injecting water into the vessels of a dog will not
cause dropsy unless the vessels themselves become altered, and he con-
cludes that in anaemia and hydremia the vascular walls undergo change
and so favor the escape of fluid into the connective tissue.

Dropsy then is in pro])ortion to the amount of hydraemia, and the
amount of water in the blood is generally dependent on the action of the
kidneys. AVe meet, however, with cases that at first sight appear excep-
tions to this statement, for we see patients troubled with extensive and
progressive dropsy who pass two, three, or even four pints of urine daily;
but it will generally be found that these patients are troubled with great
thirst, and drink far more tlian they void through the kidneys or skin,
and the excess of their drink over the quantity of urine accumulates in
the blood, causing hydrsemia and dropsy.

Are we right, however, in asserting with some writers that mere venous
obstruction caniiot cause though it may favor dropsy, but that without
some affection of the nervous system dropsy will not occur ? Thus, the
ascending vena cava in dogs has been tied without producing dropsy of
the posterior limbs, but on cutting the nerves of the sciatic plexus,
dropsy came on immediately; and as the division of the nerves inside the
spinal canal (that is before the vaso-motor nerves join them) does not
produce dropsy, it is concluded that paralysis of the vaso-motor nerves is
the cause of dropsy. (Kanvier.) Clinical facts, however, certainly prove
that mere venous obstruction will cause dropsy. Cirrhosis of the liver,
or a tumor pressing on the vena porta?, or coagulation in the vein as it
enters the liver, will produce ascites. Are we to conclude that these dis-
eases paralyze the vaso-motor nerves of the abdominal blood-vessels ? I
think, then, we must admit that mere venous congestion may cause dropsy,
but that paralysis of the vaso-motor nerves greatly favors dropsy.

Is the venous congestion consequent on tricuspid regurgitation suffi-
cient to cause dropsy, or is the dropsy chiefly due to hydraemia ? Chiefly
to hydremia, for we meet with cases of extreme tricuspid regurgitation,
with full pulsating jugulars, much lividity and dyspncea, and yet no
dropsy, and it is found these patients pass a normal quantity of urine;
but when the urine diminishes, dropsy sets in, and in proportion to the
scantiness of the urine. Still, no doubt venous congestion from tricuspid
rf.gnrgitation favors dropsy in other ways than by causing hydraemia, for
distension of the right side of the heart, with general venous obstruction.

34 DROPSY.

must lessen absorption by the veins and lymphatics, and in this way cause
the parenchymatous fluid to accumulate.

Kemedics may remove dropsy: — (i.) By diminishing lateral pressure
on the walls of the blood-vessels, and so lessening transfusion from the
blood-vessels, (ii.) Increasing absorption, (iii.) Both ways combined,
(iv.) By increasing the lateral pressure in the blood-vessels of the glo-
meruli and so increasing the quantity of urine, (v.) By removing
those diseased conditions of the kidneys which hinder their secretion.

Digitalis affords a good example of a remedy acting through several
of the foregoing methods. By its action on the diseased heart it obvi-
ates the effect of mitral disease; hence more blood is sent into the aorta.
Arterial pressure is thus raised in all the organs, and amongst other
parts in the glomeruli of the kidneys, and hence more urine is secreted,
the blood is purged of its excess of water, and the dropsy is thus absorbed
into the circulation, and quickly eliminated through the kidneys. But
it also acts in other ways. By obviating tricuspid regurgitation, through
its influence on the left side of the heart, digitalis lessens or removes
passive congestion, diminishes blood-pressure, and consequently filtration,
reduces the amount of transfusion from the blood-vessel, and j^revents
further development of the dropsy. By obviating venous obstruction, it
removes lymphatic obstruction, and thus favors absor2)tion by the lym-
j)h:itics; hence the excess of liarenchymatous fluids is taken up by these
vessels. Moreover, if there is much dropsy, on removing the congestion,
the pressure of the fluids outside the blood-vessels very probably be-
comes greater than the pressure in the vessels, and hence the fluids will
flow into the blood-vessels. The water in the tissues is then brought
back into the circulation, and eliminated by the kidneys. But digitalis
also by its indirect influence acts on the kidneys. During tricuspid re-
gurgitation the kidneys become congested, hampered, and inactive. Ee-
moving general congestion by its effects on the heart, digitalis relieves
the kidneys, and allows them to return to their natural state, and hence
they quickly eliminate the excess of water in the blood, due to the ab-
sorption of the drojjsical fluid. When all the water has been absorbed
from the tissues into the blood, and eliminated by the kidneys, digitalis
no longer causes an excessive flow of urine, as would happen if it acted
directly on the kidneys.

It may be urged that we have regarded the dropsy of tricuspid regur-
gitation as in part due to heightened vascular tension through the great
venous congestion, and that if digitalis increases arterial tension it should
increase rather than diminish the dropsy; but it must be borne in mind
that digitalis removes the tricuspid regurgitation and venous congestion
by the same means that it causes more blood to be sent into the arterial
system, and so heightens arterial tension.

There is another form of dropsy needing descrijition, that due to
anaemia. After severe loss of blood, or exhausting drains of albuminous
fluid, as in diarrhoea or chronic dysentery, a patient often becomes very
dropsical. A small amount of dropsy at the ankles also is common in
other forms of ana?mia, as in chlorosis. How is this dropsy produced ? It
cannot be explained satisfactorily by ascribing it to hydraemia ; for though
the Avater is relatively increased to the amount of albumen and corpuscles,
the total volume of the blood is diminished by hemorrhage, and there
cannot, therefore, occur increased lateral pressure from increased volume
of the blood, as occurs when water is retained in the system from dimin-

EFFECTS OF COLD ON" THE BODY. 35

ished excretion from the kidneys; an increased pressure leading to in-
creased transfusion through the capillaries into the parenchyma.

If not due, then, to an absolute excess of water increasing the total
amount of blood, how is the dropsy explained ? Is it due to the deficiency
of red corpuscles or of albumen ? It is not due to deficiency of the red
corpuscles; for in chlorosis, where the red corpuscles are greatly dimin-
ished while the amount of albumen remains much the same, very little
or no dropsy occurs, and it is in those cases only when the blood is greatly
drained of albumen that extensive dropsy ensues.

From Cohnheim's experiments it is assumed that in anaemia the vessels
undergo change and permit fluid more easily to transude through the
vessels.

THE EFFECTS OF COLD ON THE BODY.

Before treating separately of the various kinds of cold baths, I think
it will save repetition, and j)rove otherwise useful, to make some j^re-
iiminary remarks on the efl'ects of cold on the human body. These
effects are various, according to the way cold is employed. Cold is a
refrigerator, an aneesthetic, a tonic, an excitant, or a depressant. Cold
applied to the surface of the body, either as the douche or cold bath,
affects the system through its influence on the nerves, reflected on the
skin, or to distant parts, and by abstracting heat.

The application of cold withdraws heat from the body, and cools both
the sujDcrficial and deep parts. The general cold bath will produce a
very considerable reduction of, the heat of the surface to the extent even
of 10° Fall, in the trunk, and even considerably lower in the extremities.
The general cold bath might be supposed capable of reducing the heat
of the body's surface for a considerable time; this, however, is not the
case, for the skin of the trunk speedily becomes warm again, although
for some hours afterward the extremities may remain cold, and the tem-
perature in the axilla almost recovers itself in a few minutes, although
the bather may have been immersed half an hour, or longer, in water at
a temperature of 60°.

Of course, it is not here maintained that heat is not abstracted from
the body; but, as will be shown in another place, the loss is so raj^idly
restored that the cold bath will not depress the skin's temperature in a
healthy person for any notable time.

Cold sponging, so often employed in fevers with such evident relief,
exerts a very slight and transient influence on the heat of the body, as
may be ascertained by aid of the thermometer; hence the sense of com-
fort derived from the sponging cannot be ascribed wholly, or hardly in
part, to its refrigerating influence. This relief may be due to the re-
moval of impurities which perhaps irritate the skin, or annoy by their
odor, and by mitigating the parched condition of the surface; for a skin
hotli hot and dry is a source of much greater discomfort than a moist
though even hotter skin. Sponging with tepid water, so as to restore
moisture to the parched skin, gives marked comfort to the patient.

The foregoing remarks apply only to the surface of the body; but
the general cold bath will likewise reduce the temjierature of the inter-
nal organs. This reduction, never very great, is restored to the deep

36 EFFECTS OF COLD ON THE BODY.

even more quickly than to the superficial parts; so that, as might be
inferred, the general cold bath is still less efficient as a refrigerator of
the internal than of the superficial organs. In fever-free persons, there-
fore, the general cold bath must rank very low as a refrigerator.

It is, however, otherwise with the body of a jiatient whose tempera-
ture is unnaturally raised with fever. The immersion of fever-stricken
patients in the cold bath, or packing them with the cold sheet, will
jiroduce a considerable and durable lowering of the temperature.
Whether this reduction is eifected by abstraction of heat, or by prevent-
ing its unnatural formation, it is impossible at present to decide.

The application of cold, partly by its topical action, but chiefly
through the vaso-motor system, first contracts the blood-vessels of the
skin, which on discontinuing the cold dilate, and the surface becomes
redder, warmer, and glowing. Moreover the vessels of distant and in-
ternal parts are similarly affected, as experiments have shown in the
case of the mesentery and the membranes of the brain (Schiiller, Frank).
Winternitz maintains that he has experimentally proved that it is jios-
sible to control the effect of cold and direct and localize its influence ; he
finds that cold applied to the foot affects chiefly the inter-cranial circu-
lation ; cold to the thigh, the pulmonary circulation ; and cold to the
back, the circulation of the pituitary region.

The moderate and brief application of cold not only heightens arterial
tension, but likewise increases the frequency of the heart's action, and if
this practice is continued daily, it increases the corpuscular richness of
the blood, and the haemoglobin of the corpuscles, and it removes anemia.

Cold, when judiciously employed, is well known to be a powerful
tonic. A cold climate and cold bathing are tonic and bracing. The
theory of the tonic action of cold may perhaps be stated thus : — During
exposure to cold, the body's loss of heat, as tested by the thermometer,
is by no means a measure of the quantity withdrawn. Many observers
have shown that at such times increased combustion occurs, whereby
much of the lost heat is compensated, and the temperature is maintained
or soon restored. This increased oxydation of the tissues is demon-
strated by the greatly increased quantity of carbonic acid thrown off by
the lungs on exposure to cold. Now the most vigorous health is main-
tained by a rapid construction and destruction of tissues, within certain
bounds, provided these two processes are fairly balanced. On exposure
to cold, the lungs absorb more oxygen, the tissues are more rapidly and
freely oxydized, and thus the processes of destruction and reparation go
on in larger measure. How is this eff'ected ?

In the process of nutrition, apart from the nerves, we have three
factors, the nutritive plasma, the tissues, and oxygen. When food is
taken, digested, and introduced into the blood, both formation and de-
struction of the nitrogenous tissues begin, formation being limited by
destruction; and Avhen the destruction of tissues ceases, the further as-
similation of the nutritive materials of the blood comes likewise to an
end. These destructive changes take place in proportion to the amount
of oxygen absorbed^ and when this gas is exhausted, many products of
destruction remain only partially oxydized. further tissue disintegration
ceases, and assimilation is suspended. (Parkes.)

Under exposure to cold, oxygen being abundantly absorbed, the effete
products in the blood are first consumed, thus purifying the blood, and
rendering it fit to nourish the body; next, by its consuming action on the

;bffects of cold ois" the body. 37

tissues, oxygen promotes tlio cycle of changes just described, food is taken
and assimilated, and the destruction and construction of the tissues rapidly
go on, so creating great physical Angor. Thus it is that cold climates are
invigorating.

Applied locally, cold may act as a tonic (see Douche) ; but if too long
continued, or excessive, it depresses; for, by contracting the vessels too
sharply or too continuously, it lessens the supply of Ijlood to the tissues,
and thereby diminishes their cell-growth and tissue change. Ijitense
cold, applied for some minutes, will abolish sensation, and in this way be-
comes an anaesthetic; and, if the cold is too long contiiuied, the part will
die and become gangrenous.

The sudden partial application of .cold may act reflexly as an excitant.
A cold hand applied to the abdomen excites contractions in the parturient
womb. Cold water smartly sprinkled on the face of a swooning person is a
familiar way of restoring consciousness. The same treatment will help to
establish breathhig in weak or apparently still-born children, or to recover
persons over-dosed with chloroform, or narcotized with opium or tipple.

The local application of cold may affect deep-seated vessels reflexly.
Kossboch finds in his experiments on animals that the application of an
ice-bag to the skin, as on the abdomen, affects the vessels of the trachea,
the mucous membrane becoming first pale, followed soon after by slight
redness, passing later into a blue-red tint, when a copious watery secre-
tion ensues. Here, then, we have an instance of the induction of venous
congestion by the local application of cold, and, as Brunton remarks,
these experiments explain '* how readily a draught of cold air on some
]3art of the body may cause inflammation of the respiratory organs."

Experiments on cold-blooded animals show how greatly temperature
modifies the action of drugs on voluntary and cardiac muscle, on motor
and secretory nerves, on the spinal cord, and probably on all tissues. As
a rule poisons act more energetically on frogs in hot than in cold weather,
a dose sufficient to produce great effect in hot weather being inoperative
in cold. Brunton finds that great heat or great cold prevent the action
of veratria on voluntary m-uscle; and I find heat greatly increases the
susceptibility of the heart and muscle to veratria and modifies its action.

Lucdisinger shows that temperature influences the motor nerves, for
he finds that extremes of temperature abolish the action of guanidine on
the motor nerves.

Temperature also modifies secretion, probably by its influence on the
secretory nerves, for pilocarpine acts less on animals whose temperature
is reduced by placing them in a cold chamber (Brunton); and it is well
known that this drug acts much more powerfully when the patient is in
a warm bed or before a fire than if his skin is exposed to cold.

Some poisons, like chloral, alcohol, etc., act in part by reducing the
temperature of the body; by lessening combustion, and by disturbing the
mechanism regulating the production and loss of heat, so that the temper-
ature is more quickly raised or cooled by heat or cold (Brunton). In such
cases, by maintaining a proper temperature of the body, may avert death.

38 COLD BATH.

THE COLD BATH, INCLUDING SEA-BATHING.

Cold water may be applied for the sake of its moisture, its tempera-
ture, or both coujoined. If we require merely moisture, and temperature
is of no consequence, tepid or warm water is both preferable and more
agreeable. Cold water is generally employed to abstract heat from either
the whole surface of the body, or from some particular ])art of it, or to
induce general or local excitement and shock.

Since the skin absorbs neither the water of the bath, whether it be
warm or cold, nor any substances, soluble or insoluble, which may be
added to the water, it follows that whatever may be the effect of baths it
must be explained by their direct action on the skin.

In speaking of the general cold bath, we shall speak mainly of cold sea-
bathing, this being a far more powerful medicinal agent than the simple
cold bath, although, indeed, their action is identical, the difference in
their effects being one merely of degree: and, as we proceed, we shall
point out how these differences affect the body.

On entering a cold sea-bath, there is at first a sensation of depression,
great or little, according to the coldness of the water. The skin becomes
pale and shrivelled, and presents the familiar appearance "goose-skin," a
condition produced by the contraction of the skin, and the consequent
protrusion of the hair-roots and follicles. There is a general shivering,
some blueness of the lips, nose, and extremities, considerable reduction of
the temperature of the skin, quickened pulse, convulsive and sobbing
breathing as the water rises to the chest, especially when the bath is en-
tered slowly. The system soon becoming roused to meet and to resist the
depressing effects of cold, in a few seconds a sensation of general exhilara-
tion ensues. The skin becomes ruddy and glowing; tiie breathing full
and easy; the pulse rather quick and strong; the spirits exalted, and the
bather feels increased vigor, both of mind and body. If he quits the bath
now, or before the period of exhilaration ceases, the buoyant condition
endures more or less for the rest of the day, showing that the bath thus
acts as a tonic to the system.

On the other hand, if the bath is prolonged, depression again comes
on. The bather feels cold, shivers, becomes blue and numb in the more
exposed and smaller parts, whence, on account of their size, warmth is
more readily withdrawn, and he is seized with a sensation of depression
and wretchedness. Baths prolonged to this injudicious extent often pro-
duce damaging results, which may continue for hours, and even days,
sometimes, indeed, inflicting serious injury on the health, especially in a
weak or growing person. For many hours after the bath he complains of
general languor, with a repugnance to exercise, whether of body or mind;
his temper is fretful and morose, the circulation feeble and languid, with
sinking at the epigastrium, loss of appetite, chilliness of the surface, and
cold extremities. It need scarcely be said that consequences like these are
to be carefully avoided: yet rliese risks will often be encountered, unless
the doctor gives specific and minute directions, so great is the prevailing
ignorance and error on the subject of bathing.

If the exposure in the cold bath is continued beyond this point, or if
the cold is severe, its effects become more manifest; great depression and
a sensation of utter misery set in, followed shortly by heaviness and drow-
siness, Avliich deepen sometimes into coma, till a kinel of apoplectic state is

COLD BATH.

readied, then asphyxia and death from paralysis of the muscles of respi-
ration.

Baths, then, on the one hand, judiciously employed, are very powerful
tonics, while on the other, if unwisely used, they induce great depression
of the bodily powers and produce serious mischief. The superiority of
sea-baths has been placed beyond mere surmise; for direct experiment has
established the fact that a sea-bath acts far more powerfully on tissue
metamorphosis than the simple water-bath. While the sea-bath increases
the process both of destruction and of construction of tissue, yet that of
construction is in excess of that of destruction, with the effect of inducing
not only increased vigor of the functions of the body but an actual aug-
mentation of its weight. Sea-air, it is true, acts in the same way, so that
it is difficult to determine to what extent improved health results from
sea climate or sea- baths.

The cold bath is almost universally employed for its tonic virtue. To
obtain this wished-for result, the bath should be discontinued at the time
it causes general exhilai'ation, for the system then appears to be roused
into action to resist the depressing influence of cold, and if at this point
the bath is discontinued tlie general healthful stimulation persists; for,
whilst taking the bath, and probably for some time afterwards, oxidation
of the tissues is increased, the blood is purified of effete products, and the
process of construction and destruction of tissue, on which vigor of both
mind and body depends, are intensified.

Bathing therefore increases appetite, improves digestion and the assimi-
lation of food. The bath, then, is a tonic in the strictest sense of the word.

Used in accordance with the rules to be immediately laid down the
good effect of the bath soon becomes apparent, and the patient gains in
weight, his complexion becomes ruddy and clearer, his muscles, especially
if he conjoins exercise with the baths, acquire firmness and strength, the
mental debility arising from deficient nutrition of the nervous system
speedily passes away, and he soon recovers mental and bodily vigor.

The important question arises — IIow can we best obtain these invigor-
ating effects ?

Our object clearly is to secure the greatest possible amount of stimula-
tion, and to ensure as long as possible the persistence of the increased vigor
of nutrition. To obtain the greatest degree of stimulation we must duly
apportion the temperature and duration of the bath to the patient's
strength; and to ensure the continuance of nutritive vigor as long as pos-
sible the patient should leave the bath at the climax of general exhilara-
tion and stimulation, avoiding carefully the onset of the next stage, that
of depression.

The bather, if very weak, manifests but little functional energy to resist
the depression from the cold. Indeed, if this is intense, the stage of stim-
ulation may not come on at all, but, depressed from the first, the patient
may so remain for a long time. Injudicious bathing often seriously
injures, and even endangers the lives of weakly persons.

The depressing effects of a cold bath are proportioned to its coldness
and duration. The colder the water, the greater the depression it occa-
sions — greater, too, when the water is in motion than Avhen at rest. More-
over, the longer the period of immersion the greater is the degree of de-
pression.

When the patient is weak and prostrated by illness, the bath must not
be too cold, nor continued too long, and the water should be at rest.

COLD EATir.

Thus, wo must have regard to the strength of the patient, tlie temperature
of the water, and the duration of the bath. •

Here it will be convenient to consider in what respect sea- baths differ
from simple water-baths, and to explain the tonic superiority of sea-baths.

1st. In sea-water various ingredients are held in solution.

2d. The variations in temperature of sea- water, in the varying seasons
of the year, are much less than those of river-water.

3d. While the sea is always more or less in motion, river- water is com-
paratively at rest.

The salts in solution are supposed to act as invigorating stimulants to
the skin, so that a patient unable to bathe in simple water without suffer-
ing great depression can bathe in sea-water with great benefit. Moreover,
as the sea's temperature never falls very low in winter, sea-bathing may
often be continued late in the autumn, or even into the early winter months.

The motion of the waves increases the depressing effects of the bath,
but if the bather is strong enough, it also increases the ensuing reaction;
and thus the commotion of the waves, while more bracing to the strong,
is at the same time highly exhilarating.

These guiding principles borne in mind, we shall be able under all cir-
cumstances to give correct answers to the various questions paticmts may
put to us concerning bathing. One most frequently asked is — How long
shall the bath be continued ?

Our answer must be regulated by the strength of the patient and the
coldness of the water. If the water is cold, or the patient is very weak,
we must at first forbid out-door sea-bathing and substitute a tepid bath,
the temperature of which should be slowly reduced until that of the sea
is reached. Then, if the day is fine and the sea calm, the bath may be
taken in the open air. Though it may be considered safe to let the
patient bathe in the sea, yet if he is very weak and unaccustomed to bath-
ing, his stay there must be very brief; it Avill often suffice to allow tAVO or
three waves to pass completely over him, when he should at once come
ashore and wipe himself thoroughly dry, using plenty of friction to the
skin, for which purpose Cash's towels are well adapted. With increasing
strength, and becoming accustomed to the effects of the water, he may
continue the bath for a longer time, but it is seldom advisable for a con-
valescent to bathe longer than from five to ten minutes. Some patients,
nay, even some healthy persons, can bear a sea-bath only every other day.

Then as to the time of day best suited for bathing the greatest igno-
rance prevails, before breakfast being currently believed to be the best
time; yet this practice is not without risk even for the robust, who are
often made ailing and fatigued by it for the rest of the day.

Our object in using the bath, as we have before said, is to obtain pro-
longed and energetic stimulation. We must therefore choose that time
when the body is most refreshed, invigorated, and nourished. These con-
ditions, it might be supposed, would co-exist in the early morning after
a sound and refreshing sleep. It must be borne in mind, however, that
before breakfast the body has undergone a fast of several hours, and is in
want of food, without which the bodily functions may very readily become
depressed. In fact, only a robust person is able to bear a sea-bath before
breakfast.

Thus theory and practice are both opposed to this period for bathing,
both pointing to a time between breakfast and dinner as the most appro-
priate.

COLD BATH. 41

This leads us to the consideration of another question; namely, after
a meal, how long a time should pass before a bath may be taken; and,
after a bath, what time should pass before taking food ? Now cold bath-
ing produces a great shock to the skin and system generally; and any
powerful mental or bodily impression will check or even arrest for a time
many of the functions, even if in active operation. This is the case with
digestion. Any great excitement, it is well known, can stay this process
more or less completely, and the cold bath is generally sufficient entirely
to arrest it; therefore, before the bath, an adequate time should elapse,
so as to permit the almost complete digestion of the breakfast, that is, an
interval of about three hours. ISTor, for the reasons just pointed out,
should the bath be taken immediately before a meal; otherwise, little or
no gastric juice is secreted, and food lies half-digested in the stomach.

And for a reason somewhat similar, the bather should not go into the
water whilst under the influence of any great emotional excitement. The
nervous force (on which there appears to be set a limit) being directed
strongly in one channel, the bath will not produce nervous stimulation, so
that the patient will feel languid, cold, shivering, and depressed. Obvi-
ously, for the same reason, children must be coaxed, not dragged into
the water against their will. In early life there is often much terror of
bathing; and if, in spite of this, the child, while screaming with fright, is
forcibly dragged into the sea, very ill effects may follow; for, missing the
stage of stimulation, the child may remain, often for days, depressed
and ill.

Is there any age rendering sea-bathing dangerous, and to be prohibited ?

It is generally accepted that young children, — say under two years of
age, — being very impressionable, ought not to undergo the shock of a cold
sea-bath. At the other extreme of life, when the enfeebled powers of
the body are incapable of strong reaction, sea-bathing is inadmissible, for
it is as well known that in old people the heat-forming force is much re-
duced. Moreover, undue vascular excitement ma}' prove dangerous; the
vessels in the aged, often brittle through degeneration, are in danger of
giving way, and thus under any unusual strain causing apoplexy.

The foregoing remarks imply that fatigue is a condition strongly ad-
verse to cold bathing. Even if other conditions are favorable, it is seldom
advisable for weakly persons to take a bath on the day following their arri-
val at the sea-side. They should wait till all fatigue has passed away.

Does pregnancy forbid sea-bathing ?

If a woman has miscarried or aborted, or if of an excitable tempera-
ment, baths may be expected to do harm; and in far advanced pregnancy
a sea-bath may perhaps produce abortion. But under other circumstances,
and with due regard to the conditions previously laid down, bathing will
benefit both mother and child. Nor, if accustomed to the practice, need
a woman discontinue bathing at the menstrual period, although it is
always inadvisable to begin at such a time, since the shock may check or
arrest the secretion, and thus induce perhaps many months of amenorrhoea.

In the choice of coast, and the time of year, we must have regard to
the condition of the patient. If not very weak, with the health only a
little undermined, then a rugged coast, where the sea is rough and bois-
terous, should be recommended. However, should the health be much
broken, then a smooth sea is preferable, and, in a cold climate, the sum-
mer is the only suitable time.

Exercise taken while bathing soon induces fatigue and even exhaus-

COLD BATH.

tion; whereas weakly patients must be cautioned to Le moderate in this
respect. Another evil should be guarded against: on leaving the bath, a
patient invigorated by it is in danger of taking too much exercise, fatigu-
ing himself, and so counteracting the bath's good effect. The amount
of exertion permitted must be strictly in accordance with the patient's
condition, who, if very weak, should take only horse or carriage exercise.

A course of sea-bathing sometimes causes the hair to fall off abundant-
ly, naturally exciting much anxiety, especially in women. Their fears,
however, may be quieted by the assurance of a rapid new growth. Other
troubles may arise. Bathing sometimes induces constipation, more or less
obstinate; but this need not lead to the discontinuance of the bath. The
constipation should be removed by exercise, regulated diet, or, these fail-
ing, by purgatives, Dyspepsia and diarrhoea also sometimes occur dur-
ing sea-bathing. The bather should be discreet as to the hour of the bath,
the time spent therein, and if, notwithstanding every care, dyspepsia or
diarrhoea continues, the bath must be temporarily or permanently discon-
tinued. In fact, sea-air alone will, in some constitutions, induce these
disorders.

Eestlessness at night is sometimes attributed to sea-bathing. Many
people, no doiibt, find that living too near the sea-shore often produces
broken and sleepless nights. On the shores of the Mediterranean, especi-
ally along the Eiviera, this is notably the case. On removal inland, a mile
or thereabouts, this restlessness vanishes: for instance, sleep unattainable
at Cannes itself is secured at Cannet, a mile or so inland. Broken rest
may often be traced to dietetic irregularities, or to late hours. A late and
heavy meal will sometimes cause restlessness, whilst a good night will fol-
low an early, light, and digestible repast. iSome patients mar their rest
by taking stimulants shortly before bedtime, while, on the other hand,
others cannot sleep without a " nightcap.'"

A bather should plunge into the waves at once, and on no account stand
undresssed and hesitating till he becomes cold and shivers. It is a com-
mon and pernicious error to suppose that it is necessary to be well cooled
down before plunging into the bath. If needful, a short, brisk walk
should be taken just before the bath, to warm the surface and extremities.

The effect of cold is, in proportion to its degree, to lessen the perspi-
ration. A cold bath at first checks perspiration, but soon afterward this
secretion becomes considerably augmented, and in a greater degree after
sea than after simple water-bathing. Driven from the skin, the blood
floAVS into and fills the internal organs, and the kidneys partaking of this
congested state, probably explains the frequent and transitory occurrence
of a small quantity of albumen in the urine, during the bath.

The effects of cold baths on tissue change have already been pointed
out, and the observations on this subject will be supplemented and con-
firmed in those we have now to make relating to the influence of sea-baths on
the constituents of the urine. Baths augment the quantity of urea or sul-
phuric acid of the urine. Whether this increase exceeds the limits of the
natural healthy variations, and whether the experiments are sufficiently nu-
merous to prove it, has been called in question. It is not to lie expected that
the tissue change would at once be greatly augmented, nor that the increase
at any time would exceed the maximum amount of health; consequently
the increase of urea in its turn would not exceed the maximum quantity
excreted in health, lint surely, if for some time the excretion of urea is
maintained at its maximum, this single fact would alone establish the in-

THE SITZ-BATH. 43

fluence of baths, so far as they coukl be expected to operate, and would
show that sea-bathing increases disintegration of the nitrogenous tissues.

Beneke's observations lead to the same conclusion. AVhen food was
taken, just sufficient to maintain the weight of the body at a fixed
point, he found that baths immediately reduced the weight of the body,
a loss certainly due to heightened disintegration of the tissues. But
this increased consumption of the tissues being accompanied by increased
appetite, and by increased assimilation, more food is taken, and his body
gained in weight. Baths, it was said, increase the quantity of uric acid,
although this is lessened by sea-air; but on this point observations are as
yet insufficient.

The urinary water is temporarily and often greatly increased, though
the whole day's urine is lessened in quantity, probably owing to the sub-
sequent excessive elimination by the skin. In Beneke's observation the
intestinal secretions were also large, so some water may have escaped in
this way.

It is scarcely necessary to occupy much space with a narration of the
cases likely to derive benefit from sed-bathing. In chronic illness at-
tended by debility sea-bathing yields the best results; but it is especially
useful to those recovering from acute diseases, and to persons whose
health has been broken by over-work, by residence in towns, by sedentary
employment, or by injurious excesses. It is a question of much impor-
tance whether phthisical j^ersons should take sea-baths, and our answer
must be qualified by the circumstances of the case. When the disease
is chronic, with little or no elevation of temiperature (little or no fever),
when, indeed, the case is one of fibroid degeneration of the lungs, with-
out active formation of tubercle, sea-baths may be permitted, due regard
being paid to the rules just laid down.

When the cold bath or cold sponging cannot be borne, it is often
useful vigorously to rub the body with a towel wrung out in tepid or
cold water, or the naked patient may have a sheet wrung out with cold
Avater thrown over his shoulders, and be rubbed down with the sheet.
This plan is useful to prepare the way for the cold sponge-bath, and is
applicable to the same class of cases, since it excites reaction and pro-
duces tissue change and stimulates digestion ; like the sea-bath, it is a
true tonic. It is useful, too, to relieve fatigue after a hard day's walk, etc.

THE SITZ-BATH.

The sitz-bath is largely and beneficially used in hydropathic institu-
tions. The Avater should be between 60° and 80°, and the patient should
sit in it from five to thirty minutes, once or twice a day. At first it
causes contraction of the arterioles, not only of the immersed skin, but
also of the intestinal vessels; hence more blood is sent to the head and
upper extremities. After the bath is discontinued the reverse process
sets in, more blood being sent to the abdominal organs, diminished sup-
ply flowing to the brain. The sitz-bath greatly relieves fatigue and
soothes an irritable restless state of the nervous system. It often les-
sens headache, and regulates the bowels; it often augments the catame-
nial flow by lessening the amount of blood in the brain, and is in many
instances usefully employed to procure sleep. After the sitz-bath reac-
tion should be promoted by friction or exercise.

44 ON PACKING WITH THE WET SHEET.

ON PACKING WITH THE WET SHEET.

Packixg Avitli the cold wet sheet, although at present seldom employed
outside hydropathic establishments, is undoubtedly, in many diseases, a
very efficacious treatment.

Dr. Johnson, in his work on hydropathy, directs the patient to be
placed on a mattress Avith a pillow to support his head; then, " upon the
mattress, and extending over the pillow, two blankets are spread, and over
this a sheet wrung out as dry as possible with cold water. The patient
lies down on his back, perfectly unclotlied, with his head comfortably
placed on the pillow; an attendant now approaches, say on the patient's
left, and first puckering the blanket from the back of the head down to
the back of the neck, reaches across his chest, seizes the right upper cor-
ners of the blanket, and brings them tightly across under the chin to his
own side (the left), and tucks them well and evenly under the left shoulder,
where it joins the root of the neck, and under the point of the same
shoulder. He now reaches across the body again, and brings over all the
rest of the right sides of the blankets to the left side of the patient, and
then proceeds to tuck them well and evenly under the left side, beginning
where he left off, at the point of flie shoulder, and proceeding quite down
to the heels. The patient is now entirely enveloped in one half of the
blankets, and the attendant finishes the operation by passing over to the
right side of the patient, and then proceeding to tuck the left sides of the
blanket under the right side precisely in the same manner as we have seen
him tuck the right sides of the blanket under the left side of the patient.
The attendant, standing on the right side of the patient's leg, finally insin-
uates his left hand under the backs of the ankles, lifts them up, and then
"with his right hand turns back the lower ends of the blankets under t^e
heels." The wet sheet should reach to the ankles, and " be wide enough
to overlap in front of the body about eight or twelve inches; over the
whole four or five blankets placed, and pressed down close to the sides."

This pack is useful in specific fevers and acute inflammatory diseases.
It has long been employed in scarlet fever, and should be used from the
beginning and throughout its course. In moderate attacks it is sufficient
to pack the patient from thirty to fifty minutes; but if the fever is very
high, if the rash comes out slowly, imperfectly, and of a dull color, if the
l^atient is restless and wandering, the packing must be continued an hour
or longer, and be repeated three or four times a day. This treatment
develops the rash, greatly reduces the fever, quiets the pulse, renders the
skin moist and comfortable, and abates the restlessness and wandering. A
short time after the application of the wet sheet a patient, previously
restless and wandering, commonly falls into a quiet refreshing sleep, and
awakes calm and free from delirium. Its influence on the pulse and tem-
perature is striking; the pulse in a few hours falling fifteen to twenty
beats in the minute; a repetition of the packing greatly reduces the fever.
The packing is especially indicated on suppression or recession of the rash,
when serious symjitoms are apt to arise; the cold sheet will then bring
out a brilliant rash, followed, generally, by immediate improvement in
the patient's condition. It has been recommended to dash two or three
pailfuls of cold water over the patient after each packing. During the
whole course of the fever a cold wet compress, renewed every three hours.

COLD BATHS IN FEVERS. 45

slionld be worn round the throat; and if, on the decline of the fever, the
tonsils remain large, or there is chronic inflammation of the fauces or
larynx, this ajiplication, renewed less frequently, or applied only at night,
should be continued till these morbid conditions cease. The compress
should be composed of linen several times folded, and fastened round the
throat by another piece of folded dry linen. Cold packing is beneficially
employed in other fevers, and in acute inflammations, as measles, small-
pox, pneumonia, pleurisy, rheumatism, and gout.

In acute rheumatism, when the pain forbids the patient to be moved,
the front of the body only should be packed, and a wet cold compress,
renewed every two or three hours, should be wrapped round each of the
painful joints. If the prejudices of the patient's friends prevent the use
of the cold sheet, the body should be sponged with tepid or cold water
several times a day, and if the perspiration is abundant and foul, soap
should be used. In addition to sponging, the wet cold compress, as pre-
viously described, should be applied to the painful joints. There can be
no question of the superiority of this treatment over that of swathing
the patient in flannel clothes, and covering him in blankets to make liim
sweat. To avoid the supposed danger of catching cold, these woollen
clothes are worn day after day, till, saturated Avitli putrefying perspira-
tion, the stench sickens and de-appetizes the patient, and a crop of irri-
tating miliary vesicles is engendered, which breaks the patient's sleep.

In pneumonia some pack the chest only, and renew the cold appli-
cations hourly, or even oftener; a mode of treatment which is said to
remove the pain, quiet the pulse, calm the breathing, and reduce the
fever.

When, as often happens, the patient's friends object to the cold pack-
ing through fear of " inflammation," or of '' turning the disease inwards,"
the sheet may be wrung out in tepid water, and by the time it is spread
for the reception of the patient it will be sufficiently cooled to answer the
purpose.

A pedestrian, after great exertion, will find it an agreeable restorative,
preventing stiffness and aching of the muscles, to strip and wrap himself
in a dripping wet cold sheet, well rubbing himself afterwards; but if stiff-
ness still remains, a few drops of tincture of arnica taken internally will
remove it.

Cold or tepid packing is useful in the summer diarrhoea of children.

A daily cold wet pack is often a very useful application in chronic
diarrhoea, like that often met with in persons coming from a tropical
climate, and due probably to chronic catarrh of the intestinal mucous
membrane.

COLD BATHS IN FEVEES.

The elaborate investigations regarding the action of cold applications
in fevers, made during the last fifteen years in Germany, induce me to
devote a separate chapter to this important subject.

These investigations confirm the conclusions' of Currie and Jackson, and
give precision to our knowledge concerning the employment and effects
of cold to the surface. This treatment has been employed in typhus,
typhoid, and scarlet fevers, measles, and other febrile diseases. More re-

46 COLD BATHS IX FEVERS.

cently, Dr. Wilson Fox and others have cured patients suffering from the
hyperpyrexia occasionally observed in rheumatic fever, a condition, owing
to its sudden onset and rapid course, hitherto regarded as almost neces-
sarily fatal.

Many of the symptoms, and therefore tlie dangers, of fevers, depend
in great measure on the elevation of the temperature. The effects of
fever, whether specific or inflammatory, are due either to elevation of the
temperature, to the specific cause of the fever, or to the inflammation.
The s^^mptoms common to all fevers are due simply to the elevated tem-
perature of the body, whilst the characteristic symptoms are due either to
the specific poison, or to the inflammation. This increase of temperature
affects the organs in a twofold manner; in the first place, it perverts, de-
presses, or, if the rise is very high, abolishes function; and, in the sec-
ond place, produces fatty degeneration, or, as it is termed, parenchymatous
degeneration of all the tissues.

That the common symptoms of fever, as headache, delirium,
quick pulse, dry skin, and general weakness, are due to the heightened
temperature is well shown by the effects of a treatment which will re-
duce this abnormal temperature: that is, by the aid of the cold bath or
quinia we lower the temperature to the normal standard, and then these
pyrexial symptoms at once disappear.

Fatty degeneration of the tissues sets in during the progress of a fever,
especially when prolonged. This degeneration has been observed more
particularly and fully in the liver, kidneys, heart, blood-vessels, and volun-
tary muscles. This fatty degeneration is in all probability due to the
fever, for the degree and extent of the changes correspond in amount to
the degree and duration of the elevation of temperature; and similar
changes occur when the temperature of an animal is raised by keeping it
in a warm chamber. The cells of the liver and kidneys become cloudy,
then granular, till the nucleus becomes obscured, and the entire cell dis-
tended with granules, and, in the case of the liver, the cells contain an
excess of fat, and ultimately many cells burst and perish. The muscular
tissue of the heart and of the voluntary muscles becomes granular, then
fatty, and in severe cases their fibres undergo extensive destruction.

These effects of high temperature, the symptoms and the deteriorating
changes, can obviously be combated only by means which either lower or
23revent the undue development of body-heat. Foremost amongst these
means must rank cold baths. Employed early enough, the\" obviate the im-
mediate depressing effect of the temperature on the tissues, and prevent the
oncoming of parenclwmatous degeneration. Thus they reduce the frequen-
cy of the pulse, strengthen the heart, and so avert danger from failure of
the heart, and from hypostatic congestion. They tend likewise to prevent
delirium, and to produce sound and refreshing sleep; to improve diges-
tion and assimilation, and to promote the general nutrition of the body,
and thus to ward off or to lessen the risk of bed-sores and exhausting
suppuration. The period of convalescence, though some deny this, is
shortened by promoting assimilation, and thus preventing parenchymatous
degeneration. It is true that the specific poison of some fevers, as typhoid
or t^^hus, will itself probably in some degree affect the heart, brain,
and functions generally; but that the depression of the heart and brain is
mainly due to the elevated temperature is shown by the great abatement
of the symptoms referable to these organs when the temperature is reduced;
though, indeed, it may be plausibly urged that without elevation of tern-

COLD BATHS IN FEVERS. 47

perature the specific poison cannot be formed, and kence anti-p_yrctic
treatment will likewise obviate its depressing effects.

Cold bathing is applied in varionsways, — by means of the general cold
bath, affnsion, packing, sponging, and by the nse of ice.

Brand, to whom the revival of this hydropathic treatment is chiefly
due, has employed it largely in typhoid fever. In mild cases he uses cold'
wet compresses, or frequent -washing with cold water, or repeated pack-
ings in a cold wet sheet, or a warm bath gradually cooled. In severe cases
he recommends affusion, the shower-bath, or the general cold bath. He
generally places the patient in a sitz-bath, and pours water of 50° to 55°
Fall, over his head and shoulders, for ten or fifteen minutes, wraps him
afterwards unwiped in a sheet, and covers him over with a coverlet, and
to his chest and stomach applies compresses wrung out of iced water; but
if the patient complains of the cold he covers the feet more warmly or
applies hot bottles to them.

Hagenbach employs a general cold bath of 68° to 77° Fall, for ten or
twenty minutes, and if there is much delirium, or coma, he at the same
time pours cold water over the patient's head. He disapproves the fre-
quent cold washings and packings, asserting that they abstract but little
heat and that they fatigue the patient.

The method employed by Ziemssen and Immerman is the most agreeable
to the patient, and being equally efficient, it is the treatment most likely
to be generally adopted. They immerse a patient in a bath of 95°, and
in the course of twenty to thirty minutes gradually cool it to 60° Fah. by
the addition of cold water. This Ixitli is agreeable to fever patients.
These observers do not employ affusion, since the patient much dislikes
it, nor cold compresses, since these do not affect the rectal temperature.
Cold packings they find, however, do reduce the temperature of the rec-
tum. For young children and old persons the severity of the application
must be apportioned to the strength of the patient. Brand wraps a child
in a wet sheet, and placing it on a table pours cold water over its head.
For children and the aged Hagenbach employs for half an hour a warm
bath, gradually cooled by the addition of cold water to 8Q° or 75° Fah.
Weakly patients should be well rubbed on leaving the bath. Hagenbach
adopts this treatment whenever the temperature rises above 102° Fah. , while
Brand recommends it whenever the temperature mounts above 103° Fah.

In private practice I find the assiduous application of cold cloths wrung
out of ice-cold Avater more convenient than the use of the general cold
bath. This plan, if effectually carried out, promptly reduces the tem-
perature. Thus, by the method I am about to describe, I have seen the
temperature in hyperpyrexia reduced in two or three hours from 107° to
101°, or even lower.

Dip four napkins, or small towels, into iced water, and wring them
nearly dry, so that they may not drip and wet the bed, then ajjply them
one below the other from the chest downwards. As soon as the four
cloths are disposed over the chest and abdomen, re-dip and re-wring the
uppermost, then the second, third, and fourth, seriatim, then the first
again, and so on continuously. Supplementary napkins to the head,
thighs, and arms will of course still more quickly lower the temperature;
and indeed, should be employed to a big and stout patient, since large
quantities of heat have to be withdrawn through the bad conducting fatty
layer beneath the skin. If the napkins are very frequentl}^ changed, this
method is most efficacious, and is often highly agreeable to the patient.

48 COLD BATHS IN FEVERS.

being in this respect preferable to the nsually very disagreeable general cold
bath. In some instances, even after the discontinuance of the cold cloths
the temperature steadily falls for several hours.

The rcjietition of the processes must be regulated by the subsequent
course of the fever. If in three or four hours the temperature again
rises to 103°, Brand repeats the aifusion. In most cases he finds that six
affusions are enough, and afterwards he applies cold cloths wrung out of
water at 60° Fah. two or three times a day; these applications, provided
the temperature does not rise higher tlian 100° Fah., being made smaller
and applied less frequently as the case progresses. In very severe cases
the affusion must be employed every two hours. When the patient is
comatose and the foregoing treatment fails to restore consciousness, Brand
applies a cold affusion of 45° Fah. to the head every half-hour.

Dr. Stolir recommends the continuance of this treatment in typhoid
even to the middle of the third week; but it maybe required longer, and
here the thermometer is the test.

Ziemssen and Immerman find that with their plan four or five baths
are necessary the first day, and that subsequently two or three daily will
suffice, the^ repetition, however, being regulated by the information
afforded by the thermometer. They prescribe the bath at 6 a.m., and 1
to 3 P.M., and at 7 p.m. Ziemssen and Immerman found, as might be ex-
pected, that in typhoid the degree of cooling and its duration differed
according to the patient's age, and the severity of the case. Thus they
find the usual reduction is 3.6° Fah. in children, and 2.5° Fah. in adults.
In severe adults cases, however, the temperature falls only 1.8° Fah., and
the effect of the bath is least evident in cases where the morning remission
is slight. In severe infantile cases they fouiid that the temperature re-
covers its former height in six hours, in adult cases of moderate severity
in seven hours, and in severe adult cases in six hours and a half, and in
cases with slight morning remissions in three hours.

A single bath often effects a considerable reduction of the febrile
temperature. Thus Mosler reduced the temperature in a case of typhoid
to T° Fall., and the late Dr. "Wilson Fox, in one of his interesting cases
of rheumatic hyperpyrexia, 13.4° Fah.

Dr. Wilson Fox's exact and continuous observations on some cases of
rheumatic hyperpyrexia add precision to our knowledge of the effects of
cold baths. He has shown that the fall of temperature continues every
six or more degrees, forty or fifty minutes after the discontinuance of the
bath. It is important, therefore, to obserxe the temperature in the rec-
tum while the patient is in the bath, and to remove him before the heat
is too far reduced, lest too great a withdrawal of it might lead to collapse.
This indeed appears sometimes to occur, for we read of cases becoming
cvanotic, although German observers aver that this is not important, and
advise in such a case the application of warm bottles to the extremities.
Still I am convinced that it is important to avoid depressing, to this haz-
ardous extent, as I have seen a child, suffering from scarlet fever, killed
by an over energetic employment of cold.

German observers show conclusively that this treatment greatly reduces
the mortality of typhus and typhoid fever. Thus Brand treated 170 cases
of typhus, and Bartels treated thirty cases of typhoid without a single
death. The mortality of Hagenbach's typhus patients was five per cent,
provided the cases were treated early, and Dr. Stohr reduced the mortality
of his patients from thirty to six per cent., and the results he thinks

COLD BATHS IN" FEVERS. 49

would have been still more favorable could he have treated some of his cases
earlier. Liebermeister lessened his mortality from twenty-seven to eight
per cent.

Notwithstanding the enthusiastic laudation of the cold-bath treatment
of fevers by German writers, this plan is not at present commonly employed
in this country. If there is reason to hesitate whether we should treat the
acute specific fevers or inflammatory fever by this heroic method, there can
be no question respecting its great value in the treatment of hyperpyrexia.
This most dangerous condition generally arises from rheumatic fever, and
to it, no doubt, most of the fatal cases of rheumatism are attributable.
It may occur, however, in the course of any fever; and may, indeed, seize
a person apparently in perfect health. The first case of hyperpyrexia
ever recorded occurred whilst I was resident officer at University College
Hospital, and this was an instance of a sudden attack in a woman who
had recovered from rheumatic fever, and was on the point of leaving the
hospital apparently in fair health. On being called to her assistance I
was surprised at the pungent burning heat of her skin, and to my aston-
ishment found her temperature to be 110°, and a little later 111°. She
died in eight hours. This phenomenon, so startling then when hyper-
pyrexia was unheard of, has beeji noticed in hundreds of cases. Hyper-
pyrexia not uncommonly attacks children just previously in apparent good
health. I have often seen children in severe convulsions, and have found
their rectal temperature 107° and 108° Fah. The hyperpyi-exia may have
been due to the onset of an acute specific fever or of an acute inflammation,
but as these children all died it was impossible to ascertain the cause of
the onset of the fatal hyperpyrexia. Ordinarily, no doubt, hyperpyrexia
occuijs in the course of a fever, and generally, perhaps, when the tempera-
ture runs very high; but this by no means rarely comes on in rheumatic
fever when the fever is moderate and the symptoms mild. In a typical
case of hyperpyrexia the temperature rapidly rises, reaching in the course
of a few hours 110°, 112°, or even higher. This severe fever perturbs
and depresses the functions. At first the patient is restless and delirious,
the delirium being either slight or so decided that he must be restrained.
Sometimes before delirium the patient becomes blind. The delirium soon
subsides, he becomes quite unconscious; the pulse, at first full and bound-
ing, becomes exceedingly frequent and feeble; the respirations are much
hurried; the skin is generally dry; but it may be drenched in sweat.
Then the coma deepens, the breathing becomes more frequent and shallow,
and in few hours the patient dies. Not a single case of hyperpyrexia, as
far as I know, recovered till Dr. Wilson Fox first treated his cases with
the cold bath. Since then this treatment has been largely employed, and
with a larger measure of success; indeed, it is not an exaggeration to say
that the majority of the cases thus treated have been saved. In my own
practi<;e, in a considerable number of cases, this treatment has generally
proved successful; and it is a source of great gratification to me that by
means of Dr. Fox's treatment I have certainly saved many lives. In
hospital we mainly use the general cold bath, but in private practice the
application of iced-cold cloths in the way previously described will I
believe, prove more convenient, pleasant, and safe. Several cold baths'
are usually necessary, for after the reduction of the temperature, and con-
sequent removal of the sjanptoms, the temperature generally rises again.
It is interesting to note the passing away of the deadly symptoms as the
temperature falls. The patient wakes out of his coma, and next his mind
4

50 AVAR.M BATH AND THE HOT BATH.

becomes quite clear; his pulse falls and becomes stronger, and he passes
quieklv from most imminent peril, from the very shadow of death, to his
condition })revious to the onslaught of the hyi)erpyrexia. Though T have
said several cold baths are generally needed completely to subdue the
hyperpyrexia, yet in three cases after the first reduction of the tempera-
ture the hyperpyrexia did not return, but the })atients forthwith passed
at once from a condition of urgent danger into convalescence, without
undergoing a single unfavorable symptom.

This treatment not only reduces the excessive heat of fever, but it
allays the nervous symptoms, limits the wasting, and Brand says it also
prevents meteorism, bleeding, and lessens diarrhoea in typhoid. On the
other hand, Hagenbach and Jurgensen assert that this treatment fails to
lessen the meteorism and diarrhcjea in typhoid fever, and to reduce the
size of the spleen and the dicrotism of the pulse. All observers agree that
cold baths do not shorten the course of typhoid, typhus, and other acute
specific fevers, but Brand asserts, while Hagenbach denies, that they
shorten the stage of convalescence.

This treatment, it is said, rarelv, if ever, induces either bronchitis
or pneumonia, and the co-existence of either with a fever does not con-
tra-indicate the use of cold baths. Liebermeister even says that hypo-
static congestion or pneumonia afford no reason for suspending the baths —
that, indeed, under their use, hypostatic pneumonia sometimes disappears.
I have several times seen all the signs of double pneumonia arise after the
bath; for instance, dulness. tubular breathing, bronchophony, and yet
these patients have done well.

LudAvig and Schroder find that this treatment of fevers greatly reduces
the quantity of carbonic acid exhaled by the lungs and the solid constit-
uents of the urine, and thus lessens the tissue change; a very singular
fact, since cold baths, in health, have the very opposite effect. Dr. Fox
observes that sometimes the rectal temperature rises a little directly the
patient is 2:)laced in the bath; and Dr. Fiedler and Hartenstein point out
that immediately after the bath the axillary is much lower than the rectal
temperature, but half an hour aftei-wards this discrepancy is reversed,
the rectal temperature becoming from 1° to 2° Fah. lower than the axil-
lary, and so continuing during three-quarters of an hour.

THE WAEM BATH AXD THE HOT BATH.

The effects of heat on the body are, of course, for the most part, the
opposite of cold. By surrounding the body with a temperature higher
than its own, the destruction of the tissues by oxidation is considierably
diminished. Moreover, experiment has shown that increased heat im-
pedes or destroys the electric currents in the nerves, Avhence it may be
fairly presumed that when subjected to this influence they are less able
to conduct impressions either to or from the brain. These two considera-
tions may perhaps account for the enfeebling influence on the body.

The general warm bath, if not too hot, is at first highly pleasurable,
but if unduly indulged in, throbbing at the heart and in the large vessels
soon comes on, with beating in the head, and a sense of oppression and
anxiety. These sensations, however, when perspiration breaks out.

WARM BATH AND THE HOT BATH. 51

greatly diminish or altogether cease; but if the bath is continued too long,
the foregoing uncomfortable sensations return, accompanied by great pros-
tration, even to the extent of fainting; the pulse becomes greatly accelerated
and enfeebled, while the temperature of the body rises very consider-
ably, and, if the heat of the bath is great, may even reach 104° Fah.,
that is, to a severe fever height.

Warm baths are employed in Bright's disease to increase the perspira-
tion, so as to lessen the dropsy, and carry oif from the blood any dele-
terious matter retained in it through the inaction of the kidneys.

We must always bear in mind the purpose of the hot bath. It is too
much the ]n-actice to employ hot baths in Bright's disease before the occur-
rence either of dropsy or ura?mia. As the baths weaken the patient con-
siderably, they increase ana?mia and so favor dropsy. They should only
be employed when dropsy or urajmic symptoms are marked. Then, no
doubt, they are often very serviceable by removing a large quantity of
water from the blood, and lessening the hydra^mia on which the dropsy
depends; but whilst of undoubted service, if often repeated, they induce
much weakness. In my experience baths are greatly inferior to the plan
of making incisions over each external malleolus in the way described in
the section on acupuncture. This treatment reduces the dropsy much
more speedily, and far more certainly.

The hot bath is also used in nra?mia with the view of eliminating the
urea through the skin. There can be little doubt that this treatment is
serviceable in removing many of the cerebral manifestations of uraemia;
but it is very questionable whether the baths so act by eliminating urea.
It is, at best, doubtful whether the uraemic symptoms depend on the re-
tention of urea in the blood; moreover, it is uncertain to what extent, if
any, the bath can eliminate nitrogenous products through the skin. It
is certain that in health very little, if any, iirea escapes by the skin, though
it is probable that in some cases of Bright's disease urea is actually sepa-
rated with the perspiration. Bartels records cases where crystals of urea
covered the face, and by their accumulation on the beard gave it a f I'osted
appearance.

The general warm bath is of signal service either in simple or inflam-
matory fever of children. If a child is not very weak, a bath night and
morning, for a time varying from five to ten minutes, soothes and quiets,
and often brings on refreshing sleep. In the febrile diseases of grown-up
people, it is generally difficult to employ the general warm bath, but, in
its stead, sponging with hot water often induces perspiration, calming at
the same time the restlessness of the patient, and favoring sleep. The
same means will soothe the restlessness of convalescence and induce sleep.

In inflammatory affections warm or tepid baths are supposed to act by
dilating the blood-vessels of the skin, and so withdrawing blood from the
internal organs, including of course the inflamed organ, and thus by
lessening the amount of blood in any given part the bath diminishes in-
flammation. Further, by withdrawing blood from the brain the warm
bath favors sleep.

The warm bath mitigates or removes the pain of colic, renal, biliary,
or otherwise. Whether its effects in relaxing spasm are induced through
its soothing influence on the skin, or from weakness caused by the bath,
is difficult to say; the bath certainly seems to ease the pain before any no-
ticeable weakness is produced. In skin diseases of various kinds the general
warm bath is invaluable. In psoriasis, eczema, icthyosis, urticaria, lichen.

52 WARM liATII AND THE HOT BATH.

prurigo, and scabies, it may generally be employed Avith benefit. It is
especially useful in the acute state of eczema and psoriasis. Rain or
boiled water should be i^sed; but if tiiese are not available, the water
should be made more soothing by the addition of small pieces of common
Avashing soda, gelatin, bran, or potato-stai'ch. These baths allay inflam-
mation and itching. The body must be dabbed dry with soft towels. If
there is much itching, flannel should not be worn, .and scratching should
be prohibited.

It has been recommended to keep quiet a patient Avith se\'ere burns
immersed for days in the warm bath; this treatment is said to ease pain,
diminish suppuration, promote the healing process, and to lessen the con-
traction of the cicatrix.

As a means of oliA-iating the A'arious symptoms occurring at the change
of life. Dr. Tilt recommends the general Avarm bath of 90° to 95° Fah. for
an hour once a Aveek, so as to promote free perspiration.

The hot sitz-bath is very useful in cystitis and dysmenorrhoea. It
allays pain and the incessant desire to micturate and straining. If the
symptoms are urgent it may be employed tAvo or three times a day from
tAventy to thirty minutes in cystitis, and even longer in dysmenorrhoea.

The local Avarm bath is used for a variety of purposes. It is hardly
necessary to refer to the common household practice of putting the feet
into hot Avater just before going to bed^ to induce general perspiration,
and so relieve catarrh. The hot foot-bath, or the sitz-bath, is of great
service Avhen the menstrual floAV is either deficient or absent. To this
bath, mustard may be added Avith advantage: but, as the late Dr. Graves
insisted, this stimulating bath should be used only at the menstrual
period. Employed nightly, or night and morning, for six days, com-
mencing one or tAvo days before the period begins, this mustard bath is a
very useful auxiliary to other treatment, and often succeeds in establish-
ing menstruation. The sitz-bath is often effectual Avlien, through expos-
ure to cold, or from other circumstances, the menstrual floAv is suddenly
stopped, to the patient's great annoyance and sulfering. Immersion in
water as bot as can be borne is said to be very useful for sprains, in their
earliest stage.

Dr. Druitt points out that sponging the body with very hot water Avill
for some hours diminish the excessive perspiration of phtbisis.

Hot water to the legs and feet sometimes removes headache, and ac-
cording to Dr. Graves relieves distressing palpitation.

Sponging the face, temples, and neck with water, as hot as can be
borne, often relieves the headache of influenza, catarrh, and other diseases.

The immersion of the feet in hot water, with or Avithout mustard,
will often arrest nose -bleeding. The vessels of the loAver extremities,
and probably reflexly the vessels of the j^elvic organs, become much di-
lated, and hence blood is Avithdrawn from the upper part of the body,
and vascular pressure is lessened.

Brine baths, as those at Droitwich, are very useful in chronic rheu-
matism, rheumatoid arthritis, gout, and sciatica. A brine bath can be
made by adding from twenty to thirty pounds of common salt to thirty
gallons of Avater at a temperature of 100° Fah. The patient should take
one daily from twenty minutes to half an hour's duration, gradually ex-
tending the time to an hour. This produces no depression like a plain
hot-water bath. On the contrary, it exhilarates. When only one or tAvo

HOT-AIR AND VAPOR BATHS. 53

parts are affected or painful, as the ankle or wrist, I have found that the
immersion of the parts in a saline bath gives much relief. Many chronic
cases of sciatica are more effectually relieved by the bath than by any
other treatment. The efficacy of the salt-bath is the more singular as
the salt is the efficient constituent ; hot baths will not replace the saline
baths; yet little or none of the salt being absorbed, this bath must exer-
cise the topical influence action of salt on the skin.

HOT-AIR AND VAPOR BATHS.

The hot-air bath very generally succeeds in promoting free perspira-
tion; but when it is difficult thus to establish a free flow of perspiration,
the hot-air bath may be preceded by the general warm bath.

Vapor-baths are used for the same purpose, and are less depressing
than the general warm bath. Vapor and hot-air baths produce much
less elevation of the temperature of the body, a circumstance which
j)robably explains their difference in this respect.

The usual hot-air bath, with the lamp or hot bricks, does not in most
instances cause heat enough to induce copious sweating. Gas is more
efficient, but it is difficult to handle unless with a special apjjaratus.
The lamp-bath under a cape often induces very free sweating if the
jiatient is strong enough to sit up. The copious perspiration thus in-
duced is very efficacious in relieving ura^mic symptoms, and this treat-
ment is much more efficient and less depressing than hydrogogue pur-
gation.

54 SHOWER. DOUCHE, AND SPONGE UATHS.

SHOWER, DOUCHE, AND SPONGE BATHS.

The forcible impact of water upon the body, and the impression it
makes on the nerves, or, to use the general expression, tlie shock it pro-
duces, is sometimes very great, sufficient sometimes, even with strong and
healthy jiersons, to produce considerable depression and languor, lasting
hours and occasionally days.

The shower-bath is a remedy not much used, patients ordinarily mani-
festing great repugnance to it. The sponge- bath, or the local douche,
may usefully supply its place.

In the sponge-bath we have all the conditions of the common batli.
Both are cleansing, bracing and invigorating; and the action of each is
identical.

The sponge-bath is often employed, not merely for its tonic effects,
but for the sake of the shock it causes to the nervous system.

In the treatment of laryngismus stridulus, cold sponging is more suc-
cessful than anything else. The practice of confining little children thus
affected in a warm close room, sousing them in warm baths several times
a day, is positively injurious, and inevitably aggravates the severity and
frequency of the crowing breathing. Cold sponging twice or thrice daily,
according to the severity of the case, will scarcely ever fail to modify the
disease, however severe the attack. So prompt is the relief of cold
sponging that a child subject to hourly attacks dunng the day, and to
ceaseless attacks at night, is frequently instantaneously delivered from
them. At all events a decided improvement always occurs, and the in-
tervals between the attacks are much prolonged; it rarely happens that
the strident crowing resists this treatment more than two or three days.
The mother should be directed to keep the child out of doors the greater
part of the day, no matter how cold the weather — indeed the colder the
better. Laryngismus seldom attacks children more than a year old. At
so tender an age it might be feared that they would run great danger of
catching cold from the sponging treatment; but no such fears need be
entertained. With the necessary precautions, even the youngest child
may be sponged with perfect safety several times a day. Nor does a child
catch cold even in the coldest weather when carried out of doors; but one
prone to bronchitis had better be kept indoors when the weather is very
severe, and should undergo the cold-water sponging only. After a very
extensive experience of this treatment I have rarely found that children
suffering from laryngismus catch cold, and in such exceptional cases the
catarrhal symptoms have been insignificant. This treatment frequently
saves life, and averts not only the crowing breathing, but dangerous symp-
toms, such as partial convulsions in the form of carpopedal contractions
and squinting, for laryngismus, when fatal, generally destroys by exciting
an attack of general convulsions. Laryngismus stridulus is sometimes ac-
companied, and is indeed apparently induced, by laryngitis, indicated b}^
the peculiar hoarse voice. In such cases cold sponging must be cautiously
used, for it often, though by no means invariably, increases the laryngitis,
and therefore the laryngismus. Among the poorer classes, at certain sea-
sons of the year, laryngismus is one of the most common causes of convul-
sions, Avhich tend so often to a fatal issue.

The surest and ^speediest way of arresting a paroxysm of crowing
breathing is to dash cold water over the child. At the onset of a jxxroxysm

SHOWER, DOUCHE, AND SPONGE BATHS. 55

cold water snonld l)e daslied on the child's face; and if this does not at
once arrest the attack, water should be applied to the whole body. Laryn-
gismus fortunately prevails In the early spring, when the cold weather
itself is a ready source of cure.

Since by this treatment laryngismus is usually cured at once, or rarely
lasts more than a few days, it is obvious that cold water does not act as a
mere tonic, although in this respect it is very useful, because laryngismus
generally attacks weakly, sickly and rickety children.

Any irritation aggravates laryngismus, and impedes its cure. Hence,
if the relief from cold sponging is less marked than might be expected,
some other sources of irritation should be sought for and removed. The
gums if swollen, red and hot, must be freely lanced and the cut main-
tained open, for if they close the irritation recurs; thus it is necessary to
lance the gums every few days. Worms must be removed, and the faulty
state of the mucous membrane favoring their production treated. At the
cutting of each tooth, laryngismus is apt to recur in spite of cold spong-
ing, but the relapse is seldom severe. When the tension of the gums is
removed, and the tooth set free, the fit ceases. Irregularities of the bowels,
diarrhoea, constipation, flatulence, etc., tend to increase the frequency of
crowing, and to render the case less amenable to cold sponging.

It may here be useful to advert to a condition, not uncommon in in-
fants. An infant in poor health frequently wakes up at night from "a,
catch in the breath." From some unexplained reason, it cannot for a
time get its breath, and wakes up with a loud snore. This condition is alto-
gether different from that of laryngismus stridulus, and the fault appears
to lie in the soft palate, not in the larynx; moreover it is not due to en-
larged tonsils, as this " catch in the breath " occurs in children of ten-
der age, long before the morbid condition of the tonsils takes place. Cold
sponging night and morning, will improve or even cure this curious com-
plaint.

Cold sponging, several times a day, holds also deservedly a very high
place in the treatment of chorea. It is at present impossible to decide
whether its efficacy is due solely to its tonic properties, or whether the
shock plays any part in promoting the cure. Of the value of this treat-
ment there is no question, yet circumspection must be exercised or the
patient may be made worse. It must be avoided if there is any rheuma-
tism, which is generally made worse by cold sponging, thus inducing an
increase of choreic movements. If there is no fever, and no pain in any
of the joints, then cold sponging may be reasonably expected to yield
most satisfactory results.

In the treatment of rickets, cold sponging, by virtue of its tonic prop-
erties, holds a very high place. Here, again, care must be observed, or
much harm may be done. We must remember that a rickety child is
often not only very weak, but, on account of its tender years, very im-
pressionable, and for these reasons it is important to adapt the application
of the cold sponging to the patient's condition. If the child is old enough
to stand, he should be placed up to the ankles in warm- water before a
good fire, and then, except the head and face, be sponged all over with
cold water from two to five minutes; he should then be carefully wiped
dry, and well rubbed with a soft towel. If weakly, the child may be re-
placed for a short time in a warm bed, to encourage reaction. The spong-
ing should be administered as soon as the child leaves his bed; but if very
weak or unaccustomed to sponging, it is advisable to give a light and early

56 SHOWER, DOUCHE, AND SPONGE BATHS,

breakfast about an bour beforehand. There is another excellent method
of administering cold sponging to weak persons or to timid children, and
therefore a plan to be adopted Avhen this agent is used in the treatment
of chorea. The water, at first tepid, should be gradually reduced in tem-
perature by drawing olf the warm water and substituting cold. The
shock is thus avoided, whilst the tonic virtue of the bath is obtained.
This latter method succeeds admirably with timid children, who. often
much fi-ightened by the bathing, sometimes scream so violently as to lead
their friends to fear an attack of convulsions.

Cold sponging is very invigorating for adults in impaired health; it is
useful also in ansemia, leucorrhoea, amenorrhcjea, spermatorrlicea, and in
that low nervous state induced by working in hot, close, ill-ventilated
rooms.

In cold weather, the water at first should be made a little warm, after-
ward the temperature should be daily lowered. By a little light food
taken about an hour before the bath, and after its completion a return
to bed for half an hour to restore warmth to the skin and extremities, will
generally prevent depressing effects on weakly subjects.

Affusion and the Douche. — Cold water thus applied impinges on the
body with considerable force, and the resulting nervous impression is cor-
respondingly considerable. Water is directed against the body in a full
stream, and is applied sometimes to every part of the surface in succession.
The depression it produces is too great to admit of its frequent employ-
ment. It is generally modified, and the cold affusion used in its place:
cold water is dashed in pailfuls over the surface of the body. Affusion is
recommended in sunstroke when a patient is struck down and rendered
unconscious. Many years ago cold afi:usion was employed in the treat-
ment of the acute specific fevers, and was especially recommended in
scarlet feyer, — a well-tried mode of treatment coming down to us sanc-
tioned by the authority of many of the ablest physicians of the past gene-
ration. Yet in the present day the reaction against all energetic treatment
is so great that this means is now very rarely adopted. Fears are expressed
lest serious consequences should ensue; but if the affusion is employed
at the right period, no apprehension need be entertained, as the experi-
ence of Currie and Jackson abundantly testifies. It should be employed
during the early days of the fever, when the skin is hot and the rash
bright red.

Currie and Jackson recommended that the patient should be stripped,
and that four or five gallons of very cold water should be dashed over him,
a process to be repeated again and again when the heat of the surface re-
turned. This treatment diminishes the fever, and sometimes, it is stated,
even extinguishes it.

The douche and affusion are generally employed for their local effects.
They are of the greatest service to rouse a patient from the stupor* of
drunkenness, or from that of opium poisoning; when a certain stage of
the poisoning has been reached no other treatment is so efficacious. Ex-
cessive tippling or an overdose of opium induces stupor more or less pro-
found, when the movements of respiration, at first languidly performed,
soon stop, and death by asphyxia results. At this most critical stage,
cold affusion, or the cold douche, applied freely to the head, is generally
sufficient to remove the conditions within the skull on which the stupor
depends. Consciousness is restored, the breathing simultaneoi;sly again
becomes natural, and for a time, at least, the fear of a speedily fatal ter-

SHOWER, DOUCHE, AND SPONGE BATHS. 57

miuiition is set at rest. The water should be poured on the head from a
good lieight, so as to secure as great a shock as possible. The vigor of
the application must be regulated by the pulse and general state of the
patient. The breathing becomes deeper and more frequent, the livid,
bloated aspect of the face soon disappears, while the pulse grows in
strength. It often happens that relapses occur, when the affusion must
be again and again employed, so as to sustain life long enough to admit of
the elimination of the poison. If promptly and efficiently applied, life
may be saved even in the most unpromising cases. It is all-important to
ply the water abundantly for some time, and from a good height. Some
time may elapse before any good effects become visible, but if the pulse
and breathing improve, or become no worse than before the douche was
tried, its application should be continued, and perseverance will often be
rewarded by success.

Dr. Sayre, and more recently Dr. Broadbent, have drawn attention to
the use of the cold douche to induce sleep in delirium tremens, and in the
pyrexia after childbirth, and probably in febrile diseases generally. A
large sponge soaked with cold water, iced if possible, is dashed against the
head, face, and chest several times. The skin is then rubbed dry with a
rough towel, and sleep follows in some instances almost immediately. If
the sleep is too brief repeat the application. In deirium tremens I have
often seen similar good results follow the application of the general cold
pack, and when the sleep was short I have repeated the pack hourly for
several hours, each repetition inducing refreshing sleep.

Probably this treatment by dilating the cutaneous vessels withdraws
blood from the brain and so produces sleep.

Many cases of furious maniacal delirium may be quieted by the cold
douche. It must be borne in mind that the douche is a powerful remedy,
Avhich makes it necessary to carefully watch its effect on the patient's
strength. To obviate excessive depression, it is an excellent method to
place the patient in a warm bath, and to apply cold to the head in the
manner just described.

Severe pain in the head, met with in acute specific fevers, or resulting
from gastric disturbance, may be relieved very gratefully and effectually
in the way recommended by Dr. Hughes Bennett: "A washhand-basin
should be placed under the ear, and the head allowed to fall over the ves-
sel, by bending the neck over the edge; then a stream of cold water should
be poured from an ewer gently over tlie forehead, and so directed that it
may be collected in the basin. It should be continued as long as agreea-
ble, and be repeated frequently. The hair, if long, should be allowed to
fall into the cold water, and to draw it up by capillary attraction." The
ice-bag may be conveniently substituted for this application, or Thornton's
cap, composed of two rolls of india-rubber tubing, through Avhich iced cold
water is made to flow. This application greatly relieves headache and
lessens or even prevents delirium and favors sleep. Dr. Hughes Bennett
agrees with Graves, that in some cases very hot water acts even more effi-
. ciently than cold.

The cold douche is also an excellent local tonic to individual parts of
the body. It may be employed to remove that stiffness in joints remain-
ing after slight injuries, or resulting from rheumatism or gout, and salt
may advantageously be added to the water. The force of the douche's
impact on the affected part, with the duration of its application, must be
regulated by the condition of the tissues. If very weak, it is better at first

58 THE TURKISH r>ATII.

to play the water in tlie noigliborhood of the injured or weakened joint.
It is also useful in chronically inflamed and swollen joints. In the early
stages, especially when tenderness persists, it is useful to immerse the part
in hot water for twenty to thirty minutes, and immediately on removing-
the joint to cold douche it either in a single stream or through a rose for
one to two minutes, well rubbing the joint afterward till it glows. Dr.
Fuller recomAiends the cold douche to be played for one or two minutes
upon joints affected with rheumatic arthritis; or the water may be slightly
warmed in winter, and then the parts rubbed till they are Avarm and dry.

Much good may be effected in spermatorrhoea by the free application
of cold water to the j^erinsum and buttocks several times a day, and by
the suspension of the testicles in cold water for a few minutes night and
morning. The same treatment is useful in varicocele. A cold-water in-
jection of about half a pint every morning before going to stool relieves
or cures piles in many cases, and is always a useful addition to other treat-
ment; and injections of cold water are highly recommended in chronic
diarrhoea and chronic dysentery. The cold anal douche is very useful in
pruritis ani, as well as for piles. Many persons, especially women, are
troubled with cold feet, particularly at night; so cold, indeed, as to effec-
tually prevent sleep for hours. This condition, which may rank as a
distinct ailment, is best treated by immersing the feet nightly for a few
minutes in cold water, rubbing them, whilst in the foot-bath, diligently
until they become warm and glowing, and then, after thorough drying,
clothinsf them in thick over-large woolen or "fleecy hosiery" socks.

A cold or tepid sitz-bath is a very useful api^lication. At first it
contracts the vessels of the cooled skih, also the intestinal vessels, and
increases the blood in the upper part of the body, causing even a rise of
temperature in the axilla. Subsequently, and especially if followed by
vigorous friction with a rough towel, the constricted vessels become
dilated, and the abdominal circulation is increased and gives tone to the
abdominal organs, and so relieves constipation and strengthens the bladder.

I have often used, with advantage, a sitz-bath for ten minutes of a
temperature between 70° and 80° Fah., for overworked patients who
return from business tired, restless, and irritable. They should take the
bath about half an hour to an hour before a late dinner. It removes
restlessness and invigorates and favors sleep.

For the troubles occurring at the change of life or in women weakened
by excessive menstruation, I often obtain considerable benefit by sponging
the spine with equal parts of white vinegar and spirits of wine, night and
morning, for five to ten minutes. Or by spongnig the spine first with
water as hot as can be borne, and then for a few seconds with a sponge
wrung out of cold water. The first application is the most successful. It
invigorates and soothes irritable nerves and prevents the fidgets. The
same applications often relieve " cold feet."

THE TURKISH BATH.

This bracing and depurating bath combines many of the properties
of the hot and cold bath. The body, subjected to great heat, is made to
perspire copiously. If the bath ended here, more or less weakness would
ensue; but at this stage the free application of cold water stimulates and

THE TURKISH BATH. 59

braces the body, and produces the tonic effects of the cold bath. At each
stage of the process, the Turkisli bath cleanses the system; the perspira-
tion carrying off, and the cold consuming,' by increased oxydation, effete
and noxious substances in the blood.

The Turkish bath, like sea-air and sea-bathing, is a true tonic. By a
tonic, I understand, any means which will increase both the destruction
and the construction of tissue, provided the constructive remains in excess
of the destructive process, and by promoting the nutrition of the muscular,
nervous, and other systems, tonics increase the potential force of the
bodily organs; in other words, tonics increase the capacity for function.
By increasing tissue change, tonics promote appetite and digestion (see
Cold).

The baths, says Dr. Goolden, are useful in gout, rheumatism, sciatica,
Bright's disease, eczema, and psoriasis; they benefit bronchitis, the cough
of phthisis, the aching of muscles from unusual exertion, pains in the seat
of old wounds, colds in the head, quinsies, and common winter coughs.

It is not amiss here to caution persons prone to colds, that the habit of
over-clothing increases this liability. This cold-catching tendency may
be obviated by using a moderate amount of clothing, taking a cold sponge-
bath every morning, and occasional wet-sheet packing, or the Turkish bath
once or twice a week.

On catching cold, a patient Avith lungs previously healthy becomes
troubled for some time with chronic catarrh, accompanied by considerable
expectoration and some shortness and oppression of breathing. In such a
case, the Turkish bath generally affords prompt and great relief/ checking
the expectoration and easing the breathing. In bronchial asthma and em-
physematous asthma, a course of Turkish baths, say one every second or
third day, is very useful; this subdues chronic bronchitis and renders the
patient less liable to catch cold. A large chamois leather waistcoat reaching
low down the body and arms, and worn over the flannel, affords great relief
in bronchial asthma and emphysematous bronchitis. This jacket is ex-
tremely warm, and protects the chest against the vicissitudes of weather.
It is a nasty practice to wear it next the skin.

At the commencement of a feverish cold, a Turkish bath will cut the
attack short, remove the aching pains, and relieve or cure the hoarseness
at once. The bath will still prove very useful for a cold of several days'
standing, though its good effects are less striking. The Turkish bath will
relieve or carry off the remains of a general severe cold, as hoarseness,
cough with expectoration, and lassitude. Whilst in the hot chamber the
voice generally becomes quite clear and natural, though the hoarseness
may afterward return in a slight degree; but it usually continues to im-
prove, becoming natural in a day or two, a repetition of the bath aiding
complete recovery. In more obstinate cases several baths may be re-
quired. Great improvement of the voice in the hot chamber may be
taken as a proof that the bath will benefit, even though, after the bath,
the hoarseness returns to a great extent.

The Turkish bath is serviceable to persons who after dining out, not
wisely but too well, suffer next day from malaise and slight indigestion.
A course of Turkish baths is very beneficial to town-dwellers leading a
sedentary life, Avho, especially if they live freely, are apt to become stout
with soft and flabby tissues, are easily tired, suffer from lack of energy
and some mental depression. Under the influence of the bath, their mus-
cles become firmer, the fatness decreases, and they acquire more spirit and
energy.

60 THE TURKISH HATH.

A course of Turkish hatlis is useful to patients whose health has broken
down Ijy residence in a tropical climate, who suffer from general debility,
enfceblement of mind, dull aching pains in the head, and broken sleep.
I have heard the Turkish bath, even its daily use, recommended highly
for convalescents from acute diseases, to promote assimilation, digestion,
and appetite. Patients suffering from jaundice, acquired in a tropical
climate, or from malaria, have often testified to the beneficial effects of
Turkish baths; but it is necessary, as indeed it is with all persons with
shattered health, to caution them against the too vigorous and unre-
strained use of the bath. The patient should leave tlie hot chamber as
soon as free perspiration occurs, and should not plunge into the cold bath,
but take a douche with slightly tepid water, especially i]i cold weather.

]\Iany dread the Turkish bath lest they should catch a cold, and one
often hears complaints of a cold coming on after a bath. So far from
tending to give cold, these baths, as we have said, obviate the tendency
to catarrh, and fortify delicate persons against a cold-catching tendency.
If ever the bath is answerable for a cold, it is almost always owing to the
bather leaving the bath-house too soon, perhaps in inclement weather,
whilst his skin is still perspiring freely, or his hair is soaking wet.

Again, it is not unusual to hear complaints that the bath has induced
considerable depression, or even exhaustion, lasting perhaps several days;
but here again the fault rests with the bather. The bath must be adapted
to the strength of the patient, and it is always prudent to take the first
bath circumspectly, the bather not staying too long in the hot chamber,
and undergoing the bracing application only n few seconds, with water
not very cold. It is difficult to point out the precise time a bather ought
to remain in the hot chamber. If delicate, and it is his first bath, he
should not enter a chamber hotter than 130° to 140° Fah., and should
stay there only twenty minutes or half an hour, or less, should he feel
faint or tired. The patient's sensations are the best guide; sometimes,
especially if suffering from pain, the bath soothes and eases, and then he
can remain in the hot chamber an hour, the first bath; but, I repeat, he
should at once leave when he feels faint or tired. At first, the patient,
not seldom, on commencing the bath, fails to perspire; in this case, he
should be removed from the chamber in ten minutes, have warm Avater
poured over him, and be well shampooed, and, unless he is tired and faint,
should then return to the hot chamber. It is a rule in these establish-
ments to advise even an old bather not to enter the hotter chamber of 180°
to 220° Fall., till the skin has become moist with perspiration; though
many disregard this injunction with apparent impunity. Even if the first
bath causes some depression, this need not happen afterward, partly be-
cause the bather will have become accustomed to the process, and partly
because he will know how to adapt it to his strength. Yet it must be ad-
mitted that some persons, even with every precaution, cannot take a Turk-
ish bath without experiencing much depression.

Acute rheumatism and acute gout have been treated with these baths;
but, as in most instances, the severity of the pain renders it impracticable
to take patients thus affected to a Turkish bath, a modified substitute for
it, shortly to be described, may be taken at home. The acute j)ain of
gout, it is said, disappears in the hot chamber, to return soon afterward
in a diminished degree.

The Turkish bath is particularly valuable in subacute and chronic
gout, but, as might be expected, it is not in all cases equally serviceable.

THE TURKISH HATH. 61

In long-standing cases in whicli the attacks have occurred so frequently
as to distort the joints by deposits, and patients are, perhaps, liable to
repeated relapses, and are scarcely ever free from pain, the efficacy of the
bath, though striking, is less apparent than in milder and more tractable
forms; yet even in these severe cases, the bath affords considerable relief
by diminishing the frequency and severity of the relapses, and by remov-
ing the pervading sensation of invalidism. The Turkish bath is, perhaps,
more efficacious than other remedies in a case of the following kind: — A
patient inclined to stoutness complains of slight and fugitive pains; the
joints, but little swollen, are merely stiff and a little red and hot. The
gout affects many parts often in succession — the joints, the head, the back,
and perhaps some of the internal organs, as the bladder, etc. During
an attack tiie patient complains of malaise, and his complexion often be-
comes dullish. The tissues are often soft and flabby, and, in spite of judi-
cious diet and abundant exercise, the patient may be seldom free from
some evidence of gout, sufficient to annoy but not to disable him for work.
After one or two baths the pains, the swelling, and the malaiae disappear,
the joints become supple, and after a time, the baths being continued,
the complexion loses its sallowness, the tissues become firm, and the undue
stoutness undergoes diminution. On discontinuing the baths, the gouty
symptoms will often recur, again to disappear on the resumption of the
treatment. A gouty patient may advantageously supplement the action
of the Turkish bath by drinking certain suitable natural mineral .waters.

The Turkish bath is useful in the various kinds of chronic rheuma-
tism.

A patient who, in damp weather, or during an east or north-east wind,
suffers from stiffness and pains in several joints, will derive much benefit
from a Turkisli bath. The shoulder joint is often affected, the pain and
tenderness being frequently limited to a small spot.

Again, a patient without any previous history of rheumatism finds his
shoulder set fast, is unable to move it, except to a limited extent, without
great pain. Here, again, the pain and tenderness may be very circum-
scribed. In such a case a Turkish bath generally affords great relief.
Galvanism too, even one application, will often entirely remove or greatly
lessen the pains and stitt'ness. Again, the Turkish bath gives much relief
in mild and chronic rheumatoid arthritis, and often retards the march of
this disease. The bath often relieves lumbago.

Mr. Milton finds the bath useful in allaying the tormenting itching of
prurigo unconnected with lice.

Should it happen that the regular Turkish bath is not available, then
one or other of the following modifications of it may be substituted: — The
patient, quite naked, seated on a wicker chair, with his feet on a low stool,
is enveloped in two or three blankets, the head alone being exposed, and
a spirit lamp with a large wick is placed under the chair. In about a
quarter of an hour perspiration streams down the body, and tiiis secretion
may be increased by drinking plentifully of water, and by placing a pan
of water over the lamp. When the patient has perspired sufficiently the
blankets are quickly removed, and one or two pailfuls of cold water are
poured over him; or, if this affusion is too heroic, he may step into a
general bath at 80°, or, better still, a few degrees lower. Dr. Taylor, of
Nottingham, finds this treatment useful in obstinate skin affections, rheu-
matism, catarrh, syphilis, and in reducing stoutness arising from an inac-
tive life. The instrument makers now supply convenient forms of the

62 POULTICES AND* FOMENTATIONS.

domestic Turkish bath. It is far better, however, when practicable, to em-
ploy the Turkish bath itself.

Dr. Nevin highly recommends the following handy steam-bath in the
treatment of acute rheumatism, available when tlie patient is lying help-
less and irremovable in bed: — A couple of common red bricks are placed
in an oven hot enough for baking bread, and in half an hour or a little
more, they are sufficiently heated for the purpose. The patient's body
linen having been previously removed, these two bricks are folded in a piece
of common thick flannel, thoroughly soaked in vinegar, and laid on two
plates; one is to be placed about a foot distant from one shoulder, and the
other about equally distant from the opposite leg, and the bed-cloth(,'s are
then to cover the bricks and the patient closely round the neck. A most
refreshing acid steam-bath is thus obtained; and tiie supply of steam may
be kept up, if necessary, by remonng one brick and replacing it by an-
other hot one kept in reserve. When the patient has been in the bath for
fifteen or twenty minutes, the bed-clothes and plates should be removed,
and the patient instanthi mopped all over, eery rapidhi, with a. towel wrung
out in cold water, and then quickly rubbed dry. Dry warm linen must
be put on at once, and dry bed-clothes must replace those which Avere on
the Ijed previously. The under-sheet can be removed, and a dry one sub-
stituted by fastening the corners of the dry sheet to those of the damp
one; generally very little difficulty is met with in simply drawing the old
sheet from under the patient, when the dry one follows it, and is left in
its place. The patient ordinarily experiences great and speedy relief from
this bath. The exhausting sweats are usually diminished, and the neces-
sity of opium much lessened. The change of the body linen can be easily
accomplished by tearing the night-shirt open from top to bottom down
the back. The steam-bath and subsequent cold douche should be con-
tinued after the patient is able to walk about, as they contribute to the
healthy action of the skin and promote free mobility of the joints. After
the patient is able to get out of bed, the bath may be administered in the
manner previously described. The steam-bath, according to Dr. Sieve-
king, relieves the pain and checks the perspiration in acute rheumatism to
a degree he has failed to attain by any other treatment.

Or the following method may be used as in some degree a substitute
for a Turkish bath. After a general hot bath sponge all over with tepid
or cold water; or sponge the whole body first with hot water and then
for a short time with cold water.

Some persons cannot stand the usual morning cold tub can substitute
these methods with much benefit, and obtain the tonic invigorating effects
which follow the morning flat sponge-bath.

POULTICES AND FOMENTATIOXS.

Poultices and fomentations, in such common use, are simply local
baths applied to the skin. When its surface, or the structures beneath it
are inflamed, poultices and fomentations are a convenient and efficacious
means of utilizing warmth and moisture in the treatment of diseased
parts. The warmth and moisture relax the vessels, and increase the
collateral circulation, and in some degree abate the tension due to

POULTICES AND FOMENTATIONS. 63

inflammation, and so relieve pain. Applied at the very beginning to
inflamed tissues, to abscesses, inflamed pimples, and the like, poultices
often summarily check the inflammation, and prevent the formation of
pus. Fomentations with water as hot as can be endured also arrest
inflammation and check the formation of matter, and should be gen-
erally employed as adjuncts to poultices. Hot fomentations will often
disperse or restrict the development of acne indurata, herpes labialis, and
similar inflamed jjimples apt to appear on the face.

These applications are of further use when suppuration has set in and
matter requires to be expelled. Poultices greatly facilitate the passage
of the matter to the surface and further its expulsion, while, at the same
time, they limit considerably the spread of inflammation in all directions.
Here, again, very hot fomentations, often repeated, continued for some
time, are a useful supplement to poultices.

It should be remembered that much depends on the heat of the appli-
cation. Poultices should be always applied as hot as they can be borne, and
should be frequently changed, lest they become cold and hard. Indeed, they
can scarcely be changed too often; in hospital practice it is difficult to con-
stantly renew poultices; yet even in such institutions, where the supply
of nurses is limited, poultices should be changed at least every two or three
hours.

Where applied to disperse inflammation, or to hasten the maturation
of abscesses, the poultices should be large, reaching beyond the limit of
the inflamed tissues; but as soon as the abscess or boil has matured and
burst, the poultice should be very little larger than the opening in the
skin through which the matter escapes. A large poultice, applied over-
long, soddens and irritates the skin, and is liable to produce an eruption
of eczema, or to develop fresh boils around the base of the original one.

Open sores, like discharging abscesses, or sloughing sores or ulcers,
are best treated with lint soaked in a saturated solution of boracic acid,
or some other antiseptic agent, to destroy germs, and so prevent sup-
puration and further destruction of tissue. The boracic application is
useful in the inflamed stage of eczema.

In the treatment of boils, carbuncles, abscesses, and inflamed lym-
phatics, it is an excellent plan to smear over the inflamed tissues a com-
j)ound of equal parts of extract of belladonna and glycerine, and on this
dressing to superimpose a poultice. The belladonna eases pain and re-
duces inflammation. (See Sulphides.)

In order to protect the adjacent tissues from the undue action of the
poultice, so as to check the production of fresh boils, it is a good plan to
place over the boil a piece of opium plaster with a circular hole, and to
apply the poultice only over the plaster. Another jjrotective plan is
to smear the contiguous surface with zinc ointment.

Poultices moderate the inflammation and alleviate the pain in skin dis-
eases, as eczema, etc., when the skin is inflamed, painful, red, and swollen.

Poultices are not only soothing when in direct contact with inflamed
tissues, but they appear to act in the same manner on deep-seated parts.
Large poultices applied very hot, and removed as soon as they become
cool, are of great service in pneumonia, pleurisy, bronchitis, pericarditis,
peritonitis, etc. To avoid exposure of the warm moist skin, the old poul-
tice should not be removed till the new one is ready to replace it.

These applications are extremely useful to children attacked with
bronchitis, broncho-pneumonia, or lobular pneumonia. As young chil-
dren are apt to be restless, and to toss about in bed, the entire chest

64 POULTICES AND FO. "MENTATIONS.

should 1)0 cnvolopod in a jacket-poultice. The ordinary poultice soon be-
comes rucked up, and converted into a narrow band encircling only a very
limited portion of the chest, whilst the uncovered part of the chest is ex-
posed to cold. The jacket-poultice should be constructed with a piece
of linen sufficiently large to go quite round the chest, and tapes should
be sewn to it in such a manner that they can be tied in front, and over
each shoulder. It is as well to have three pairs of tapes, so as to admit of
three fastenings down the front of the chest.

A poultice, to retain its heat, should be spread an inch or more thick,
or it may be made thinner, and externally coated with a layer of cotton-
wool. The cotton-wool being light, does not hamper the breathing — a
matter of importance, especially with children.

In inflammation of deep-seated organs the same methods, modified to
suit the part, should be adopted. In peritonitis it is of great importance
to spread the poultice thin and cover it with a layer of cotton- wool; if
heavy it aggravates the pain.

Poultices are useful in acute rheumatism, lumbago, sciatica, pleuro-
djTiia, myalgia, and in those so-called rheumatic pains which often attack
limited parts of the body, as one arm, etc' They are soothing and
pleasant to the inflamed joints in rheumatic fever, although cotton- wool is
often preferred. In acute lumbago, poulticing often brings speedy relief,
the severest cases being greatly benefited in a few hours, and generally
cured in one or two days. The poultice must be very hot, and large
enough to cover the whole loins or part affected, and thick enough to
remain quite hot for half an hour, when it must be changed. If the pain
is persistent this treatment shmild ])e continued for three hours, or longer;
the skin must then be covered with a piece of flannel, and the flannel
covered with oil-silk; this after-treatment promotes, what is most desir-
able, free perspiration.

When electricity, the needle, or poultices, fail to give more than
slight temporary relief, it will often be found that the lumbago is accom-
panied with high fever, being sometimes the first symptom of an attack
of rheumatic fever.

Sciatica may be treated in the same way, but the result is not often
so satisfactory. (Vide Ether.)

Poultices applied in the same way as for lumbago, and followed by
the application of lint and oilskin, are often useful in severe forms of
pleurodynia and myalgia. Belladonna liniment is usually sufficient, and
even to be preferred in pleurodynia; and sometimes ether spray at once
and permanently removes the pain of this annoying affection.

As we have said, poultices may be made of various substances, lin-
seed meal, oatmeal, bread, or starch. Each has its peculiar character.
Linseed-meal and oatmeal poultices have most properties in com-
mon; they make compact and only slightly porous poultices, retaining
heat and moisture longer than other kinds, and are consequently often
to be preferred to bread or starch. Rut linseed contains an acrid
matter, wdiicli sometimes irritates, especially if the skin is of a fine
and delicate texture, or if it is inflamed by some eruption, in which case

' Galvanism is highly useful in some forms of these complaints, especially in lum-
bago. In sciatica it gives at least temporary relief, and in some cases a few applications
effect a curg. Sciatica and deep-seated pains about tlie shafts of the long bones, even the
dull aching pain in the joints, which not unfrequently remams after an attack of acute
rheumatism, will often yield to galvanism.

POULTICES AND FOMENTATIONS. 65

oatmeal or bread must lie siibstitiited. Bread poultices are more porous
and blander than those of linseed-meal, but the porosity depends very
greatly on the way of making them. Bread poultices cool more quickly
and give less moisture to the skin, than those made of linseed-meal.
Starch poultices retain their heat for a considerable time, and are very
^land, unirritating applications.

It is as well to mention that linseed -meal poultices are more tenacious
than those made of bread, and are therefore less liable to break up and
fall about the bed and clothes of the patient, rendering him uncomfort-
able.

In making a poultice, care should be taken that the water boils, and
that all the materials, linseed-meal, linen, strappings, bandages or tapes,
wool and oil-silk, are close at hand ready for use, and placed before a good
fire to be thoroughly w^armed. To manufacture a linseed poidtice, suffi-
cient boiling water should be poured into a heated bowl, and the meal
must be quickly sprinkled into the bowl with one hand, while with the
other the mixture must be constantly stirred Avitli a knife or spatula, till
sufficient meal has been added to make a thin and smooth dough. The
mixture should be compounded as rapidly as possible, otherwise the poul-
tice when made will be almost cold. Only an experienced hand can make
a model poultice. By adding the meal to the water, with constant stir-
ring, instead of the water to the meal, a thorough blending of the two in-
gredients is ensured, not a knotty, lumpy, uncomfortable mass, too often
vexing instead of soothing the patient. The dough must then be spread
quickly and evenly on the warm linen, already cut of proper size and shape,
the edges of the linen turned a little way over the meal to prevent any
portion escaping beyond the linen, and to protect the patient's clothes.

There are two methods of making bread jioultices. One way is to cut
the bread in thickish slices, put it into a basin, pour boiling water over
it, and place the soaking mass by the fire for five minutes; then pour ofE
the w^ater, add fresh boiling w^ater, and place by the fire; afterwards
draining the bread, beat up with A fork, and spread the poultice. The
other plan is to cut stale bread into thick slices into a saucepan and pour
enough boiling water over it to cover it; place the whole by the fire, and
allow it to simmer for a short time, then strain and prepare the poul-
tice. The first plan makes a porous poultice, the second a more compact
poultice, sharing the character of linseed-meal. As w'e shall see, each
pojiltice has its fitting application.

Bran poultices are useful on account of their lightness.

Starch poultices are entirely unirritating, and retain their heat for a
considera];)le time. The way to proceed is to add a little cold water to the
starch, and to blend the tw^o into a pap; then add sufficient boiling water
to make a poultice of the required consistence, which must be spread on
linen in the manner already described. Starch poultices soothe open
cancers, and allay skin eruptions, when there is much inflammation, heat,
and pain.

There are several ways of employing charcoal as a poultice. It is used
to prevent disagreeable odors from foul sores, and it is thought also to pro-
mote a healthy condition of the tissues. When employed for this double
purpose, charcoal is added to the poultice. As a porous poultice is here
reqiiired, bread is better for the purpose than linseed-meal. A portion of
the charcoal should be uniformly mixed wnth the bread, but the greater
part should be sprinkled over the surface of the poultice. It is doubtful
5

66 POULTICES AND FOMENTATIONS.

wht'tlier a charcoal poultice is greatly superior to a simple bread poiiltice;
for the charcoal must soon cease to absorb gases, and thus lose its deodoriz-
ing property. It may, perhaps, promote a healthier condition in the sore.
If the object is merely to prevent disagreeable smells and to keep the air
of the room pure, the plan pointed out in the section on charcoal is to be
preferred. •

It is a good practice to sprinkle foul, sloughing, putrid sores with dry
charcoal, and over the charcoal to place a simple poultice, or to make the
poultice of well-toasted or of burnt bread. This treatment apj)ears to
hasten the separation of the sloughs, and to promote a healthier state of
the tissues, and may be applied to a boil when the core is separating, or to
a bed-sore while the black slough still adheres to the living tissues.

Some maintain that a yeast poultice is useful in sloughing sores, and
that it prevents destruction of the tissues, and promotes the separation
of sloughs. Yeast poultices are made m two ways. Yeast and water may
be added to floiir till ordinary dough is made, and the dough is applied
while fermentation is going on. In this case it is simply an application of
*' rising dough. ^' The other way is to smear warm yeast over the surface
of a simple bread poultice.

A carrot poultice, which is supposed to make wounds cleaner and
healthier, is made by boiling carrots till they become quite soft, mashing
them with a fork, and spreading the pulp on the linen in the ordinary way.

To sloughing sores, as we have seen, better apply some efficient anti-
septic. They should be washed with saturated boracic acid solution, or
with carbolic acid solution, etc., and then covered with lint or cotton-
wool soaked in one or other of these solutions.

Laudanum is sometimes added to poultices to ease pain; and it is es-
pecially effectual when the skin is broken.

Solutions of chloride of lime or of soda may be added to poultices to
destroy offensive gases given off from unhealthy sores.

In eczema, with much inflammation and sensation of heat. Dr. McCall
Anderson recommends a cold potato poultice sprinkled with a small quan-
tity of absorbent powder, containing camphor. The powder, a useful
dusting powder without the poultice, is composed of half a drachm of
camphor, reduced to powder, with rectified spirit and three drachms each
of powdered talc and oxide of zinc.

Professor Marshall employs an iodide of starch poultice to clean slough-
ing sores. A jelly is made with two ounces of starch mixed with six
ounces of boiling water, to which before it cools should be added half an
ounce of liquor iodi. The mixture is spread on lint, and applied cold.

Fomentations by means of flannel wrung out of boiling water are em-
ployed for similar purposes as poultices. They are used for the sake of
their moisture, but especially for their warmth, and they differ from poul-
tices in being less weighty, and therefore less likely to increase the pain
of very tender parts. The flannel is wrung out by means of a wringer
made of stout towelling attached to two rods. The boiling wet flannel is
placed in the wringer, which is then twisted round the flannel very strongly
till the water is thoroughly squeezed oiit. As the flannel when fi.rst taken
from the boiling water is too hot to be held in the hands, the wringer is
useful. In the absence of a wringer an ordinary towel will ansv/er fairly
well. Wrung as dry as possible, these fomentations may be used very hot
without fear of scalding or blistering the skin. The fomentation should
be covered outside with a piece of macintosh, and tied on with bandages.
As hot fomentations quickly cool, and being chiefly used for the sake of

THE MEDICINAL USES OF ICE. 67

lu'iit, they must be frequently renewed: when finiilly removed, the skin
must be carefully wiped dry, and covered with flannel or cotton-wool to
prevent catching cold.

Fomentations, in a less degree poultices, relax spasm in the internal
organs, as in intestinal, renal and biliary colic. In very extensive inflam-
mation fomentations are preferable, as a large poultice is heavy and un-
comfortable. Thus fomentations are employed when a limb is extensively
affected with erysipelas, or when the tissues have been widely contused
and have become inflamed.

Sponging the face Avith water as hot as can be borne is a very useful
application in acne indurata; it will disperse the incipient spots, and limit
the size and hasten the maturation of the more matured ones, and at the
same time greatly lessen for some hours the redness of the eruption.

Twenty or thirty drops of turpentine sprinkled on a hot fomentation
of the above description makes a good counter-irritant, useful when it is
needful to combine a stimulating with a warm, soothing action.

An alkaline poultice, composed of nine parts of linseed-meal and one
part of bicarbonate of soda, is a useful application in gout.

Sometimes it is desirable to apply heat to a part of the surface of the
body, when at the same time it is important to avoid relaxation of the
tissues which moisture Avould produce. In such cases various drv, strongly
heated applications are used. Flannel, almost scorched before the fire,
or in an oven, is sometimes employed, but it speedily loses heat. Sand or
chamomile flowers retain heat far better; they may be strongly heated
over the fire in an iron pan, and then be run into a heated linen bag
made for the purpose, of such shape and construction that the contents
shall form a thickish and even layer. Each substance |x»ssesses its re-
spective advantages; sand, though heavy, retains heat; chamomile flowers,
though light, soon lose their warmth. A tliin piece of flat tile heated in
the oven, and wrapped in flannel, is lighter than sand, retains its heat for
a considerable time, and is easily procured. These apialications are of
great service in relieving the pain of spasms.

THE MEDICINAL USES OF ICE.

Ice is frequently used to abstract heat, to check bleeding, to allay inflam-
mation, and to destroy sensation. Ice broken up with the help of a large
needle into fragments may be enclosed in a bladder or thin india-rubber
bag, flrst squeezing the air out of the bag. After fllling the bag about
one third of its capacity, its mouth should be tied on a cork, so as to
afford a purchase for the twine. The ice-bag may then be adapted to
almost any shape, and fitted to the inequalities of the body, and, if re-
C|uired, may be fashioned into a sort of cap for the head.

This cap is applied to the head in tubercular and simple meningitis,
and may be employed to allay the severe headache of the early stages of
acute fevers. Sometimes the ice-bag laid on the epigastrium will ease the
severe pain and vomiting of chronic ulcer, or of cancer of the stomach.
It may be applied in prurigo of the vulvae; other treatment, however, is
generally to be preferred.

In typhlitis and typhoid fever an ice poultice applied over the right
side of the lower part of the abdomen is often useful in relieving inflam-
mation and pain.

68 THE MEDICINAL USES OF ICE.

A lump of ice inserted into the uterus, or jiushed into the rectum,
IS sometimes used to arrest uterine hfemorrhage after delivery.

Ice is used internally for a variety of purposes. Sucking ice allays
thirst, and is very grateful to fever patients. It is likewise sucked to
check bleeding from the mouth or throat, stomach or lungs. To check
bleeding from the stomach small jneces should be swallowed.

The constant sucking of ice is most efficacious in combating acute in-
flammation of the tonsils or throat ; it also is very beneficial in the sore
throat of scarlet fever, and other acute specific throat diseases, and even
in diphtheria. It often proves most soothing, allays the heat and pain,
and checks the abundant secretion of mucus, which is so harassing from
the constant liaAvking and deglutition it occasions. In tonsillitis, and
indeed in all inflammations of the throat, the good effects of ice,
especially when used at the very beginning of the attack, are most marked.
The ice should be sucked as constantly as possible, and be continued till
the disease has fairly declined.

In the same way ice is employed to allay the nausea, sickness and pain
of disease of the stomach.

Ice may be applied to an inflamed and prolapsed rectum or uterus, to
reduce inflammation and swelling, so as to enable these parts to be re-
turned to their proper place.

8ome apply ice to the head in delirium tremens and in the convulsions
of children.

The application of a small bladder or india-rubber bag of ice will dull
or even neutralize pain from inflamed piles, or after an operation for piles
or fissure of the anus.

^I. Diday strongly recommends the local application of ice in certain
painful affections of the testis, as neuralgia and blenorrhagic orchitis.
Two pigs' bladders partially filled with ice are applied one under the other
over the testis, the neighboring parts being protected with napkins. The
pain in orchitis is at first rather increased, but soon declines, and in a few
minutes altogether ceases. The continuous application of ice bladders
for twenty-four to forty-eight hours in many cases permanently removes
the pain. If on pressure any tenderness remains, the pain will return,
and the ice must be continued three or four, and even five days accord-
ing to circumstances. On discontinuing the ice, wet cold cloths should be
used, to permit the tissues to return gradually to their normal temperature.

Two parts of finely pounded ice with one part of common salt produces
cold sufficient to freeze the tissues, and to deprive them of sensibilitv.
This mixture, largely used by Dr. Arnott, is confined in a gauze bag and
placed in contact with the skin till sensation is abolished and the skin has
a leathery feel, and assumes a shrunken tallowy appearance. If applied
too long, this mixture may vesicate; but this will not occur under five or
six minutes. This application is employed to prevent the pain of minor
operations, as extraction of the toe-nail, and the opening of abscesses.
Dr. Arnott recommends it in chronic rheumatism, in erysipelas, lumbago,
and in wounds. In chronic rheumatism, it should be applied to the
diseased joints for six minutes; it should then be replaced for a short time
by pounded ice, to prevent the occurrence of inflammation from too rapid
a return of heat to the tissues. An attack of lumbago may be often cured
by freezing the skin over the painful ])art. Dr. Arnott asserts that when
applied to wounds this mixture prevents inflammation without hindering
union by the first intention.

SPINAL ICE-BAG SPINAL HOT- WATER BAG. G9

When applied for some hours, this mixture destroys sensibility to
Tjuch a degree that chloride of zinc paste may be used in sufficient quan-
tity to destroy the tissues to a considerable depth, without inducing pain
or '^inflammation. But ether spray, so conveniently and rapidly used in
the manner introduced by Dr. Kichardson, is now generally preferred
for the purpose of freezing the tissues. Chloride of methyl spray ap-
plied by a suitable instrument from the condensed gas is more certain in
its freezing action than ether spray.

A single application of ether spray Avill often remove lumbago; ' ether
spray sometimes relieves sciatica, and those frontal headaches commonly
called nervous, arising from either mental or bodily fatigue. Frontal
headache, dull and uniform in character, lasting many days, occurring not
nncommonly after excitement or an acute illness, such as erysipelas, a
severe cold, or a sore throat, often succumbs to ether spray; but it is
generally requisite to freeze the skin of the forehead.

An ice poultice, i.e., finely broken ice in a thin india-rubber bag, is
a useful application to the throat in tonsillitis, scarlet fever and diphtheria,
especially when the lymphatic glands become greatly swollen and threaten
to suppurate. I have seen swelling of the glands behind the angle of
the jaw so great that swallowing was well-nigh impossible, become so
mucii reduced after a few hours' application of an ice poultice that the
child was able to take food easily.

ON THE SPINAL ICE-BAG AND THE SPINAL HOT-
WATEK-BAG.

The profession is indebted to Dr Chapman for the introduction of
these appliances.

Concerning the spinal ice-bag, Dr. Chapman says, " I have proved by
numerous experiments that cold applied to the back exerts not only a
sedative influence on the spinal cord, but also on those nervous centres
which preside over the blood-vessels in all parts of the body. The modus
operandi of this influence on those centres, and its effects, may be thus
stated: ' 1st. It partially paralyzes them. 2nd. By means of the partial
paralysis thus eft'ected it lessens the nervous currents in the vaso-motor
nerves emerging from the ganglia or nerve centres acted upon, and
stimulating the muscular fibres surrounding the arteries influenced. 3rd.
By thus lessening those currents it lessens the contractile energy of the
muscular bands of the arteries to which those currents flow, and by doing
so facilitates the dilatation of those arteries themselves. 4th. By thus
inducing the condition of easy dilatability in the arteries acted upon, it
enables the blood which flows in the direction of least resistance, to enter
them in greater volume, and with greater force than before.'"

These elfects are analogous to those obtained by Claude Bernard. On

' The pain and stiffness of the muscles of the back in lumbago may often be instan-
taneously renio\e(l by running a needle an inch or more into the painful part; Avhen
the lumbago is double, this almost painless operation should be performed on both sides
of the loins. Inserted along the course of the sciatic nerve, the needle sometimes
affords instant and marked relief, even in very chronic cases of sciatica. This treatment
indeed, sometimes, as if by magic, cures severe and long-standing cases. The passage
of an interrupted galvanic current will speedily relieve lumbago.

70 SPINAL ICE-BAG SPINAL IIOT-WATER EAG.

dividing tlie PN-mpathetic nerve, he fouiul that the vessels of the parts
supphed with this nerve became dilated and received an increased supply
of food, with a proportionate augmentation of the vital properties.
Chapman avers that. "Those phenomena which Professor C. Bernard
produced in the head of an animal by section of the cervical sympathetic
I have induced in the head, thorax, abdomen, pelvis, and four extremities
of man, by the application of ice to the different parts of the back.''

To supply an increased afflux of blood to any part of the body. Dr.
Chapman ai)plies the ice-ljag to various parts of the spine; to the neck
and between the shoulders, when more blood is needed for the head; to
the upper part of the back, for the chest and arms; to the lower part of
the back, for the abdomen, pelvis and legs. Dr. Chapman says:

I. " Muscular tension is diminished by tlie application of ice along the
sjiine." In support of this statement he asserts that the ice-bag will
prevent the cramps of diarrhoea and cholera, and is useful in laryngismus
stridulus, chorea, tetanus, infantile convulsions and epilepsy, and " in
prolonged muscular rigidity due to acute or chronic disorder of the
nervous centres."'

II. " Sensibility is lessened by the applicatioti of cold cdong the spine.
This is proved conclusively by my experience, which has been considera-
ble, in the treatment of neuralgia."

III. "Secretion is lessened by the application of cold cdong the spine.
I have assured myself by experience in numerous cases of the truth of this
proposition. Morbidly excessive sweating, broncJiorrhcea, the excessive
action of the alimentary mucous membrane constituting the chief cause
of diarrhoea, excessive action of the kidneys, leucorrhoea, and spermator-
rhoi'a. I have restrained over and over again by cold properly applied to
the appropriate part of the spine."

IV. *' The jjeripheral circulation, and consequently bodily heat, is
increased by ice applied along the spine.'' He narrates the following singu-
lar cases in confirmation of this proposition: " A woman, aged sixty, who
for more than twenty years had always been cold to the touch, even over
her shoulders and bosom, though she was warmly clothed; and her feet
were habitually and extremely cold. After using ice during three weeks,
several hours a day. the whole surface of the body, including her feet,
became wonderfully Avarm. She was extremely astonished by the increase
of the temperature of her body, as well as by the subsidence of every
symptom from Avhich she had suffered for so many years; and when she
called upon me a week after the treatment had ceased, her newly-acquired
increase of general circulation, denoted by her increased warmth, still
continued. Case 2 of this series affords a remarkable proof of the propo-
sition in question: The patient, a man aged fifty-six, who seemed nearly
seventy, suffering from paralysis, epilepsy and other grave troubles, com-
plained that he was always 'cold all over;' that he suffered especially
from coldness of the feet, even in the hottest weather, and was obliged,
as his wife said, ' to sit near the fire in summer.' Within one week after
the treatment, which was continued three months, this patient had become
warm all over — especially the feet. "Within a month he said, ' I feel as
well as possible; but very hot, very hot.' In this case, after the ice had
been left off for some days, the patient became cold again."

Dr. Chapman asserts that ice applied along the lower dorsal and lumbar
vertebra?, by increasing the amount of blood supplied to the pelvic organs,
promotes menstruation, and will even restore the supjjressed monthly flux.

INTERNAL USE OF WATER.

The ice-bag, by increasing the flow of blood to tlie legs, proves very com-
fortable to persons harassed with cold feet; and I have often seen the
feet become comfortably warm a few minutes after the application of the
ice. _ _ •

r)r. Chapman asserts that ice applied along the spine is extremely
useful in cholera and tetanus, in sea-sickness, and the vomiting of preg-
nancy.

THE SPINAL HOT-WATEE BAG.

The physiological effects produced by heat to the spine are, as might be
inferred, the opposite of those induced Ijy cold. Dr. Chapman says that,
"1st. The temperature of the sympathetic ganglia being raised, the flow
of blood to them l3ecomes more copious, and the functions consequently
become more energetic than before. 2d. Their nervous influence passes
in fuller and more powerful streams along the nerves emerging from them,
and ramifying over the blood-vessels which they control. 3rd. The mus-
cular bands surrounding those vessels, stimulated by this increased nervous
afflux to contract with more than their usual force, diminish proportionably
the diameter of the vessels themselves. 4th. The diameter of the vessels
being thus lessened, the blood flows thongh them in less volume and with
less rapidity than before; indeed, it is probable that, while the nervous
ganglia in question are made to emit their maximum of energy, many of
the terminal branches of the blood-vessels acted upon become completely
closed." The temperature of the hot-bag should not exceed 120°.

Dr. Chapman employs heat along the spine to contract the blood-ves-
sels, and states that if properly applied, it will not only lessen but will
arrest the menstrual flow. He asserts, as the result of his experience,
that it will arrest menorrhagia and bleeding from the nose and lungs. In
bleeding from the nose or lungs, the hot spinal bag must be applied along
the cervical and upper dorsal vertebrae; in menorrhagia, along the lower
dorsal and lumbar vertebrse.

THE INTERNAL USE OF WATEE.

A FEW remarks may be made here conveniently on the drinks best
suited to fever patients. The importunate and distressing thirst often
causes much restlessness and irritability, whilst these in their turn often
increase the fever. Therefore, the urgent thirst must be allayed; but if
left to himself a patient, to satiate his craving, will always drink to excess,
Avhicli is very liable to derange the stomach, impair digestion, produce
flatulence, and even diarrhoea. Theory and experience both show that
drinks made slightly bitter and somewhat acid slake thirst most effectu-
ally. A weak infusion of cascarilla or orange-peel, acidulated slightly with
hydrochloric acid, was, with Graves of Dublin, a favorite thirst-quelling
drink for fever patients. Easpberry vinegar is a useful drink. Sucking
ice is very grateful. Sweet fruits, although at first agreeable and refresh-

72 INTEKNAL USE OF WATER,

ing, must be taken with care and moderation, for they often give rise to
a disagreeable taste, and are apt to produce flatulence or diarrhoea.

There is no advantage in "curtailing beyond a moderate degree the
amount of water drunk by diabetic patients. The urine and sugar may
by this means be lessened, but the general distress increased " (Koberts).
In the thirst of diabetes Prout recommends tepid drinks.

Rincing the mouth with water as hot as can he borne will often relieve
and indeed sometimes, subdue toothache, though occasionally cold water
answers better.

Water is necessary both for the digestion and solution of food, but an
insufficient as well as an excessive quantity are alike harmful. Tlie char-
acter of the fermentations, it is well known, depends on the amount of
water present; for instance, Avith sugar, if there is ]:)ut little water present,
no fermentation will take place; while, on the other hand, with excess of
water, acetous, instead of vinous fermentation, will be set up. It is more
than probable that the quantity of water taken with the food may, in a
similar way, affect the changes which it undergoes in the stomach. This
much is certain, that the drinking habitually an excess of water with the
meals often aggravates dyspepsia, and, on the other hand, indigestion ap-
pears in some cases to be connected with an insufficient quantity of fluid.
Flatulent dyspepsia is often traceable to excess of drinking at meal times.

Too much water taken with the food impairs digestion, simply by di-
luting the gastric juice, and so weakening its solvent power. The popular
idea proves to be correct, that <lrink should he taken chiefly at the end of
the meal, when it serves many useful purposes; it then aids the passage of
the peptones from the intestines to the blood, and so favors the continu-
ance of digestion, since it is held that these peptones hinder that process
until they pass from the canal. Moreover, indigestible substances, only
partially dissolved, are carried by the fluid through the pylorus into the
intestines, and there subjected to further digestion or are eliminated
with the motions, thus removing a source of irritation from the stomach
and intestines. The prevailing, perverse modern fashion of tea-drinking
a short time before dinner cannot be too strongly condemned; the early
tea, if permissible at all, should be taken at least two hours before dinner.

In our desire to avoid the ingestion of too much drink, we must be
careful not to err on the side of undue abstinence, for it has been shown
that a proper amount of water favors the secretion of the gastric juice,
and promotes the passage of the peptones into the blood. Iced drinks at
meal-time are often harmful by constringing the vessels, and preventing
the secretion of the due quantity of gastric juice.

Chomel described, and Dr. Thorowgood recently narrated, some cases
of a form of dyspepsia, called by him " indigestion of fluids," characterized
by uneasiness after drinking, and a splashing noise heard on percussing
the stomach or shaking the body, even when the patient has taken no
drink for some hours. The best treatment for this curious indigestion is
not to drink till some time after a meal, and as little as is compatible with
comfort.

After taking an emetic, warm water, or various infusions, as chamo-
mile tea and mucilaginous drinks, are employed to promote vomiting.
For this purpose, the quantity of fluid taken should not be too large,
otherwise it distends the stomach, paralyzes its muscular walls, and im-
pedes, instead of promotes, vomiting. Half a pint to a pint is sufficient.

The action of water in the intestines is similar to that in the stomach.

INTERNAL USE OF WATER. 78

and its presence is necessary for the absorption of the digested substances
in this part of tlie canal.

A glass of cold water, taken early in the morning, acts to some persons
as a purgative. The cankery taste, hot sensation in the mouth and lack
of appetite for breakfast experienced by many persons on waking is gen-
erally removable by drinking half a tumbler of pure cold water half an
hour before that meal.

A glass of cold water, taken immediately on leaving bed, promotes the
reaction after the " morning tub."

A too free indulgence in fluids often increases or keeps up diarrhoea.

Free water-drinking increases the water, but not the solids, of the
faeces.

Water readily passes into the blood, but with certain limitations.
When the system has undergone great loss of water, this fluid is ab-
sorbed with much avidity, and its rapid passage into the circulation may
materially affect the blood; indeed, this sudden and copious influx of
water is said sometimes to destroy cattle by the rapid destruction of the
blood-corpuscles by osmosis. But when the amount of water in the blood
is already ample, the absorption of a further quantity from the stomach
and intestines is much diminished.

Excess of water is eliminated in various ways. Some, as we have said,
passes off by the intestines; some is thrown off by the skin and lungs;
l3vit most is excreted by the kidneys. In six hours the chief part is elim-
inated, though after strong exercise much water is retained in the muscles
considerably longer.

Copious drinking exerts a further action on the urine than that just
mentioned; for not only does it increase the urinary water, but it also aug-
ments the other constituents as urea, phosphoric and sulphviric acid, and
chloride of sodium. The augmentation of these constituents, with the
exception of the chloride of sodium, is permanent, but with respect to
this salt the increase is only temporary, for after a while its amount falls
below the quantity excreted in health, and thus the previous increase is
balanced; and water must, therefore, in regard to common salt, be con-
sidered merely a temporary eliminator. The case is different, however,
with urea, phosphoric and sulphuric acid; for water-drinking induces a
fixed increase of these substances, giving rise not only to their increased
elimination, but to their increased formation, which can happen only from
augmented disintegration of substances containing nitrogen and sulphur.
Did water-drinking exert solely a disintegrating influence, it would lead
merely to a loss of weight; but simultaneously with this rapid disintegra-
tion a corresponding increase of assimilation takes place in the same tis-
sues; whence it happens that water, taken under certain precautions, may
increase both construction and destruction of tissue,- and so act as a true
tonic, improving the vigor of body and mind. These considerations
suggest an explanation of the benefit often derived from the " water treat-
ment " in hydropathic institutions.

The effects of water-drinking vary in different persons. The disintegra-
tion is greatest in weakly persons, on whom this process may produce
almost a febrile state. Disintegration is greater in children than in adults,
and greater, perhaps, in women than in men A high temperature of the
water, or of the external air, increases disintegration. Bodily exercise
produces the same effect (Parkes on Urine).

An old and useful practice of drinking a tumbler of hot water twice

ENTEMATA.

or thrice a day, midway between meals, has recently been revived. It is
nseful in flatulent and acid dyspepsia. After absorption it increases
oxidation, and by flushing the kidneys tends to remove effete products
from the blood. It is certain that many persons find much relief from
this treatment.

ON ENEMATA.

Injections are used for a variety of purposes; to procure evacuations
of the bowels, to restrain diarrhoea, to ease pain about the region of the
pelvis, to destroy worms, to introduce medicines into the general system,
and lastly, to pass nutritive substances into the rectum, in cases where food
cannot be taken by the stomach.

For each of these purposes certain points must be attended to in the
administration of enemata.

First, concerning injections used to relieve the bowels. It must be
clearly understood that an enema seldom acts by merely Avashing away the
fffices; for it acts efficiently when the faecal matter is lodged high up the
intestines; even in the transverse colon or cfecum. An injectioTi probably
stimulates the whole intestinal tract to more vigorous peristaltic action,
by which means the contents are propelled along the canal, and finally ex-
pelled, the injected fluid distending the lower part of the large gut, and
so exciting the vermicular action of the intestines far beyond the point
reached by the fluid. The object, therefore, is to distend the rectum and
the adjoining j^art of the intestine, but an enema constantly fails because
not enough fluid is introduced to excite contraction. It is necessary to
introduce a considerable quantity of fluid, as much as two, three, or even
four pints. Any one who, for the first time, without due observance of
certain conditions, attempts to introduce a cojjious injection into the
rectum, will in all probability fail.

When a copious injection is to be given, the patieiit should be placed
on the left side, and the fluid must be slowly pumped into the rectum;
after a variable, but usually a short time, the patient complains of inabil-
ity to retain more, and suffers from colicky pain in the belly, and an
urgent desire to empty the bowels. The pumping must now be inter-
mitted for a while, and the patient directed to prevent the escape of the
fluid; but if he is nnable to control the sphincter, the administrator must
help him. T'his can be done in several ways, each having for its object
the strengthening the contraction of the sphincter. The simplest, but
not always the most successful plan, is to firmly support the perina?iim
and structures around the anus, either with the bare hand or with the aid
of a folded towel. Should this support prove ineffectual, which is often
the case after a considerable quantity of fluid has been introduced, further
assistance is afforded by passing into the rectum, alongside the nozzle of
the enema-pipe, one, two, or even three fingers, as circumstances may
require, and pressing them with the nozzle strongly upward. Stimulated
in this way, the sphincter firmly grasps the fingers, and effectually pre-
vents the escape of the fluid; indeed, with these precautions, almost any
amount of fluid may be pumped into the intestines. From time to time
the patient will complain of griping pains and an oiipressive desire to go

ENEMATA. ' 75

to stool, when the pumping should be stayed awhile, and recommenced as
soon as these symptoms pass away. The operation over, the patient must
be directed to lie cpiite quiet on the left side, and if possible, to retain the
fluid for ten minutes or more, so as to ensure a more active and thorough
contraction of the bowels.

It need scarcely be mentioned that if the rectum'or lower part of the
large intestines, is the seat of cancer, or is diseased in other ways, copious
injections, and the introduction of a long tube, are attended with danger.

Sometimes the rectum and lower part of the gut are blocked to disten-
tion with fffices, against which the injected- fluid impinges, and finding
no passage it of necessity flows back through the sphincter as fast as it is
])umpecl"in. One or two ways may be adopted to force such a blockade.
A hollow tube of some inches in length is passed through the im-
pacted fasces, till its free extremity reaches the sigmoid flexure, or even
higher. If the tube is passed through the accumulation in the intestine,
the injection can easily proceed. Should this mauieuvre fail, and the need
is urgent to obtain an evacuation, then two or three fingers, according to
the yielding of the sphincter, are to be introduced in the rectum to with-
draw the fasces. This can be easily accomplished if the fasces are hard
and firm. Obstinate constipation of this character occurs most commonly
in diabetes. The hard and almost stone-like fasces can easily be withdrawn
by the fingers in the manner described; and nnich more may be with-
drawn than is contained in the rectum, for although the intestines may be
unable to force the hardened fasces through the sphincter, they are quite
capable of propelling them into the rectum; consequently as fast as the
feeces are withdrawn fresh supplies are propelled downwards within easy
reach of the fingers.

Various fluids are employed as enemata. Sometimes simple warm
water or gruel; at other times, to one or other of these is added soap,
turpentine, or castor-oil. AVhen castor-oil or turpentine is added to the
injection, soap and gruel are generally employed to help to suspend these
substances. It must be recollected that castor-oil and turpentine are lighter
than water, and will float on its surface, so that if the oil or turpentine is
added to the'fluid to be injected, although the whole may be well stirred,
yet as the injection proceeds, the oil rises to the surface. As the tube of
the syringe lies at the bottom of the vessel, the lower stratum of the liquid
is first injected, and much of the oil or turpentine either floats on the sur-
face or sticks to the sides of the vessel, while the small portion ultimately
injected operates only upon the rectum and the neighboring intestines.
Tiie object should be to make the oilor the turpentine, as the case may
be, rise as high up the canal as possible, so as to bathe and influence the
mucous lining of the intestines. The oil or turpentine, well beaten up
with three or four ounces of gruel, or soap and water, should be first in-
jected, and then the water is to be pumped in, so as to force the oil far
up the intestinal canal.

A t'lblespoonfulof senna leaves infused for ten hours in cold water,
and then warmed to 100° Fah., makes an excellent evacuant enema.

What should be the temperature of an injection ? Tepid fluid is
generally used, but some consider that an injection differing in tempera-
ture widely from that of the body acts more energetically on the tissues,
and excites the intestines to more vigorous action. Thus cold or hot
water may be used, and very cold water may be injected without incon-
venience, and without the patient's cognizance of its temperature.

It is unadvisable to use warm evacuant enemata habitually lest a

76 ENEMATA.

torpid condition of the intestines ensue, and so ultimately render the
constipation worse.

Firm kneading of the abdomen night and morning for ten minutes
often overcomes chronic constipation, especially in children.

As we hare said, largo quantities of water arc employed to unload
the bowels: but tiiis is not the sole use of a free injection. If used com-
fortably warm, it is very soothing to the intestines and to the neighbor-
ing organs. Thus, warm injections will often much mitigate the pain of
cancer, either of the intestines or of the adjacent organs; injections also
often greatly relieve the very distressing straining desire to evacuate, with-
out any riddance of fasces, which occurs in intestinal cancer. "Warm in-
jections soothe the pain of cystitis, prostatitis, abscess of the prostate,
and pelvic and abdominal pains generally. ( Vide Opium and Belladonna. )

In cases of much flatulent distention of the Ijowels the addition of
turpentine or asafoetida to the injection gives great relief. A table-
spoonful or two tablespoonfuls of turpentine is enough, and it must be
thoroughly mixed with the injection, as unless it is freely diluted it will
cause much irritation and smarting at the anus.

In some instances of suppression of urine copious injections appear to
act beneficiallj^

Injections are often successful in restraining obstinate or dangerous
diarrhcea. It is by no means necessary for the injection to reach that
part of the intestines upon which the diarrhoea depends; for whether the
mischief is situated in the small or large intestines, the injection is equally
beneficial, owing, no doubt, to a close sympathy between the different
parts of the intestines, so that an impression made on one part is communi-
cated to another. In restraining diarrluea only a small quantity should
be injected, otherwise the intestine is stimulated to contract and expel the
enema when it should be retained as long as possible in order the more
effectually to influence the bowels. An injection of an ounce, or at most
two ounces, is sufficient for an adult; and it may be repeated several times
a day, according to the urgency of the diarrhoea.

The material used iu such enemata is starch, boiled or raw, of the con-
sistence of cream, and at a temperature of 100^. An injection simply
composed of starch proves effectual, but its astringent sedative action may
be much heightened by the addition of some drops of laudanum, graduated
in quantity according to the patient's age and condition. The addition of
some acetate of lead or sulphate of copper renders this injection more as-
tringent. These injections are invaluable in cases where delay is death.
They will save many a life in the choleraic diarrhcea of children, which so
rapidly proves fatal unless speedily restrained. The diarrhoea of typhoid
fever, which, if excessive, adds extremely to the patient's danger, yields
generally to these injections, so, usually, does the diarrhoea of phthisis.

Injections are commonly used to destroy thread- worms, which infest
the rectum and the intestines in its immediate neighborhood, but occur
in no other part of the canal. As the object of the injection is to destroy
these entozoa, a quantity of fluid should be employed sufficient to reach a
little higher than the rectum. For an adult half a pint is adequate, and for
a child, of course, less. To the water injected various substances can be add-
ed, as common salt, tincture of sesquicliloride of iron, lime water, quassia,
and various other similarly acting vermicides, with the object either of di-
rectly poisoning the worms, or of destroying them by coagulating the
albuminous structures of their bodies. Injections are always successful in

ACUPUNCTURE. 77

removing worms, and thus affording temporary relief; lout it must always
be recollected that the morbid state of the mucous coat of the intestines,
favoring the production of worms, must be remedied if jjermanent relief
is to be obtained. A teaspoonful of salt, or a drachm of the tincture of
steel, to half a pint of water, is sufficiently strong to effect the destruction
of these delicately-formed animals. Solutions too concentrated must not
be injected, otherwise inilammation may occur, perhaps severe enough
to cause sloughing in the rectum and margins of the anus.

Nutritive enemata are employed in stricture of the oesophagus, or
when tumors press upon this tube and render swallowing impossible, in
persistent vomiting, and in painful diseases of the stomach, like chronic
ulcer. A nutrient enema should not exceed three or four ounces of bland,
unirritating material, otherwise the lining membrane of the rectum
becomes irritated and inflamed, a condition adverse to absorj)tion. Mr.
Marcus Beck advises the addition to the injection of pepsine and dilute
hydrochloric acid. From experiments on dogs, M. Bauer finds that the
large intestines freely absorb peptones, but that pure soluble albumen is
not absorbed, though it is taken up readily on the addition of salt. Acid
solutions of albumen, as meat dissolved in weak hydrochloric acid, are
also freely absorbed. Fats and starches injected into the large intestine
failed to supjjort life for any considerable time. It sometimes happens
that the rectum will not retain even four ounces, and this inability is more
liable to occur after injections have been continued for some time. Be-
fore giving a nutritive injection, it must be ascertained that the rectum
is not filled up with ffeces.

Dr. W. 0. Leube employs the pancreas of the ox or pig as a ferment ;
one part of finely-minced pancreas being mixed with three parts of
scraped meat rubbed well together with warm water, so that the mixture
is easily injected. Fat, not exceeding one-sixth part of the meat, may be
added. This injection is 'retained from twelve to thirty-six hours, and
the stools afterwards generally possess an ordinary faecal character. By
ex2:)eriments on dogs, Dr. Leube has proved that by means of injections a
considerttble quantity of nitrogen can be taken up into the system.

Pancreatized substances are ulso useful as injections.

Peptones made into suppositories are also serviceable.

Three to five eggs beaten up with four ounces of 20 per cent, solution
of grape sugar form an excellent nutritive enema. Eggs are absorbed
without peptonization.

Astringent and stimulating injections, composed of a pint of water,
and containing ten to twenty grains of sulphate of copi)er, or correspond-
ing quantities of nitrate of silver and sulphate of zinc, prove of great ser-
vice in restraining the troublesome straining diarrhoea of chronic dysen-
tery. In the earlier stages, also, of dysentery, large emollient enemata
prove useful, especially by removing the foetid discharges, and soothing
the inflamed mucous membrane. In other sections, while treating of in-
dividual drugs, various additional uses of enemata are pointed out.

ON ACUPUNCTUEE.

Acupuncture is a very successful mode of treating lumbago. It will
rarely fail to afford relief, and in the majority of cases it will cure at

78 ACUPUNCTURE.

once, though the himbiigo has lasted a week, or even three weeks. It
succeeds best by far in typical cases of lumbago, when the loin muscles of
both sides are affected, and the pain is most severe on a to-and-fro move-
ment. I have treated a large number of such cases by acupuncture, and
find that it gives almost instantaneous relief. It is generally sufficient to
run the needle once deeply, say an inch, into the muscles on each side of
the spine, over the seat of greatest pain. Perhaps it may be better to
leave the needle for a few minutes sticking in the back, but I have hither-
to found this proceeding unnecessary.

Generally, when the needles are first withdrawn, the patient says the
pain is slightly eased, but presently it decreases rapidly, and in three or
four minutes it is entirely gone, perhaps a little stiffness only remaining;
but even this may be absent. The patient, who just before could not
bend in the slightest degree without the greatest pain, wlio could not
possibly stoop to touch his toes, now bends backwards and forwards witli
the utmost ease, often with a look of astonishment mingled with incredu-
lity, as if the. cure were too wonderful to be true.

Faradization of the back is in my experience almost as successful as acu-
puncture, though the pain more frequently returns than after acupuncture.
TJnder either treatment it sometimes happens that after several hours
of relief the pain returns, and a renewal of the treatment may either be
almost without avail, or its influence may rapidly grow less and less.
Freezing the back with etlier spray or with Arnott's ice mixture is also
very successful. So also is the old-fashioned Avay of ironing the back Avitli
a common flat iron, as hot as can be fairly borne, passed over a piece of
brown paper placed across the loins. The thermic hammer, too, often
succeeds in subduing lumbago. These modes of treatment I have found
not so successful in the less typical forms of lumbago; for instance, if the
pain on movement is restricted to one side, or is felt only on twisting or
turning the body, and not on bending to or fro.

Lumbago is not uiicommonly associated with sciatica or shooting pains
along some branches of the lumbar nerves, sometimes the pain shooting
along the skin in the front of the body, and along the lumbar or sacral
plexus, which then assumes a neuralgic character. When these two pains
are associated I find that it is easy to cure the .lumbago, but that the scia-
tica or other neuralgic complication, remaining unrelieved, is far more
difficult to dispose of. Occasionally, after curing the back by galvanism
or the needles, the neuralgic pains give way, to be replaced by lum-
bago; and when the lumbago is got rid of the neuralgic pains recur. Let
me repeat that these compound cases are generally obstinate, and the neu-
ralgic factor most so. A'cupuncture Avill prove useless when lumbago is
accom])anied by high fever, or when it is the first symptom of acute
rheumatism.

It is a good plan, when rid of the lumbago, to apply to the back a
belladonna, or a lead, or a Burgundy-pitch plaster spread on leather, both
on account of the warmth and the support it affords. The Burgundy-pitch
plaster sticks closest, but is very apt to irritate delicate skins, especially in
warm weather, and often indeed cannot be borne. Even lead or belladonna
plaster may irritate the skin, bringing out a papular or eczematous erup-
tion, due in part to the retention of perspiration, which, decomposing,
irritates the skin. By removing the plaster every few days, wiping it, and
washing the skin, and then reapplying the plaster, this irritation may often

ACUPUNCTURE. 79

be prevented, or the plaster may be perforated after tlie manner of Al-
€0ck's porous plaster. I have found acupuncture far less successful in
the treatment of sciatica; in a few cases it acts no doubt as speedily and as
completely as in lumbago, but this prompt action is unfortunately the ex-
ception. Some hold that it is necessary to pierce the nerve, and the un-
certain results of acupuncture in sciatica may possibly be due to the needle
sometimes impaling the nerve, but more frequently missing it. This
treatment generally gives some, tbough usually very transient, relief,
lasting only from a few minutes to an hour or so. In cases due to diseased
spine or pressure on the nerves from abdominal solid tumors, abscesses,
or ffecal accumulation, acupuncture is not appropriate. The needle must
be thrust in deeply, even to the bone, in various places over the seat of
pain in the course of the affected nerve. When only partially successful,
this treatment removes the pain along the course of the sciatic nerve, but
generally leaves unaffected the pain below the knee, especially outside the
ankle. Indeed, I may add, that whilst all forms of sciatica are obstinate,
those cases are most rebellious when the pain reaches below the knee, or
when it is restricted to the region above the sciatic tuberosity.

Dr. Dumontpallier finds that acupuncture of a spot — not the painful
part, but the corresponding spot on the opposite side of the body — will re-
lieve the pain of neuralgia, acute articular rheumatism, pleurodynia, the
relief being in some instances permanent. This " corresponding spot" is
sometimes tender; acupuncture over or near the seat of pain also relieves it.

Acupuncture, or incisions, into the dropsical tissues of the feet and
ankles, or lower part of the calf, is an old, but now too much neglected
mode of treating both cardiac and renal dropsy. Acupuncture no doubt
sometimes excites erythematous inflammation, sufficient to cause the
dropsical, vitally depressed tissues to slough extensively and progressively.
In one instance I have seen the muscles not only laid bare, but dissected
out, over the lower part of the calf to the extent of eight square inches,
yet in this case, after the dropsy had drained away, the tissues recovering
their lost vitality, healed, and the man left tlie hospital greatly improved.
It is better to make incisions instead of pricks with the acupuncture
needle. The incisions should be from three-quarters to an inch long, and
should reach well into the subcutaneous tissue, or three or four punctures
should Ije made around each ankle with the ordinary exploring trocar,
thrust up the leg in the subcutaneous tissues for an inch or an inch and a
half. The legs should be kept dependent and the wounds covered with
lint or sponge soaked in hot boracic acid or carbolic acid solution. The
feet and ankles should also be placed in hot boracic water for an hour
night and morning, to aid the escape of serum. Dr. Southey's now well-
known plan is highly useful in many cases.

As the discharge quickly decomposes and becomes offensive, the
cloths and sponges used should be washed in a solution of chlorinated
soda, or moistened with a weak solution of carbolic acid. These free
incisions allow the easy escape of the dropsical fluid, to the relief of the
distended and depressed tissues in the neighborhood of the incisions, thus
lessening the likelihood of inflammation and sloughing, which are very apt
to occur after mere pricks. One incision over eacli outer malleolus is
generally sufficient.

With incisions, though there is not much fear of sloughing; still as
this untoward event may occur, it is better not to incise, especially with

80 ACUPUNCTURE.

very old or very weuk patients, till other methods have been tried and
have failed. The benefits are prompt and striking. 8erum runs freely
from the wonnds. so that in a few hours pints may be discharged. As
the fluid runs away, of course the dropsy grows less, first in the upper
parts of the body, of the pleura, and the abdomen; hence the dyspncea,
due to hydrothorax, disappears, and the tightness over the upper
part of the abdomen ceases. At last the fluid drains out of the legs, an<l
all the dropsy is removed, and without producing depression, for the
dropsical fluid from the cellular tissues, unlike inflammatory exudations,
contains very little albumen; so little that it only becomes opalescent on
boiling, and on adding nitric acid.

If the subcutaneous tissue is hard and brawny, and will pit only im-
perfectly, then neither incisions nor Southey's tubes will drain off any
fluid. An incision, or one of Southey's tubes, often sets up irritations
in the neighborhood; so that a fresh incision, or the introduction of a
fresh tube, draws off no serum, but the trocar becomes blocked up with a
pinkish jelly-like substance, suggesting the idea that the previous opera-
tions have excited inflammation which has filled the intercellular spaces
with this jelly-like substance.

In cardiac dropsy it appears to me that this treatment is more benefi-
cial when due to aortic than to tricuspid mischief. In dropsy due to
aortic regurgitant disease there is a greater tendency to effusion into
the pleural and abdominal cavities than when due to tricuspid disease, and
the dropsy increases more rapidly. Thus when dropsy invades the feet,
it usually spreads quickly up the legs, and, before the legs are extensively
swollen hydrothorax often sets in, embarrassing the already distressed
breathing; so that in heart disease, and especially in the aortic regurgitant
form, in addition to the paroxysmal panting dyspnoea due to the heart mis-
chief we have the constant dyspnoea or orthopnoea of hydrothorax ; the or-
thopnoea greatly predominating over the dyspucea directly dependent on
the heart. The incisions into the leg drain off the fluid from the upper
parts of the body, first emptying therefore the pleural cavities, and
promptly removing the greater part of the dyspna3a. This treatment is
also useful in the dropsy of Bright's disease.

How long will it be before the fluid re-accumulates and the advantage
thus gained is lost ? In tricuspid dropsy, so long as the valvular incom-
petency continues the dropsy will return, and the rapidity of its recur-
rence will of course depend on the degree of regurgitation. In aortic
dropsy, and the dropsy from Bright's disease, success is often much
greater. In some cases, indeed, one operation often dissipates the fluid,
never to reaccumulate; though more often two or even more operations at
varying intervals are necessary, the fluid each time returning less and less
rapidly. In cases of very extensive dropsy, strange to say, I have known
the fluid not to return, although the disease of the heart or kidneys has
remained unaffected. Thus, the amount of albumen, and the quantity
of urine, has remained just the same in cases of Bright's disease, and yet
after draining away the fluid it has never returned. I have seen this ex-
cellent result in a cose where the tissues were shiny with distention; the
abdomen largely distended with fluid aiid the albumen on boiling occupy-
ing half the test tube, yet, after draining away the dropsy by incisions,
the fluid never re-accumulated, though the proportion of albumen con-
tinued the same. This patient remained free from dropsy more than six
months after the operation.

IRRITATIOlSr AND COUNTER-IRRITATION. 81

lERITATION AND COUNTER-IRRITATIOK

Cantharides applied to the surface of the body soon excites tingling,
smarting, and a sensation of heat; the papilla? of the skin quickly become
reddened and raised; next, in a variable time determined by the strength
of the application, on these. papular elevations minute vesicles form, which
gradually enlarge, and by their lateral extension soon coalesce, so as to
form blebs of various sizes, filled with a fluid rich in albumen, and gener-
ally containing some fibrine. It is of great importance to bear in mind
that the effects of these applications are very different according to
whether extensive vesication is produced or simply reddened skin, with the
formation of a few small miliary vesicles. Dr. Graves insisted on the
different and even opposite effect of blisters, according to the degree of
their action. The primary action of a blister is that of a stimulant to the
body generally, and to the individual organs in whose neighborhood it is
applied ; but if allowed to remain long enough to produce much vesica-
tion, and to form large blebs, it depresses the bodily powers in proportion
to the amount of serum Avithdrawn from the vessels, and so lost to the
system, — a lowering effect often exemplified in weakly people, who,
through the abstraction of serum, are apt to remain weakened for several
days. As the serum of blisters contains almost as much albumen as the
blood itself, we might as well bleed the patient to the same amount.

Should it be held desirable to reduce somewhat the patient's strength
and to produce simultaneously a counter-irritant effect on any of the in-
dividual organs or tissues of the body, then a blister may be applied, even
to vesication; but as the good effects of blistering are for the most part
ensured by a milder measure, treatment so energetic and so depressing is
seldom called for.

Dr. Graves commonly employed blisters as a general stimulant in cer-
tain critical condition 5. In acute diseases, as the idiopathic fevers and
inflammations, a patient, sometimes already much prostrated, drifts into
a dangerous, apathetic, and unobservant state, which goes on till it reaches
even partial insensibility or coma, so that he can be roused only with dif-
ficulty, and tlieii wears a stunned, stupid, vacant aspect, understanding
very imperfectly what is said to him. With this depressed mental condi-
tion the body generally sympathizes, its functions becoming more and
more languidly performed, till those necessary to life altogether cease. It
is a condition which may be compared, not inaptly, to that produced by
opium-])oisoning, where the partial coma produces a lethargy in the func-
tions of the body, their activity diminishes as the coma continues and
deepens. Now a patient in the partially comatose state of which Ave are
speaking, gets no true and refreshing sleep; yet sleep is urgently needed,
and an opiate and plenty of stimulants carefully given, often produce a
refreshing slumber, out of Avhich the patient wakes strengthened and
much improved. (See Opium.) When the functions are very languidly
performed this blistering treatment may Avell precede the use of opium.

In this precarious condition, it is essential to rouse the patient from

his lethargic state. This accomplished, the bodily functions will act with

renewed force, and he will pass from imminent danger to comparative

safety. Large blisters or mustard poultices should be applied for a short

82 COUNTER-IRRITATION".

time in quick succession to various parts of the body,- for instance, to the
chest, the alxlomen, and to the thighs and calves. The great A'alue of
flying bUsters in these circumstances will Ijc the better appreciated if we
bear in mind that the critical condition Just descriljed generally occurs
near the end of an acute illness, when, i'f the patient can be kept alive for
one or two days, the near danger of death passes away, acute diseases
having a definite duration, so that if the patient can l)e sustained to this
point his life may be saved. Counter-irritants, by rousing the patient,
and spurring the flagging vitality, may rescue an almost hopeless life.

Preparations of cantharides may be applied as stimulants of special
parts of the body; for instance, when with a general condition like that
just described, there is fear of hypostatic congestion of the lungs, or of
pneumonia, in which such congestion often ends, flying blisters applied
to the chest, and perhaps, as recommended by Dr. Graves, along the
course of the pneumogastric nerves, may. brace up the vessels, and avert
a serious and often fatal complication. Or we may stimulate the heart,
and in intense weakness strengthen its contractions for a short time, by
flying blisters or mustard poultices placed over the precordial region, and
then maintain the advantage thus temporarily gained by the free ad-
ministration of alcoholic drinks.

Flying blisters are largely employed in various diseases of the deep-
seated organs, as pleurisy, pneumonia, asthma, biliary and renal colic, etc.

Blisters are frequently employed in pneumonia and pleurisy. Yet
great divergence of opinion exists, not only as to the stage of the disease
in which they are useful, but even as to their utility in any case. Some
maintain that during the febrile state blisters increase the fevers; but the
increase, if any, certainly must be very slight, for I have not been able to
excite fever in fever-free persons by blistering, nor have I ever seen it
increase a fever already existing. The advocates of blistering in pneumo-
nia maintain that it removes pain, quiets cough, and lessens expectoration;
but many competent authorities discredit the efficacy of blistering in this
inflammation.

Whatever doubt may exist as to the influence of blistering in acute
pneumonia and pleurisy, most observers agree that it lessens the pain,
and must therefore benefit the patient by subduing the restlessness, op-
pression and sleeplessness consequent on pain. In estimating the effect
of blistering, it must be recollected that in these acute afl:ections the
severe pain is of short duration, and spontaneously lessens or disappears
in about forty-eight hours. It is, perhaps, not superfluous to re-caution
against too free vesication.

Opinion is more agreed on the usefulness of counter-irritation in
pleuris}', after the subsidence of inflammation and fever. At this stage
the prompt application of large flying blisters, often repeated and
quickly healed, further the absorption of the fluid in the pleural cav-
ity, and lessen the risk of the disease remaining indefinitely chronic.
The counter-irritant, as we have said, should be frequently applied,
and the vesication, if it occur, healed at once; for all the good of
counter-irritation is eUected during the first few hours while it stimulates
the skin. The notion that free vesication and the maintenance of the
discharge by irritating ointment will drain off the fluid, as it were, from
the water-logged pleura?, is altogether fallacious. This barbarous treat-
ment drains important nutritive material from the system and weakens
the patient when strength is most needed. We have already referred to

COUNTER-IRRITATIOlSr. 83

the fact that blisters will redden and even inflame the plenra. Many
consider counter-irritation worse tliaii useless wlien pleural etfusion has
lasted a long time. The production of a free discharge of serum is no
doubt useless; but although in a long-standing case of elfusioii there is
but slight chance of improvement by any treatment, yet mild flying
blisters will in some cases help to the absorption of the fluid, and at any
rate may prove serviceable, if in no other way, by removing the trouble-
some intercostal pains which often accompany chronic pleurisy; although
a mustard poultice is to be preferred.

Counter-irritants are often of signal service in removing the oppression
of the breathing in asthma, especially of bronchitic asthma, and the short-
ness of breath accompanying bronchitis with emphysema.

They relieve the pain arising from the passage of renal and biliary
calculi.

Counter-irritation is useful in many other diseases, as phthisis, phle-
bitis, sciatica, facial paralysis, gleet, leucorrhcea, rheumatism, gout, and
pleurodynia.

Counter-irritation is very beneficial in certain forms of phthisis. In
the acute and rapid forms it is of little other service tlian to remove pain.
But when the disease is chronic, when we have to treat what is now called
the fibroid lung, when the cough is paroxysmal and violent, or frequent
and distressing, preveiiting in either case rest and sleep, active counter-
irritation of the chest, corresponding to the seat of the disease, often
quickly quiets cough, greatly diminishes the profuse expectoration, and
thus olDviates a severe drain on the strength. In blistering these weakly
patients, vesication must be avoided, or the exhaustion produced by the
loss of serum may be so great as even to endanger life. In phthisis iodine
liniment is a better counter-irritant than blisters.

In inflammation of the superficial veins a blister applied over the
course of the inflamed vessel reduces the inflammation, hastens absorption
or liquefaction of the coagulated blood, and assists the restoration of the
circulation through the obstructed veins.

Blistering is of the greatest service in neuralgia. A flying blister to
the temple or behind the ear generally relieves frontal or facial neuralgia.
The obstinate form of facial neuralgia dependent on a diseased tooth,
rebellious to all treatment except extraction, often yields to a blister; the
neuralgic pains ceasing, although the toothache may continue. Blisters
relieve the shifting neuralgic pains common in nervous sensitive women,
although the pain is apt soon to fix upon another nerve; but flying
blisters will drive it from place to place. In this migratory form the pain
may alternate between a few, or may affect in succession i»ost of the
nerves, producing in addition great cutaneous tenderness; or the nerves
supplying the viscera may be affected, and without pain produce functional
disturbance, as nausea, sickness, diarrhoea, etc. This form of neuralgia,
though it is right to say the disease lacks many of the more distinctive
characters of neui-algia, is most difficult to cure. The obstinate intercos-
tal neuralgia left by shingles, occurring mostly in old people, generally
yields to blisters. Anstie points out that blisters applied over the seat of
pain aggravate the suffering; " but, on the other hand, if they are applied
to a posterior branch of the spinal nerve trunk from Avhich the painful
nerve issues, a reflex effect is often produced of the most beneficial
character. "

Blistering paper, although mild in its action, requiring to be applied

84 COtTNTER-IRRITATlON".

some hours, generally produces enough irritation to relieve facial and
frontal neuralgia; but. if the pain continue unabated, a stronger prepara-
tion of eantharides should be tried.

Blisters are of tiie greatest service in sciatica.' They should "je ap-
plied every day or second day in the neighborhood of the sciatic nerve,
reaching in severe cases from the buttock to the knee. Free vesication
sometimes succeeds where slight vesication fails. Otlier counter-irritants
are useful in neuralgias, as mustard poultices, croton-oil liniment, iodine
paint; but eantharides is superior to them all.

Blisters behind the ear, and es})ecially to the temple, are very useful
in rheumatic, gouty and simple inflammation of the eye; relieving pain
quickly, and subduing inflammation, tliough less rapidly. As it is im-
])ortant to repeat the application frequently, blistering paper is preferable
to stronger preparations. Oljstinatc^ forms of tinea tai'si sometimes yield
to repeated applications of flying blisters to the temples. Counter-irrita-
tion, by blistering fluid or croton-oil liniment behind the ear, often
removes earache.

Counter-n-ritation at the epigastrium often allays pain and obstinate
vomiting, due to disease of the stomach.

Mr. Furneaux Jordan employs counter-irritation to remove enlarged
glands. "In enlarged glands, in abscess, carbuncle, boils, erysipelas, the
best locality for the counter-irritation is around, or adjacent to, the
disease. Blisters or iodine may be employed." "In enlarged cervical
glands a large patch of iodine irritation at the back of the neck, which
may be prolonged below the glands, will certainly prove successful in a
short time."

Dr. McCall Anderson recommends blistering in erythematous lupus,
and in chronic skin affections, especially in eczema of the hands, when
the tissues, thickened and cracked, hinder free movement.

In paralysis of the seventh nerve, dependent on alterations in its pe-
riphery, from draughts or cold, painting the skin over the paralyzed
muscles with blistering fluid will in some cases quickly remove it. The
earlier the application, the greater the probability of good results.

A blister applied to the peri]ia?um and along the course of the urethra
will sometimes cure a gleet obstinately rebellious to all the usual methods.

Blisters are of the greatest service in rheumatism. Large flying
blisters, applied in proximity to an inflamed and painful joint, often
quickly remove the pain, and with the ease- thus brought about sleep
often ensues, and a concurrent general improvement takes place in the
patient's condition. But blisters have been of old recommended as the
sole or cl^ef treatment of acute rheumatism, and some apply them, to
the extent of free vesication, with the unfounded hope of removing from
the blood the poison on which rheumatism is supposed to depend. This
metliod has the disadvantage of reducing the strength of the patient in'
proportion to the quantity of serum lost, the depletion tending to prolong
the attack, and to retard the convalescence, usually sufflciently tedious
after a severe attack of rheumatic fever, Avhich indtices more ana?mia tlian
most other diseases. The advocates of free vesication assert that this
method moderates and shortens the attack, and lessens the danger to the

' The most obstinate forms of sciatica are sometimes benefited l\v the insertion of a
needle for an incli or more in one or two places along the course of the sciatic nerve.
More relief is sometimes obtained by allowing several needles to remain imbedded in
the tissues for half an hour, or even longer.

COUNTER-IRRITATION. 85

heart; and some attribute its efficacy to the influence large bhsters have
on the urine, changing in a few days the acid urine of rheumatic fever to
a neutral or even alkaline state. I think that due regard is not paid to
the great influence age exerts on the duration of aji attack of rheumatic
fever; moreover, the reported cases appear not to have recovered more
speedily than frequently happens in persons of the same age, and mani-
festing the same body temperature, Avho recover Avithout any medicine.

The nightly application of a small flying blister greatly relieves the
pain and swelling of chronic and subacute gout, gonorrhceal rheumatism
and chronic synovitis; but if this mild apphcation fail, strong vesication
should be tried.

Pleurodynia usually yields to anod3aie liniments or mild counter irri-
tants, but sometimes strong vesication is necessary, although the weakening
loss of serum may increase the pain for a day or two.

It is surprising how much relief a small blister no larger than a florin
will often give in the foregoing diseases. Indeed in many cases it is better
to apply a small blister nightly to adjacent parts rather than to apply a
single large blister. For the relief of pain, as neuralgia, pleurodynia, or
spasm, as in asthma, etc. , a blister the size of a five-shilling piece is gen-
erally sufficient.

The active principle of cantharides being soluble in oil, it is useful to
smear a little simple oil over the blistered surface. The oil, moreover,
helps to maintain the plaster in contact with the skin.

It must be borne in mind that blistering paste and blistering paper
require several hours to produce a blister, and that the paper rarely pro-
duces much vesication. If a speedy and sharp action is necessary, we must
employ blistering fluid, which sometimes vesicates in twenty minutes to
half an hour.

The active principles of the Spanish-fly may become absorbed by the
skin in sufficient quantity to produce congestion of the kidne^^s, strangury,
and its other characteristic toxic effects; hence, in the treatment of acute
or chronic Bright's disease, cantharides should be avoided, as we are un-
able to regulate the quantity which may be absorbed, and a damaging
amount may be taken up by the skin.

We hope it has been made sufficiently plain that, in the great majority
of cases, preparations of cantharides should not be applied long enough to
cause much vesication. The vesicles should not be opened, but be covered
with a layer of soft cotton-wool, till the effused scrum is absorbed, when a
superficial desquamation follows, and no troublesome conseqiiences nged
be apprehended. If blistering is carried far enough to produce blebs, the
serum will not become absorbed, and the bleb will at last burst; even in
this case it is not advisable to open the blister, but to allow the un-
derlying dermis first to heal partially, when no ulceration need be feared.
If the bleb is punctured, the air will perhaps irritate the raw surface, pro-
ducing much inflammation, which may end in extensive sloughing, an
untoward event, especially apt to follow the blistering of young children
or old people, or persons with broken-down health, as the victims of
Bi-ight's disease, etc. Hence, in such cases, it is generally considered ad-
visable to use other counter-irritants. ( Vide Mustard, )

86 CHARCOAL.

CAEBON. ANIMAL CHARCOAL. WOOD CHARCOAL.

Carbon, in proportion to its porosit}^ absorbs many gases in consider-
able quantity; and wood, being more porous tluin animal charcoal, its ab-
sorbability is greater.

Charcoal does not absorb all gases in an equal degree; it will absorb
but little hydrogen, though it will imbibe a considerable amount of
oxygen, a large quantity of sulphuretted hydrogen, and a stili greater
proportion of ammonia. Charcoal is much used on account of this prop-
erty as a disinfectant, to remove bad smells, or to prevent the air in rooms
becoming contaminated by the effluvia from foul ulcers. Its non-volatility
renders it very inferior to chlorinated lime or chlorine gas and other
agents for purifying an*, since it can act only on the air in immediate
contact with it.

It is more effectual in absorbing the offensive gases given off by foul
sores, and is employed in the form of a poultice, mixed either Avith bread
or linseed-meal. Bread, Ijeing more porous, is to be preferred, as it
permits the gases to permeate the substance of the poultice, and so to-
come into contact with the particles of charcoal, some of which should
be scattered on the surface.

After becoming thoroughly moistened, and its pores filled with water,
it may reasonably be doubted if the charcoal does not lose its capacity to
absorb or oxidize gases and so to act as a deodorizer. It is certain that
charcoal poultices often fail to act in this manner. Charcoal may act by
preventing decomposition, for, when swallowed after admixture with
v/ater, its pores being thus filled or obstructed, it will still prevent flatu-
lence, an effect not due to absorption ; it must, therefore, act by arresting
fermentation or decomposition. A thoroughly efficient mode of employ-
ing charcoal is to fill a small flat muslin bag with it, in a finely granulated
form, and to place it over the poultice covering the sore.

Charcoal poultices are reputed, on doubtful grounds, to clean and heal
sloughing or gangrenous wounds.

How does charcoal destroy smells depending on noxious gases? It
has been stated in a previous page that it is endowed wnth the property of
condensing many gases in its pores, and some accept this as a sufficient
explanation of its action. Others assert that the oxygen condensed and
accumulated in the pores of the charcoal, combining Avith the other gases
with which it comes in contact, breaks them up and destroys their ill
odor. It rapidly oxidizes and so destroys sulphuretted hydrogen.

A question of more practical importance is whether the carbon becomes-
inert by use, thus losing its property to condense gases or to destroy them.
Buchheim is probably right in stating that the carbon becomes inert, but
others assert that if kept dry, it Avill retain its properties unimpaired for
many years. At all events exposure to a dull red heat restores its gas-
absorbing power.

Charcoal is likewise employed as a disinfectant, and Dr. Stenhouse has
ingeniously devised a charcoal disinfecting respirator, which, no doubt,
will protect the wearer against many gases, but at present no evidence

CHARCOAL. 87

exists to show that charcoal will destroy the organic matters which propa-
gate disease, although, acting like a filter, it may prevent their entrance
into the system.

Cliarcoal, by its chemical or mechanical action, possesses the property
of carrying down from sokitions many coloring matters, many bitter sub-
stances, alkaloids, and mineral substances. Hence Dr. Garrod advises its
administration in poisoning by corrosive sublimate, arsenic, morphia,
strychnia, belladonna, etc., but, at present, this treatment has not found
much favor with the profession. As it is said that half an ounce absorbs
only one grain of alkaloid, large doses of half an ounce to an ounce, or
even more, must be given. Charcoal also precipitates the coloring matter
of urine, carrying down at the same time all the uric acid, and some of
the urea in solution. The sugar of diabetic urine is unaffected by char-
coal. As a precipitant, animal charcoal freed from its earthy impurities
is found to be the most efficacious, on account, it is said, of its more finely
divided state.

Cliarcoal is employed with much success in certain diseases of the stQm-
ach. It is said to ease the pain of chronic ulcer, and of neuralgia of the
stomach, possibly by checking fermentation and so preventing the forma-
tion of acids which must irritate the stomach, especially when ulcerated.
It is markedly useful in flatulence. In the majority, if not in all cases,
intestinal flatulence is the result of gases generated by fermentation. The
symptoms accompanying flatulence, hoAvever, are not always alike, and
their various complications afford indications for treatment. Sometimes
" the wind " is produced in enormous quantities, with great rapidity, pro-
ducing distention, eructatiou, and mental depression, the patient com-
plaining only of these symptoms, not of pain or of acidity. This'enormous
production of wind, ii-respective of other symptojns, prevails chiefly
among middle-aged Avomen, especially at the change of life. This condi-
tion is met with sometimes during pregaticy and suckling, and seldomer in
the course of phthisis. It is often very difficult to check the formation
of wind, but vegetable charcoal is one of the best remedies. Sometimes
after a few mouthfuls of food the wind is formed in quantity so large
that the patient is constrained to cease eating; here the charcoal should
be taken immediately before each meal. Another patient is not troubled
with the wind till half an hour or longer after food; here tlM» charcoal
should be taken soon after the meal. Five or ten grains of charcoal is
generally enough, and this dose failing, it seldom happens that a larger
one succeeds. Some give a teaspoonful or more of powdered charcoal.
Supposing charcoal to fail in cases like these just described, we have an-
other efficient resource in the sulpho-carbolates, or carbolic acid, which,
indeed, often succeed when the charcoal fails.

At other times profuse formation of wind is accompanied by acidity.
Cliarcoal, administered as just described, will generally obviate both these
symptoms; and sulpho-carbolates and carbolic acid, although less suc-
cessful than when acidity is absent, will often prevent the production
of both wind and acidity.

Some persons after meals are troubled with a little wind, acidit}', and
a sensation of weight at the pit of the stomach. Charcoal will relieve
these cases; but nux vomica, in five-minim doses of the tincture, taken a
feAV minutes before meals, is to be preferred. In the treatment of flatu-
lence it must never be forgotten to direct the patient, as far as possible,
to abstain from those kinds of food prone to fermentation. Sugar and

88 SULPHUR.

starchy foods must be avoided or taken sparingly, and thin well-l)rowned
toast, on account of the carbonization of its surface, may be substituted
for bread. The meals should be very moderate, the food well masticated,
and drinking postponed till the meal is nearly linished, or, better still, till
an hour after its completion. Tea is very obnoxious to flatulent jxitients.

Most of the charcoal .passes away with the faeces, though a little, it is
stated, finds its way into the blood and lymphatics.

Wood is preferable to animal charcoal for internal use. It is often ad-
vantageously mixed with an equal quantity of bismuth, when flatulence
is combined with acidity and pain.

CAEBONIC ACID.

It is asserted that this gas applied to the eye relieves the pain
and photophobia of scrofulous ophthalmia, and that injected up the
vagina it eases the pain of ulceration of the os uteri and of cancer
and neuralgia of the uterus. According to Sir J. Simpson, the inhala-
tion of this gas is serviceable in chronic bronchitis, asthma, and irritable
cough.

Carbonic-acid gas is generally employed dissolved in water. Natural
waters containing a large quantity of carbonic acid are used externally in
chronic gout, chronic rheumatism and many chronic affections. Car-
bonic acid is an excitant of the skin, producing tingling redness, a sen-
sation of .warmth, and increasing the flow of perspiration; but after
a time the gas acts in some measure as an anaesthetic, lessening the sen-
sibility of the skin, and removing or diminishing pain.

Carbonic-acid water is employed in painful and irritable conditions of
the stomach. It eases pain, and checks vomiting. It is an excellent
addition to milk, which is then generally retained, though previously it
was rejected.

Lime-water and milk may be profitably substituted for milk and
carbonic-acid water in diarrhoea with irritability of the stomach; but in
case of constipation carbonic-acid Avater and milk is much to be preferred.

SULPHUE.

SuLPHUE dusted on the skin produces no effect, but mixed with lard,
or other unctuous substances, and rubbed in, it excites a slight degree
of inflammation; hence sulphur ointment has been used to stimulate in-
dolent sores to a healthier and more healing condition; but for such a
purpose more efficient agents have superseded sulphur ointment, which is
now almost entirely restricted to the cure of itch. The object is to destroy
the insect {acarns scabiei) and its ova, for it is on the presence of this
animal that itch depends; and a knowledge of the habits of the acarus
and its ova suggests the means best calculated to effect this purpose. The
female as soon as impregnated burrows obliquely under the skin, and day
by day deposits her eggs till she dies. The male remains a wanderer on the

SULPHUR. 89

surface, and is easily attacked and killed by the ointment. To reach and
destroy a female and her eggs it is necessary to break up the burrows where
these lie concealed, and to lay them bare to the destructive action of the
sulphur. The destruction of the bnrrovvs is easily effected by the liberal
use of soap and water, which removes the superficial and dead cuticle, and
exposes the animal and its ova.

Various methods of sulphur treatment are in use, but it is sufficient
here to record only a few.

M. Hardy claims that his method will cure in four hours. He first
subjects the" body for half an hour to a friction of soft soap, to cleanse
the skin and lay bare the burrows. Then follows a Avarm batli of an
hour's duration; meanwhile the skin is well rubbed, to complete the
destruction of the burrows. Then the skin is well rubbed all over —
except the head and face, unless in the rare instances when these parts
are attacked— with an ointment composed of two parts of sulphur, one of
carbonate of potash, and eight of lard.

This rather severe method not unfrequently irritates and chaps the
skin, and is, therefore, inadvisable for delicate skins, especially if much
eczema or inflammation is present, affections which this vigorous treat-
ment would undoubtedly much aggi-avate.

It is often sufficient to treat vigorously only certain parts of the body
where the rash is most apparent, and to apply the ointment to other parts
in milder manner.

If the skin is delicate, much irritated, or inflamed, a mild soap may
be substituted for soft soap, and an ointment, without alkali and with less
sulphur, while the times of the application should be shortened, and in-
stead of one continuous severe application, the several washings and in-
unctions should be repeated on successive nights. The ointment should
be left on all night. The simple ointment of the Pharmacopceia, little
irritating to the skin, containing no potash or other alkali, is in most
instances sufficient to cure itch in three days. The patient should be di-
rected to take a nightly warm bath, and to rub the skin with soap, bland
or strong, according to the condition of the skin. After wiping the body
thoroughly dry, the ointment is to be well applied to the skin by the
fireside, jiist before bedtime, and to be washed off on the following morn-
ing.

The irritation set up by the parasite and its eggs excites sometimes
more or less eczema and impetigo. The treatment adapted to cure the
itch would certainly aggravate these accompanying eruptions. To avoid
such a complication, Hebra recommends a milder ointment of a different
composition; namely, chalk 4 oz., sulphur and prepared tar, each 6 oz.,
conmion soap and lard, each a pound, the various constituents in this prep-
aration each serving a distinct purpose. The chalk helps mechanically to
remove the dead cuticle and to l)reak up the burrows; the tar serves the
twofold i)urpose of diluting the sulphur and acting beneficially on the
eczema, while the soap and lard further effect the dilution of the sulphur;
and the soap, by virtue of its alkali, checks the weeping from the red,
raw, eczematous eruption. This ointment, accompanied with the use of
the warm bath, is employed twice a day, and cures completely in three
days.

After the itch '.s cured, it often happens that the mildest ointments
excite and increase the eczema and other eruptions produced by the
scabies; hence it is inadvisable to continue the use of such unguent for

90 SULPIIT R.

many days. On withholding this treatment the rashes produced l)y the
scabies will frequently disappear at once. After the course the patient
must put on an entire change of linen, and the soiled clothes should either
he boiled in Avater, or heated in an oven at a temperature above 212" Fall.,
in order to destroy the animals and ova that may be concealed in the
linen.

Some maintain that the sulphur of the ointment plays no part in the
destruction of the parasites, but that the fatty matters, by obstructing-
their breathing pores, suifocate and so destroy them. This opinion seems
to be erroneous, a sulphur ointment being far more effectual than an
ointment of simple fat. Sulphuretted hydrogen is very destructive to
vegetable and animal life, and it is probable that this gas is the efficient
insecticide in destroying the developed itch hisect by the conversion of
the sulphur.

Except in rare cases, the ointment need not be applied to the head
and face, for in this country these parts are not often affected. The dis-
agreeable odor of the ointment may be in part concealed by the addition
of otto of roses or other fragrant substances.

To avoid the disagreeable odor and irritating effect of sulphur, many
dermatologists substitute storax, which is said to be just as effectual.

The complexion of young women, in whom the menstrual flow is dis-
ordered, is sometimes spoiled by numerous small elevations or pimples,
scarcely or not at all reddened, and sometimes a minute pustule on the
summit of some of the elevations forms, the skin at the same time losing
its healthy transparency. This is a form of acne perhaps, though unlike
that commonly seen. Sometimes the eruption appears independently of
menstrual disturbance, and, indeed, may almost vanish at the menstrual
period, to recur when it has ceased. This eruption may last months, or
even years, greatly to the patient's annoyance. It will, however, generally
yield to the a])plication, twice or three times daily, of the following lotion:
— Sulphur, a drachm; glycerine, an ounce; rose-water, half a pint. This
lotion speedily benefits the eruption, even when for years it has remained
uninfluenced by other treatment. Acne may be treated in the same way.

An ointment composed of two drachms of hypochlorite of sulphur and
an ounce of simple ointment, or especially iodide of sulphur ointment, is
very useful in the severer forms of acne (see Sulphides). They should be
applied twice daily. Where acne indurata is accompanied by much acne
punctata frequent washing with j^lenty of soap and warm water Avill assist
the action of these applications. In genuine prurigo Dr. Anderson applies
night and morning an ointment composed of an ounce of sulphur, six
drachms of liquid tar, and four ounces of benzoated lard.

Being quite insoluble in any of the fluids of the mouth, sulphur pos-
sesses no taste; btit as it often contains a small quantity of either sulphur-
ous acid or of a sulphide, it may partake of the flavor of these substances.
It undergoes no change in the stomach, and in no way affects the mucous
membrane of this organ.

The powder of sulphur is sometimes blown upon the diseased sur-
face in diphtheria, apparently with some benefit.

In the intestines, however, the case is quite otherwise. Here in or-
dinary doses sulphur causes rumbling, slight colicky pains, followed in
a short time by a softened evacuation, sometimes soon repeated. From
the occurrence of colic, and the semi-solid condition of the motions, it is
generally held that sulphur acts only slightly on the mucous membrane.

SULPHUR. 91

but purges chiefly by exciting contractions of tlie muscular coat of the
intestines. From the mildness of its operation it is ranked among the
laxatives. The precipitated sulphur being more finely divided than
the sublimed, acts more surely and effectually as a purgative.

The too prolonged use of sulphur excites a catarrhal state of the
mucous membrane, and impairs digestion.

Sulphur is a useful purgative in piles and fissure of the anus, when
it is needful to maintain the motions in a soft and yielding state, so that
the passage may not be irritated and pained by hard, difficult stools. It
is also employed in stricture of the rectum. In habitual or obstinate
constipation it often succeeds after the failure of other remedies. The
compound liquorice powder of the German Codex, or ten grains of sul-
phur mixed with confection of senna, are couvenient forms. Com-
pound liquorice powder contains both sulphur and senna, and is not
disagreeable. Dr. George Bird tells me that children like it, and that
for them it is an excellent purgative. The dose for adults is one to
two teaspoonfuls stirred in a little water or milk. Apart from its soft-
ening effect on the motions, sulphur exerts a beneficial action on the
I'ectum in prolapsus and in piles. A morning dose of five to ten grains
of sulphur mixed in a drachm of confection of senna is a very useful
laxative in piles.

What changes does sulphur undergo in the body, and in what way
does this drug act as a purgative ?

It has been suggested that some of the sulphur becomes dissolved in
the fat it meets with in the intestines, and thus blended, is in a fit condi-
tion to act both as a purgative and to fiass into the blood; but the fact
that Avhen sulphur is administered simultaneously Avith much fat. the
quantity of sulphur in the ui'ine is not increased, renders this explanation,
improbable.

Some of the sulphur, undoubtedly, is converted into a sulphide by the
action of the alkali of the bile; for after the ingestion of sulphur the gas
generated in the intestines contains not only a considerable quantity of
sulphuretted hydrogen, but much of the gas is given off by the skin, to
the extent even of tarnishing metal articles worn about the person. Sul-
phur acts as a purgative through conversion into a sulphide, and by virtue
of the same change it is enabled to enter the blood, a view supported by
the fact that sulphides act in the same way as sulphur. Yet a portion in
the form of fine particles j^robably passes "through the walls of the intes-
tines undissolved, though the quantity so conveyed is undoubtedly very
small.

The action of sulphur on the physical or chemical constitution of the
blood is at present unknown. It has been said to produce salivation oc-
casionally, in persons who had previously taken mercury. It is generally
held that it excites an increased secretion from the mucous membrane of
the air-passages of healthy persons, although this is denied by Bucliheim.
Graves and other authorities strongly recommended sulphur in doses of
from five to ten grains, repeated three or four times a day in severe
chronic bronchitis, with abundant discharge, especially when accompanied
by constitutional debility. It is said to lessen the secretion, and to render
its expulsion easier.

It is said to increase both the frequency and force of the heart's con-
tractions, and to promote the flow of perspiration; but these assertions
greatly need confirmation.

92 SULPHIDES.

It is commonly supposed that the application of sulphur to the skin
"will relieve the pain of chronic rheumatism and sciatica ; but, as in ap-
plying the sulphur, it is generally recommended also to envelop the
ali'ected limbs in soft flannel; it is difficult to discriminate whether the
relief is attributable to the sulphur or to flannel. Administered inter-
nally suljahur is useful in chronic rheumatism and muscular rheu-
matism.

It is said that the internal administration of sulphur is service-
able in chronic eruptions of the skin, as acne, psoriasis, impetigo, and
eczemn.

Most of the sulphur taken into the stomach escapes with the fasces;
while of that portion which enters the blood, some of it becomes oxi-
dized, and appears in the urine as a sulphate, or one of the lower oxides
of sulj)hur. The sulphuretted hydrogen, from its great volatility, es-
capes in some measure b}" the lungs and skin, and occasionally with the
m.ilk, and by the. urine.

A portion of the ingested sulphur is said to pass through the system
and to be separated by the kidneys in the uncombihed state. Sulphur
produces no change in the quantity of the constituents of the urine,
with the exception of the sulphur compounds, which it augments.

Sulphur may be conveniently administered in milk.

THE SULPHIDE OF POTASSIUM, SODIUM, AMMONIUM,

AND CALCIUM.

Maxy natural waters contain one or more of these substances. Sul-
phurous waters are found at Harrowgate, Bareges, etc. They have a
characteristic odor, like that of rotten eggs.

The three first substances are freely soluble, the last is very scantily
soluble in water.

Sulphuretted hydrogen and sulphides possess the same action, and
sulphides owe their virtues to the sulphur and not to their base.

Sulphuretted hydrogen is very jDoisonous to both animal and vege-
table life. It decomposes the blood, first reducing and then decompos-
ing hsemoglobin; hence it j^roduces asphyxia. It also poisons the tis-
sues, and paralyzes the nervous and muscular tissues.

Strong solutions of these soluble salts excite active inflammation of
the skin; weak solutions stimulate the skin, augment its supply of blood,
and increase perspiration.

Baths containing these substances are very useful in the chronic forms
of some skin diseases, as psoriasis, eczema, and lichen ; likewise in
chronic rheumatism, chronic gout, and chronic lead-poisoning. In these
diseases the natural sulj^hurous waters are largely used as baths: but in
eczema and psoriasis care must be taken not to employ them till the

SULPHIDES, 9 3

subsidence of the acute stage, otherwise they will greatly aggravate the
rash. Obstinate forms of these skin diseases, rebellions to other treat-
ment, often yield to sulphide baths.

It has been attempted to explain the efficacy of sulj)hurous baths in.
cases of chronic lead poisoning, by the assumption that they eliminate
the lead with the sweat. Under the use of these baths the skin, it is
said, becomes covered with innumerable black points of sulphide of
lead ; but in fact the lead thus blackened was deposited on the skin from
external sources, and was not eliminated with the perspiration. This
objection,' however, is met by the assertion that if a lead-poisoned pa-
tient carefully abstains from all contact with lead, yet, as often as he
uses a sulphurous bath, his body still becomes blackened time after time.
On theoretical grounds it is hard to understand how this metal can be
eliminated with the perspiration; but for the further consideration of
this point we must refer our readers to the section on lead.

The use of these baths at a very high temperature will often restore
a considerable degree of suppleness to joints distorted and stiffened by
chronic rheumatoid arthritis. Yet as other baths of like temperature
appear to do equal good, it is difficult to say whether the sulphides play
any part in the beneficial results, although, it is true, there is a wide-
spread, and perhaps well-grounded, belief in their efficacy.

A very efficient application to cure itch is made in the following
way: — Boil one part of quicklime with two of sublimed sulphur in teu
parts of water, until the sulphur and lime combine; let the solution
stand, and afterward decant the clear part. Metal vessels should not be
used in its preparation. After the patient has bathed and wiped him-
self dry the liquid solution is to be painted over the body. This appli-
cation is rather irritating, and sometimes produces a roughness of the
skin, which may continue some time. Dr. Bourguignon, who intro-
duced this plan, claims that it will cure in half an hour. (See
Sulphur.)

The suljihides are in part decomposed by the acids they encounter
in the stomach, giving rise to disagreeable eructations of sulphuretted
hydrogen gas.

The sulphides in small doses excite a sensation of warmth at the epi-
gastrium, but in excessive doses they produce active inflammation in the
digestive canal, with the customary symptoms.

Small doses act as a slight irritant to the intestines, and determine
gentle relaxation of the bowels. It is supposed that sulphur acts as a
purgative, by its conversion into a sulphide through the agency of the
alkali of the bile.

In cases of poisoning by certain metallic salts the sulpides are em-
ployed, as they precipitate the metal in the form of an insoluble sul-
phide, and so render it harmless. There is danger, however, of giving
the sulphide in too large a quantity, since in its turn it might itself ex-
cite inflammation of the stomach ; wherefore sulphide of iron is generally
preferable to the alkaline sulphides.

The effect of the sulphides on the blood after absorption into that
fluid is at present unascertained.

Persons habitually breathing air impregnated with sulphuretted hy-
drogen are certainly prone to suffer from great anaemia, and the gas
appears to cause much functional depression.

94 SULPHIDES.

Sulphides affect chiefly the mucous membranes and the skin. Given
in the form of natural waters, they are highly efficacious in chronic
catarrh of the pharynx and of the res2:)iratory tract. They are especially
useful in follicular pharyngitis, and are much resorted to abroad by
j)ublic singers. Some observers find these waters very useful in phthisis,
even in the febrile form; but no doubt the higli altitude where these
waters are generally taken exerts some beneficial effect. Many of these
sulphur waters are obtainable in this country, but probably sulphides act
as well. I have, however, tried sulphide of calcium, pushed to its full
limit of toleration in phthisis, but without any apparent good result.

These substances, in certain troublesome diseases, often yield strik-
ing results.

This group of remedies influences the suppurative process in a very
decided and manifest manner.

Thus the common case of a sore, discharging a thin, watery, unheal-
thy ichor, Avill speedily undergo a healthy change under the administra-
tion of sulpliide of calcium, the discharge becoming at first more abun-
dant, afterward diminishing, and throughout continuing creamier,
thicker and healthier, with all the characters indeed of " laudable " pus.

Dr. Bergeon, of Lyon, after extensive trials, strongly recommends
intestinal injections of sulphuretted hydrogen in consumption. He
mixes the gas with carbonic acid gas, as atmospheric air does not be-
come absorbed. Carbonic acid should be liberated from bicarbonate of
soda by the action of' an acid, and then mixed with sulphuretted hydro-
gen set free from the following solution : sodium sulphide, 10 grammes,
distilled water, 100 c.c, to which is added 15 c.c of the following solu-
tion : tartaric acid, 25 grammes, salicylic acid, 1 gramme, distilled water,
100 c.c. A special apparatus is required. The gas must be adminis-
tered twice a day, and slowly discharged from the apparatus, each charge
of the elastic bottle being expelled into the colon every ten or fifteen
seconds. In phthisis he claims that it lessens cough and expectoration ;
the fever abates, the appetite increases, sleep improves, and weight in-
creases. Its mode of action is not yet explained. It does not destroy
the tubercle bacillus. The treatment is said, too, to be useful in chronic
bronchitis and asthma, and notably to check profuse secretion. The
gas is evidently quickly absorbed. It rather accelerates and strength-
ens the pulse, and quickens respiration. If too much is administered,
the pulse becomes very frequent, amounting to 120 or more, and it be-
comes feeble; respiration, too, becomes much hurried, may reach even
100 per minute. The face is flushed, aspect anxious, and the j^atient
may become quite unconscious, and yet, in ten minutes the ill effects
may quite pass away. The reports of subsequent observers corroborate
in varying degrees these statements. Some, however, maintain that no
specially good results are due to this treatment. Owing to the trouble
and annoyance of this method, it has not at present received a full and
impartial trial.

The sulphides appear to me to possess the property of preventing
and arresting supparation. Thus in inflammation threatening to end
in suppuration they reduce the inflammation, and avert the formation
of pus. This effect, for instance, is manifested by the action of the
local application of sulphur compounds in acne indurata, a subject to be
dealt with further on more in detail.

SULPHIDES. 95

After tlie formation of pus, tlie influence of this group on the sup-
puration process is still more conspicuous; then the sulphides hasten ma-
turation considerably, whilst at the same time they diminish and circum-
scribe the inflammation, promote the passage of the pus to the surface,
and the evacuation of the abscess. Their efficacy may be frequently
demonstrated in cases of the following kind. An unhealthy child, from
six to twelve months old, perhaps in the course of measles or scarlatina
is the subject of a slight sore-throat, which produces behind the angle of
the jaw considerable enlargement of the glands, and the swelling, of stony
hardness, may be large enough to interfere with swallowing, and even to
push the head on one side. Very deep-seated suppuration takes place,
and for a long time there is neither redness of the skin nor fluctuation,
and the pus very slowly makes its way to the surface, so that a fortnight,
three weeks, or even a month may elapse before the abscess bursts, or is
fit to be opened, when a deep hole is left, with considerable indurations
around it. So great are the pain and constitutional disturbance that the
child sometimes dies; and even if this fatality be averted, the deep dis-
charging hole heals very slowly, owing to the indurated and unhealthy
state of the adjacent tissues. Now, in such a testing case, if we give a
tenth of a grain of sulphide of calcium, mixed with a grain of sugar of
milk, every hour or two, the results are most striking. The pain and
constitutional disturbance begin to diminish, the swelling becomes smaller,
the pus reaches the surface in four or five days, leaving when it is evacu-
ated a benign wound which quickly heals. The effects of these remedies
are equally conspicuous in mammary abscesses, although in rare instances
they appear temporarily to increase the pain — a fact which seems some-
times to hold good with respect to boils, though as a rule the ]uxin is
speedily mitigated. Singular to say, I have found these remedies much
less useful in forwarding the maturation and expulsion of pus in indolent
buboes; but in such cases my experience of the sulphides has been but
small.

It may be urged that it is difficult to imagine how these remedies can
produce effects so different and apparently opposite as the dispersion of
inflammation in one case, and the expulsion of pus in another; poultices,
however, and hot fomentations, both subdue inflammation and prevent
suppuration, and in other cases considerably hasten the evacuation of pus.

In boils and carbuncles these remedies yield excellent results. A
tenth of a grain of sulphide of calcium given hourly, or a quarter or half
a grain three or four times a day, will generally prevent the formation
of fresh boils, while it lessens the inflammation and reduces the area of
existing boils, and quickly liquefies the core, so that it separates much
more speedily, thus considerably curtailing the course of the boil. Where
the skin is not yet broken, and the slow-separating core not yet exposed,
the sulphides often convert the boil into an abscess, so that on bursting
pus is freely discharged, and the wound at once heals; or if the centre of
the hardened swollen tissues is not yet dead, the pustule dries up, the
inflammation subsides, and a hard knot is left, which disappears in a few
days, without the formation of a core, and without any discharge. These
remedies meanwhile improve the general health, removing tliat debility
and malaise ordinarily so markedly associated with boils aiid carbuncles.
In some cases, however, as in the deep-seated boils and abscesses of dia-
betes, they are less efficacious. In carbuncles the sulphides will generally
be found equally serviceable, melting, as it were, the core into healthy

96 SULPHIDES.

pus, and so quickly expelling the dead and otherwise slow- separating tis-
sue. Belladonna applied over abscesses and carbuncles reduces inflam-
mation and allays pain. The skin should be thickly smeared with equal
parts of belladonna and glycerine, and over this a poiiltice should be ap-
plied and the smearing renewed each time the poultice is changed. Poul-
tices, however, being liable to bring out a fresh crop of boils, it is well to
smear belladonna ointment some distance round but not over the boil, and
then to apply a poultice, the greasy application thus protecting the neigh-
boring tissues. Or, still better, apply a belladonna or opium plaster on
leather, with a hole the size of the boil, around the SAvelling, and through
the opening smear glycerine and belladonna, covering all with a small
poultice. The leather ]ilaster efficiently protects the surrounding skin,
and averts the production of fresh boils. I have thought it worth while
to point out these useful accessory plans of protecting the boil; ])ut it
is scarcely necessary to observe that whilst investigating the effects of sul-
phides I have employed them alone, or at most sometimes using only a
poultice. Indeed, the effect of sulphides on boils is so excellent and
prompt that external applications are generally unnecessary, though of
course they are required in the treatment of carbuncles. Sulphides
should be continued till the discharge has nearly ceased, and till stimulat-
ing applications are needed, when tonics must replace sulphides.

The good effects of sulphides are conspicuous in certain scrofulous sores
not uncommonly seen in children. Scrofulous children during the first
fcAV months are sometimes subject to indolent abscesses in the cellular tis-
sue which nm a very slow course. At first only small hard substances are
observable, no larger than a pea, under the skin, Avliich is of natural color,
and movable over them. The small substances next suppurate and gradu-
ally enlarge, the skin becomes adherent, and changes in color to red or
even violet, while the smaller vessels in their neighborhood sometimes
become enlarged and even varicose. The tumors may attain the size of a
florin, and when maturated feel soft and boggy. After a time a small
circular opening appears, not larger, perhaps, than a pin's head, through
which escapes a thin unhealthy pus. If deep-seated, as on the buttocks,
or occurring in fat children, there may be very little or no discoloration of
the skin. The cliief noticeable character, then, is the small sharply-cut
opening, as if a piece had been punched out. These formations follow
one another, and may continue to distress the child for months or years.
In mild cases a few only may form, whilst in severe cases there may be at
one time ten or a dozen in different stages of development. When they
heal they leave a white, sharply-defined, but not deeply-depressed
scar. Xow this troublesome and pertinacious condition will give Avay
speedily to the administration every hour or two of a tenth or twentieth
of a grain of sulphide of calcium. The formation of new nodules is at
once checked, for a fresh one rarely now makes its appearance, although
for months or years the child may have been infested with successive crops.
Many of the abscesses, especially in a very early stage of development, dry
up and disperse; others generally speedily maturate their contents, the
thin and unhealthy pus becoming creamy and " laudable." The abscesses
already in an open state improve, the pus becoming healthier, and the
wounds healing quickly.

In some cases, in addition to these subcutaneous formations, the bones
likewise become affected. The phalangeal bones of the hand are most
frequently attacked, though not uncommonly the metacarpal, and more

SULPHIDES. 97

rarely tlie metatarsal. Where the phalangeal bones are affected one or
several of the fingers become nodose. For a long while the skin remains
pale and freely movable, bnt then suppuration ensues, the swelling in-
creases, the skin becomes red and painful, and after a time slowly softens
at one point, remaining boggy for a considerable period before the abscess
opens naturally. Then generally a little bone separates, or in bad cases
the whole of the shaft comes away, leaving the epiphyses behind. AVhen
an opportunity occurs to examine these bones before suppuration sets in
the shaft is found considerably enlarged, very pale, and the cancellous
structure infiltrated with a straw-colored firm substance, whilst the epi-
physes and their cartilages are healthy. Even in these severe cases the
sulphides will benefit considerably; thus before suppuration has set in, or
whilst it has made little way, they often remove the swelling, though large
doses may be required. After much suppuration the good effects of sul-
phides depend in a great measure on the amount of the disease of the
bone. If the whole shaft becomes necrosed of course the sore will not
heal till the bone has b^en got rid of, but suppuration often occurs, and
yet but little, or perhaps none, of the bone dies. In such a case the sul-
phides hasten the expulsion of the pus, and when the skin is already broken
they improve the character* of the wound and the discharge, and heal the
sore, leaving a sunken scar adherent to the bone, whilst the finger slowly
assumes its natural proportions. The sulphides similarly affect large
indolent abscesses on the back of the hands or on the feet. Whilst thus
influencing locally strumous formations and abscesses these remedies im-
prove the child's health, which perhaps had failed before in spite of cod-
liver oil and steel wine. That the improvement is due to the sulphide is
shown by the fact that the amendment occurs when this drug only is ad-
ministered. Sometimes, instead of improving the general health, sul-
phides produce marked anaemia, due, I think, to the administration of
too large a dose. On prematurely discontinuing the sulphide fresh for-
mations are apt to appear, especially on the occurrence even of a slight
illness; indeed, a severe illness will often excite a few fresh abscesses, in
spite of the sulphides.

In suppurating scrofulous glands in the neck the sulphides appear to
me to exercise a very beneficial influence by hastening the elimination of
the pus, and subsequently the cheesy scrofulous matter. After the
abscesses have burst, and continue to slowly discharge a scanty, unhealthy
pus, and when the edges of the sores have become much thickened and
indurated, the sulphides render the discharge more abundant, thick,
creamy, and healthy, considerably hasten the evacuation of the scrofulous
matter which prevents the healing of the wound, and at the same time
soften the round indurated edges, so that the sore heals much more
speedily. If small doses appear to affect these sores inadequately, larger
doses, as half a grain or a grain, should be given several times a day, or
even every two hours. I need hardly say that to compass the results
described the treatment must be continued several weeks, for when the
sores have been discharging perhaps for months or even years, it is vain
to expect much amendment in a few days.

The topical effect of sulphur ointment, or of an ointment of the
hypochlorite of sulphur, or, still better, of the iodide of sulphur of the
Pharmacopoeia, is very marked on acne indurata and acne rosacea. Here,
again, according to the stage of the eruption, the effects are twofold, and
even opposed. If applied at the very commencement of the eruption, as

98 CHLORINE.

soon Jis the little hard knot is felt under tlie skin, the ointment iirrests
further development and quickly dissipates the hardness. For instance,
if smeared over the hardness just before going to hed, scarcely any in-
duration will be felt in the morning, though after a time, perhaps from
exercise, or the irritation from washing, much of the hardness may return,
to be again removed by a renewed application of the ointment, so that in
two, or at most three days, it will completely disperse a papule which
threatened to become of considerable size. When, however, the nodule
has advanced further, and suppuration has set in, then the effect of the
ointment is much like that of sulphides administered internally, on boils.
The ointment hastens maturation, limits the swelling and hardness, and
thus considerably curtails the duration of the eruption. Nay, further, if
rubbed over the skin it appears to check the formation of the acne spots;
rubbed over the nose and neighboring parts of the face in acne rosacea,
its effects are often striking. Not only does it act as in acne indurata,
but the hardened, swollen tissues become softened and reduced to a more
natural state. I have found the iodide of suLphur useful likewise in
hromic acne; it reduces the eruption, or, at least, lessens the size of each
spot considerably. The ointment should be thickly smeared over the
eruption of acne night and morning.

To adults sulphide of calcium is best administered in a coated pill in
quarter or half grain doses, three or four times a day. For children I use
the following formula?:— Mix a grain of the sulphide of calcium (the
member of this group which I always employ) with half a pint of water,
and give to a child a teaspoonful hourly. It is essential that the medicine
in this form should be comjwunded daily, since the salt rapidly becomes
oxidized and changed into a sulphate, so that in a very short time none of
the sulphide remains. It is still more convenient to give the sulphide
in powder. A child should take one-tenth or one-twentieth of a grain,
and the powder should be put upon the tongue and washed down with a
draught of water, or a tenth of a grain made into a small varnished pill,
should be taken hourly.

In employing these agents in baths, porcelain or wooden vessels must
be used, as the sulphide attacks and discolors most metals. These baths
emit a powerful odor, very offensive to some people.

CIILOEINE GAS.
CHLORINE WATER.
CHLORINATED SODA ] , ,, ■ , , •
CHLORINATED LIME \ ^'''^ ^^^^^^ solutions.

These substances are used as disinfectants, antiseptics and deodorizers.

This action depends in part on their power to destroy the organisms
that produce putrefaction, and those that produce the septic poison or are
themselves the cause of specific fevers.

Whatever power they possess in these respects is due either to chlorine
or to hypochlorous acid.

Chlorine gas, jwssessing very strong chemical affinities, acts probably
by seizing with avidity upon the hydrogen in organic and inorganic sub-
stances, thus breaking up their composition.

CIILORIN"E. 99

Hypoclilorous acid, wliicli is given off abundantly by the two last-
mentioned members of this group, is an active oxidizing agent. It yields
up its oxygen readily, and is tlius destructive to many substances; at the
same time chlorine gas is set free, which in its turn acts in the way just
described.

These substances are employed in sick rooms as disinfectants, Init the
evidence in favor of their possessing such a property, although very
generally held to be sufficient, is inconclusive.

Some infecting matters, it is true, when treated with these substances,
lose their power to propagate disease; but it is impossible to subject
objects, and particularly persons, to such destructive action as is found
to be required in these experiments. It is uncertain, then, whether, in
the gaseous form, or in the dilute state in which it can be borne, chlorine
can destroy germs and their spores.

Chlorine is a deodorizer acting in two ways. It can destroy the germs
which produce putrefaction, or it can destroy the noxious gases produced
by decomposition, such as the ammonias, sulphuretted hydrogen, and
sulphides of ammonium, which create the disagreeable odors of sick rooms.
■ Owing to its gaseous state, chlorine is admirably suited as a deodorizer;
it penetrates every cranny of the room, searching out and destroying
noxious and offensive gases.

While these substances may be conveniently and profitably used as
deodorizers, it must always be borne in mind that it is better to prevent
bad smells by free ventilation, and that chlorine gas itself has an odor very
disagreeable to most people. If these deodorizers are often required in a
sick room, it is a sure sign that ventilation is defective, and probably that
the nurse is careless.

To disinfect unoccupied rooms, the air must be very strongly impreg-
nated with chlorine. M. Eegnault recommends the following plan, first
blocking the chimney and closing the room: — 8ew one pound of chloride
of lime loosely in a strong canvas bag, and put it into a mixture composed
of a pint and a half of commercial hydrochloric acid with four and a half
pints of water. Then after twenty-four hours, freely ventilate the room
for forty-eight hours.

Besides their capacity to destroy many offensive gases, these substances
prevent decomposition; hence they are useful as washes or injections to
prevent the decomposition of the pus of sores, or cavities of the body.
Sloughing, foul-smelling sores, should be washed with solutions of these
or other kindred substances. Chlorine compounds, being slightly stimu-
lating, improve the condition of indolent sores. After an operation, the
pus which sometimes collects in the hollows left becomes corrupt, and
gives off foetid gas, which becomes absorbed and poisons the system.
This may be avoided by washing out the cavities several times daily with
a weak chlorine solution. In puerperal peritonitis, or at any time when
the uterus contains decomposing matter, the vagina must be thoroughly
and frequently washed out, some deodorizing and antiseptic substance
being mixed with water. Many obstetricians in puerperal fever and other
conditions wash out in this Avay the cavity of the womb itself.

Antiseptic solutions in sloughing of the throat, as in scarlet fever or
diphtheria, and in salivation and ulceration of the mouth, will remove
the foul odor and tend to arrest putrefaction.

A strong solution of chlorinated soda has been highly recommended
in diphtheria.

100

IODINE.

The deodorizing and antiseptic substances chiefly in use, besides the
members of this group, are iodine, permanganate of potash, and car-
bolic acid. Solutions of permanganate of potash, unless unnecessaril}'
strong, are bland and unirritating; while the chlorine and carbolic acid
solutions are stimulating, and even irritating. Carbolic acid is in some
respects inferior to the other members of this group, since it seems to
lack power to destroy offensive gases.

IODINE.

Iodine, like chlorine, possesses powerful chemical affinities, and com-
bine energetically with many organic and inorganic substances, and is a
disinfectant, antiseptic, and deodorizer.

Iodine maybe used as a deodorizer and disinfectant by simply suspend-
ing over the patient's head a lidless chip-box, or a saucer, containing ti
few grains.

It is volatile, and readily penetrates the animal textures.

It is applied to the skin for a variety of purposes. A strong solution,
as the liniment, is frequently used as a rubefacient and counter-irritant,
producing at first a sensation of heat and burning, which may increase to
an unendurable extent. The inflammation it excites separates the cuticle
to a greater or less extent from the dermis, so slight it may be that in a
few days mere desquamation results; but if the liniment is strong it
rapidly produces even a blister containing serum with much fibrine, leav-
ing sometimes a permanent scar — a misadventure which should be care-
fully avoided.

The skin can generally bear two lightly-painted coats of the Pharma-
copoeia liniment, unless a previous application has rendered it thin and
delicate, when one coat, lightly applied, is all that can be endured. If,
as sometimes lia2')pens, the application causes much pain, the iodine should
be washed off with spirits of wine, gin, or whiskey, eau de Cologne, or,
best of all, with a solution of iodide of potassium, and the pain subdued
by the application of a poultice. On and around the painted spot iodine
liniment will often excite a crop of itching papules, which often appear
as late as the third or fourth day after the application.

The liniment applied to the chest as a counter-irritant in chronic
pleurisy is used to promote the absorption of the fluid accumulated in the
pleura. Painted under the clavicles in the chronic forms of phthisis, it
is of great service to allay hai'assing cough, and to check secretion from
the bronchial tubes and cavities of the lungs. Painted over the front and
back of the chest it often affords relief In chronic bronchial catarrh by
easing the cough and lessening the expectoration. It may also be painted
on any part of the chest affected with pleurodynlc pains, although a
mustard poultice is preferable, as it can be reapplied should the pain
return. The iodine, however, may succeed where the mustard fails.
Iodine is painted around joints affected with chronic rheumatism or

IODINE. 101

chronic gout, or with chronic synovitis. Like blisters, it eases the pain,
and often removes the fluid distending the cavity of the Joint; Uke
blisters, too, it often causes, for a few days, increased distention of the
joint, tli(^ good etfects not becoming apparent till later. This increase of
the swelling may be regarded as an indication of the success of the appli-
cation. The liniment is useful when painted on the skin over a bron-
chocele. It should be applied — though it can seldom be borne oftener
than once a week — as often as the state of the skin will permit, till the
tumor disappears. The liniment or tincture is recommended as an ap-
plication to lupus, painted not only on the edges of the sore, but also over
the tissues around it. It is said to arrest the spreading of the disease.
In the form of ointment its applications are manifold. It is of the great-
est benefit in chilblains, if Avell rubbed over the affected part before the
skin is broken. The tincture lightly painted over the part is often used
for chilblains, but the ointment is far more efficacious, curing unbroken
chilblains in one or two days. In this harassing affection I know nothing
so effective. The intolerable itching of chilblains is often very difficult
to relieve. Hot water often affords temporary relief. I have heard
])atients say that an infusion of celery, used as hot as can be borne, is
liighly efficacious, and that the efficacy is not simply due to the hot Avater,
as the celery infusion affords far more enduring relief than simple hot
water. Benzoin, iodine dissolved in ammonia (colorless tincture of iodine
and liniment of ammonia) are each useful in chilblains.

Iodine ointment is often useful in removing some of the non-inflam-
matory pains of the chest; but these, not being always of the same nature,
discrimination must be exercised. When the pain is situated in the
muscles (myalgia), and these are teiuler on pressure, while the skin may
be pinched without pain, this ointment is indicated. But if the tender-
ness is situated in the skin (pleurodynia), belladonna is to be preferred.
I believe Dr. Hare first pointed out this distinction, and it is one which
holds true, though not without exceptions.

The ointment, tincture and liniment of iodine are used for the same
purposes; but it must be recollected that the ointment and tincture are
much milder preparations, and will even after several applications prodnce
but a small amount of desquamation. When a strong irritant action is
needed, the liniment must be employed; and a medium effect can be pro-
duced by suitably diluting the liniment with spirit.

The tincture or the ointment is often applied over indurated swollen
glands, or parts thickened by inflammation, with the intention of remov-
ing the diseased products; but when painted over scrofulous glands, or
glands subacutely inflamed, care must be taken lest the applications in-
crease the inflammation and favor suppuration.

Iodine is a powerful parasiticide, and is used for this purpose in skin
diseases. A mixture of light oil of wood tar in the proportion of two
drachms of iodine to an ounce of oil of wood tar has been recommended
by Mr. Coster as an efficient application in tinea tonsurans. It usually
produces no pain, and without doubt prevents the extension of this
troublesome disease.

In many cases where the disease involves a large part or the whole of
the head, this application may be painted over the entire scalp. Occasion-
ally, however, the skin is so delicate that this extensive applicatio'n cannot
be borne, and then it should be apj^lied only to a small surface and painted
on a fresh part daily. In some cases it gives so much pain that it cannot

102

IODINE.

be at all tolerated. Coster's paint, as miglit be expected, is far more
effectual in the circumscribed than in the diffuse form.

The liniment, ointment, or tincture will remove herpes cireinatus.
One application of the liniment is enough, but the ointment or tincture
must be applied once or twice daily.

Painting the affected and circumjacent skin with a solution oJ' iodine
is strongly recommended to prevent the spread of erysipelas.

Mr. Jordan speaks highly of the application of the liniment in the
neighborhood of local inflammation; applied so as to produce vesication
around a bubo, an abscess, or a carbuncle, it considerably reduces inflam-
mation.

In hydrocele, iodine in solution, generally the tincture, is perhaps
the best fluid to inject into the serous cavity surrounding the testicle.
The serous fluid is first drawn off, then the iodine is injected into the
cavity, which, exciting adhesive inflammation, the contiguous surface of
the sac unites, and the fui'ther effusion of serum is rendered impossible.

Iodine solution is injected into joints affected with white swelling, into
the cavity of the pleura in empyaema, into ovarian tumors after tapping,
and into large abscesses after their evacuation. Ten ounces of the tinc-
ture, and even more, may be injected into an ovarian sac. The results
of the cases thus treated are most satisfactory. The injection of white
swellings is said to produce no ill symptoms, and unless there is caries or
necrosis of the bones, or swelling of the surrounding parts, this treatment
is generally favorable.

In chronic pleurisy, after the side has been evacuated, iodine injec-
tions remove the great fcetor often present from the decomposition of pus
in the pleural sac, and at the same time diminish the secretion from its
walls. The injection must at first be weak, say four or five grains of
iodine and iodide of potassium to a pint of water, but when the structures
have become accustomed to it a stronger solution may be employed. No
doubt this treatment is often successful; still it must be carried out with,
the greatest caution, otherwise inflammation, with high fever, may set in,
and prove fatal.

Milder injections, containing permanganate of potash, or a small quan-
tity of creosote, or quinia, are generally adequate to destroy the fa3tor, in
which case the more powerful agents are of course not to be used. Since
the Avasting, the loss of appetite, and depression in cases like these is
mainly traceable to the absorption of poisonous gases and putrid fluids, it
is of the highest importance to keep the sac free from them.

Iodine solutions, injected into the cavities of large abscesses, their con-
tents having been discharged, often prove very serviceable. The tincture
itself may be freely used; the cavity of the abscess should subsequently be
kept clean and sweet by frequent washings with a weak solution of per-
manganate of potash. Iliac and lumbar abscesses, too, may be treated in
this way.

Lister's method of treating abscesses and empyemas has, in most
cases, rendered the use of chlorine and iodine applications unnecessary.

The hypodermic injection of tincture of iodine, in five to fifteen or
more minims, is now much used for the cure of bronchocele. Iodine is
useful also in hypertrophied tonsils and glanduLir tumors. The tinc-
ture must be injected into the glandidar eidargement, and not into the
connective tissue, or ulceration will ensue. The injection should be re-
peated once or twice a week.

IODINE. 103

The tincture of iodine may be used as an inhalation, witli signal bene-
fit in the four following instances: —

1. In the chronic forms of phthisis (fibroid lung); when the expecto-
ration is abundant, and the cough troublesome, an inhalation used night
and morning will generally lessen the expectoration, and allay the cough.

2. In children, six to ten years of age, after measles, or independently
of it, on exposure to cold, seized with hoarseness, a hoarse hollow cough,
and some wheezing at the chest. This affection involving the larynx,
trachea, and larger bronchial tubes, often proves very obstinate, is apt to
return, and to persist a considerable time.

3. In some epidemics of diphtheria, the inhalation recommended by
Dr. Waring-Curran: — 4 grains of iodine, 4 grains of iodide of potassium,
4 drachms of alcohol, and 4 ounces of water. A teaspoonful of this should
be added to boiling water, kept hot by a spirit lamp whilst the steam is
inhaled. As the patient becomes accustomed to the iodine, the quantity
of the solution may be increased till half an ounce of it is used at each
inhalation. It should be repeated many times a day, and each inhalation
continued from eight to twelve minutes.

4. In itching of the nose or of the inner can thus of one or both eyes,
sneezing, running at the nose of a watery fluid, weeping of the eyes, and
severe frontal headache. Patients of various ages are greatly troubled,
often for many years, with daily attacks, lasting it may be several hours.
Iodine inhalation often removes this affection at once, and when it suc-
ceeds partially it almost always lessens the headache and the discharge
from the nose. Its effect is most marked on the itching. (See Arsenic.)

I generally adopt the following simple, handy, cleanly, and effectual
plan of inhalation: — Heat well a jug capable of holding about two pints,
by rinsing with boiling water, then partially fill with boiling water, into
which pour twenty to thirty drops of the tincture of iodine; then direct
the patient to put his face over the mouth of the jug, and to breathe the
iodized steam; covering both the jug and the patient's head with a towel
to prevent the escape of the steam. This inhalation should be used night
and morning, for five minutes, or a little longer. Occasionally an excess
of iodine Avill temporarily produce a sensation of soreness in the chest, and
throat, sometimes with redness of the conjunctiva, running from the nose,
and pain in the head.

In chronic ozaena it is useful to flush the nose with a solution of
common salt, containing a few drops of tincture of iodine.

The tincture is useful to remove tartar from the teeth; and to stimu-
late the gums when they begin to recede, leaving the teeth exposed, and
more liable to decay. It should be painted over the gums close to the
teeth. An iodine gargle, made with two or four drachms of the tinc-
ture to eight ounces of water, has been recommended to allay mercurial
salivation; and the tincture of iodine is applied to sores of the throat,
syphilitic and simple.

Iodine, in undue quantity, irritates and excites inflammation in the
delicate structure of the stomach, inducing pain at the epigastrium,
vomiting, diarrhoea, sometimes much collapse, and even death. It should
be given soon after a meal, when the mucous membrane is protected by
the food.

When iodine reaches the stomach or intestines, and certainly when
it enters the blood, theory would suggest that this drug becomes converted

104 POTASSIUM AND SODIUM SALTS.

either into an iodide of potassium, or, more probably, of sodium, and
thenceforth, in its career through the body, it would behave as an iodide.
Practically, there is much to confirm this view, as the action of iodine
on the distant organs of the body is very generally admitted to be iden-
tical with that of the iodides; yet some practical authorities state, that
in chronic rheumatic arthritis the tincture of iodine is serviceable when
the iodide of potassium fails, although it is difficult to understand how
this should be. Some becomes converted into an albuminate.

Dr. Anderson recommends iodine in malarial fever. He has treated
"upward of 300 c;ises with almost invariable success." He gives from
twelve to fifteen minims of the compound tincture. It is said it is not
only a cheap but an efficient substitute for quinine, curing some cases
of ague where quinine has failed.

A FEW INTRODUCTOEY REMARKS REGARDING THE REL-
ATIVE EFFECTS OF POTASSIUM AND SODIUM SALTS.

Ix prescribing a medicine it is important to recollect that an ele-
ment on combining with another element does not lose its characteristic
action, and that the action of a salt is the sum of the action of its com-
ponent parts. For instance, in bromide of potassium we still have the
action both of bromine and potassium, and these substances on combin-
ing do not lose their individual properties, nay, their separate activities
are but little diminished, so that all potassium salts appear to be equally
poisonous to the animal body. Of course if the salt has an acid or alka-
line reaction it will act in virtue of its acidity or alkalinity; but from
numerous experiments all neutral salts of potash appear to be equally
poisonous.

We often prescribe remedies for their acid radicle only. This is
the case with iodides and bromides. Iodides act certainly in most
diseases in virtue simply of the iodine or bromides in virtue of the
bromine. Hitherto the practice has largely prevailed of prescribing
potassium comjjounds of iodine and bromine in preference to the sodium
or ammonium salts, but this practice ought certainly to be avoided, for
potassium salts are far more poisonous than the sodium salts, without
being in many cases more therapeutically active. It is obvious we ought
to avoid this unnecessary depression, arising from the use of jDotassium
salts in preference of sodium salts.

I will now draw attention to the differences chiefly between sodium
and potassium salts; differences in degree, but in some particulars like-
wise in kind.

Potassium salts are highly poisonous to all the animal tissues, suspend-
ing the functional activity of the nervous and muscular structures, and
probably of all the tissue* of the body. On the other hand, the corre-
sponding sodium salts are almost atoxic, even when administered in much
larger doses than the potassium salts.

This difference between potassium and sodium compounds is well ex-
emplified in experiments on the ventricle of the frog's heart. Potassium
salts markedly affect both nervous and muscular functions. Small doses
affect the spontaneous contractions, at first greatly reducing their fre-

POTASSIUM AND SODIU3[ SALTS. 105

quency, and then arresting them, whilst considerable contractility still
persists, which may be made evident by stimulating the ventricle by an
induction shock. A slightly increased dose of the potassium salts soon
suspends contractility likewise; sodium salts, on the contrary, aft'ect spon-
ta7ieous action very little, so that as long as contractility lasts spontaneous
action continues. Sodium salts, moreover, must be given in doses fourteen
to fifteen times larger than the potassium salts, in order to suspend mus-
cular contractility.

Whilst potassium salts largely increase the latent period in an induced
muscular contraction, sodium salts produce very little effect.

Potassium salts greatly augment the duration of the period of dimin-
ished excitability. Sodium salts very slightly extend this period.

AVhen the ventricle is strongly faradized it is thrown into a tetanic
state. Potassium salts in small closes prevent this tetanuS; whilst sodium
salts, even in much larger doses, but slightly lessen it.

Faradization arrests the spontaneous contractions in a ventricle poisoned
with only a small quantity of a potassium salt; but, on the contrary. Fara-
dization applied to a ventricle, even when arrested by sodium salt, in-
duces the return of contractions, one contraction being piled on the top
of another, and thus a considerable contraction of the ventricle is produced,
and is sustained, as in tetanus.

Thus we see that potassium, even when combined and forming neutral
salts, still acts as a powerful poison, whilst so weak is the action of sodium
that it can hardly be called a poison. From these facts it is obvious that
when we seek to profit by the action of the acid radicle of iodine or bro-
mine we should give the preparation of sodium in preference to that of
potassium. So far I have based this conclusion on physiological experi-
ment on animals, but clinical experience has long taught the same lesson;
indeed, potassium salts are far more powerfully depressing, whilst not
more therapeutically active than the sodium salts. These considerations
have led latterly to the introduction of hydriodic and hydrobromic acids,
and of iodoform in place of iodides and bromides. These ])reparations
are still on their trial, in respect to their relative value comjjared Avith
bromides and iodides.

The poisonous action of potassium, sodium, ammonium, and some otiier
salts, depends mainly on the percentage dose, not on the total amount
conveyed to the heart. In experiments on the detached frog's heart, when
sufficient of the salt is added to the circulating blood to cause arrest of
contractility, this annulled property can be restored by diluting the
blood with an equal quantity of saline solution, so that the ventricle re-
ceives the same quantity of the salt, but in a more diluted form.

These facts elucidate the meaning of the experiment of injecting a large
dose into the jugular vein, so that the salt reaches the heart in a con-
centrated condition, and arrests its action, whilst the same dose injected
at a distance from the heart, so that it becomes freely diluted with blood,
does not depress that organ, or at least in a very small degree.

In poisoning by such salts it is evident that the treatment should
consist of free drinking to dilute the blood, and also to promote elimina-
tion by the kidneys and skin. Bleeding, too, should be of some service.

These remarks merely mean that after absorption all potash salts ap-
pear to be equally, or nearly equally, poisonous to the nervous and mus-
cular tissues, affecting first the brain and central nervous system, next the
nerves, and lastly the muscles. But clinical experience abundantly shows

lOG POTASSIUM AND SODIUM SALTS.

that some potash compounds are far more harmful than others. The
most injurious are alkaline in reaction, and produce a depressing effect
through the stomach, for at fii'st alkalies increase the secretion of gastric
juice, but if too long persisted in they disorder the mucous memhrane,.
and so diminish its digestive powers. In many investigations with potas-
sium salts the results have been undoubtedly due entirely to the potassium,
tlie acid radicle not playing any part in the results; and this statement
holds particularly with bromide of potassium.

IODIDE OF POTASSIUM. 107

IODIDE OF POTASSIUM, IODIDE OF SODIUM, AND IODIDE

OF AMMONIUM.

Iodide of potassium being an extremely soluble salt, endowed witli a
very high diffusion-power, finds ready entrance into the blood, and speedy
exit from it with the secretions of the body.

As an external application it formerly enjoyed more favor than is
accorded to it now. As an ointment to the skin over enlarged glands,
or joarts thickened with inflammatory products, in conjunction with the
internal use of iodide of potassium, it hastens the resolution of obstinate
nodes, and is especially useful when the internal use of this salt disa-
grees, causing nausea, diarrhoea, or great prostration. The ointment is
sometimes used for the itch, and the ointment of this salt, or of iodine,
is often used in bronchocele.

According to most authorities the iodide, probably after its absorption
into the blood, produces decided changes in the mucous membrane of
the mouth, causing redness and injection of the lining of the cheek, the
throat, soft palate, and of the tongue, and an increased growth and sep-
aration of the epithelium covering these parts, and an augmented flow
of saliva. These phenomena, however, are certainly often absent after
large doses of the medicine, and even in severe iodism.

A j)atient told me that he had tried spirone for asthma, but could
not continue it, as it produced in his throat a disagreeable sensation,
just like that induced by potassium iodide. He was convinced it con-
tained an iodide; and on testing spirone with Mr. Martindale in his
laboratory, we found abundance of iodine, and Dr. Paul gave us the fol-
lowing result of his analysis: Glycerine, about 24 per cent., about 2 per
cent, of potassium iodide, whilst nearly half its volume consisted of ace-
tone. In one case of bronchitic asthma I tried a 2 per cent, solution of
potassium iodide as a spray, using about a drop diluted with water,
thrice daily. It greatly relieved the patient during her attacks, and
seemed quite as efficacious as Ilimrod's powder, whilst its effects seemed
more permanent than the powder or than the iodide of methyl, which
is also useful in paroxysms, acting in part no doubt through its iodine
constituent.

A large dose irritates the stomach and disorders digestion. Some
are far more prone than others to be thus affected, so prone that even
minute medicinal doses sometimes irritate the stomach.

Like the chloride of sodium and chloride of ammonium this salt in-
creases the production of mucus from the stomach and intestines, as well
as from the mucous membrane of other parts of the body; but when this
result is intended we resort to the chloride of ammonium in preference
to this salt.

Its great diffusion-power enables it to pass with great rapidity from
the stomach into the blood, and it very speedily appears in the, urine, so
that only a small proportion passes into the intestines. It purges only
when taken in very large doses, but it is never employed for this purpose.

Some maintain that when iodide of potassium comes in contact with
the chloride of sodium, either in the stomach or blood, it changes its
base, becoming iodide of sodium. At present we know but little what
physical or chemical changes it produces in the blood, or in the organs
to which it is carried.

If its administration is continued for a long period, or if the patient

108 IODIDE OF POTASSIUM.

manifests great susceptibility to its action, we may produce a condition
termed iodism.

Many persons can take this drug in very large quantities for an almost
indefinite time, without the induction of iodism, while very small doses,
even of a grain or part of a grain, produce it in others.

The tissues most frequently and most severely influenced by this drug
are the mucous covering of the eyes and lining of the nose, frontal sinus,
and mouth, with the skin of the face. Some slight running at the nose is
first noticed, with occasional sneezing, and a little frontal headache; these
symptoms becoming more marked when the conjunctiva becomes injected,
and the tears flow abundantly. The loose tissues about the orbit become
swollen, reddened, and oedematous, and occasionally a peculiar rash ap-
pears on the skin of the face, at first noticed around the eyes, after wliicli
it attacks the nose and its neighboring parts, and then the chin. The
parts in the order here stated are severally most severely affected. The
nose is sometimes reddened, especially at the tip, and is rather swollen.
The rash does not always present the same appearance. It is often very
much like acne, and is always hard, shotty, and indurated, but the
papules may be broad and large, and covered with what looks like a half-
developed vesicle or i:)ustule. The changes in the mouth have already
been mentioned when speaking of the influence of this medicine on that
part. With some persons the stomach is at the same time deranged,
although in the author's experience this organ often escapes when the
face is affected; on the other hand, the stomach sometimes suffers when
the nose and eyes are unaffected. When the stomach is singled out by
the iodide, it induces nausea, and a sensation of sinking at the epigastrium,
with loss of appetite, and sometimes water}^ diarrhoea. A grain or even
less may thus affect the stomach.

If the drug is discontinued on the occurrence of iodism the symptoms
just described speedily disappear; and the rash on the face, the running
at the eyes, etc., will greatly decline in the course of twenty- four to forty-
eight hours.

Iodides sometimes, as I shall show presently, cause diuresis. In some
persons iodides produce a petechial rash, affecting almost always the leg
exclusively, rarelv extending above the knee, and rarer still to the trunk
or upper extremities. It may, at first, take several days to produce this
rash, but when the spots have disappeared a single dose of five grains may,
in three hours, suffice to reproduce it. Sometimes on persisting Avith the
medicine no fresh rash appears, and the old spots die away; wliile in otlier
cases the rash endures as long as the medicine is continued. This rash
may be the only apparent effect of the iodide, but it is generally accom-
panied in a variable degree by a few or many of the symptoms of iodism.
The salts of iodine differ with respect to the production of this rash; thus
in many cases the ammonium salt is most apt to induce it, and the sodium
salt the least liable: in other cases, where the ammonium and potassium
salts produce a large crop of petechite, the sodium salt is inoperative.
Some persons are equally affected by each of these three preparations. In
one case, while the ammonium and potassium salts produced numerous
petechige, the sodium salt failed to do so, but excited on the arms some
erythema marginatum. The petechial rash is often preceded by a sensa-
tion of heat, accompanied by some tenderness. These facts seem to dis-
prove the assertion that either in the intestines or in the l)lood all iodides
ultimately become iodide of sodium. A patient some years after suffering

IODIDE OF POTASSIUM.

109

from a white leg took iodide of potassium on three separate occasions;
each time an abundant crop of petechia appeared below the knee of the
damaged leg, whilst none appeared on tlie other leg.

Iodide of potassium sometimes produces distressing depression of mind
and body, rendering the patient irritable, dejected, listless, wretched, and
unable to take moderate exercise without fatigue, and perhaps with a ten-
dency to fainting. The appetite is generally very bad. These symptoms
may arise from a very small dose, and may occur without coryza or irrita-
tion of the stomach — a fact important to bear in mind, otherwise, the
cause of the depression being overlooked, the medicine may be persisted
in. On discontinuing the drug these distressing symptoms disappear in
one or two days. It now and then exceptionally happens that the symp-
toms just described sometimes cease in a few days, even though the patient
goes on taking the medicine.

When the potassium salt is not tolerated the ammonium or sodium
salt can sometimes be borne. Thus iodide of potassium in ten-grain doses,
thrice daily, produced so much headache, sneezing, and running at the
nose, that it could not be continued, whilst the same dose of iodide of sodium
was easily borne, causing no headache, and only a little running at the
nose.

A full dose of carbonate of ammonia' or spirits of ammonia given with
the iodide of potassium will, it is said, obviate these symptoms of iodism;
but though I have many times put this recommendation to the test, 1
have seen no decided results, although perhaps the ammonia did occa-
sionally somewhat control the iodism.

Arsenic will lessen or prevent the eruptions produced by iodides.
Dr. Phillips, of St. Mary's Hospital, reports the case of a patient who took
fifteen grains of potassium iodide thrice daily, which produced marked
generarpurpura, and he found the addition of five minims of liquor
arsenicalis to each dose quite removed the petechia rash, which, however,
returned on discontinuing the arsenic, and again disappeared on resum-
ing it. He tested the effect of arsenic four times on this patient, and
each time removed the petechife.

Ten grains of iodide of potassium taken at bedtime often cuts short
an acute cold in the head, especially at the onset. It is much less effica-
cious if the cold attacks the lungs also, and in influenza it appears to be
useless. In ten-grain doses several times a day it is said to cure that
troublesome and obstinate affection, violent paroxysmal sneezing (see
Arsenic). It is likewise useful in chronic colds in the head in two or
three-grain doses thrice daily. Iodide of potassium is very useful in
chronic bronchitis, and may be profitably given with chloride of ammo-
nium, both drugs first increasing the amount of expectoration and making
it less viscid. Five grains of potassium iodide, half a grain of tartar
emetic, iin ounce of syrup of orange peel and three ounces of water make
an excellent mixture in teaspoonf ul hourly doses in acute febrile catarrh
of the respiratory tract. It is especially serviceable for children; the
tartar emetic, acting very like aconite, induces a copious jDerspiration.

The iodide is employed in a great variety of diseases. It is largely
employed in syphilis, but is not equally efficacious in all its forms, being
more useful in secondary and tertiary syphilis, especitilly in the tertiary
form, where mercury may do harm. The iodide should be employed
when the health is broken, when mercury has been taken without good
results, or when the bones are diseased. It is conspicuously beneficial

110 IODIDE OF POTASSIUM

when the disease fixes on the periosteum of the bones or fibrons structure
of the softer organs and forms nodes. Its action on this form of the disease
isahnost magical; it soon subdues the pain, and the nodes, if not of hnig
standing, quickly disappear. In the treatment of tubercular syphilitic
skin eruptions Dr. Neligan prefers it to a salt of mercury. The iodide of
potassium is of very great service in syphilis of deep-seated and important
organs. It has been commended in syphilitic iritis; but in this case most
authorities prefer mercury. The secondary syphilis of children is best
treated with mercury; yet the following somewhat rare form of syphilis
gives way best to iodine. In children a few months or years old, a syphi-
litic thickening of the periosteum is sometimes observed, usually attacking
the heads of several of the long bones, and sometimes also tlie shafts.
The thickening is first felt around the bones; but as the disease advances
the neighboring soft tissues become infiltrated with a firm exudation,
which may increase to such a degree that the implicated jiart of the limb
becomes much swollen, the skin very tense and shining, and a little red-
dened. The affected parts are very painful. When the disease is seated
at the head of the bones the movement of the joint is not impaired. If
long uncured, this condition leaves behind it permanent thickening and
enlargement; and so we sometimes see children with syphilitic teeth, and
blind from syphilitic iritis, with considerable enlargement of the heads
of several of the long bones.

Certain non-syphilitic periosteal thickenings yield likewise to this
remedy.

The iodide of potassium has been recommended in mercurial saliva-
tion. 1 agree with those observers who believe that iodide of potassium
often aggravates mercurial salivation; though the iodide sometimes ap-
pears to be undoubtedly Ijeneficial.

As the action of the iodide on the mercury in the system throws much
light on this- question we will now shortly discuss it. The mercury salts,
like those of most other metals, form insoluble compounds with albumin-
ous substances. These compounds are very generally soluble in the
chlorides, bromides and iodides of the alkalies, but especially in the
iodides. Many metals, amongst others mercury and lead, are deposited
from the blood in an insoluble form, in the animal structures, and iodide
of potassium, by re-dissolving either of these two metals, brings one or
the other again into the circulation, and so re-subjects the system to its
influence. But then iodide of potassium will promote the separation of
both mercury and lead by the urine, and thus help to free the system
from their pernicious effects.

It has been said that iodide of potassium will dissolve mercury com-
pounds of albumen in the body, and bring them back into the circulation;
and herein we have the explanation of a Avell-known property of this salt,
namely, that of producing salivation in persons who had previously taken
a considerable quantity of mercury. After taking mercury for some
time, if a patient had then become salivated, it would naturally be antici-
pated that iodide of potassium would still further increase the ptyalism,
and not check it. In other cases it might happen otherwise; for we have
seen that the salt will affect the separation of this metal through the urine.
In a case, therefore, where but little mercury has been taken, during only
a short time, yet sufficient to produce salivation, the iodide of potassium,
by quicklv separating the metal from the system, would remove the mer-
curial symptoms, including the salivation. Should it ultimately prove

IODIDE OF POTASSIUM. HI

that the increased elimination is due to the mercury being bronght back
into the circulation, and so under the influence of the kidne^-s, and that
the iodide does not promote the exit of the metal in any other way, then
the iodide must be simply harmful in mercurial salivation.

It has been said that this salt of itself will produce salivation, an effect
which has been ascribed to the action of the iodide on the mercury in the
way Just explained; others hold, even where no mercury has been taken,
that the iodide of potassium itself increases the salivary secretion to a
variable amount in different persons.

The unequalled efficacy of iodide of potassium in eliminating lead from
the system through the urine has led to the employment of this drug in
lead-poisoning. Further on, when treating of lead, it will be shown how,
by virtue of its power of eliminating this metal, iodide of potassium may
prove itself useful in certain forms of gout.

It is of signal service in bronchocele, when the enlargement of the
thyroid gland is due to hypertrophy, not to cystic formations, or to other
causes. Its internal employment is often supplemented by painting the
swelling with the tincture or liniment of iodine. Iodide of potassium is
used -too in either induration or enlargement of the glands, as of the
mamma or testicle, though with less advantage than in bronchocele.

The iodides quicken the absorption of inflammatory effusion, such as
occurs in pleurisy and in inflammatory thickening of organs. Iodide of
potassium sometimes relieves sciatica and lumbago, although it very often
fails to affect either, especially sciatica, even when the pain is worse at
night.

Iodide of potassium sometimes benefits chronic rheumatism, chronic
rhciimatic arthritis, chronic gout, especially the two former affections.
It should, however, always be borne in mind that the pains of secondary
syphilis, frequently resembling in all respects those of so-called chronic
rheumatism, are frequently confounded Avith, and included among, the
manifold affections termed chronic rheumatism. Some of the so-called
cases of rheumatism relieved by iodide of potassium are probably cases of
syphilis.

The pains which yield to iodide of potassium are mainly those marked
by nocturnal increase of suffering, a symptom which may be accepted as
a strong indication for the employment of this medicine — an indication
holding true, whether the pains are referable to rheumatism or to some
other source. Syphilitic pains, it is well known, are generally worse at
night, and so are the pains of many cases of chronic rheumatism; now,
the iodide generally benefits these rheumatic cases.

Iodide of potassium is sometimes singularly useful in peptic and bron-
chial asthma. Five grains or more, three times a day, may be required.
Kow and then its good effect is not manifested for some time, though
possibly in such a case larger doses would bring prompter relief. The
late Dr. Hyde Salter, whilst admitting the great efficacy of this salt in
some instances, was inclined to think that in the majority of cases it is
useless. JVIy limited experience leads me to think it more frequently
useful than Dr. Salter was willing to admit.

Iodide of potassium has sometimes obviated barrenness, presumably
due to syphilis. Many employ it to lessen the secretion of milk.

Iodide of potassium occasionally acts as a powerful diuretic in Bright's
disease. I have seen it remove all the dropsy in thoroughly water-logged
patients, every part of the body being oedematous, the legs swollen till

112

IODIDE OF POTASSIUM.

thoy could not bo bent, the skin sliiny from distention, and the abdomen
distended with fluid. The iodide increased tlie scanty urine from a few
ounces daily to 30, then 50, GO, and 120 ounces, till the dropsy disap-
V)eared, every vestige of it, in a fortnight. While, however, this drug
increased the urinary Avater and removed the dropsy, it produced very little
effect on the amount of albumen. Of course, in proportion to the in-
creased quantity of urine, the relative amount of albumen diminished;
but, in fact, the albuminous urine is simply more diluted, and in estima-
ting the amount of albumen separated in the day, we must bear in mind
the amount of urine voided. For instance, if a patient is passing only
ten ounces daily, and on boiling the urine the coagulated albumen occupies
half the tube, if then the urine is increased to twenty ounces, the coagu-
lated albumen Avill occupy only a quarter of the tube, although the quan-
tity of albumen separated remains the same. Where the iodide proved
so useful, I at one time thought the patient had suffered from syphilis
of the kidneys, and that the drug, removing this disease, the kidneys re-
covered their lost power and eliminated the dropsical fluid. In some of
my cases, however, there was no reason to conclude that the patients .
were syphilitic; the disease, in some cases, following scarlet fever, in
others it appeared to be due to cold. Like other diuretics, as, for
instance, resin of copaiba, its action is very uncertain. In many cases,
in most indeed, the iodide fails altogether; but this uncertainty can in
part be ex|)lained ; thiis a moderate dose of from five to ten grains will act
powerfully with a certain number of patients, whilst in others the dose
must be very large. In one case I did not obtain its diuretic action till I
gave one hundred grains daily, and even this dose had to be increased to
two hundred daily to maintain the effect and eliminate all the dropsy.
Now, in most patients, large doses bring on severe iodism and depression,
so that probabfy the diuretic dose cannot be reached. In my experience,
iodide of potassium, like digitalis, ceases to act as a diuretic Avhen the
dropsy disappears.

Dr. Balfour recommends in aneurism iodide of potassium from five
to thirty grain doses continued for a considei'able time, even for tAvelve
months, conjoined with the recumbent posture and a restricted diet; and
he narrates several cases strikingly confirmatory of the efficacy of this
mode of treatment. Dr. Chuckerbutty supports his statements. I, too,
have seen on several occasions large doses of the iodide of potassium
afford prompt relief in the severe pain from aneurism; the drug presum-
ably acts by lessening both the size of the tumor and its pressure on the
nerves. In some cases it is certain that the tumor grows smaller and less
pulsatile. Patients sometimes assert that a slight discontinuance of the
iodide of only 36 to 48 hours is always followed by an increase in pain,
which ceases on returning to the remedy. Large doses are sometimes re-
quired. 130 grains or more daily may be necessary to afford relief.

It probably acts partly by depressing the heart's action and so lessen-
ing pressure in the aneurism and partly by some direct action on the
dilated vessel. As aneurisms often occur in syphilitic jiersons, the drug
may in some cases act antisyphilitically, but certain it is that in cises
quite free from syphilis it is highly beneficial.

Dr. Huchard claims to have cured twenty cases of angina i^ectoris by
the administration of fifteen to thirty grains of sodium iodide daily. 11 (^
considers angina to be an affection of the arteries, inflammatorv in
nature, and he maintains that iodide of sodium y\\]\ cure this condition

IODIDE OF POTASSIUM. 113

if employed early enough, by obviating narrowing of the origin of the
coronary vessels.

Iodine has been detected in the blood, saliva, milk, and urine, even
in the urine of the sucking child, whose mother was taking iodide of potas-
sium. Its great diffusion-power renders it probable that it might be de-
tected in all the fluids bathing the tissues or moistening the cavities. It
appears in a few minutes in the urine, and still more rapidly in the saliva.
The rapidity of its absorption is of course influenced by the state of the
stomach and vascular system, the absorption occurring more slowly when
these are replete. The statements concerning its influence on the various
constituents of the urine are so discrepant, and the observations made on
the subject are so imperfect, that at present our knowledge in this respect
must be considered untrustworthy. It is rapidly separated from the body,
and, even after large doses, soon becomes indefectible in the urine; indeed,
after withholding the drug, every trace of it may vanish in less than
twenty-four hours. It is stated, on doubtful grounds, that it may be de-
tected in the saliva some days after it has ceased to appear in the urine.

Some writers hold that iodide of potassium given in large doses for
long periods may produce albumen in tlie urine, and even Bright's disease.

Atkinson finds that iodide of potassium often causes oxalates to appear
in the urine.

It is said that in Bright's disease iodides are not eliminated by the
kidneys; and Duckworth found their appearance in the urine delayed for
an hour or longer.

Five grains three times a day is generally a sufficient dose. Some-
times, as in rheumatoid arthritis, and in syphilis, no benefit is obtained
until much larger quantities, or ten, fifteen, or even twenty grains are
given at a dose.

Large doses arrest the rapid sloughing of certain syphilitic sores and
promote the healing process. Full doses sometimes succeed when smaller
ones fail.

For the removal of syphilitic nodes from the membranes of the brain
five to ten grains, repeated three times a day, is generally sufficient. At
first the drug sometimes intensifies the pain, then the disease rajndly
declines. In no other affection does this medicine yield such striking
results.

Iodide of potassium may be conveniently administered in milk.

114 BROMIDE OF roTASSITM.

BROMIDE OF POTASSIUM, SODIUM, AMMONIUM, AND

LITHIUM.

These salts in physical and chemical properties are closely allied to
the corresponding iodides; yet in their action on the body, the bromides
and iodides severally exhibit considerable differences.

The persevering use of bromides occasionally produces an acneform
rash, and even boils. Yet Dr. Cholmeley reports the cure of some obsti-
nate cases of acne by moderate doses of bromide of potassium.

Bromide of potassium, in five parts of glycerine, has proved useful, it
is said, as a local apj^lication to ease pain in hemorrhoids, fissure of the
rectum, and in painful growths.

If taken in moderate doses for some time, or in larger doses for a
shorter time, bromide of potassium diminishes the sensibility of the soft
palate, uvula, and upper jjortiou of the pharynx, as evidenced by the ab-
sence of movement in these parts when they are touched. Zoepffel finds
that bromide of potassium affects the reflex irritability but not the sensi-
bility of the pharynx; thus, after its use, irritation of the throat will not
excite deglutition, but the pain of operations is not lessened. He agrees
with Voisin, that thirty grains may be insufficient to affect the pharynx,
and that sometimes it may be necessary to repeat this dose two or three
times, a few hours apart. It has been recommended to give the bro-
mides to reduce the excitability of the throat preparatory to a laryngo-
scopical examination; and it is even averred by some writers that merely
brushing the pharynx and soft palate with a solution of the bromide is
sufficient to quell the irritability and to permit a laryngoscopic examina-
tion with comfort to the patient. Many observers, however, question
this use of bromide, and Dr. Mackenzie considers that ice is more effica-
cious; a cocaine solution or spray of five per cent, strength aj)2:)lied to
the throat is very efficacious.

Assuming that the bromides possess the property of diminishing the
sensibility or the reflex irritability of the pharynx, it was naturally sur-
mised that they would lessen the excitability of the larynx, and thus
prove useful in those diseases accompanied by spasmodic contraction of
the glottis, as whooping-cough and laryngismus stridulus.

It is possible to reconcile the discrepant statements concerning the
influence of this remedy on these diseases. Now, as to whooping-cough,
all observers must admit that some cases are altogether uninfluenced by
this remedy, and that it lessens neither the frequency nor the severity of
the paroxysms of coughing. In other cases, it appears to control both
the frequency and the severity. The bromide, I believe, will only be
found serviceable in simple uncomplicated whooping-cough. If there is
fever, or much catarrh of the lungs, if there is i)neumoni;i, or tuberculo-
sis, if the child is teething, and the gums are swollen, red, and painful,
or if any gastric irritation exists, then till these complications have been
met by appropriate treatment this remedy fails; but when the case has
been reduced to a simple form, the bromide of potassium does certainly
influence the disease, lessening both the frequency and severity of the par-
oxysms. It is thus found to be of most service in the summer, or when
the weather is genial and mild. Like other remedies for Avhooping-cough,
the bromides are more efficacious in some epidemics than in others.

The efficacy of bromide of potassium in laryngismus stridulus, is sub-
ject to conditions very similar to those which limit its usefulness in

BRO.AIIDE OF POTASSIUM. 115

whooping-cough. Any irritution, as that from teething, must be removed
before the remedy appears to manifest any power. As, however, in cold
sponging, we possess a cure for laryngismus stridulus, ready, prompt, effi-
cient, we need not often have recourse to the bromide. (See Cold Bath.)

The bromides are sometimes useful in whooping-cough, and laryngis-
mus stridulus when complicated with convulsions. During a paroxysm
of laryngismus stridulus, or whooping-cough, the obstruction in the
larynx sometimes becomes so urgent as to induce very imperfect oxida-
tion of the blood, and to cause partial asphyxia, resulting in an attack of
convulsions. Convulsions, moreover, are not uncommon in laryngismus,
independent of as])hyxia, unaccompanied with an attack of crowing, the
early and less developed stage of these convulsive attacks being mani-
fested in carpopedal contractions, squinting, etc. The bromides will
control the recurrence of these convulsions, even when the disease itself
is apparently otherwise uninfluenced. With regard to laryngismus
stridulus, cold sponging is generally sufficient to avert convulsions; but
in cases where, from the elfects of any irritation, cold sponging is in-
effectual, the bromide of potassium will, in most instances, avert the
convulsions, thus obviating one of the gravest dangers of this disease.

The bromide of potassium will much benefit a curious affection we
sometimes meet with of a child, which, from the time of his birth, can
swallow solids with ease, yet is choked every time he tries to drink. This
strange affection is in no way connected with diphtheria or any visible
affection, or malformation, of the throat. The bromides, so far as we
know, appear to have very little influence on the stomach.

In certain cases, these salts exert a beneficial influence on the intes-
tines; for instance, in a form of colic, which sometimes affects children
from a few months to one or two years old. The walls of the belly are
retracted and hard, while the intestines, at one spot, are visibly contracted
into a hard lump, the size of a small orange, and this contraction can
be traced through the walls of the belly, travelling from one part of the
intestines to another. These colicky attacks, unconnected with' consti-
pation, diarrhcea or flatulence, occur very often, and produce excruciat-
ing pain. Sometimes they are associated with a chronic aphthous con-
dition of the mouth. They generally resist all other kinds of treatment
but the bromides. Like the iodides, these salts pass quickly into the
blood, and we shall now treat of their influence on the organs to which
they are conveyed by this fluid.

The bromides lessen considerably the functions of the brain and cord.
Experimentally, it is found that in animals under their influence irrita-
tion of the motor centres of the brain fails to excite convulsions.

Bromide of potassium is used in a variety of diseases, but its virtues
are chiefly conspicuous in convulsions.

It is serviceable in all forms of convulsions — in epilepsy, in the con-
vulsions of Bright's disease, and in the convulsions of children, whether
due to centric or eccejitric causes. Albertoni finds that potassium bro-
mide given for several weeks greatly diminishes the excitability of' the
motor centres of the brain, so that he could not excite epileptic convul-
sions in dogs by irritating the cortical substance.

In no disease is the bromide of potassium more signally efficacious
than in epilepsy, though it is not equally useful in all forms, for this
drug leaves attacks ot petit vial often unbenefited. It is the convulsive
form of epilepsy which is so remarkably amenable to the bromide, for in by

116 BROMIDE OF POTASSIUM.

far the greater number of cases, tlie fits, under its influence, become much
less severe and less frequent. Even when of great severity, and repeated
perhaps several times a day, the fit may be postponed for weeks, and
even months; nay in some cases it has been delayed for years.

Cases of the convulsive form, however, occasionally occur, over which
the bromide apj^ears to be powerless; the fits recurring as often and as
severely as if no medicine had been taken. Sometimes when the drug
arrests the epileptic convulsion, the patient becomes dull, irritable, idiotic,
conditions which on the recurrence of a fit are removed. Again, though
stopping the greater attacks, bromides may increase the frequency of the
jMit mal. It is not possible to foretell when the medicine will succeed,
and when it will fail. As might be expected, the effects of the drug are
most marked when the disease is of short standing.

Dr. Weir Mitchell recommends bromide of lithium in epilepsy.

It contains a larger percentage of bromide than either the sodium or
potassium salts, and it acts more powerfully, so that smaller doses mav be
given. Dr. Mitchell thinks the lithium salt succeeds sometimes when the
potassium and sodium salts fail. As a hypnotic, he says, " it is superior
to the potassium and other" salts of bromine." Echeverria thinks it is infe-
rior to the potassium salt in epilepsy, and as a hypnotic superior to the
sodium and calcium salts.

Echeverria considers the potassium salt much superior in epileps}^ to
the ammonium salt. The ammonium salt is more disagreeable to the
taste. In epileptic maniacal excitement Echeverria finds bromide of sodi-
um far less serviceable than bromide of ammonium. He moreover asserts
that bromides fail to suppress mental excitement in epileptics unless com-
bined with some other narcotic, as conium, cannabis indica, hyoscyamus,
chloral (15 to 20 grains each), or, still better, ergot of rye.

In mild epileptic cases ten grains three times daily is sufficient. AYlien
the attack occurs only at night, the best way to avert it is to give at bed-
time a full dose of thirty grains. Echeverria finds that the average dose
required is sixty grains daily, but in severe cases a much larger quantity
may be needed. In respect to the dose, Voisin says, "I have emplo3^ed
for many years a method which has given me the best results, which con-
sists in determining the condition of reflex nausea by introducing a spoon
as far as the epiglottis. I have remarked that a therapeutic dose of the
bromide of potassium is not attained till reflex nausea is suppressed; it
is not till then that the bulb is certainly acted on, and its excito-motory

force diminished The study of other reflex phenomena, such as

lachrymation, cough and sneezing, enables us to follow the action of the
medicine upon the bulb and spinal cord. I'he dose should not be increased
beyond the suppression of reflex nausea, but it should be given continu-
ously for years together. If the malady be ameliorated, or in process of
cure, at the end of two years of amelioration, the remedy, instead of being
administered every day, may be given every second, third, or fourth day,
provided reflex nausea be alway^and certainly absent." Voisin considers
that the early manifestation of toxic effects is a good and their late aiipoar-
ance a bad augury.

If the patient is not cured, but only benefited, by the bromide, it may
be continued for months or years. But its administration should l)e sus-
pended at times for a week or ten days, or on two days in each week, vsay
^Monday and Thursday, otherwise the system becomes accustomed to it,
when it loses its influence, so that the good effects, so well marked origi-

BROMIDE OF POTASSIUM. 117

nally, cease altogether, the fits recurring with their old severity and fre-
quency. If in such a case the drug is withheld for a time, and then re-
sumed, it again manifests all its previous etticacy.

It has been asserted and denied that chloride of potassium in epilepsy
is as efficacious as bromide of potassium.

We have already spoken of the effect of bromide of jDotassium on the
convulsions sometimes accomjianying whooping-cough and laryngismus
stridulus. The bromide will often prove useful in all other diseases asso-
ciated with general convulsions. Of course the exciting cause of the
convulsive attacks should, if possible, be removed; but even when the
cause is indetectable, this salt will often lessen or prevent the epileptiform
seizures. The convulsions caused by intestinal worms sometimes resist
this remedy completely.

Bromide of potassium will often check the convulsions resulting from
simple meningitis, when the fits which sometimes jjersist after the de-
cline of the inflammation inflict serious damage.

Many writers extol bromide of potassium in the incidents of teeth-
ing, averring that it lessens pain, obviates irritability and restlessness,
and prevents convulsions. Bromide of potassium checks the Scilivation
sometimes occurring in pregnancy, and succeeds sometimes after the
failure of atropine and pilocarpine. (Schunn.) The bromides are most
valuable hyjjnotics.

Voisin, referring to his patients in the Bicetre, says, "The hypnotic
action upon them was very remarkable night and day. Some were obliged
to slee23 for a few minutes at a time in the midst of their work. Xone,
in spite of whatever efforts they made to the contrary, could resist sleep
directly after their evening meal." They have been found of especial
use in obviating that sleeplessness and wandering at night, not unfre-
quently occurring during convalescence from acute diseases.

As a soporific bromide of potassium is especially useful in the sleep-
lessness caused by worry or overwork, orthat occurring at the climacteric,
or from menstrual disturbances. The brief amount of sleep obtained by
these patients is often harassed by nightmare, whilst the sleeplessness
further depresses the nervous system and other functions, and the pa-
tients become still more dejiressed and irritable in temper. They are
excessively nervous, and often easily yield to crying. In such a condi-
tion bromides at night, in twenty to twenty-four grain doses, are invalu-
able. They induce quiet, dreamless, refreshing sleej), even where tbey
induce an equal amount of sleep. They are greatly preferable to other
soporifics or narcotics, since they do not produce the ill effects on tlie
stomach, liver or intestines that opiates induce. Their good effects, too,
are more marked than the effects of other narcotics, like chloral; so that
in addition to their soporific action it is fair to conclude that bromides
act beneficially in the conditions described.

There is a group of symptoms variously combined, occurring mostly
in women, generally townspeople. The patient is very "nervous,"' sub-
ject often to great despondency, at times so unendurable as to make
her, as she expresses it, feel as if she should go out of her mind. She is
very irritable, is unable to fix her attention, and noises distress her. She
sleeps badly, her rest being broken by harassing dreams. This condition
often arises from overwork, grief, worry, or too long residence in town,
or want of change

118 BROMIDE OF POTASSIUM.

The bromide of potassium will always cure this group of symptoms.
Their occurrence, independently or associated with other illnesses, as
the change of life, or migraine (sick headache, nervous sick headache,
bilious headache), is a distinct indication to give the bromide. In sucli
a case a bromide acts by inducing sleep, and so strengthening the nerv-
ous system.

The bromide has been often extolled for its efficacy in the symptoms
pertaining to the " change of life "and in migraine, and though often
very serviceable, yet it often fails. The distressing symptoms occurring
during the change of life are very various, but generally occur in defi-
nite groups, though these may be more or less combined. The group of
symptoms I have Just described commonly occurs at the menopause, and
yields almost always to the bromides. This group is often associated
with heats and flushings, followed by free perspiration and prostration,
sometimes extreme. These symptoms too will also generally give way
to the bromide. If, however, the heats, flushings, and perspirations
predominate over the mental depression, nervousness, irritability and
sleeplessness, then small doses of nitrite of amyl (see this drug) will gen-
erally prove more serviceable than bromide of potassium. Whilst re-
moving the heats, flushings and perspiration, the nitrite of amyl con-
trols the other group of symptoms, quiets the nervous system, produces
sound dreamless sleep and relieves the nervousness and depression. At
the change of life patients often comjilain of much fluttering at the
heart, a symptom best controlled b}^ large doses of the astringent prep-
arations of iron (see Iron). Indeed, if a patient is anaemic the bromide
or indeed any treatment, though efficacious for a time, fails in the long
run. All the troubles of the menopause, except sleeplessness, are much
benefited by valerianate of zinc, which may be given thrice daily after
food, whilst taking the bromide at bed time.

Occasionally the troubles just described yield but partially to the
treatment here recommended; or, if removed for a time, they recur with
greater intensity and eventually become unendurable. Then the only
resource is thorough change of air and scene, or travelling for three or
six months.

In migraine, too (sick headache and its allies), bromide of potassium,
though often of great service, in many cases altogether fails. In the
article on croton chloral I have treated of migraine, and here I merely
add that we often find the headache associated with the group of symp-
toms previously described, namely, nervous depression, sleeplessness,
irritability, etc. Perhaps for years previously the patient has been
troubled with attacks of migraine, at intervals of a month or so. On
the occurrence of this group of symptoms the attacks of migraine be-
come much more frequent and severe; indeed, the pain may become
continuous, though at times, generally once a day, it may be paroxys-
mally worse. The irritability, sleeplessness, etc., are indications of a
depressed nervous system, which accounts for the increased frequency of
the migrainous attacks. With this condition of the nervous system,
slight disturbances and causes of irritation bring on severe headaches;
sometimes so easily induced that they occur daily. Bromide of potas-
sium produces refreshing sleep, soothes the nervous system, dispels the
other symptoms, and at the same time lessens the frequency and severity
of the headaches. Again, derangement of the womb excites migrainous

BROMIDE OF POTASSIUM. 119

attacks either at a normal or menorrhagic period. Here again bromide of
potassium is useful, and its efficacy, when the attacks are caused by men-
orrhagia, is not entirely due to its checking this condition, for, given be-
tween the periods, it may improve the migraine before the next attack
of menorrhagia. Whilst speaking of uterine disturbance as an exciting
cause of these headaches, I may mention that sometimes they are due to
uterine mischief, generally of the neck of the uterus, and remain rebel-
lious to any treatment till the womb is cured either by injections or by
other treatment.

Sometimes during an attack a full dose induces sleejD, and after a few
hours the patient awakens free from headache.

Sometimes in the later months of pregnancy a woman becomes at
night the prey of the most frightful imaginings, laboring under the im-
pr^sion that she has committed, or is about to commit, some great crime
or cruelty, as the murder of her children or husband. The bromide dis-
pels these delusions, and induces calm, refreshing sleep. Freidreich
gives 15 to 30 grains daily for vomiting of pregnancy.

Bromide of potassium is of great service in the treatment of children
subject to night-screaming, a symptom which appears to be allied to
nightmare. Children from a few months to several years old may be
attacked with this affection. Sometimes the attack occurs only once or
twice a week, as is usually the case with older children; or it may be
repeated several times each night. The screaming may last only a few
seconds or it may endure for several hours. While screaming, these
children are generally quite unconscious of what is occurring around
them, and cannot recognize, nor be comforted by, their friends. They
are generally horribly frightened. A somewhat similar condition is met
with in children a few years old, a state very similar to somnambulism,
but sometimes apparently allied to epilepsy. The child gets out of bed
while fast asleep, walks about the house, and performs, as if awake, vari-
ous acts, quite unconsciously. This stage is not accompanied with any
terror. With the screaming and fright, squinting sometimes occurs,
which after some time becomes permanent. In these cases bromide of
potassium will prevent the screaming, and remove the squinting. This
affection in children being connected very generally with deranged di-
gestion, the condition of the stomach or intestines should be attended
to; but even in spite of this derangement the bromide will give quiet
and refreshing sleep.

The nightmare of adults will generally yield to the same medicine.

Bromide of potassium is often of conspicuous benefit in delirium
tremens, removing the delusions, calming the delirium, and inducing
sleep, and its efficacy is most apparent in the earlier stages, before the
delirium becomes furious. Moreover, it is of great service in dispelling
delusions which may remain after the partial subdual of the attack.

In delirium tremens bromides often succeed where opium fails.

Bromides will sometimes induce sleep in febrile diseases, but in such
cases opium or chloral, or both combined, produce a far more certain and
beneficial result.

To produce sleep, twenty to thirty grains should be given at night, and
should this prove insufficient, a like dose may be taken in the morning.
Likewise twenty to thirty grains, or even more, may be given in delirium
tremens every two hours till the patient falls asleep.

120 BROMIDE OF POTASSIUM.

The bromide is soothing in hysteria, gives patients greater self-con-
trol, and prevents h3'sterical paroxysms.

It is also used with decided benefit in certain derangements of the
organs of generation. Large doses are said to lessen the natural men-
strual discharge. In some forms of menorrhagia it is equal, if not supe-
rior, to any remedy we possess; but it is more useful in the flooding of
young than of old women. It is very useful in the case of young women
Avho menstruate too often as well as too copiously. It first regulates the
time of the discharge and often lessens the amount. It is also very serv-
iceable in the floodings or too frequent menstruation occurring at the
change of life, and at the same time relieves many other of the troubles
incidental to the menopause. Over that form of flooding, due to uterine
tumors of various kinds, it exerts less control in many cases than ergot
and some other remedies. To check profuse menstruation, its adminis-
tration must be regulated by the circumstances of the case. If the loss
of blood occurs only at the natural period, the medicine is then com-
menced about a week before; and when the menstrual flux has ceased
the remedy should be discontinued till the next attack is about to begin.
On the other hand, when the loss of blood occurs every two or three
weeks, or oftener, the medicine must be given without intermission till
the loss is controlled; and wlieu the discharge has been brought to its
right period and amount it is still desirable to give a few doses for a
short time before each monthly period. Ten grains three times a day is
a dose sufficient in the flooding of young women, but much larger doses
are required in the more obstinate forms depending on organic changes
in the womb. This remedy has been recommended by Dr. Begbie in
jiuerperal mania and nymphomania. Dr. Clarke also says it reduces
sexual excitement in those instances of hysterical excitement verging on
nymphomania. Small doses are unavailing. Twenty grains, not less,
thrice daily, will exert a decided control over excessive sexual propensity.

It also restrains spermatorrhoea. Its employment should be supple-
mented by cold sponging of the scrotum and perina^um, and the suspen-
sion of the testicles in cold water for some minutes night and morning.
Seminal emissions are generally excited by dreams, which may often be
avoided by abstaining from suppers, and sleeping on a hard mattress.
Dr. George Bird has pointed out that seminal emissions occur from un-
due indulgence in bed, the emissions taking place almost always early in
the morning, during the second sleep. He recommends, therefore, that
the patient should be roused after six or seven hours' sleep, and should
never give in to a second sleep. The observance of this simple means
will often cure this otherwise troublesome affection. Dr. Hardman,
of Blackpool, tells me that he has cured some obstinate cases of sper-
matorrhea by directing the patient to empty his bladder on waking
from the first deep sleep.

Bromides are useful in sea-sickness. They should be given three
times a day, and be begun some days before sailing.

It proves useful in allaying various forms of hyperfesthesia, and
sometimes eases the severe pain of chronic arthritis.

Dr. Da Costa finds that bromide of potassium lessens, or even pre-
vents, many of the disagreeable symptoms of opium, as giddiness, con-
fusion of mind, fainting, lieadache, and sickness. It manifests this
effect over morphia and codia, less than over laudanum. A large dose

BROMIDE OF POTASSIUM. 121

— 20 grains — of bromide must be given half an hour before and two
days after the laudanum. Even larger doses are necessary; he even
gives 40 to 60 grains some hours before the administration of the
opium. Da Costa says the bromide exerts most control over the faint-
ness. He avers also that the bromide heightens the " anodyne or hyp-
notic effects of opium." Bromides, like hydromic acid, prevent the
deafness and buzzing caused by salicylate of soda or quinine; ten to fif-
teen grains must be added to each dose of either drug.

If the medicine is continued for a long time, as is sometimes required
in the treatment of epilepsy, the physiological effects of the drug become
apparent. " Diminished sensibility, followed by complete anesthesia of
the soft palate, uvula, and upper part of the pharynx, is tlie first symptom
that the patient is getting under the influence of the drug. The sexual
organs are among the first to be influenced, for there is soon produced
failure of sexual vigor, and, after a time, marked diminution of the sex-
ual appetite itself." (liazire.)

These effects vary greatly; in some the remedy jn'oducing only moder-
ate diminution, in others, temporary impairment. On discontinuing the
remedy, the sexual organs regain their lost jjower. Another frequent re-
sult of the prolonged administration of the bromide is an eruj^tion, gen-
erally acnef orm, occurring most on the face and back, but it may affect
even a larger surface. These spots do not generally suppurate, nor do
they scar. Echeverria finds that five to ten minims of liquor arsenicalis,
given with the bromide, will prevent the eruption, and the experience of
the Epileptic Hospital confirms him; and J have seen cases where the
rash has been quickly removed and subsequently prevented by arsenic. I
have found that iodide of sulphur ointment, frequently applied, consid-
erably lessens the quantity and the severity of these eruptions. The effi-
cacy of the remedy bears no proportion to the amount of acne. The
hromide sometimes excites, it is said, eczema, and spots like erythema
nodosum. The acneform spots may become true boils, and these boils
sometimes form large ulcers with conical scabs, looking like rupia. Dr.
Weir Mitchell narrates a case of this kind. He found that bromides of
potassium, sodium, ammonium, and lithium, produced these ulcers. He
tried also bromides of calcium, magnesium, and bromine itself, but as
these preparations failed to control the epileptic fits, they were not given
long enough to determine if they too would produce these rupoid ulcers.
Professor Duhring, in addition to acneform pustules, enumerates brown-
ish discoloration of the skin; simple papular eruption; confluent or mol-
luscoid acne ; maculo-papules, carbuncular acne, and bulle and rupia as
the occasional consequences of bromides. Undue administration of the
bromides renders a patient low-spirited, easily fatigued, and unfitted for
work, and greatly lessens the brain's functional activity, sometimes to a
very marked extent. It produces this effect, as Brunton remarks, with-
out disturbing the relation of one part of the brain to another. All
these symptoms soon subside on the suspension of the medicine.

Acne, and the other evidences of bromism, rarely occur, unless more
than one dose, however large, is taken daily.

M. Rabuteau says that bromide of potassium may be detected in the
urine and saliva twenty days after the administration of a dose of fifteen
grains. Dr. Amory could not find it more than forty-eight or fifty-two
hours after a single dose, but after the drug had been taken several days.

122 ACIDS.

and then discontinued, he could find evidences of it after a longer time.
Elimination by the urine is less rapid than absorption by the stomach.
Traces appear in the urine in ten minutes. Elimination is most active
during the first eight or ten hours, and in less than twenty-four hours the
greater part disappears. It can be detected in the milk and sweat.
Bromide of potassium is conveniently administered in beer or milk.

A THEORY CONCEENING THE " TOPICAL '' ACTION OF
ACIDS AXD ALKALIES ON SECRETION.

Previous to treating in detail of acids and alkalies, I wash to note
their action on the secretions of the body, and to draw attention to a theory
which I think explains their action in this resjiect; moreover, this
theory serves as a useful guide to their correct employment in disease.

Acids are powerful stimulants of salivary secretion: the impression
from the acid is conducted to the spinal cord, and is thence reflected
through the cerebro-sj^inal nerves supplying the salivary glands; for
if these are divided, acids cease to augment the salivary secretion.

Repeated and careful ex^ieriments have established the fact that dilute
acids taken into the stomach check its secretion; alkalies, on the other
hand, powerfully excite the secretion of the gastric juice.

Acids, then, check acid, but increase alkaline secretions; while
dilute alkalies stimulate acid secretions.

From these facts the more general law is inferred, that acids, applied
topically, check the j^roduction of acid secretions from glands, while they
increase the flow of alkaline secretions ; the very reverse being the case
w'ith alkalies, for alkalies applied to the orifices of glands with acid secre-
tions increase their secreting power; while alkalies applied in a corre-
sponding way to glands with alkaline secretions lessen or check this
secretion.

In support of this generalization I have ventured to propose, I will
noAv adduce some practical instances of the efficient therapeutic employ-
ment of acids or alkalies.

Acids are useful to allay thirst, by joromoting, through their topical
action on the mucous membrane, the secretion of the alkaline saliva.

Acids given shortly before a meal generally check acidity.

Alkalies given shortly before a meal increase the secretion of the acid
gastric juice, and so promote digestion.

A weak alkaline lotion is often useful in the weeping stage of eczema,
by checking the alkaline watery exudation.

A weak alkaline injection is eflticacious in that form of leucorrluea de-
pending on a too abundant secretion from the glands of the os uteri,
the secretion in that part being alkaline.

Some of these instances will be referred to in greater detail in their
fitting places in this volume.

ACIDS. 123

SULPHUEIC, HYDKOCHLORIC, NITEIO, PIIOSPHOEIC,
AND ACETIC ACID.

The members of this group are powerful acids, and accordingly have
a strong affinity for alkalies and bases. Some, as sulphuric acid and
phosphoric acid, absorb water with avidity. All possess high diffusion-
power, and so pass readily through animal membranes and textures.
These are the properties which explain most of their action on the liv-
ing body.

These acids, when concentrated, produce decided changes in the skin
by tlieir affinity for the bases and water of the tissues, as well as in a
minor degree for the organic substances themselves. Their great diffu-
sion-power enables them to penetrate readily and deeply beneath the sur-
face, with a continuous destructive action, till they are diluted with water
or neutralized by the bases of the animal structures.

From their great affinity for water, sulphuric acid and phosphoric
acid are especially energetic; they withdraw this element from the tex-
tures, and thus effect their complete destruction. In adequate quantity
they Avill destroy the tissues to a considerable depth, and produce a brown
or black eschar.

The remaining members of this group, owing to their feeble affinity
for water, destroy the tissues less extensively, and their action is much
more superficial.

Sulphuric acid and phosphoric acid are never used undiluted, on ac-
count of their physical action on the tissues. On the other hand, nitric
acid is frequently employed to destroy and remove the surface of foul and
unhealthy sloughs and ulcers, and in virtue of a property of which we
shall shortly speak, it changes an unhealthy and indolent sore into o^.e
more healthy and prone to heal. It is frequently employed in cases of
soft chancre, indolent and broken bubo, cancrum labialis, etc.

Nitric, hydrochloric, and especially acetic acid, may produce some
vesication. Nitric acid colors the skin characteristically yellow.

No treatment is easier nor more speedy or certain in its action than
the application of strong acetic acid to ringworm of any part of the body
except the scalp. Nitric acid induces a healthier action in indolent ulcers,
or arrests the spreading of sloughing sores.

Acetic acid and somewhat diluted nitric acid, are frequently applied
to warts, which are destroyed by withdrawing the bases, and by dissolving
the tissues of the warts themselves. But although any of these acids are
effectual, and in many cases completely remove the warty growths, yet
sometimes a fresh and abundant crop springs up in the neighborhood
of those undergoing treatment. Dr. George Bird finds the glacial acetic
acid very effectual in removing warty growths. Small syphilitic warts
and condylomata, kept constantly moist with a wash of diluted nitric acid
— a drachm or two of the dilute acid to a pint of water, is sufficient — are
thus surely aud painlessly dispersed.

124 ACIDS.

The members of this group are more generally eVnployed externally,
mixed with water. Although diluted, they still excite a beneficial irrita-
tion, and may be used as lotions in urticaria, controlling the very trouble-
some itching, even preventing the formation of wheals, and in some cases
appearing to be mainly instrumental in curing this disease.

Acids, especially nitric acid and hydrochloric acid, are less employed
as batbs than formerly, yet beyond doubt, they exert a very powerful in-
fluence on the skin. A general bath, with two to eight ounces of the
strong nitric or hydrochloric acid, is a very active exciter of a torpid skin.
Whether these baths have any elfect on the other organs of the body, is
at present quite unknown, no experiment having been made to settle this
question. It is highly probable, however, that in common Avith other
materials dissolved in baths, these acids remain unabsorbed by the skin,
and that any chtinge in the deep parts of the body resulting from medi-
cated baths must be ascribed to the direct action of the dissolved ma-
terials on the skin itself. Spongi]ig the surface of the body with water
weakly acidulated with acids will, in some cases, effectually control pro-
fuse sweating.

They, however, act as stimulants to the skin when stripj^ed of its cuti-
cle; thus nitric acid is frequently used with much benefit as a lotion in
the treatment of indolent and painful ulcers.

Applied to the softer tissues, the dermis, mucous membranes, etc.,
acids act as astringents, causing a direct condensation of the tissues, proba-
bly by removing part of the base by combination with which the albumi-
nous substances were held in the soluble form.

By virtue of their astringency, they check profuse secretions from
unhealthy sores. Nitric acid is most preferred in such cases. Xitric
acid is generally used as a test for albumen, in solution; it precipitates the
albumen by abstracting the "base combined with it, and in setting the albu-
men free, converts it into an insoluble substance.

When diluted, these acids very effectually check bleeding from the
smaller vessels and capillaries by constringing the tissues, exciting the
muscular coat of the arteries to contract, and by coagulating the blood in
the ends of the wounded vessels, and so plugging them, ^"inegar, always
at hand, will check bleeding from leech-bites, piles, cuts, etc. The vine-
gar should be diluted.

These acids produce the same effect on the mucous membrane of the
mouth as on the skin, and for the most part are used for the same pur-
poses. Strong nitric acid is often applied to foul and sloughing ulcers
of the mucous membrane, to change their character and to cheek their
progress.

Acids are, in part, neutralized by the alkaline secretion from the sal-
ivary glands, while any acid remaining free precipitates the mucous coat-
ing of the mucous membrane, and if in sufficient quantity, attacks the
mucous membrane itself. They act beneficially as astringents, when the
lining membrane of the mouth is relaxed or ulcerated, as in ulcerated
stomatitis, salivation, etc. ; but other astringents are preferable. These
acids being apt to dissolve the earthy constituents of the teeth, should be
taken through a quill, a glass tube, or reed.

Nitric acid exerts a further action on the mucous membrane of the
mouth, and may be given in small medicinal doses with conspicuous bene-
fit, when this membrane is inflamed or diseased in various ways, as in
ulcerated stomatitis, aphthte, salivation from mercury, or when reddened.

ACIDS. 125

inflamed, and glazed, a condition not unfreqnently met with in great irri-
tatioiL of the digestive organs.

These, witli other acids, as citric, tartaric, etc., qnell tlie thirst of fever
patients mnch more efl'ectnally than sim})le water, esjiecially if the drink
is made rather bitter with some agreeable-tasting snbstance, as orange-
peel or cascarilla. Mnch of the tronblesome thirst of fevers is solely dae
to dryness of the mouth and throat. This disagreeable local sensation of
thirst is very liable to lead fever patients to drink more water than is
really good for them, producing loss of appetite, indigestion, and even
diarrhoi^a and flatulence. ( Vide Water. )

The action of acids in lessening thirst has already been explained in
the chapters on the topical action of acids and alkalies on the secretions.
As we have seen, acids probably increase alkaline secretions, and tlnis
the acid drinks used by fever patients promote an increased secretion in
the salivary glands. Bitters, as we shall presently see, possess the same
power; hence, acids and bitter drinks acting on the salivary glands, keep
the month and throat comfortably moist and quench the thirst. By less-
ening the harassing thirst, they comfort the patient, qnell irritability of
temper, favor sleep, quiet the pulse, and diminish the heat of the body.
Organic acids are largely employed as fever medicines.

Acids are applied to the throat for the same purpose as to the month.
Undiluted nitric acid acts beneficially as a topical application on the foul
sloughs or nlcers occurring in the course of scarlet fever or other diseases.

Bretonneau warmly rt^commends the application of strong hydrochloric
acid to the throat, in diphtheria. The acid may be used undiluted, or it
may be mixed with an equal part of honey, which gives the mixture con-
sistence, and makes it cling about the parts on which it is painted. It
should be applied only to those spots of the mucons membrane attacked
by the diphtheritic inflammation, and not to the neighboring healthy tis-
sues, where it would produce active inflammation. The diphtheritic
membrane being very prone to implant itself on inflamed surfaces, the
application of the acid to the sound tissues, by exciting inflammation,
might favor the spread of the disease.

Lactic acid was at one time largely nsed as a topical application to
dissolve diphtheritic false membrane. It may be employed as spray in
the strength of 3 ss. 3 i to 3 i, of water, or it may be mopped on the
diseased parts. It should be used every hour or even oftener.

Nitric acid, in small medicinal doses, may be given with benefit,
when the throat presents the same aj^pearances as those of the month
previously described.

The albuminous constituents of food are digested and rendered solu-
ble mainly by the agency of acids, but all acids are not equally efficient.
Hydrochloric acid far outstrips all others in this respect, while sulphuric
acid hinders rather than promotes digestion by precipitating the albu-
mens in an insoluble form. The action of acids on nitrogenous sub-
tances is intensified by the addition of pepsin.

In scanty secretion of gastric juice, dilute hydrochloric acid may be
employed to assist digestion. The considerations developed in the section
on the topical action of acids and alkalies on the secretions, render it ob-
vious, that the time of administration, in respect to meals, is all-important.
If given before a meal, acids check the secretion of the acid gastric juice,
and so hinder, instetid of aiding, digestion. Where the secretion is scanty,
the acid must be given after the meal, when the secretion from the mem-

12(5 ACIDS.

l)raneof tlie stomach isromploted; the additional acid will assist the action
of that secreted naturally, but too scantily. In many cases of atonic dys-
])epsia, alkalies are preferable to acids, but they must, of course, be given
a short time before a meal, because then they stimulate an abundant secre-
tion of the gastric juice. In most cases of atonic dyspepsia, alkalies given
with the precautions noted, are superior to acids given after a meal,
although, as is well known, certain cases occur where acids answer better
than alkalies. In such cases, the mucous membrane is presumably consid-
erably damaged by excesses in eating or drinking, and owing to degenera-
tion of the glands of the stomach, no stimulant could excite a sufllicient
flow of gastric juice.

Acids, as we have seen, Avill check or lessen the secretion of gastric
juice. In many stomach diseases, or from its sympathy with distant
organs, the follicles pour into the stomach an excess of acid, which undue
secretion may be checked by the administration of acids shortly before
food. But acidity of the stomach is often due to excessive or irregular
fermentation, leading to the production of a large quantity of various
acids, as acetic, butyric, mid lactic; and this excessive or irregular fer-
mentation of acids is itself checked by acids; and as undue secretion of
the gastric juice, or excessive formation of acids by fermentation, are the
two causes of acidity, Ave have in acids themselves, remedies able to con-
trol and check the acidity of the stomach, and relieve the consequent dis-
tressing symptoms, whether due to pregnancy,' uterine disease, calculus
of the kidneys, the various indigestions, or more serious diseases of the
stomach.

Practical men, indeed, know well that the administration of an acid,
will remove acid eructations, heartburn, and the sense of discomfort at the
chest and epigastrium, arising from excess of acid in the stomach.
Hydrochloric, lactic, or nitric acid, is generally preferred, and small me-
dicinal doses, separately or combined, are ordinarily sufficient, provided
the prescribed conditions are obeyed.

Patients are sometimes greatly annoyed by eructations of an oft'ensive
gas, with the odor and flavoi of rotten eggs — a gas evidently consisting
largely of sulphuretted hydrogen. The late Dr. Day, of St. Andrew's,
noticed that in such cases the urine is loaded with oxalic acid, and in their
treatment, he strongly recommended the employment of mineral acids.
Dyspeptics with oxalic acid in the urine, who sutfer from great mental
depression, but who are free from sulphuretted hydrogen eructations, find
much benefit from nitric acid treatment.

In the treatment of dyspepsias, a clue to the administration of acids on
the one hand, or of alkalies on the other, may sometimes be obtained by
testing the reaction of the fluids ejected from the stomach. Not unfre-
(piently, soon after a meal, fluid regurgitates almost unconsciously into
the mouth, sometimes so strongly acid that it sets the patient's teeth. on
edge. The exhibition of nitric or hydrochloric acid shortly before each
meal, almost immediately removes this acid pyrosis. Sometimes the fluid
of pyrosis has an alkaline reaction, often accompanied with much distress,
with nausea, and vomiting of the just-eaten food, and the rejected con-
tents of the stomach generally show a strong alkaline reaction. Here
an acid immediately after a meal relieves the nausea, the vomiting, and

' Two or three drops of tincture of nux vomica, taken a few minutes before meals
will ol'teu obviate the acidity of pregnancy. Sometimes ipecacuanlia will control it.

ACIDS. 127

all distressing symptoms. On theoretical grounds, we should expect that
an alkali, administered shortly before food, would yield even more satis-
factory results, hut in such cases I have had no experience of alkalies.

It need hardly be repeated that acids given soon after a meal to patients
troubled with acidity and heartburn, greatly aggravate the suifering. It
is adding fuel to the tire. If continued too long these remedies may
not only check undue acidity of the stomach, but even exceed this office,
and by lessening the secretion of gastric juice to an undue extent, actually
induce the very opposite condition to that for which, in the first instance,
they were employed. Those who have watched the action of acids on
the stomach, well know that if too long continued, the improvement first
noticed ceases by degrees, then fresh symptoms arise, which, strangely
enough, are relieved by the very opposite treatment which had previously
benefited.

Too long a course of acids excites catarrhal inflammation of the mucous
coat of the stomach and intestines, often accompanied by diarrhoea, and
even by genoral wasting. This damaging action of acids explains the
occasional thinning effects of vinegar, when taken for a long time, by fat
people. Vinegar is sometimes taken surreptitiously in wineglassf uls several
times a day to reduce obesity. This foolish practice, which cannot be too
strongly condemned, may thin the patient, but it does so at the expense
of serious injury to the body. Obesity can be reduced by harmless means.

These acids are inoperative to check the growth of sarcinge in the
stomach; and they often fail even to check the acidity accompanying these
growths.

It is a common practice with drunken soldiers to drink a wineglassful
of vinegar in a tumbler of Avater, to cut short intoxication; but whether
it does sober a drunkard is not certain, but it seems to steady a tipsy
soldier and to enable him to pass muster on presenting himself at barracks.

By virtue of their astringent action, and their power of coagulating the
lilood, acids are useful in bleeding from the stomach. Sulphuric acid is
generally preferred to the other members of this group. But many other
astringents are surer.

Owing to their high diffusion-power, these acids pass readily from the
stomach into the blood. The acids which pass into the intestines must,
to a great extent, become neutralized by the alkalies of the bile and pan-
creatic juice, and therefore, as acids, can, by direct contact, affect to a
very small extent the middle and lower part of the intestinal tract. But
as they become neutralized, some of the biliary and weaker acids are set
free, heightening in some degree the acidity of the contents of the intes-
tines.

Dilute acids are used as antidotes in poisoning by alkalies. It has been
shown experimentally that acids applied to the mucous membrane of the
duodenum cause an increased flow of bile, attributed to the consequent
contraction of the gall bladder and bile ducts. I suggest that part at least
of this augmented flow is due to increased secretion brought about in ac-
cordance with the alkali acid (V. Section 7) theory I have propounded,
the acid contents of the duodenum stimulating the secretion of the alka-
line bile, and the still more alkaline pancreatic juice.

It has long been held that* nitric acid acts in some way beneficially on
long-standing diseases of the liver, as in chronic congestion and ciri'hosis,
and that it will augment the flow of bile after the liver has struck work
from the excessive use of mercury.

128 Acros.

From his experiments on fasting dogs, Rutherford conchides that
nitro-h3'droehloric acid is an hepatic stimulant, thus confirming the con-
clusions founded on clinical experience.

There can be no doubt that sulpliuric acid is highly useful in checking
summer and choleraic diarrhcea, although, as it is generally administered
with opium and warm carminatives, it is difficult to distribute to each
remedy its exact share of merit. Its mode of action is less obvious than
its efficacy. It may control the formation of acid in the intestines, or it
may act as an astringent, and so check diarrhoea. If, then, it acts as an
astringent, as the acid is soon neutralized and converted into a sulphate
in the upper part of the small intestines, losing its astringency at once,
its influence on the lower and middle part of the small intestine must be
exerted through nervous sympathy between one part of this canal and
another. Sulphuric acid is considered to act often capriciously, giving
rise to much uncertainty in its administration; but the lack of uniform-
ity in its results can be accounted for, in many instances, by the dose; a
small medicinal dose often benefits, whilst a full one, by increasing the
acidity of the canal, may even aggravate the diarrhoea. Dr. Neligan, and
other authorities, recommend it in chronic diarrhoea, and to control the
" profuse sweating and colliquative diarrhoea of hectic."

In small medicinal doses, nitric acid is of great use in many diar-
rhoeas; it often acts admirably in the straining diarrhoea of children;
when the motions are green, curdled, and mixed with mucus, other rem-
edies are to be preferred to acids. Nitric acid may sometimes be used
with great benefit, especially when given with pepsin, in that chronic
diarrhrea of children when the jjale and pasty motions smell sour and
disagreeable.

Strong nitric acid is an efficient remedy for internal piles, two or at
most three ap2:)lications to the enlarged and dilated vessel being suffi-
cient; it should not be applied to the whole surface, but only to one or
two points. It is useful, too, in granular or ulcerated piles. It i^roduces
little or no pain. A superficial slough follows, and after the separation
of the slough the contraction of the sore diminishes the size of the pile.
A drachm or half a drachm of the dilute nitric acid to half a pint of
water, is an excellent lotion for bleeding piles, staying the haemorrhage,
constringing the swollen and inflamed tumor, and easing the heavy, ten-
sive, Avearying pain. Acids are reputed to heighten the action of pur-
gative medicines, and for this purpose sulphuric acid is sometimes em-
ployed. Sulphuric acid increases the purgative effect of extract of aloes.
Acids are usually added to purgative salts, as Epsom salt, when a tonic
and bracing action on the mucous membrane is desired, as in many cases
of anemia of young Avomen.

If not already neutralized on their passage into the blood, these acids
must at once become so, and it would appear that henceforth their history
must follow that of the salts they form. Yet the received notion of the
action of these acids on the organs of the body is so different from that of
any of their salts, that the behavior of the acids must be spoken of sepa-
rately.

On combining with the alkalies of the blood, the acids must set free
some weaker acids, and so to a slight extent lessen the alkalinity of that
fluid, as is evidenced by the increased acid reaction of the urine folloAving
the use of mineral acids. What further eifects tliev mav have on the blood

ACIDS. 129

is at present quite unknown. They are reputed to be tonic and bracing,
but the improvement in the general health may more safely be attributed
to their action on the intestinal canal. Still, they do produce certain
changes in the fluids and solids of the body, since in the absence of lime-
juice or fresh vegetables, acids, especially vinegar, act as preventives of
scurvy.

The functions of the body are supported only with alkaline or neutral
blood. Slight acidity is at once desti'uctive of all function. This is well
seen in experiments with the detached frog's heart. When supplied with
blood, or with saline solution and a physiological quantity of potash and
lime salts, if a small quantity of acid is added, enough to cause the faintest
reaction, the heart soon ceases to beat spontaneously, and in a little while
all contractility is lost, the ventricle refusing to contract when stimulated
by a strong faradaic shock. I find that a ventricle will beat for hours
when fed by a neutral solution, composed of saline solution containing
one ten-thousandth part of potassium chloride and a minute dose of cal-
cium chloride. It is obvious then that alkali in the blood is not necessary
for function. But with every performance of function acid is formed,
certainly in the muscles, and soon the neutral fluid would become acid,
when function would be destroyed. The alkali of the blood neutralizes
the acid and prevents its depressing effect on the tissues.

Hydrochloric acid is frequently given in fevers, especially of a typhoid
character, and phosphoric acid in cases of nervous weakness.

Dr. Eees recommends large doses of lime-juice to the extent of eight
ounces daily, in acute rheumatism. Dr. Inman speaks highly of this
treatment, and observes that neither tartaric nor citric acids nor lemon-
juice can be substituted for lime-juice.

Nitric acid is recommended in secondary syphilis. It has been said
sometimes to induce salivation; if so, this may have been due to the direct
action of the acid on the mucous membrane by increasing the alkaline
secretion of the salivary glands.

Acids seem sometimes to abate the rapidity of the pulse in fevers, a
result not due probably to the direct action of the acid on the heart or
nervous centres, but more likely to the relief arising from diminished thirst.
Sulphuric acid, especially in conjunction with sulphate of zinc checks the
profuse sweating of phthisis and other exhausting diseases. Dr. Graves
ascribed a similar action to vinegar, and often used this favorite receipt:
Distilled vinegar 3 ij, Laurel water 3 ij, Syrup 3 vj. Aqua 3 v. An
ounce or two ounces to be taken every third or fourth hour. Sulphuric
acid is supposed to check bleeding from the lungs or womb. It is diffi-
cult, indeed, to understand how an ordinary dose of sulphuric acid can
exercise such an influence after becoming so greatly diluted by admixture
with the blood, and the difficulty is enhanced by the consideration that
these acids, either before or immediately after their entrance into the cir-
culation, are converted into salts, as sidphates, nitrates, and phosphates.
Whatever influence, therefore, is exerted on distant organs must be effect-
ed through these combinations; yet we cannot ascribe to any salts of these
acids properties similar to those ascribed to the acids themselves.

In such questions experience is a safer guide than speculation. The
subtle influence of even small doses on distant organs of the body is well
exemplified by the effect of these medicines on the mother's milk; for
acids taken for some time induce in the child sickness, diarrhoea, and
colicky pains.

130 SULPHUROUS ACID.

Many recommend acids in chronic bronchitis, and find that they les-
sen secretion. Ivohrig, in his experiments on animals, found that acids
lessened the secretion from the tracheal mucous membrane.

Phosphoric and lactic acids are employed in diabetes. Griesinger, who
has carefully studied the action of phosphoric acid, considers that it does
more harm ithan good. He employed the acid to the extent of an ounce
daily, and found that this dose increased the sugar. Since the members
of this group augment the acidity of the urine, it has been proposed to
dissolve phosphatic calculi by artificially acidifying the urine, but since
these acids but slightly augment the acidity of urine they must be taken
for a prolonged period before they could materially diminish the bulk of
a stone; moreover there remains the insuperable objection that this
method of treating calculi would seriously damage the mucous membrane
of the stomach and intestines.

Sucking the juice of one or two lemons is a domestic remedy for
excessive menstrual fiow.

The injection of nitric acid, sufficiently diluted, has been employed
with success by some eminent surgeons, and is a far more effectual treat-
ment for phosphatic calculi. The experiments of Sir W. Roberts, on the
solvent power of dilute solutions of this acid on calculi, after their re-
moval from the body, lead him to the conviction that this treatment is
worthy of much wider apjDlication than it at present receives; moreover,
by neutralizing the urine if alkaline, and preventing its decomposition,
nitric acid injections protect the mucous membrane of the bladder f j'om
the irritation of the alkaline urine.

The further infinence of sulphuric, nitric, and hydrochloric acids on
the urine is unknown. Of the influence of acetic and phosphoric acids
we shall speak in another place.

It should be remembered that phosphoric acid may possess many other
properties than those already specified, but these will be referred to in
speaking of the phosphates, i'or it is in this form that phosphoric acid
exists in the blood, and manifests many of its beneficial effects on the
diseased body.

SULPHUROUS ACID, SULPHITES, HYPOSULPHITES.

SuLPnuROUS acid is generally considered a potent poison to the lower
forms of life, and is commonly used as a deodorizer and disinfectant. It
is a deodorizer by virtue of its power to arrest putrefaction ; hence it may
be used to prevent bad smells, but it possesses little or no power to decom-
pose ofliensive gases, and therefore it is of little service in destroying foul
odors. It arrests fermentation by destroying the minute organisms which
determine this process. It is supposed to disinfect by destroying the
micro-organisms that propagate contagious diseases. Roch's experiments,
however, satisfy him that sulphurous" acid, gaseous or in watery solution,
is not a disinfectant and does not destroy bacterial life.

It must be borne in mind that sulphurous acid corrodes metals, so
that, when used as a disinfectant, these sbould be protected by a covering
of some greasy substance. In fumigating a room, sufficient sulphur,
about an ounce to each hundred cubic feet of space, should be burned to

SULPHUROUS ACID. 131

render the air unfit for respiration, and the escape of the gas by the chim-
ney, windows, and crevices of the doors, should be prevented. It is better
to repeat this process three or fonr times at intervals of twenty-four hours.
To disinfect a bed, ]\Ir. Startin recommends that a warming-pan corjtain-
ing live coals sprinkled with sulphur should be put between the clothes,
till the sulphur is consumed. A damp napkin held before the mouth
will prevent sulphurous acid from irritating the lungs. It is far better,
however, to submit the bedding, etc., which cannot be boiled, for some
hours to a temperature between 250 ° and 300° in a disinfecting chamber
or oven.

Baxter finds that sulphurous acid is more destructive of the vaccine
virus than either chlorine or carbolic acid.

The quickest way of curing itch is to immerse the patient, leaving
his head free, in a gaseous bath of sulphurous acid, made by burning 12
drachms of sulphur in a suitable apparatus. AVhilst in the bath, the
patient's clothes should be baked, so that in half an hour he is cured of
his itch, and is made free from risk of re- infection.

The acid will cure chloasma, by destroying the parasite on wdiicli the
disease depends. The acid of the Pharmacopoeia, mixed with an equal
quantity of glycerine, may be used. Warm baths should also be employed
to remove the cuticle infested by the parasite. It is useful also in favus,
and in tinea tonsurans; but when these aifections are unusually obstinate,
its action should bo assisted by epilation.

Dr. Dewar, of Kirkaldy, has drawn attention to the beneficial action of
sulphurous acid in various diseases, and many of his statements have been
confirmed by subsequent observers.

Dr. Dewar applies the sulphurous acid in three ways, — as a solution,
by fumigation, and by the spray-producer. A solution of the acid or
fumigation with it, he says, will speedily cure chilblains and chapped
hands. Equal parts of the acid of the Pharmacopoeia, and of water or
glycerine Avill, he states, at once ease the burning, and prevent the spread
of erysipelas. Wounds and sore nipples he treats with the solution, con-
stantly applied, either neat or diluted. The same treatment, he says, Avill
preveiit or quickly dissipate the eifects of bruises.

According to the same authority, many internal diseases are equally
amenable to sulphurous acid; amongst others, cold in the head, influenza,
tonsillitis, malignant sore-throat (scarlatinal or otherwise), laryngitis,
chronic bronchitis, chronic phthisis, asthma, croup, clergyman's hoarse-
ness, and tyhoid fever.

The acid may be applied to the throat by fumigation, or by inhala-
tion: a few drops should be added to boiling water, and the steam inhaled;
or the acid may be applied by a camel-hair brush, or by the spray-producer.

It may be carried into the lungs by fumigation, inhalation, or by spray.
If properly and carefnlly employed, the Pharmacopoeia acid excites
scarcely any irritation or annoyance. The application of sulphurous acid
may be conducted in the following ways: —

" Put a few red cinders into a kitchen shovel, set this upon a wooden
stool, and then sprinkle flowers of sulphur from time to time till the
room is not inconveniently filled with smoke. "

The spray may be applied by a vaporizer now in common use, fur-
nished with vulcanite tubes constructed upon Dr. Dewar's plan. For a
child the instrument should be held about three feet from the mouth, and
the fine spray should be inhaled and the process repeated according to

132 CHROMIC ACID.

circumstances. In an acute attack of diphtheria with no time to lose,
it may be repeated liourly, or even oftener. Sulphurous acid may also be
used as a gargle or wash.

In applying the spray to adults, Dr. De war directs the operator "to
hold the nozzle of the instrument about six inches from the patient's
month, and administer three or four wliiifs to begin Avith; then, after a
corresponding interval, during which a cough or two is given, the process
is repeated, about twenty squeezes, in all, which represents the injection
of from forty to sixty minims of acid. The acid should be pure."

For the relief of rheumatism and gout, besides the fumigation. Dr.
Dewar advises that the bed-clothes should be exposed to the strong fumes,
and then spread over the patient, who after sweating and sleeping wakes
much relieved.

The solution, either strong or diluted in various proportions, speedily
removes thrush. Dr. Lawson speaks highly of sulphurous acid as a
remedy for pyrosis; indee \ he says it never fails to be of service, and in
my experience it seldom fails. Ten to fifteen minims should be taken ten
minutes before &ach meal. The sulphite he finds useless.

Sulphurous acid in doses of five to ten minims often prevents flatulence
produced by fermentation, and is especially useful when the gas is abun-
dant. It is more efficient than sulphites and hyposulphites. Sulphurous
acid is useful as a wash or gargle in diphtheria.

Sulphites, administered by the mouth, will, it is said, prevent decom-
position and putrefaction of urine in the bladder.

Sulphites and hyposulphites have been employed to destroy sarcmi»
and torulte in the stomach.

It is said that hyposulphite of soda, in fifteen to twenty grain doses
every two hours, will cure intermittent fever, but more careful observers
do not corroborate this statement.

It was at one time said to be useful in the acute specific fevers.

CHEOMIC ACID.

Chromic acid coagulates albumen, powerfully oxidizes organic mat-
ter, destroys low organisms, and decomposes ammonia and sulphuretted
hydrogen, and so acts as a disinfectant and deodorizer.

Chromic acid was first used as an escharotic by Mr. John Marshall,
who employed it to remove warty growths from the nose, genital orgaus,
or elsewhere. Immediately after touching the parts with chromic acid
Mr. Marshall applies lead lotion, " Mdiicli restrains the subsequent inflam-
mation, relieves the subsequent soreness, and does not in any way neu-
tralize or retard the rapid effects of this apparently useful escharotic."
He uses a solution containing a hundred grains of crystallized chromic
acid to an ounce of water. " The solution is best applied by the aid of a
pointed glass rod, or when a large quantity is needed, by means of a
small glass tube, drawn to a point, (inly so much should be applied as
will saturate the diseased growth, avoiding the surrounding healtliy
mucous membrane, for, though the solution is not sufficiently powerful
as an escharotic to destroy or even vesicate the mucous mem])rane. it
may give rise to an unnecessary amount of inflammation." "Any
superfluous acid may be removed by a piece of wet lint. The first effect
of its application to the warts is to ])roduce a flight smarting pain. If,
however, any ulcerated surface be touched, the pain is of a buruiug

ALKALIES. 133

character, more lasting, but not so acute and intolerable as that caused by
nitrate of silver, or by nitric acid, with or without arsenious acid. Under
its influence, the morbid growths rapidly waste, in some cases being
thrown off altogether, and in others undergoing a partial, though evident,
diminution in size. The best immediate dressing is dry lint, afterwards
the part may be Avashed with lead lotion, and dressed with lint moistened
in the same." " In most cases one application suffices, the cure being
completed in from four to eight days. In severe cases, where the warts
are large, repeated applications are necessary." Mr. Marshall further
states that "chromic acid solution neither burns nor stains linen; it all
washes out."

BORIC OR BORACIC ACID.

This substance is largely used as an antiseptic dressing for wounds,
and is employed as a lotion or ointment. The lotion is composed of
one part of boracic acid in twenty of hot water. It is not, however, de-
structive to all low organic growths. The ointment is now largely used
for burns, eczema, etc. The lotion is often useful in pruritus pudendi,
eczema of the vulva, some forms of leucorrhoea, and vaginitis. Ayon finds
that it has very little physiological action. A pint of saturated solution
of boracic acid used daily to flush the nose is very useful in chronic ozoena.
The saturated solution is also useful to wash out abscesses, emjiysmas,
etc. It is less irritating than many substances used for the purpose.
Mixed with starch it is highly sjioken of as a dusting powder for infants.

The late Dr. Simpson, of Highgate, told me that boracic acid dissolved
in glycerine is a very useful local application in diphtheria. In a letter
to me, he says: — "During the last epidemic of diphtheria I have used
boracic acid dissolved in glycerine (in a water bath) of the strength of 1
in 30, applied by means of a brush to the throat, every two hours day
and night, until all traces of membrane had disappeared. The patches
took on a white color, with no offensive odor emanating, and in the
course probably of forty-eight hours, and often much earlier, no trace
of membrane was visible. Dr. Cossar Ewart and I found by experiment
that bacteria present in the membrane so treated could not be propa-
gated. Children do not dislike the taste. I find boracic acid, of
strength of 1 in 50, of service also, in stomatitis."

An ointment composed of three parts of acid, five of paraffin and
ten of vaseline, makes a good ointment for eczema and burns.

Boracic acid in solution or mixed with honey or glycerine (1 in 4 or
5) is useful in simple and ulcerative stomatitis and in thrush.

Boro-glyceride, discovered by Barft', is powerfully antiseptic, and is
recommended to preserve meat and vegetables. Barff shows that it will
preserve meat for months without impairing its quality. It is useful as
an injection in ozoena, vaginitis, and urethritis.

Group embracing CAUSTIC POTASH, SOLUTION OF POTASH,
CARBONATE AND BICARBONATE OF POTASH, ACETATE
OF POTASH, CITRATE OF POTASH, and the corresponding
preparations of SODA, POTASH SOAP, SODA SOAP, BORAX.

The members of this group are all endowed with very high diffusion-
power, the potash in a greater degree than the soda-safts. All are very

184 ALKALIES.

freely soluble in water. With the exception of the acetates and citrates
of potash or soda,, they have an alkaline reaction, weak in some, as the
hiborato of soda, but very marked in others, as caustic potash or soda.

They dissolve the nitrogenous constituents of the animal textures, and
their solvent power is in proportion to, yet distinct from, their affinity
for Avater.

Owing to their affinity for water, and their solvent action on the nitrog-
enous tissues, several of these substances, by abstracting the constituent
water, will destroy the skin or other structures to a considerable depth.
The caustic alkalies possess a greater affinity for water, and therefore a
more solvent and destructive action on the tissues than the remaining
members of this group. The carbonates and solutions of the caustic al-
kalies come next; while the bicarbonates, acetates, and the rest of this
group, are comparatively feeble agents.

The caustic alkalies, undiluted, or sometimes mixed with caustic lime
to lessen their activity, are occasionally employed to destroy warty
growths or the hard edges of some unhealing sores, such as chancres, or
to open abscesses, or to make issues.

It must be borne in mind that, in common with the rest of this group,
the caustic alkalies, possessing a very bigli dilfusion-power, will penetrate
the tissues and destroy them widely and deeply; unless great care is taken,
the undue diffusion of the alkali will destroy a far larger amount of struc-
ture than is intended, producing a large slough, and leaving, of course,
a correspondingly large sore. The application of the alkali should always
be checked before it has taken full effect, since the destructive effect Avill
continue for some hours; other precautions should likewise be observed,
or the caustic alkali dissolved in the fluids of the tissues will run over a
large surface, subsequently destroying it. In making an issue, pieces of
plaster, with a hob in them of the required size, should be ^^laced one
over the other, and the caustic applied to the skin exposed through the
hole, while the neighboring parts are effectually protected. As soon as
the application is finished, it is desirable to wash the surface with vinegar
and water, to neutralize any remaining alkali. The caustic, very slighth^
moistened, should be rubbed on the surface till it assumes a dull bluish
look, and till the cuticle is softened and easily rubs off, when the applica-
tion of a poultice will help the separation of the dead parts, and ease the
pain.

A solution of a member of this group sponged over the peccant part
will often allay the troublesome itching accompanying many skin dis-
eases. A Aveak solution of the caustic salt, or of its carbonate is best.
A solution of carbonate of potash or soda, containing a drachm of the salt
to a pint of water, applied with a small piece of sponge, is often of ex-
treme comfort in urticaria or lichen. A solution of the same strength,
of cyanide of potassium, Avhich has also a strong alkaline reaction, is,
perhaps, a still more effective application.

The itching of many other eruptions, as of scabies, eczema, pruritus
ani, and pruritus vulvje, and prurigo from lice, yield more readily to
other applications, Avhich are indicated elsewhere.

The carbonates of tlie alkalies ai-e employed in the treatment of itch,
either in soap, or in the form of ointment, to remove the superficial and
dead cuticle, aiul so to break up the burrows of the itch insect.

By virtue of the alkali it contains, soap facilitates the removal of the
scales of psoriasis.

ALKALIES. 135

In the treatment of eczema a weak solution of carbonate of potash or
of soda finds much favor, I have no doubt of its usefulness in the early
and middle stages of the disease, when the red and raw surface weeps
copiously; but when the weeping has ceased, and especially when mere
desquamation remains, the alkali fails to be of use, and other applications
are preferable. Dr. Hughes Bennett recommends a solution containing
half a drachm of carbonate of soda to a pint of water, and the affected
surface to be kept constantly moist by a thin piece of lint, soaked in the
solution and covered Avith oilskin, or with a piece of lint spread with sim-
ple ointment. A weaker solution acts sometimes still better. Like tbe
oilskin, the ointment prevents evaporation, but is less " heating " and is
more comfortable to the patient. This treatment is an instance of the
general proposition {vide section on the topical action of alkalies and acids
on the secretions) that alkalies, as local applications, check an alkaline
secretion; for the fluid which oozes so abundantly from eczematous sur-
faces is strongly alkaline, and an alkaline application very speedily checks
the abundant weeping.

It must be admitted, however, in some instances, that an alkali appears
to irritate the skin, a result often due to an over-strong solution. During
this treatment attention must be paid to the state of the digestive organs,
and any irritation produced by teething or worms should be attended to.

It is sometimes useful to wash the moist and weeping eczematous
surface night and morning with soap and water, which in many cases
checks the secretion, and allays the heat and irritation. If a strong soap
is too irritating, a milder one must be used. In chronic forms of eczema,
Hebra recommends the application of liqiior potassas, or of the stronger
solution of caustic potash. He advises that liquor potasste should be
brushed once a day over the surface, and if it produces much smarting,
the residue must be washed off with cold water. When the skin is only
slightly infiltrated and tbickened, he employs a solution composed of two
grains of caustic potash to an ounce of water; but when the infiltration is
greater he uses a solution containing from five to thirty grains or more
to»the ounce. These stronger applications must be employed only once a
day, and must be quickly washed off with cold water. This treatment
speedily allays itching, but is liable to make the skin brittle, and to obviate
this condition Dr. McCall Anderson applies every night either cod-liver
oil or glycerine. Dr. Anderson frequently employs alkalies in conjunc-
tion with tar or oil of cade. He recommends the following prescription:
— " Equal parts of soft soap, rectified spirit, and oil of cade. A little of
this to be firmly rubbed over the eruption night and morning and washed
off before each re-application." Mr. Startin condemned the use of soap
in eczema, or in any skin disease, using instead a wash consisting either of
yolk of egg and water, or milk and water.

Sponging the head several times a day with a saturated solution of
borax and water is an effectual application in pityriasis of the scalp; it at
once eases the itching, loosens the scales, and cleans the head. Pityriasis
often gives way in a short time to this treatment; although, unfortunately,
after a variable period the affection generally returns, which indeed
happens when the disease is removed by other treatment. Should the
pityriasis prove rebellious glycerine of borax often proves more useful, as
it keeps the seal]) continually moist with the weak alkaline preparation.
This plan is useful, too, in eczema of the ears and scalp.

Acne punctata generally yields to hot water and plenty of soap several

136

ALKALIES.

times a day, a treatment Avhicli keeps open the orifices of the sebaceous
follicles and prevents the accumulation of the abundant secretion. If this
treatment roughens, reddens, and irritates the skin, it should be Avell
rubbed with glycerine of starch after each washing.

Free ablution with soap and water is very effective in decomposing
and removing the acid irritating secretions wliich keep up the intertrigo
so often infesting the buttocks of children, or in the irritation in the folds
of the skin of stout children or underneath the breasts of fat women.
After carefully drying the parts, they should be smeared over with some
greasy application, which is generally preferable to dusting powders, as
starch powder or oxide of zinc, or boracic acid. Caustic potash or soda is
sometimes used to open abscesses with the intention of preventing scarring.

Alkaline baths are often employed, but their action on the skin and
its secretion is not yet satisfactorily determined; like acid or simple baths
they lessen the acidity of the urine.

Soap with excess of alkali will induce pityriasis of the face, which will
often disappear at once on substituting oatmeal or a milder soap, as
*' Compressed glycerine soap" or " Solidified glycerine."

Mr. Peppercorne recommends a saturated solution of carbonate of soda
as a local application to burns and scalds. Cloths dipped in the solution
are applied and covered with oil silk.

A weak solution of bicarbonate of potash or soda, a drachm of the salt
to a pint of water, is a useful injection to check leucorrhoea, when this
discharge depends on an increased secretion of the glands of the os uteri.
The secretion is strongly alkaline, and when unduly abundant, the effi-
cacy of the alkaline injection in such cases is another proof of the general
proposition that alkalies check alkaline secretions.

When the leucorrhoeal discharge is clear, like white of egg, or when it
is lumpy, but not yellow, three or four injections will generally check it.
On the other hand, when the discharge is yellow and puriform, the injec-
tion may fail; although in many cases, when this yellow discharge is due
to mere abrasion of the os uteri, the injection, continued for one or two
weeks, will change the yellow to a white discharge, and sometimes cai^se
even this to disappear. If the leucorrhoea is produced by displacement
of the uterus, or ulceration of its neck, this injection, like many others,
may temporarily check the discharge; but it soon returns, and in such
cases the leucorrhoea cannot be cured till these conditions are removed.

The success of this injection obviously depends on its reaching, and
coming well in contact with, the os uteri, the offending part; hence it is
necessary to give full and careful directions as to its use. The patient
should be directed to lie on her back, to raise the buttocks by placing a
pillow under them, and then to introduce the syringe as far as she con-
veniently can, and to leave the injection in the vagina about five minutes.
The injection should be used cold, Avlien it can be borne, twice or three
times in the day. A Kennedy's syringe, by means of which any quantity
of lotion may be forcibly injected, and which, by washing away the dis-
charges and douching the part with a cold or warm medicated application,
is even more effectual.

Mr. Norton, of St. Mary's Hospital, ingeniously employs a solution of
liquor potassge (two drachms to the ounce of water) in the treatment of
ingrowing toe-nail. ''Apiece of cotton-wool is saturated with the solu-
tion, and pressed gently down between the upper surface of the nail and
the soft tissues. The solution permeates the substance of the nail, and

ALKALIES. 137

softens and pulpetizes the superficial cells. The wool is kept constantly
moist with the lotion, and softened tissues are wiped away each morning.
The nail in a few days becomes thin and flexible, and, if desired, it can
be pared away without pain. The lotion should be continued until all
ulceration has disappeared."

liorax is antiseptic, and prevents fermentation and putrefaction. It
coag'ulates yeast, and destroys its power to decompose sugar into alcohol.
It destroys the action of diastase or amygdalin, and so prevents the for-
mation of essence of bitter almonds and prussic acid, and the conversion
of starch into glucose. It also destroys the action of myrosine, and
prevents the formation of the pungent essence of mustard from the
mustard farina.

Sir J. Simpson recommended borax in "the pruriginous eruption
which appears on the mucous membrane of the vulva, and extends up
along the vagina as far as the cervix uteri. It may also extend, and is
sometimes, indeed, originally situated on, the cutaneous border of
the vulva, and appears on the outer cutaneous surface of the labium,
spreading backwards along the perinteum to the circle of the anus. Ac-
cordingly it is a flitting and transient affliction, recurring with menstrua-
tion, pregnancy, or delivery. It may be more fixed, and last weeks, or
months, or years, producing constant irritation and distress, frequently
interfering with rest and sleep, and rendering the victims miserable and
almost deranged when the disease has become somewhat chronic, and
necessitates the patient to attempt to alleviate it by constant and some-
times rough friction. The mucous membrane becomes at the most irrita-
ble parts white, and thickened with red fissures." This distressing com-
plaint, says Sir J. Simpson, " may be generally cured by the assiduous
and persevering application of a solution of biborate of soda (five or ten
grains to the ounce of water)." A hot solution much enhances the effi-
cacy of borax. Water alone, as hot as can be fairly borne, will often allay
this itching; but hot water with borax is far more efficacious. If this
treatment fail, infusion of tobacco may be tried; or an ointment of iodide
of lead ( 3 i. to §1.), or of bismuth and morphia. Chloroform vapor,
liniment, or ointment, is often found useful; a drachm of chloroform
may be added to an ounce of some sedative liniment or ointment. A
strong lead lotion or a solution of nitrate of silver often does good. Dr.
Simpson says, " There is a great advantage in alternating these local ap-
plications; for most of them begin to lose their effects when persevered
in above a few days. In the most obstinate and severe cases strong astrin-
gents are sometimes of the greatest use, as a strong solution of alum or
tannin. "

Dr. Garrod employs strong solutions of lithia salts to remove gouty
enlargements. Gout-stones are composed of urates. Urate of lithia
being the most soluble of uric acid salts, a strong solution of a lithia salt
is applied with the intention of converting the urates in the tissues into
urate of lithia, and so to soak the urates out through the skin. The
swelling must be constantly enveloped in lint or rag kept moist with the
lithia solution. In Dr. Garrod's practice this treatment has proved very
successful. He thinks that lithia salts formed Avitli the uric acid pass
into the blood, and that in this way gout-stones are reduced. He employs
carbonate of lithia, five grains to the ounce, with which he has removed
considerable enlargements and restored suppleness and even free move-
ment to stiff and useless joints. I also have employed this treatment with

138 ALKALIES.

considerahlo success. It is especially useful when the skin is broken over
the gouty enlargement. It is well known that a sore of this kind is ex-
tremely difficult to heal. The urates being ultimately mixed with the
connective tissue, and oozing very slowly through the wound, are dissolved
and washed away by the lithia solution, thus enabling the sore to heal.
The citrate of lithia is to be preferred; but a strong solution of citrate of
potash is nearly, if not quite, as useful. It probably converts the biurates
into neutral urates, and in this more soluble form the urates are carried
off through the skin. Equal jmrts of citrate of potash and water may be
used. Neither the solution of citrate of lithia, nor that of citrate of
potash, irritates the skin. As might be expected, this treatment takes
many weeks, or even months, to effect considerable reduction of large
deposits.

Kappesser has drawn attention to the value of soft-soap as an applica-
tion to scrofulous enlargements and in acute and chronic inflammations,
and Beetz and Senator confirm and supplement his recommendation. It
is useful in scrofulous enlargements, lymphadenitis, subcutaneous inflam-
mation, as abscesses and whitlow; also in chronic glandular enlargements
or abscesses. Soft-soap is applied each night and rubbed off next morn-
ing, or linen rags soaked in a solution of soft-soap 3 ij. ; alcohol or eau
de Cologne 3 j. It has been used successfully in scrofulous mesenteric
disease, caries and periostitis. In caries and periostitis about fifteen
grammes of green soap is rubbed over the part, and in half an hour is
washed off. Senator finds soft-soap inunctions useful in chronic non-
scrofulous glandular enlargements, syphilitic glandular swellings, and in
serous exudations, including exudations into synovial cavities.

Borax and honey, or the gh'cerine of borax, is often used for aphthfe.
In aphthffi the mucous membrane is usually covered with small, round,
sharply-cut superficial ulcers, covered with a pultaceous exudation.
AphthfB natnrally runs a short course, and when left untreated gets well
in most cases in a week or ten days. The same preparations are useful
in removing the curdy exudation of thrush.

Dr. Corson finds that a piece of borax the size of a pea, dissolved in
the mouth, acts magically in restoring the voice, in cases of sudden hoarse-
ness brought on by a cold, and, frequently, for an hour or so, it renders
the voice ' ' silvery and clear. "

Borax is useful in hoarseness common among clergymen and singers.

The action of the members of this group on the stomach was some-
what anticipated Avhen it was shown that alkalies increase the secretion
of the gastric juice, and may thus prove useful to promote digestion. It
is obvious, however, that method must be observed, or the contrary effect
to that intended will ensue; for, if given soon after a meal, the alkalies
will neutralize the acid of the gastric juice, and effectually retard and im-
pede digestion. Alkalies intended to increase the quantity of gastric
juice, and to promote digestion, mnst be taken a short time before a meal.
The alkaline saliva swallowed at the beginning of a meal is highly useful;
although, as it must speedily become neutralized by the acids of the stom-
ach, its action must be but temporary. Alkalies may be usefully admin-
istered in many forms of atonic dyspepsia, and in other forms associated
with deficient secretion of the gastric juice. The bicarbonate of soda is
the salt generally employed.

\Yhen, on the other hand, a patient complains of heartburn and acid
eructations, these disagreeable symptoms may at once be removed by the

ALKALIES. 139

exliibition of an alkali, as tlie bicarbonate, wliicli neutralizes the excess
of acid in the stomach; but it must alwa3^s be remembered that this treat-
ment is merely palliative. No doubt a course of alkaline treatment
appears sometimes to remove acidity; but the good attributed to alkalies
may with great probability be ascribed to the tonic with which they are
generally combined. The bicarbonates are preferred to the more caustic
salts on account of their milder action, while the acetates and citrates are
neutral, becoming alkaline only by decomposition in the intestines or
blood. The bicarbonates being milder can be continued longer than the
more caustic preparations; but they have the disadvantage of giving off
much carbonic acid gas, which may cause trouble from distention of the
stomach. To prevent this, magnesia, which is an alkali, and acts like
the members of this group, mtiy be substituted if the bowels are confined,
or lime-water if they are relaxed.

Alkalies are apparently sedative to the stomach, at least they often
relieve the pain of this organ. Liquor potassaj is generally employed in
such cases.

In cases of poisoning by any of the acids, alkalies the least irritating to
the stomach are employed to neutralize and to prevent the further action
of the acid on the tissues.

In poisoning by metallic salts and alkaloids the same salts, namely,
the bicarbonates of the alkalies, may be used, to precipitate the insoluble
oxide of the metal or of alkaloids. Magnesia, as it acts as a slight purga-
tive, and so helps to expel the poison from the intestinal canal, is gener-
ally preferred.

By virtue of their diffusion-power, the substances contained in this
group pass so readily into the blood, that but a small portion of them
reaches far into the small intestines. Little is known of their action on
the small intestines, and on the organs which pour their secretion into
them; yet it seems probable that those secretions having an alkaline re-
action may be affected in a double and opposite way, according to the
period of administering these drugs. The secretion from the intestinal
glands is alkaline; hence, if the general propositioii elsewhere formulated
be valid, acids ap]5lied to the orifices of the ducts should augment their
secretion, while alkalies should have the contrary effect. But we have
seen that alkalies, given before meals, increase the secretion of the acid
gastric juice, and thus augment the acidity of the intestinal canal; they
should likewise increase the biliary and pancreatic secretion. On the
other hand, if given after a meal, alkalies neutralize the acid in the stom-
ach, and should lessen the secretion from the liver and pancreas. On
these points, however, nothing is known with certainty, the foregoing
statements being merely conjectural.

Rutherford, from his experiments, concludes that bicarbonate of soda
injected into the duodenum of fasting dogs " has scarcely any effect on
the secretion of bile."

The milder alkalies, as bicarbonates of potash, soda, or magnesia, may
be used with great benefit in diarrhoea, caused by excess of acid in the
intestines. By neutralizing the excess of acid, these substances arrest
the diarrhoea.

Soap is often added to anal injections, to suspend castor-oil or turpen-
tine. Soap itself, moreover, may be used as a mild and safe purgative.
A piece the size of the thumb, covered with castor-oil or merely wetted
with water, and thrust up the rectum as high as the finger will carry it.

140 ALKALIES.

in a short time will produce an easy, copious, and natural evacuation.
This plan is especially available for infants and children.

On entering the blood, alkalies undergo various changes, according
to their composition. The acetate or citrate, which has not already under-
gone a like change in the intestines, becomes converted into the carbonate,
the form probably ultimately assumed by the oxide of the alkalies.

The alkalinity of the blood must therefore be increased by these alka-
lies, not probably to any great extent, as from their high diffusion-power
they are rapidly eliminated by the kidneys. There has been much specu-
lation concerning this increase in the alkalinity of the blood. The alka-
lies are known to promote oxidation, whence it has been conjectured that
its oxidation, and that of the tissues, may be increased by increasing the
alkalinity of the blood. It has been suggested that alkalies might be
profitably employed in diabetes to promote the oxidation of the sugar.
Alkalies have been advocated also for excess of uric acid in the urine,
with the expectation of oxidizing this product of the nitrogenous tissues,
and so converting it into urea or some other substance. Alkalies are
sometimes given to fat people to increase oxidation, in order to consume
the superfluous fat, and so to control unseemly obesity. The solutions
of the bicarbonates, and especially of the oxides, are occasionally, and I
should think unsuccessfully, used for this purpose.

The action of alkalies in diabetes appears to be nil, or rather, it should
be said, they in no degree lessen the amount of sugar separated by the
kidneys, although, if long persisted in, some derangement of the stomach
must occur, with diminution in appetite, so that less food being taken,
less sugar is excreted.

Nor does it appear that alkalies can oxidize uric acid in the blood; at
least there are no experiments in proof of this. It is, however, very use-
ful to give alkalies, so as to render the urine, weakly acid, or even alkaline,
so as to convert the excessive quantity of uric acid into a more soluble
urate. This treatment, too, will prevent the growth of uric acid calculi.

Micturition in young male children not unfrequently causes severe
pain, traced to thci existence of uric acid or biurates, in the form of spicu-
lar crystals, which in their passage irritate the urethra. By alkalinizing
the urine, these crystals are dissolved and rendered innocuous. The
citrates having very little action on the mucous membrane of the stomach,
are the salts best adapted to deacidize the urine.

As to the jiower of alkalies to increase the oxidation of fats, it is clear
that the long-continued administration of the more alkaline preparations
will induce much wasting of the body, and admits of no doubt, but this is
effected by the disordering action on the mucous membrane of the stomach.

To diminish fatness in a way so likely to damage health, and even to
endanger life, is surely a mistake. Some writers of authority insist that
obesity may be thus reduced without any ill effects on the mucous coat
of the stomach; Dr. Neligan states that he has often removed an uncom-
fortable excess of fat by the use of liquor potassa?, Avithout in any way
injuring the patient's general health. Though occasionally successful,
this treatment generally fails signally.

After the passage, of alkalies into the blood, and their conversion into
carbonate, the action of these substances on that fluid is at present l)ut
little knoAvn. Dr. Garrod is of opinion that scurvy is due to deficiency of
potash salts with the food, a surmise supported by many facts, but not
yet confirmed by exact observation.

ALKALIES. 141

Eossbacli, in his experiments on animals, finds that alkalies acting
through the blood dry up the normal secretion of the bronchial mucous
membrane. The reverse of this happens, therapeutically, when alkalies
are given in chronic bronchitis with viscid, scanty expectoration; for then
alkalies increase secretion and lessen viscidity. Eossbacli in his experi-
ments used very large quantities of alkalies, and this excess may explain
his results.

The bicarbonate or citrate of potash is often employed in rheumatism.
This disease is supposed to be produced by an excessive formation of lactic
acid, which, having an afhnity for certain tissues of the body, excites in
them the rheumatic inflammation. Alkalies are given to neutralize this
acid, and to protect the tissues from its action. But so little is known
about the nature of rheumatism, that it is impossible to approach the
question of its treatment on the theoretical side. As careful and exact
observations of this treatment are non-existent we can only be influenced
by individual impression. This much, however, must be conceded, that
in many cases rheumatic pain is much relieved as soon as the patient is
well under the action of an alkali and the urine has ceased to be acid.

Many eminent authorities are firmly convinced that the alkaline treat-
ment renders rheumatic fever both milder and shorter, and diminishes
the danger of heart complications. I have made many careful observa-
tions on this question, and am led to believe that, due attention being
paid to the age of the patient, and to the nature of the rheumatism, it
will be found that these salts are unavailing either to lessen the intensity
or the duration of the fever.

In the fifty-second volume of the Medico-Cliirurcjlcal Transactions,
Drs. Gull and Sutton published a paper on the value of remedies in rheu-
matic fever. The cases quoted, although not numerous enough to settle
this much-vexed question, lead them to the conclusion that alkalies,
lemon- juice, or blistering, do not shorten the course of rheumatic fever,
but it is not denied that these remedies may allay pain. They further
conclude that neither alkalies, lemon-juice, nitrate of potash, nor blis-
ters, prevent the occurrence of heart disease in rheumatic fever. In
dealing with statistics relating to the treatment of rheumatism it is neces-
sary to be specially cautious; the present tendency, warranted by observa-
tion, leads to the conviction that hereafter rheumatism will be discrimi-
nated into many varieties. Already we have distinctive rheumatic fevers,
due not only to weather influence, but to syphilis, lead, etc. , and it is often
difficult, and at first even impossible, to distinguish gonorrhoeal rheuma-
tism and acute febrile rheumatoid arthritis from rheumatic fever. In
rheumatism there is a large unworked field of inquiry.

The influence of age, too, in acute rheumatism must be taken into
account. Thus in children the attack is sharp and short, declining even
when untreated in from five to ten days; and, wliilst the danger to the
heart is much greater than with adults, the joint affection is so slight that
in an acute attack, with a temperature varying between 103 and 10-4, the
child may not even complain of joint-pain, or complain so slightly that the
nature of the case may easily be overlooked.

Fever in a child, with even the slightest pains in the joints, leads us
to investigate carefully if we have not to deal with an attack of acute
rheumatism. On the other hand, in middle-aged and old people, slight
fever is generally accompanied by severe pain in many joints, whilst the
danger to the heart is almost nil, and the attack is often chronic. Again,

142 ALKALIES.

the fatality of rheumatism is much influenced hy age. Rheumatic hyper-
pyrexia, the most common cause of death in acute rlieumatism, rarely
occurs in children or in middle-aged people. Children rarely die of acute
rlieumatism — indeed, I have never seen a child die of this disease. The
foregoing observations make it obvious that, in testing the efficacy of
remedies, we must take care not only to discriminate one kind of rheuma-
tism from another, but to compare cases occur ing in persons of much the
same age.

The frequency of relapse in acute rheumatism is well recognized. I
believe this relapse is in many cases explicable and avoidable. Thus I
have found that when the temperature has become nearly normal, rising
only to 99.5 to 100, or a little over, there maybe no pain, especially in
the case of a child, and the patient feels so well that he is often allowed
to get up and walk about, at the great risk of bringing back the fever and
joint- pain. In the ward I have frequently verified the fact that relapses
are often brought about in this way, and I am sure it is much siifer to
take care that the temperature should become normal, and remain so for
several days, before the j^atient is allowed to get up. These cases will
illustrate the importance of the thermometer, as so slight a degree of fever
is quite indetectable by the hand. But the temperature must be taken
several times a day, as the preternatural rise may last only a few hours
daily. Movement of the joints in rheumatic fever inflames them and
heightens the fever. If a joint, free from inflammation and pain, is
Avorked by the hand for a short time, it often becomes in a few hours
acutely painful and red. Again, it is well known that the journey to the
hospital often excites inflammation in patients' joints and heightens the
fever, so that simple rest during the few first days in the ward almost
always causes a diminution of pain and fever.

Potash salts exist abundantly in the milk, Avhence it has been sug-
gested that the administration of these salts may promote this secretion.

The sustained administration of the alkalies and their carbonates ren-
ders the blood, it is said, poorer in solids and in red corpuscles, and im-
jiairs the nutrition of the body. These results are probably due to disor-
dered digestion, produced by the long-continued use of alkalies, and are
not dependent on an excess of alkalinity of the blood. Such excess must
always be slight on account of the ra])id elimination of these salts by the
kidneys. It has been shown by Sir \V . Koberts that the citrate of potash
may be taken for an almost indefinite time without deranging the gen-
eral health, yet this drug increases the alkalinity of the blood, while,
owing to its neutral reaction, it is harmless to the stomach.

Liquor potassa3 bears the reputation of promoting the absorption of in-
flammatory formations, and is occasionally employed in pleuris}', but
its good effects are not evident, and the disorder it produces in the stom-
ach renders its use unadvisable for any length of time. Dr. Walshe
recommends liquor potass^ in plastic bronchitis.

Carbonate of potash, in one or two grain doses, given three or four
times daily, with a little syrup to cover the taste, is much used in Phila-
delphia for whooping-cough.

Sodium bicarbonate, ten to fifteen grains to the ounce of water, read-
ily dissolves false membrane, as of diphtheria, and this solution is at
present largely used as a local application to the throat and to the trachea
and larynx, through the wound after tracheotomy.

AVliat influence have the alkalies on tissue change ? Dr. Parkes has

ALKALIES. 148

investigated the action of liquor potassse, and lie thinks that it probably
increases the disintegration of the nitrogenous substance of the body. He
believes that his experiments justify him in concluding that it disintegrates
also the sulphur-holding tissues, for liquor potasste increases both the urea
and the sulphuric acid of the urine. The strong reaction of liquor potas-
s£e unfits it to be given in doses sufficiently large to affect in any great
degree the reaction of the urine, so that when it is required to alkalinize
this fluid the bicarbonates or citrate must be employed.

Large doses of potash salts considerably depress the temperature.
Eecent experiments by Feltz and Ritter and Astaschewsky support the
idea that uraemia is due to the retention in tlie blood of potash salts.
They tied the renal arteries of animals, and injected various substances
into the blood, amongst others potash salts, and produced uremic symp-
toms. ,Drs. Wood and Reichert find that potash salts increase about
equally both heat formation and heat dissipation through the skin.

What action have alkalies on the constitutents of the urine ? They
are all reputed to be diuretic, but, as no exact observations have been
made with these salts, this statement must be regarded as only a probable
assumption.

Before referring to the presumed diuretic properties of these sub-
stances, it Avill be well to digress for a short space to speak in general
terms of diuretics.

By diuretics, we understand medicines which act as eliminators of the
urine; and we must distinguish diuretics from those medicines which, by
promoting tissue change, cause an increase in any of the constituents
of the urine. Diuretics merely separate from the system already-existing
products.

As the urine is a complex fluid containing, besides water, many salts
and other ingredients, we may have medicines which will eliminate one
or more of these substances, leaving the rest unaffected. We may there-
fore have diuretics of water, or of urea, or of uric acid, etc. The reten-
tion in the blood of materials which should be eliminated by the kidneys
may be due to a variety of conditions. The physical state of the kidneys
may be altered, and these organs disabled by diseases of distant organs, as
of the heart. Or, through insufficient oxidation and combustion of the
effete products of disintegration, refuse materials may remain in a form
unexcretable by the kidneys; and, lastly, the retention of the urinary
ingredients in the blood may be dependent on organic disease of the kid-
neys themselves.

Thus, in one instance, a medicine acting on some organ at a distance
from the kidneys, as the heart or lungs, will be a diuretic; while in
another, those means which promote oxidation in the blood will prove
diuretic; and, lastly, diuretics may act immediately on the kidneys by re-
moving or altering those physical conditions which hinder the action of
those organs.

How far do the members of this group act as diuretics ? and in which,
of the foregoing ways? We cannot give very satisfactory answers to these
questions.

First, as to their diuretic action.

It is generally held that all these substances are diuretic, and, under
certain circumstances, they may possibly become so. Acetate of potash
and acetate of soda enjoy the highest repute in this respect, though some
careful observations have been made with these substances on persons in

144 ALKALIES.

health, which have led to unexpected results. It was found ])y Bocker
(quoted hy Parkes), "that so far from acting as a diuretic in health, the
acetate of potash diminished the Avater, the urea, the extractives, and, in a
remarkable manner, the earthy salts." Some valuable observations con-
cerning the action of citrate of potash and acetate of potash, as diuretics
in health, have been made by Dr. Nunneley on himself. He took daily,
for twelve days, three to five drachms of citrate of potash. On an aver-
age, the daily excretion of Avater was increased by two ounces and a half,
but the urea was lessened by eighty-four grains, and the solids by sixty
grains. The acetate of potash, in daily doses of from two and a half to
three and a half drachms, exerted a similar influence in a somewhat less
degree.

But should we expect medicines to act as diuretics or eliminators in
healthy persons? In their blood there should be but little urea, or uric
acid to be eliminated, and we must be careful how far Ave alloAv physio-
logical experiments on healthy subjects to guide us as to the action of
diuretics in disease. That such caution is highly necessjiry is shown by
the experiments of Ranke, who, after giving acetate of potash, noticed
a very considerable increase in the quantity of urine voided soon after,
shoA\-ing that this salt will sometimes act as a diuretic of Avater.

So far as to their diuretic properties; and we Avill endeavor now to
answer the second part of the foregoing question — In what Avay do they
act as diuretics ?

It is not supposed that any members of this group act on organs re-
mote from the kidneys. They may possibly promote oxidation in the
blood, and so reduce effete products to urea, in Avhicli form they are
separated by the kidneys.

Some of the alkalies are considered to be febrifuge, as the citrates
and acetates. If so, they Avould act as eliminators of Avater, as, on the
decline of fever, an increase takes place of the urinary Avater previously
held back in the system during the febrile state, and often accompanied
by a simultaneous increase in the solids of the urine. If, therefore, these
substances Avill check fcA'er, this increase of water and solids must, in
some measure, be due to their action.

These alkalies are generally reputed to act as diuretics when the kid-
neys are diseased, the citrates and acetates being given in acute and
chronic Bright's disease. By making the urine alkaline, some consider it
is enabled to dissolve the organic but diseased matters, Avhich block up
the uriniferous tubes in Bright's disease, and hinder the secretion of the
kidneys.

It has already been mentioned, that the members of this group render
the urine less acid, or even alkaline; but, strange to say, the amount of
acid excreted Avitli the urine is actually increased, but being neutralized
by the alkalies, it gives no acid reaction.

The citrates and bicarbonates are constantly employed to render the
urine alkaline, Avhen the urinary organs are irritated or inflamed, as in
cystitis and gonorrhoea. If in cystitis, the urine, before it is passed, is
already alkaline from decomposition of the urea, alkalies must be inter-
mitted; for they Avould, of course, increase the alkalinity, and, as alkaline
decomposes much more readily than acid urine, they Avould still furtlier
promote the decomposition of urea, and the formation of carbonate of
ammonia.

AVhen excess of uric acid occurs in the urhie, it should be kept for a

ALKALIES. 145

time alkaline. By many careful and ingenious experiments, Sir W.
Roberts has shown that uric acid calculi may probably be dis-
solved in the bladder if the urine is maintained alkaline for some weeks.
This treatment is probably useful in renal calculus, which is generally
composed of uric acid only. It is reasonable to expect that the alkaline
urine would in time reduce the calculus sufficiently to pass down the
ureter. We certainly meet Avith patients complaining of much pain in
the back, passing bloody urine, containing a large quantity of uric acid
crystals, and a little jius, who are curable with large doses of citrate of
potash. A solution of borax is very usefid as an injection for leucorrhcea.
It probably acts in part on account of its alkalinity.

A tablespoonful of common washing soda, added to half a gallon of
warm water, is useful in the treatment of tenderness of the soles. The
feet should be immersed for half an hour twice a week or oftener.

I may here introduce a summary of some interesting experiments made
by Dr. Paul Guttmann, and some by myself, which confirm many of the
conclusions of Claude Bernard and others, on the action of potash and
soda salts. The results are singular, and scarcely in acccordance with
medical experience of the action of these substances on the human body.

Potash Salts are all far more poisonous than soda salts.

Potash salts are all eciually poisonous and equally fatal in the same space of time,
if administered in the same way.

Chloride of potassium, carbonate of potash, and nitrate of potash, in identical doses,
are equallj' powerful to destroy life, and in the same period of time, even when either
salt, previous to injection, is mixed with a solution of albumen.

The acid of the salt ])lays no part in the fatal result.

In poisonous doses great muscular weakness sets in, first appearing in the hinder
extremities; while, in warm-blooded animals, dyspnwa and convulsions take place.
Large doses lessen the frequency and force of the heart's beats, and sometimes make
them irregular. This holds good with all potash salts. Large doses at once arrest
the action of the heart, which always ceases to act in the diastole.

Traube asserts that the action on the heart is affected through the vagi nerves.
Guttmann considers this view erroneous, as, after the vagi were both divided, and the
medulla removed, the potash salts still affected the heart as before, and even when the
vagi was i)aralyzed by woorali, the potash salts still acted as usual on this organ.
Whether their effect on the heart is owing to their action on the heart's substance, or
on its ganglia, Guttmann cannot say. He states that these salts lower the temperature
of the body; but certainly to a very insignificant extent.

Soda Salts, in twice or three times the quantity which proves fatal in the case of
the potash salt, produces no effect on the sj'stem except a passing weakness.

Even in larger doses, soda salts exert no action on the heart, cause no diminution
in the temperature, and produce no apparent effect on the cord, brain, nerves, or
muscles.

The heart of a frog suspended in a solution of potash quickly ceases to contract,
whilst it takes a much longer time to produce a like effect in a solution of soda of
similar strength.

Many soda salts produce an opacity of the lens in frogs, but this does not occur
with sulphate of soda. Guttmann shows that the opacity is not due to mere abstraction
of water from the lens; though this condition is removed by immersing the opaque
lens in water. This opacity does not take place in mammiferous animals.

Some experiments on chloride, bromide, and iodide of potassium I made, in com-
pany \\ith Mr. E. ]Morshead, lead us to conclusions similar to those arrived at by Gutt-
mann. We find that these three salts produce the same symptoms in the same order,
and with an intensity proportioned to the amount of potash they contain.

In conjunction with Dr. Murrell, I have recently made some further investigations
concerning the action of chloride of potassium {Journal of Physiology , vol. i.. No. 1).

This salt, we find, is a protoplasmic poison. It poisons all nitrogenous tissues and

destroys their functions. A subcutaneous injection speedily affects the brain and cord,

causing complete general paraljsis, and in a few hours the motor nerves, when directly

stimulated by the interrupted current, cease to conduct impressions. A little later still

146 AMMONIA.

the muscles will not contract to electric stimulation. Now this paralysis of all the tis-
sues is due to the dircft action of tlic jiotash, and not to the arrest of the circulation,
since the i)aralvsis of the nerves and nnisclcs occurs nnieh earher after poisoning with
chloride of iiotassiuni than after mere mechanical arrest of the circuhvtion.

We conclude also that tlie chloride acts by an equal affinity for all protoplasm,
and destroj's the tissues in the order of their vital endowments. Potash salts are de-
pressors and paralj'zers of the heaiH. How do the}' paralyze the heart ? In the same
manner, we conclude, as they paralyze the other structures, by an atlinity for all the
nitrogenous tissues. The uiore highly endowed nervous ganglia are the tirst to suffer,
hence small doses will arrest the heart, whilst the muscular tis.sue will still respond to
galvanic stimulation; but, if into the jugular vein a large quantity of potash .salt is at
once introduced, it will destroy not only the functioris of the nervous structures,
but also muscular contractility. Thus Guttmanu found that the injection of small
doses into the jugular vein of warm-blooded animals paralyzes through the nervous
system; whilst Traube found that the injection of a large dose paralyzes also the mus-
cular tissue, so that it failed to contract on the application of galvanism. These ex-
periments strongly support the views we have advanced.

If it seems strange that chloride of potassium produces such profound effects on
frogs, whilst it appears so harmless a drug to man, we need merely i)oint out that our
frogs were given a quantity proportionate to from 3 to 9 ozs. for a man weighing 150
pounds, and so large a dose thrown at once into his circulation would doubtless pro-
foundly affect the chemical condition of the blood, and the functional acti\ity of the
organs.

As arrest of the circulation is itself a paralyzing influence, we conclude that arrest
of the circulation caused by the chloride of potassium must, in some degree, assist in
direct action on the tissues.

In the chapter on Bromide of Potassium, we have shown that it produces the same
symptoms, in the same order, as other potash salts, and that the more or less rapid
induction of these symptoms depends on the amount of potash the salt contains.
Bromide of potassium, like the chloride, paralyzes not only the central nervous system,
but likewise the nerves, muscles, and heart, the central nervous system being affected
sooner than the nerves, and the nerves sooner than the muscles, and therefore we con-
clude that these effects of bromide of potassium, which it possesses in common with all
potash salts, are due solely to the potash, the bromide playing no part in their produc-
tion.

Potash salts differ from soda salts, not merely in degree, but in kind. We find in
the vegetable kingdom that soda salts will not replace potash salts. In animals we find
potash salts predominating in the formed; soda salts in the unformed constituents of
the body. A potash salt is neces.sary for the due dilatation of the heart after a contrac-
tion, and for this purpose soda salts cannot in any degree take the place of potash salts.
Potash salts lessen muscular excitability; prolong the period of diminished excita-
bility, and retard reparation following a contraction, in these respects strongly contrast-
ing Vith soda salts. These physiological differences imply therapeutic differences,
and hence one base cannot be given in place of the other.

AMMONIA, CARBONATE OF AMMONIA, SPIRITS OF AM-
MONIA.

These preparations have many properties in common with the alkaline
potash and soda group. They possess a strong alkaline reaction, are freely
soluble in water, have a high diffusion-power, and dissolve the animal
textures. They differ from the potash and soda preparations in their
volatility, in being more powerful local irritants of the living animal
tissues, and exciting very active inflammation.

Their action on the skin is, in many respects, similar to that of the
alkaline potash and soda preparations. "^ Owing to the water in its com-
position, liquid ammonia manifests but little attraction for that of the
tissues; and since its solvent action on the textures is less than that of
the soda or potash salts, its destructive powers are much less rapid and
extensive. Owing, however, to its high diffusion-power, it readily pene-

AMMONIA. 147

ti-ates the cuticular covering of the body, and excites a degree of active
inflammation sufficient to destroy the tissues, and so produce, first a
slough, then an ulcer. The preparations of the members of this group
are never purposely employed to produce formidable destructive changes
in the tissues, but are used in the form of liniment, or the solution of
ammonia itself, as vesicants and rubefacients.

Ammonia solution may be emjDloyed to produce very speed}' vesica-
tion. A few pieces of lint should be cut a little larger than the required
blister, and on the lint should be poured ten or twenty drops of the strong
solution of ammonia; the pledget must be applied at once to the skin,
and covered with a good-sized watch-glass. Heat, with some smarting and
tingling, is soon felt, and in a short time a rim of redness appears around
the glass, denoting that the application has done its work; then a poultice
promotes the vesication, and eases the burning pain. In this way, a
blister may be produced sometimes in ten minutes, though it ma}' take
half an hour; so great is the difference in the vesicating action of ammo-
nia, that with some a blister does not form at all. Hence, it must be con-
sidered a very uncertain vesicant.

As a rubefacient, or "counter-irritant," it is more useful; but it is in
no respect superior to a mustard poultice, the materials for which are
always at hand. The liniment of ammonia, if merely rubbed or dabbed
on the skin, acts very imperfectly as a counter-irritant. It must be ap-
plied on lint, or linen, kept in contact with the skin, when decided rube-
faction takes place in a few minutes. As a counter-in-itant, ammonia is
used for the same purposes as mustard poultices or blisters. Ammonia
is a useful stimulant to the scalp to promote the growth of hair thinned
by illness. Wilson uses half an ounce of strong liquor ammonias to six
ounces of honey water, scented with almond oil and spirit of rosemary.

Dr. Tilt extols Easpail's sedative lotion in the treatment of headache
occurring at the change of life, or produced by defective uterine functions.
The lotion, made by adding two ounces of liquor ammonias, aiid of com-
mon salt respectively, and three drachms of camphorated spirits of wine,
to thirty-two ounces of water, is applied to the jDainful part with a small
sponge, and is renewed as often as may be required. It excites a sensa-
tion of burning, and reddens the scalp. If too strong, it should be di-
luted with water. I have often found a similar application very useful
to remove the " heat and weight " at the top of the head, so frequently
occurring in women at the change of life, or from uterine derangements,
or generally impaired health.

The weaker solutions of ammonia are sometimes applied to the bites
or stings of insects, as wasjDS, spiders, etc., to neutralize the formic acid,
the active principle of the poison.

Formic acid is commonly' said to be the poisonous principle in insects, whose
bites or stings excite pain and inflammation. This, I thinlv, can hardly be correct.
The sting or bite of an insect afl'ects some persons moie than others. The bite of
a bug or flea will, in one person, cause considerable swelling, whilst in anotiier it
will excite neither pain nor swelling. Even in the same person we find tliat per-
haps, when young, insect bites or stings scarcely aft'ected him, whilst later in life
they cause much swelling and pain. Again, a bug-bite will cause great swelling,
whilst in the same individual a gnat, a flea, or midge, will cause no inflammation.
The bite of a midge, too, will excite considerable swelling with much itching, last-
ing eiglit or ten dajs, wliilst in the same person the bites of other insects are quite
innocuous. Now this dirt'eren^'e could not be if tlie active principle were always
tlie same. It is evident, tlierel'ore, that there must be some difference in the nature
of the poisons secreted by diflerent insects, and that it cannot depend on formic

148 AMMONIA.

acid ; or were this always present in the poison of insects, it must be mixed with
some otlier virus differing in different animals.

Ml". Philip Miall recommends fomentations, with a solution of twenty
grains of carbonate of ammonia in a pint of boiling water, for tlireatened
mammary abscess. When the breast is hot, reddened, throbbing and
l^ainful, the effect is very sjDcedy, the swelling often subsiding in a few
hours. The fomentations must be assiduously applied for half-an-hour
at a time, and repeated every two or three hours.

Salts of ammonia, applied to the nose, and breathed into the air-pas-
sages, are commonly used in fainting, and in poisoning by narcotics.
Stimulating the mucous membrane, it excites the vasomotor centre,
heightens the blood-pressure and averts syncoj^e. Thej' are also used
in the early stages of cold in the head, and as derivatives, to remove pain
and inflammation of the nose and frontal bones. Ammonia inhalations
have been recommended in chronic bronchitis to ease, and probably to
lessen, the over-abundant expectoration.

Ammonia in the stomach acts much in the manner as it acts on the
skin. It neutralizes the acid it encounters, and is therefore an antacid;
at the same time, if completely neutralized, it acts as an excitant, or
even irritant of the mucous membrane.

Soon after the administration of ammonia, a sensation of warmth at
the pit of the stomach sets in, which quickly spreads to the rest of the
body. When the functions of the stomach and upper part of the intes-
tines are depressed it may be used as an excitant. It often obviates spasm
of the intestinal canal, and braces up the relaxed mucous membrane.
Ammonia compounds of this group are therefore among the best antispas-
modics. They are useful remedies for children, especially for infants,
who are frequently tormented by colic or flatulent distention of the intes-
tines brought on by bad feeding.

These jireparations may be profitably employed in the after stages of
diarrho-a, after the removal of the irritating excitant cause, when the
mucous membrane continues to pour out a watery secretion, which per-
petuates the diarrha;'a.

The alkaline preparations of ammonia are employed -in flatulent dis-
tention of the stomach and intestines, Avitli the view of absorbing the
excess of gas, generally consisting of carbonic acid. In such affections
these remedies no doubt are often temporarily useful as palliatives. They
excite the muscular coat of the intestine to contract, and so promote the
expulsion of the distending gases.

In full doses, these remedies excite an increased formation of mucus,
and even vomiting; as emetics, they act without inducing nausea or de-
pression. They are seldom employed alone, but are used to counteract
the depressing effects of other emetics.

If administered too long, they excite catarrh of the stomach and in-
testines.

These substances readily enter the blood, and must to some extent
increase its alkaline reaction; but owing to their volatility and high diffu-
sion-power, they are rapidly eliminated, and therefore exert only a
transient action on the blood and the organs of the body.

Feltz and Ritter find that toxic doses prevent the respiratory functions
of the blood, and hinder the oxidation of the red corpuscles, which will
not absorb oxygen even when it is shaken up, ammonia acting in this
respect like many other substances.

AMMONIA. 149

Large doses injected into a vein excite tetanic convulsions of spinal
origin.

In experiments with the detached frog's heart, fed with an artificial
circulation. Dr. Sainsbury and I find that ammonium salts, in small doses,
increase the strength of the ventricular contractions, but larger doses
destroy muscular contractility, spontaneous action continuing till con-
tractility is lost, even when the ventricle is strongly stimulated. Ammo-
nium salts act nearly as powerfully as potassium salts on the cardiac
muscular tissues; but ammonium salts do not weaken the spontaneous
rhythm, and in this respect diifer strikingly from potassium salts. A
large dose of ammonia injected into the blood of warm-blooded animals
arrests the heart at once.

Carbonate of ammonium, and, in a less degree, citrate and acetate of
ammonium, produce perspiration. A small dose, one or two grains of car-
bonate, given hourly, generally produces jDerspiration as abundantly as
either aconite or turtar-emetic. Carbonate of ammonia is one of the
most certain and efficient diaphoretics in febrile diseases.

It has been maintained, without much show of proof, that carbonate
of ammonium is the poisonous agent in uremia; the urea, it is said, de-
composes in the blood, forms this carbonate, which in its turn produces
the serious symptoms constituting ureemic poisoning.

Ammonia induces a slight increase in the force of the pulse, some ex-
citement of the brain, and a general sensation of warmth. Being a slight
stimulant of the heart, ammonia is used in fainting and exhaustion. It
is frequently administered as an antispasmodic — an action depending
probably, in part, on its power to strengthen the heart's action, but, like
all other antispasmodics, its influence is brief.

Carbonate of ammonium is often employed as a stimulating expectorant
in chronic bronchitis, when the expectoration is profuse and the patient's
strength is diminishing. It is often given with chloride of ammonium,
which probably acts in a similar manner. Carbonate of ammonium is
frequently of signal service in severe bronchitis, or broncho-pneumonia
of children, especially when they are prostrate and livid from obstructed
breathing.

Carbonate of ammonium is largely used in typhoid conditions due to
erysipelas, or in the other acute specific fevers, pyaemia, etc.

Carbonate of ammonium, in three to five grain doses, administered
uncombined with any other drug, hourly, or even two or three hours,
according to the severity of the case, has been much lauded in scarlet
fever. It was largely used by the late Dr. Peart, who " did not lose one
patient out of nearly three hundred." The late Mr. Wilkinson also em-
ployed it largely with equal success; and recently Mr. Charles Witt has
written a pamphlet extolling its virtues. It is said to be useful in all
forms of scarlet fever, especially when given early. The immediate effects
are stated to be diminution of heat, fever and delirium, and a disposition
to sleep. Mr. Wilkinson says it is equally useful in measles, and that
the ammonia treatment leaves no secondary evils. I have used this treat-
ment largely in measles, apparently with considerable benefit. Carbonate
of ammonium induces free perspiration, and appears to develop the rash
and cause the disease to run a benign course. Mr. Charles Witt says,
care must be taken that no acid drinks nor acid fruits of any kind are
permitted, or the ammonia, becoming neutralized, loses its efficacy. Solu-
tion of acetate of ammonium, and citrate of ammonium, are useful dia-
phoretics, and are largely employed in fevers. It is especially useful in

150 mag]s:esia.

the milder forms, as in common catarrh. A full dose of acetate of am-
monia, or Mindererus's spirits, will often speedily steady and sober a
drunkard. The supposed effect of ammonia in preventing iodism is
noticed in another place.

Ammonium salts are powerful antiseptics, especially the liquor and
carbonate, and possibly they may act beneficially in the acute specific
fevers, in virtue of this property.

Owing to its high diffusion-power, ammonia escapes very readily from
the body in various ways, a portion passing with the breath, some proba-
blv with the sweat, and much with the urine.

The taste of carbonate of ammonium is much masked by administer-
ing it in milk.

MAGNESIA, LIGHT MAG^^SIA, CARBONATE OF MAGNESIA,
LIGHT CAEBOXATE OF MAGNESIA, SOLUTION OF CAR-
BONATE OF MAGNESIA.

These substances, having an alkaline reaction, might be placed in the
group of potash and soda alkalies, but the effects of the magnesia group
on the body are, in many respects, very different from those of the potash
and soda group. We have elsewhere treated of the properties pertaining
alike to all alkaline substances, including, of course, the members of this
group. (See Potash group.)

Some of the oxide of magnesia combines with the acids of the gastric
juice, and becomes soluble; the remainder, being unaffected, is left in-
soluble. Part of the carbonate, decomposed by the acids of the stomach,
sets free its carbonic acid.

These substances act as antacids and as antidotes, in poisoning by the
strong acids and by some metallic salts. In some cases, they are prefera-
ble as antacids to bicarbonate of soda or lime. The advantages of the
members of this group are: — (1) their large saturating capacity for acid;
(2) their purgative property; (3) their harmlessness, on account of their
insolubility, when given in excess.

Their disadvantage consists in their great bulk. The oxide or carbon-
ate of magnesia is generally used as an antacid, but the oxide is prefera-
ble, as the carbonate, by giving off much gas, may produce disagreeable
distention of the stomach. It must not be forgotten that tliev are merely
temporizing remedies, and that acids are far better correctives of acidity
of the stomach. (See Acids.)

The oxide of magnesia is a convenient antidote to the strong mineral
or vegetable acids. It neutralizes them, and piotects the delicate struc-
tures of the stomach from their corroding action; and it precipitates many
metals from their acids, rendering them less soluble, and, therefore, less
poisonous. The magnesias form an insoluble compound with arsenic, and
thus take rank among the antidotes of this poison.

The magnesian salts combine in part with the acids of the gastric juice.
The oxide and carbonate, on account of their insolubility, cannot pass into
the blood, nor does the chloride pass in any amount because of its low
diffusion-power. Hence, almost all the magnesia passes into the intestines.

In the intestines, the salts of magnesia undergo changes according to

LIME. 151

their composition. The chloride, probably, is decomposed by the bile,
and the oxide precipitated, part of which combines with the biliary acids.
The oxide is converted first into the carbonate, then into the bicarbonate
by the carbonic acid of the intestines, and so made soluble, and capable
of acting as a purgative. The carbonate is changed in a similar manner
into the bicarbonate, and likewise becomes a purgative. Thus they act as
purgatives only after conversion into bicarbonates, in which form they
possess most of the properties of the groiip which includes sulphate of
magnesia, etc. Like the members of this group, the bicarbonate has a
very low diffusion-power, and, like them, it is purgative; its action in
this respect being very mild, it is termed a laxative. Their mild action,
freedom from taste, and antacid property, fit these substances admirably
for children. They are generally combined with a little rhubarb. If
unduly employed they occasionally accumulate, and form concretions of
ammonio-magnesian phosphates in the intestines.

Bicarbonate of magnesia, fluid magnesia as it is termed, is a useful
and mild aperient.

Magnesia has been lauded in sympathetic vomiting, as that of preg-
nancy, when it is to be presumed the vomiting depends on excessive secre-
tion of acid from the stomach; but its eft'ects are very transient. Should
it fail, recourse may be had to oxalate of cerium (one grain every three
hours), ipecacuanha, quinine, acids, etc. (See Ipecacuanha.)

The chief of the magnesia passes out witii the faeces, and, for the
reasons stated, a small portion only enters the blood. In excess of uric
acid, members of this group prove useful by saturating much of the acid
in the stomach, and carrying it out of the body.

LIME, CAUSTIC LIME, LIME-WATER, LINIMENT OF LIME,
SACCHARATED SOLUTION OF LIME, CARBONATE OF
LIME.

This group contains highly valuable medicinal substances, which
might with advantage be more extensively used.

Lime is a necessary constituent of the hard and soft tissues of the
body, of bone, and the parts more vitally endowed, as the nerves and
muscles; wherever there is active growth, whether natural or unnatural,
lime salts are found in excess, probably as phosphate, being in all likeli-
hood the form of lime required by the body for the performance of many
of its functions. In practice, however, we find the other salts of lime of
equal service in almost precisely the same morbid state in which the phos-
phate is so valuable, and it seems feasible that a portion of the lime salts
becomes united in the body with phosphoric acid.

The importance of lime is well shown in its influence on a cardiac con-
traction. Without lime it is probable that no contraction could occur.
If too little lime is present then the contraction is weak, but if a full
physiological quantity is present in the fluid circulating through the heart
the contraction becomes complete.

Their diffusion-power being very low, and having little aflfinity for
animal structures, when applied to the skin they produce very little

152 LIME.

change. But caustic lime, having a strong attraction for water, will with-
draw it from tlie dermis when deprived of its cuticle, and to some extent
effect the destruction of the tissues. Yet, as its diffusion-power is slight,
it fails to penetrate the tissues, and its action is superficial. Caustic lime
is not often used as an escharotic. Mixed with caustic potash, it forms a
compound less deliquescent, far more manageable, and safer than simple
caustic potash, especially in affections of the neck of the uterus, as first
pointed out by Dr. Henry Bennet.

Applied to broken skin and to sores, the carbonate and lime-water are
slightly astringent; hence lime is sometimes used to check the discharge
from sores and skin eruptions.

Lime-water and oil in equal quantities, or in the proportion of four of
lime-water to one of oil, enjoys a high reputation in the treatment of
burns.

Lime-water is of service as a lotion to cracked nipjiles. '

Lime-water is sometimes employed to check the abundant discharge
of certain skin diseases, as eczema, and likewise as a sedative to ease the
smarting and tingling. When the inflammation of eczema has been sub-
dued, the discharge being great, lime-water and glycerine form a useful
and comforting application.

Carbonate of lime is sometimes used as a dusting powder in eczema or
intertrigo, to absorb. the abundant secretion, to prevent discharges from
irritating the already inflamed skin, and to protect the skin from the air.
In common with other dry powders, carbonate of lime is inferior to some
simple bland, or slightly stimulating greasy application. Certain cases,
however, are certainly more benefited by dry powders, as oxide of zinc,
bismuth, and carbonate of lime, than by ointments.

As we have said, carbonate of lime is used for intertrigo of the buttocks
and perinajum of young children, and to protect the skin from the irrita-
tion of the urine and of the air. Napkins soaked in urine being very
generally the cause of this eruption, it is obvious that greasy applications
afford a more efficient protection, since the powder readily absorbs dis-
charges, becomes itself irritating to the skin, cakes and cracks, leaving
parts of the surface exposed. The best treatment indeed consists in fre-
quent ablutions with soap and water, and anointing with greasy applica-
tions, as boracic-acid ointment.

Lime-water, on account of its astringent quality, is used as a wash in
discharges from the ears and vulva, and is of most service when some
active inflammation is still present. In the chronic stages of ear disease
it is far inferior to the glycerine of tannic acid and other astringents.

Dr. Joseph Bell recommends lime-liniment with cotton-wool to prevent
small-pox pitting. Cotton- wool cut in proper shapes is dipped into the
liniment, and applied so as carefully to cover the face and neck, leaving
apertures for the eyes, nose, and mouth. Xo crevice must be allowed,
and a large handkerchief must be tied over all, and the dressing allowed
to remain on until convalescence.

iiime- water, probably owing to its alkalinity, is often iiseful as an in-
jection in leucorrhasa.

' To prevent cracked nipples is far better and much easier than to cure them. Im-
mediately the child is removed from the breast the nipple should be carefully Avashed
and driexi. The nipples may be hardened by washing Ihem some short time before
delivery, and after each suckling, with a little brandy and water. A zinc sliield worn
constantly over the nipple is both healing and protective.

LIME. 153

Chalk makes a good tooth-powder, and is safer than powder with hard
and angular particles, which wear away the enamel and lay bare the
dentine.

Lime-water is occasionally used to lessen the discharge, and to pro-
mote the healing of inflammatory and ulcerative diseases of the mouth.

Solutions of lime, as lime-water, will dissolve false membranes, as
diphtheritic membranes, and either lime-water itself, or the following
formula: — Calcis half an ounce, glycerine two ounces, water eight
ounces. It should be used as a spray frequently. Though strongly
recommended by several excellent authorities, still this treatment of diph-
theria is of doubtful efficacy. It is also recommended in plastic bronchitis.

Lime preparations neutralize the acid in the stomach, but other reme-
dies are mostly preferred. Salts of lime are useful in oxalic acid poisoning.

It is not easy to indicate precisely the therapeutic value of lime-water
in vomiting, but in some forms of it few remedies are more useful. It is
generally serviceable iu chronic vomiting; thus it often arrests the vomit-
ing from chronic ulcers of the stomach. It should be mixed with milk,
either in ecpial parts or in the proportion of one of lime-water to four of
milk; and if the vomiting is incessant the patient should be fed only on
this, in frequent small quantities of a tea or tablespoonful. Young chil-
dren often eject much of their milk in lumpy masses; some passing into
the intestines, and escaping with the motion, cause in their transit much
wind and severe colic. Cows' milk is apt to induce this condition, as
gastric juice coagulates it in lumps, while it generally coagulates human
milk in fine flakes. Lime-water, by j)reventing this lumpy coagulation,
checks this kind of vomiting generally at once, or, should it continue, the
rejected milk is no longer curdled. In case of constipation, bicarbonate
of soda should be substituted for lime-water. One-eighth of lime-water is
generally suffiicient, but this failing, a larger quantity, even equal parts of
each should be tried. Half a drachm to a drachm of bicarbonate of soda
should be added to a pint of milk. These remedies both sometimes fail,
and it may be necessary for a time to withhold milk, and to feed the child
on sopped bread, water gruel, and chicken broth, or veal broth.

This vomiting occurs in the early months of life, sometimes even
during suckling. If the child is brought up " by hand " the milk should
be sufficiently diluted, and during the first month witli at least an equal
quantity of water; indeed, some authorities advise two parts of water to
one of milk, the relative quantity of milk increasing as the child grows
older. A child a month old may take a pint to a pint and a half. Dr.
Meigs, of Philadelphia, recommends an excellent food for healthy chil-
dren, and especially for those suffering from the kind of vomiting under
consideration: — Soak a scruple of gelatine in a little cold water for a short
time, and boil it in half a pint of water till it is dissolved, that is about
ten or fifteen minutes. Just before finishing the boiling, add milk with
some arrowroot made into paste with cold water, and afterwards some
cream. The proportion of the milk, cream, and arrowroot depends on
the age of the child. For an infant less than a month old he advises three
to four ounces of milk, a teaspoonful of arrowroot, and half an ounce to
an ounce of cream to half a pint of gelatine- water; for older children the
milk may be increased to half or two-thirds. The gelatine and arrowroot
prevent the lumpy coagulation of the milk, while the small quantity of
arrowroot will not disorder the stomach. If even this food is rejected,
then dilute the milk with three or even four parts of a very thin decoc-

154 LIME.

tion of arrowroot, or try merely cream and Avater, one part of cream to
three or four of water. This food consisting of milk, cream, arrowroot,
and gelatine-water is very useful in diarrh(ea.

Again, in young children suffering from chronic vomiting and diar-
rhoea, and consequent wasting, lime-water is often of great benefit, im-
proving digestion, and apparently assimilation, and obviating that highly-
irritating state of the urine which so commonly occasions intertrigo.

Solutions of these salts pass but slowly into the blood, on account of
their low diffusion-power, hence the greater part pass through the intes-
tines, and are ultimately voided with tlie faeces.

These substances neutralize any acid present in the intestines, and
check the secretion from the mucous membrane; and, sometimes by one
means and sometimes by both, act efficaciously in diarrhoea. Carbonate
of lime, and in a less degree lime-water, deservedly hold a high place
among remedies for diarrhoea in the latter stages, Avhen the irritant is got
rid of. Common chalk mixture is useful in diarrhoea depending on more
serious causes, as ulceration in phthisis or typhoid fever; but in these
graver cases other remedies are to be preferred.

It has been said that the saccharated solution of lime does not confine
the boAvels, but on the contrary relieves constipation. It should not be
taken on an empty stomach, lest it excite nausea.

Lime-Avater is a useful injection to destroy the thread- Avorms which
infest the rectum. It has been also used as an injection in gleet.

From their Ioav diffusion-power, a small quantity only of these sub-
stances passes into the blood; so small, probably, that it may well be
doubted if they can in any way influence the organs remote from the in-
testines. But experience shows that lime-AA'ater or carbonate of lime is a
valuable remed}" in deficient nutrition, and in conA'alescence from serious
disease, its good effects being most marked in children, in most stages of
rickets, mal-nutrition, etc.

In some instances these good results are traceable to the action of the
lime salts on the mucous membrane of the intestines. The action of
these salts, however, being A'ery similar, although inferior, to that of
phosphate of lime, we refer our readers to the section Avhicli treats of this
salt. One point may be noticed here, confirmed by both theory and ex-
perience, that small Avill do as much good as large doses, since but lit-
tle lime passes into the blood.

In scrofula with glandular enlargements of the neck, in cases resem-
bling tabes mesenterica, and chronic diarrhoea with weak digestion. Dr.
Warburton Begbie extols cldoride of calcium in ten to tAventy grain doses,
given in milk after food and continued for a considerable time, its good
effects, in many cases, not at once becomiiig apparent. It is recommended
too in phthisis, and many Avriters report very favorably of this treatment.

Lime-Avater is reputed to be useful in Avhooping-cough, and this may
well be, OAving to its astringency; for in certain forms of this disease as-
tringents, as alum and tannin, often effect a decided improvement.

Transfusion of a saline fluid has saved several lives in danger from
s5mcope of haemorrhage. Death in these cases is due to too small a
quantity of fluid in the vessels; so that the heart cannot propel enough
fluid, and is not due apparently to the Avant of nutritive fluid. This lack
of quantity can be supplied by a saline fluid (Golz, Kronecker, Sander);
as much as two pints should be injected. The injection restores con-
sciousness, removes convulsions, the pulse gains greatly in strength and

PHOSPHATE OF LIME. 155

falls in frequency. The patient at first complains of feeling cold. I have
already drawn attention to the influence of lime on cardiac muscular eon-
traction, and the same holds good probably in respect of other muscle. I
would suggest then that the saline injection should contain a lime salt,
preferably lime phosphate, which is quite sufficiently soluble to sustain
the contraction of cardiac muscle.

PHOSPHATE OF LIME.

This salt is of very great importance both in health and in disease. It
must be ranked among the most valuable and necessary foods, being proba-
bly as essential to a proper growth and nutrition as the nitrogenous and
faitty foods. Observations have abundantly proved its physiological im-
portance. It gives solidity to the skeleton ; hence if the quantity supplied
to the body is small, or if the demand for it is greater than the supply,
these solid structures suffer and lose their rigidity. Chossat produced
softening of the bones of animals fed on food free from lime-salts; while,
during pregnancy, much phosphate of lime being required for the ossifi-
cation of the skeleton of the foetus, it is found that the fractured bones of
pregnant women unite slowly and imperfectly. Some experiments by
Milne-Edwards bear practically on this point, for he found that animals'
bones intentionally fractured united more quickly when the animals were
supplied with phosphate of lime.

The urine of pregnant women is said to be deficient in lime salts, but
on this point the evidence is very discrepant.

The cardinal importance of this essential food to the soft and growing
tissues is to promote cell-growth and nutrition; and that this is a very
feasible conclusion the following considerations tend to show: —

1. The presence of this salt throughout the body.

2. Its presence in much larger proportion in the intercellular fluid of
the body than in the blood itself.

3. The fact that in herbivora the intercellular fluid is as rich in this
salt as it is in carnivora, though the vegetable-feeders take so little of it
with their food; hence it must be carefully retained in the intercellular
fluid for some important purpose.

4. Smith's observations show that a certain quantity of phosphate is
required to supply the first basis for the new tissues, even in the case of
those organs which subsequently exhibit an excess of carbonate of lime,
as the shells of animals; an observation showing that phosphate of lime is
necessary to initiate growth, and, in this respect, is not interchangeable
with the carbonate.

5. Wherever cell-growth is active, there is phosphate of lime in excess
— a statement holding good both watli regard to healthy and diseased
growths; for this salt is found to prevail in disease associated with rapid
formation.

With regard to the second and third points, it must^ be borne in mind
that phosphate of lime is soluble in acids, and, as the intercellular fluid
is acid, we should expect that the phosphate would accumulate in it.

Theoretically, it might be supjjosed that abundant data exist to enable
us to forecast the occasions when to employ this salt remedially; it would

156 PHOSPHATE OF LLME.

be riglitly assumed that in defective nutrition, or deficient cell-growth,
the phosphate of lime Avould prove serviceable. Certain hypothetical ob-
jections have, indeed, been urged against the employment of this salt.
The fault, it has been said, is really not due to deficiency of lime, but
inheres in the tissues, which fail to assimilate it; that, in cases of defec-
tive cell-growth and of mal-nutrition, the quantity of the pliosphate in
the urine is unusually great; and, consequently, our elforts should be
directed to remove the circumstances which check assimilation, for it is
as little reasonable to treat diabetes with sugar as a diabetes of phosphate
of lime with phosphate of lime. Some truth no doul)t there is in these
strictures, and too much attention cannot be paid to the hygienic condi-
tions favorable to assimilation — good air, abundant light, and sufhcient
exercise. The case before us is more analogous to anaemia than to dia-
betes; and we give iron with decided benefit in anaemia where this condi-
tion is due, not to want of iron in the food, but to the non-assimilation
of it by the tissues. The efficacy of phosphates, however, must be decided
by experience, and experience speaks abundant!}' in their favor. Beneke,
to whom on this subject we owe much of our knowledge, both physiologi-
cal and therapeutical, has shown that phosphate of lime is especially use-
ful in those "very diseases wherein it occurs in excess in the urine, as hectic
and chronic wasting disease.

Tills salt is of great use in the anremia of young and rapidly-growing
persons, and women weakened by rapid child-bearing, prolonged suckling,
or excessive menstruation. In checking chronic tubercular and non-
tubercular diarrhoea, and other profuse discharges, as in leucorrhoea,
chronic bronchitis and large abscesses, it is a valuable remedy, effecting
in these states both general and local improvement. Beneke speaks highly
of its influence on scrofulous" sores. It is useful also in caries of the
bones.

This salt is apt to be deficient in town-dwelling women, who improve
under its administration; an increased quantity, too, finds it way into the
lime-lacking milk of a suckling mother, who with her child are thus
simultaneously benefited.

Persons in broken health from prolonged town life or over-work, or
who from other causes are languid, hipped, and incapable of much exer-
tion, often derive much benefit from this medicine. In cases like this, a
good formula is a grain of phosphate of lime, phosphate of iron, and car-
bonate of lime; but phosphate of lime will act admirably by itself. This
medicine is useful in the chronic forms of phthisis with little or no fever.
It should be taken on the tongue either dry or mixed with a little milk.

No reasonable doubt can, I think, be entertained of tlie efficacy of
phosphate of lime in many cases of rickets.

It has been sought to establish a connection in all cases between rickets
and a deficient supply of lime; it is urged, firstly, that rickets commonly
occur during the first dentition, Avhen much lime is required by the grow-
ing teeth, and, secondly, that rickets affect the children of mothers in just
that state of ill-health in which it has been established that the milk is
deficient in lime. There may be much truth in these statements; but, as
in many cases of rickets an excess of lime is found in the urine, the disease
in such cases cannot be held to depend on a deficient supply of the salt,
but must be due to other circumstances, with which, at present, we are
only partially cognizant. In cases where the disease is dependent on
deficiency of phosphate of lime, its administration is obviously all that is
required.

PHOSPHATE OF LIME. 157

A deficiency of lime and pliosphoric acid in food does not produce in animals the
changes cliaracterislic of rickets, but the bone becomes fragile.

In rickets, moreover, tliere is not merely deficient ossification of the
bones, but unnatural growth and defective nutrition, both in the skeleton
and in the other textures. The phosphate of lime appears to control this
defective and perverse nittrition, and to induce healthy growth, so as not
merely to favor the consolidation of the skeleton but to improve the con-
dition of the soft organs, and experience shows abundantly that many
rickety cases are benefited more decidedly by lime-salts than by any other
single drug.

German authorities, who have studied this subject most attentively,
consider that the fittest time to give this remedy is after the cessation of
the active stage of the disease, that is, when the pains and tenderness of
the bones have disappeared.

It is well to repeat a caution against the uselessness of administering
this or other lime- salts in large quantities, for, owing to their very low
diffusion-power, very little passes into the blood. A grain, or two grains,
several times a day, is a sufficient dose. Given in excess, it hinders diges-
tion.

Phosphate of lime in the stomach must be variously affected by the
free acids, as lactic, hydrochloric, and, in a lesser degree, acetic acid,
dissolve it.

Most of the phosphate passes into the intestines, where, if the salt is
administered too long a time, it is liable to form concretions. Being un-
affected by the pancreatic and biliary secretions, and but slightly soluble
in the intestinal juice, most of the phosphate passes off with the stools.

Phosphate of lime is highly recommended in various forms of chronic
diarrhoea, and especially in that of young children, to wdiom it may be
given with carbonate of lime and lactate of iron. Whether the beneficial
effects are due to its direct action on the mucous membrane, or take place
after absorption, in the manner previously described, our present knowl-
edge does not enable us to decide.

Being soluble in the acids of the gastric juice, and to some extent in
solutions of commoi:| salt, its passage into the blood takes place probably
in several ways. It has, however, been doubted whether any portion, if
uncombined with food, passes into the blood, since no augmentation of this
salt is met with in the urine; nay, in some cases it seems even lessened.
The observations on this point are, perhaps, too scant to set the question
at rest.

Much phosphate is taken, either in combination with the food, or so
intimately blended with it that it is well-nigh impossible to separate it
from the tissue-forming substances, and so it finds ready entrance into the
blood, with the digested materials constituting the chief, and, in ordinary
cases, the only source of phosphate of lime for the supply of the system.
That so alkaline a fluid as the blood is capable of dissolving the phosphate
is explained by its solubility in solutions containing free carbonic acid or
common salt.

158

CHLORIDES.

HYPOPHOSPHITE OF LIME, HYPOPHOSPHITE OF

SODA.

Dr. Churchill recommends these drugs in plitliisis, and his state-
ments regarding their action have for the most part been upheld b}'^ Dr.
Thorowgood and some other observers.

Dr. Churchill commences with a grain and increases the dose to six
or seven grains a day, giving it in the form of syrup or pill. Dr. Thorow-
good gives a grain three times a day in the form of syrup. In too large
doses it may produce weakness, sleepiness, headache, giddiness, noises in
the ears, loss of appetite, colic, diarrhoea, and even bleeding from the
nose and lungs. Dr. Churchill administers these agents uncombined, and
cautions against giving them with iron, cod-liver oil, or stimulants. It
is said that the hypophosphites increase appetite and digestion; promote
the formation of the blood; lessen cough and expectoration; relieve pain
in the side, and diarrhoea; and often effect a cure. They are said to be
more useful in the first than in the second stage; and in the second than
in the third stage; and when only one lung is affected— a statement suffi-
ciently obvious and applicable indeed to every remedy. Thorowgood sa3^s
they are more successful with young than with old people. These rem-
edies are also recommended in nervous and general debility; teething;
spermatorrhoea; chlorosis; and anaemia.

CHLOEIDE OF POTASSIUM, CHLORIDE OF SODIUM,
CHLORIDE OF AMMONIUM.

These substances, having many chemical and therapeutic qualities in
common, have been grouped together; but the remarks in this section
refer mainly to chloride of ammonium.

These salts are freely soluble, and possess high diffusion-power. The
saltish taste common to them all is, in the case of chloride of ammonium,
somewhat disagreeable, and constitutes one of the objections to its use.

These chlorides considerably increase the secretion from the mucous
membrane; and may indeed even excite catarrh. This is notably the
case with chloride of ammonium, which is consequently employed chiefly
when it is proposed to influence the mucous membrane. How do these
chlorides promote the formation of m.ucus? Let us take the instance of
common salt. Chloride of sodium is a large constituent of mucus, and
salt, Avhen taken into the system, probably promotes the production of
tliose secretions of Avhich it forms a large part. It is, indeed, a food to
the mucous membranes. This suggestive hypothesis may possibly apply
in the case of other members of this group. These substances, especially
sal ammoniac, are sometimes employed in catarrhal conditions of the
intestines, to prevent the formation of that thick tenacious mucus which
forms a convenient nidus for the various worms infesting this canal.

CHLORIDES. 159

Dr. Eutlierford's experiments with fasting dogs lead liim to the con-
chision that common salt very slightly increases the secretion of bile.

Owing to their high ditfusion-power, these salts pass rapidly into the
blood, and so travel along the intestines too small a distance to act as pur-
gatives; hence, unless administered in considerable quantity, they exert
very little influence on the character of the motions.

Common salt is used to produce sickness, or to promote the action of
other emetics. Given in poisoning by nitrate of silver it effects a double
decomposition, precipitating the silver as the harmless insoluble chloride.

Chloride of ammonium is often given with considerable success in
chronic catarrhs of the bronchial, intestinal, and urinary mucous mem-
brane. It is indicated in bronchitis when the secretion is thick and
abundant, and it may be applied topically to the morbid mucous mem-
brane of the respiratory tract by the atomizer. It should be given in
twenty-grain doses every three or four hours, adding it to milk; or, still
better, mixing a drachm of liquid extract of liquorice with eachdose, freely
diluting it with water, and thus concealing its disagreeable taste. It is
recommended in catarrhal jaundice. It certainly appears to be very useful
in the congestive stage of cirrhosis. It is largely employed in India in
hepatic congestion and abscess.

The same remedy has been landed for whooping-cough. It is said to
be frequently successful in removing the pain of facial neuralgia "of
rheumatic character." It should be given in half-drachm doses, and if,
says Sir T. Watson, four doses fail to give relief, the drug may be con-
sidered unsuitable for the case. In full doses, several times a day, I have
many times found it useful in facial neuralgia. Dr. Anstie speaks well
of it in migraine, clavus, myalgia, intercostal and hepatic neuralgia, and
in mild forms of sciatica.

Many doctors employ this salt in all forms of neuralgia; and I have
heard some eminently practical men go so far as to assert that in this
painful affection they require no new remedy, since chloride of ammonium
so rarely fails in half-drachm doses several times a day.

Chloride of ammonium is given with advantage in headaches due to
menorrhagia, amenorrhoea, etc.

Common salt sometimes arrests hgemoptysis. Half a teaspoonful should
be taken undissolved, and be repeated occasionally till it excites nausea.

1 (JO SULPHATES.

Group containing SULPHATE OF POTASH, SULPHATE OF
SODA, SULPHATE OF MAGNESLV, PHOSPHATE OF SODA,
TAKTRATE OF POTASH, BITARTEATE OF POTASH, TAR-
TRATE OF POT AS B AND SODA.

With the exception of the sulphate and bitartrate of potash, these sub-
stances are freely soluble in water.

The sulphates have a very disagreeable bitter taste, which in the phos-
phate of soda is but slight, and in the tartrates is absent.

They are all purgative, producing watery evacuations.

They have little or no afhnity for animal textures, or much attraction
for water, whence they effect few changes in the organic constituents of
the body.

AVhile they all act as purgatives, producing watery evacuations, they
excite very little irritation in the mucous membrane.

How do they produce their purgative effect ?

Purgatives may act in one of two ways, or in both combined.

Some purge by increasing the moisture of the intestines, and so facili-
tating the passage of the contents along the canal; others act by increas-
ing the peristaltic action of the intestines, so that the contents are urged
more rapidly towards the rectum ; whilst most purgatives combine both
modes, although one action usually predominates.

The watery character of the motions shows without doubt that, in part
at least, these drugs purge by augmenting the moisture of the contents of
the intestines — an augmentation effected in three wa3's: by causing water
to flow from the blood into the intestines; by exciting the mucous glands
of this tract to increased secretion; or by effecting the retention of the
water already present in the intestines, Buchheim concludes, from his
careful observations, that these salts purge solely in virtue of their power
to retain in the intestines the water existing there, producing no flow of
fluid from the blood, no increased secretion from the mucous glands,
shown bv the fact that, after purgation Avith these medicines, no albu-
minous substances are found in the faces,

Thiry and Radziejewski conclude that these salts and other purgatives
act by increasing the peristaltic action, especially of the large intestine.
Brunton has shown that a solution of sulphate of magnesia does cause
fluid to pass from the blood to the intestine, for, Avhen a solution of sul-
phate of magnesia is put into a knuckle of intestine secured at both ends,
it is found tliat after some hours the contents of the bag are increased,
and the question arises whether this augmentation is due, according to
the old view, to simple osmosis from the blood, or is due, as Brunton
thinks, to stimulation of the mucous membrane of the intestine. AVlien
we bear in mind how an irritant like snuff or pepper applied to the nose
and eyes causes a copious flow from these parts, we can easily conceive
that stimulation will cause a copious outpour into the intestine. Moreau
has shown that section of the intestinal nerves causes a free serous exuda-
tion into the intestine, but it does not appear that paralysis of these nerves
explains the purgative action of salines. The stools provoked by salines
do not contain albumen, as they would were the excess of water they
contain due to serous exlidation.

SULPHATES. 161

In an elaborate and valuable paper, Dr. MattheAV Hay has re-investi-
gated the mode by which saline cathartics act. His experiments show
that saline purgatives act by exciting an increased secretion from the
mucous membrane, chiefly of the small intestine, and the increase in the
contents of the intestinal canal is not due to an increased pancreatic or
biliary secretion. This increase in the quantity of fluid in the intestine
is a true secretion, and not due to inflammatory irritation nor to osmosis,
for the intestines are not congested, and the fluid in the intestines only
contains a trace of albumen, and the quantity of fluid in the intestines a
short time after the administration of the saline, compared with the qvian-
tity of salt absorbed, is far too large to be explained by osmosis.

The saline passes rapidly along the small intestine to the colon, and
almost the whole of the fluid reaches the colon of a fasting animal iij an
hour. Food probably delays the passage of the fluid, and so weakens the
purgative action.

The saline is absorbed by the small intestine, but excreted by the
colon, hence whilst the fluid is in largest quantity in the small intestine
and becomes rather less as the contents pass downwards, the salt is less in
the small intestines, and is in larger quantity in the colon. The purga-
tive action is not, however, caused by the secretion of the saline by the
colon, for, when injected into a vein, sulphate of soda and sulphate of
magnesia do not purge.

He finds the absorption of these salts very slow from the stomach, but
rapid in the small intestines.

Magnesium sulphate he finds much more poisonous to the respiratory
centre and the heart when injected into a vein than sodium sulphate.

Like other purgatives, these salts are used to evacuate the bowels, to
remove water and poisonous matters from the blood and to reduce blood-
pressure. As simple evacuants, they prevent contamination of the blood
by removing the alkaloids and other poisonous substances generated from
the fa?ces in the intestine.

Owing to their increasing secretion from the intestines and their in-
fluence in retaining fluids in the intestinal canal, these salts remove im-
purities, like those which occur in ureemia, jaundice, etc. Further, by
freely removing fluid from the blood, and by dilating the abdominal
vessels, they lower blood-pressure. Hence saline purgatives are often
used with advantage in bleeding from the lungs.

An excellent way to administer some of these salts is in the form of
Pullna, Friedrichshall, or yEsculap water^ in doses varying from a wine-
glassful to half a tumblerful or more. Usually one dose before breakfast
is sufficient; if not, a second, and even a. third, dose maybe taken in the
course of the day. It is advisable to mix the natural water with a third,
or an equal quantity of boiling water; for when taken cold, it is some-
times liable to " lie heavy on the stomach," Usually a wine-glassful of
one of these waters, with an equal quantity of hot water, is sufficient to
open the bowels without much griping or pain.

A wine-glassful of Friedrichshall water in a breakfast-cupful of hot
water is very useful in bilious sick headache. The best time is before
breakfast, though it is useful at any time. It stays the nausea and soon
relieves the headache, sometimes without purging. The taste of this mix-
ture is not very disagreeable. Pullna or Friedrichshall water mixed with
milk is a good purgative for children, the milk disguising the bitterness.

An orange or two eaten before breakfast is a pleasant and often effec-
11

162 SULPHATES.

tual way of overcoming moderate habitual constipation; and sometimes,
indeed, "this plan overcomes the most obstinate forms. xVnother good
means of obviating consti2)ation is to take a glass of cold water before,
and an orange soon after, breakfast, and if oranges before breakfast dis-
agree, the}' should be taken soon after it.

Stewed rhubarb, or stewed gooseberries, cooked or uncooked apples,
are effectual; grapes and strawberries, on the other hand, are often use-
less. Strange to say, we occasionally meet with people in whom fruit
causes constipation. Again, we see individual peculiarities in respect of
fruit. Thus, some are made bilious by oranges or strawberries; some are
constipated by strawberries, whilst other fruit relaxes.

There are many persons, esjiecially busy, worried men, whose com-
fort iind well-being seem to depend on an efficient daily evacuation of the
bowels. If they pass a day without relief of the bowels, or if the defeca-
tion is delayed to the after part of the day, they suffer from mental dul-
ness and inactivity, a kind of fogginess, with mucii irritability, and per-
haps a dull, "stupid" headache. They are quice conscious of their
irritability, but cannot well control it. Directly the bowels act freely,
these symptoms vanish at once, the head clears, the spirits revive, the
ill- temper disappears, they recover their full mental capacity, and in a
short time longer, perhaps half an hour or an hour, the headache dis-
apj)ears. With many such patients the constipation is not obstinate,
but they pass daily a hardened, dry evacuation, insufficient to give com-
fort. Porridge,^jrown bread, whole-meal bread, and exei'cise are generally
sufficient to overcome the constipation. If not, then fruit before or after
breakfast should be tried, and this failing, the natural purgative waters
will often prove useful.

Carlsbad waters are eminently useful in many abdominal diseases.
The imported Avaters are esj)ecially efficr.cious when a dietary is adopted
similar to that enjoined at Carlsbad. The vrater should be warmed to
about 100° to 110°, and the patient must drink three to six tumblerfuls
before breakfast, prolonging the drinking over an hour or more, and if
j)ossible, whilst taking exercise in the open air. Dr. Stephen "Ward says,
"Even when first taken, and in moderate quantity, they usually cause
pulpy slimy stools of dark color and offensive odor. These stools are
generally frequently repeated, and the patient is astonished at the quan-
tity that sometimes comes aAvay, but in many persons no very evident
symptoms beyond the purgative action attend the drinking of the waters."
I have rarely seen them purge, because, perhaps, I havechiefly used them
in obstinate constipation. The cpiantity to be taken depends on their
effects. It is better to begin with three tumblerfuls and gradually increase
the quantity to four, five, or six, according to the action. This treatment
must be continued three weeks or a month. It often induces some weak-
ness. It reduces stoutness, and sometimes even makes a jiatient very
thin. But if it produce much depression, or excite nervous symptoms,
a smaller quantity must be taken, and the course must be limited to a
fortnight or three weeks. The good effects are sometimes not appar-
ent till a week or so after the course. The diet at Carlsbad is extremely
simple. " Fat, butter, cream, pastry, cheese, rich meats, as pork, goose,
sausages, salmon, mackerel, herrings, anchovies, entrees, and other dishes
seasoned with spices, pepper, onions, garlic, etc., are to be avoided. Dressed
salads, cucumber, and uncooked fruit generally are objected to as being
indigestible, and likely to cause flatulence and irritation of the bowels.

SULPHATES. 163

The use of spirits is absolutely forbidden, and the wine of the country
or the lighter French wines are permitted only sparingly, and in cases
especially requiring a certain amount of stimulus. The breakfast, which is
usually taken about an hour after drinking the last cup of water, consists
merely of weak tea or coffee, Avith milk and a little sugar, and small well-
baked rolls, or second day's bread; meat, fish, or eggs being excluded, ex-
cept for the very delicate. The dinner, which takes place at one, consists
of but three courses; soup, free from grease and spices, and thickened
with barley, rice, or vermicelli; meat, as beef, mutton, lamb, poultry, or
game, with well-boiled fresh vegetables; and a light, simple jjudding, or
a compote of stewed fruit; a cup of coffee may be taken in the afternoon;
a light supper is takenat eight o'clock; and smoking in moderation is not
objected to.'' (Dr. Stephen Ward.)

This treatment is extremely useful in obstinate habitual constipation,
and by its means I have cured some of the most rebellious cases. In such
instances it may not relieve the bowels for some days, indeed even a
week may pass without relief; in other cases it at once produces one or
two soft, copious, natural evacuations, and on discontinuing the water,
the bowels act daily. After some months, however, a recourse to the
waters may again become necessary, owing, generally, to some fault in
the patient's habits. In cases of simple, obstintite constipation, it is not
necessary to enforce very strictly the rigorous Carlsbad regimen just
described.

Again, in cases like the following, Carlsbad waters are very useful : —
a middle-aged woman, accustomed to eat and drink somewhat too freely,
suffers from acidity, much flatulence, constipation with attacks of pain
at the epigastrium, or over the liver, or between the shoulders, the con-
junctiva becoming rather jaundiced, and the complexion sallow. In a
case like this, a well-regulated diet greatly assists the action of the
waters. This treatment is also very useful in gall-stones and gout. It
is the most successful treatment for the removal of gall-stones, and the
prevention of their formation. Patients sometimes say they have tried
Carlsbad waters without good results, when they have simply taken
Carlsbad salts dissolved in a small quantity of water. In such a form
the Glauber salts purge, but fail to yield the same excellent results, as
when given largely diluted with water; I have no doubt that the large
bulk of water plays a prominent part in the therapeutic effects.

Some members of this group, as sulphate of soda, bitartrate of pot-
ash, and tartrate of potash and soda, owing to their hydrogenic action,
are largely used in general dropsy, both cardiac and renal. Owing to
their action in largely increasing intestinal secretion, and to a less ex-
tent to their action in retaining fluid in the intestinal canal, they lessen
dropsy, and so free in some measure the water-logged organs, and thus
remove many distressing symptoms; for instance, in the case of Bright's
disease, the fluid withdrawn from the blood holds in solution some of the
deleterious matters that produce urasmia. These purgatives, therefore,
purify the blood, and thus assist in controlling coma,, convulsions, head-
ache, sickness, etc. It must, however, be borne in mind that often
repeated pifrgation is weakening, and may, by increasing anaemia, actu-
ally subsequently increase dropsy.

The purgative action of these salts is most marked when adminis-
tered in a concentrated condition, and Hay advises giving six drachms to
an ounce of suij)hate of magnesia in an ounce of w.iter before food, and

164 SULPHATES.

directs abstention from fluids for some time afterwards. This treatment
withdraAvs much water from the blood-vessels, and speedily reduces
dropsies, general rather than local. He recommends this treatment in
pleuritic effusion.

A brisk purgative frequently promotes free and abundant secretion
from the kidneys, either Avhen healthy or diseased; and, herein we have
perhaps, further elucidation of the good effects of these remedies in
Bright 's disease.

Some member of this group, generally either siilphate of magnesia or
phosphate of soda, is often given as an intestinal evacuant in fever;
hence they are reputed to be febrifuge. But their action is due simply
to the unloading of the bowels, since it is well known that constipation
augments the preternatural fever heat.

For fever patients, Dr. Armstrong strongly recommended free pur-
gation, to the extent of several evacuations daily, during the first few
days, before exhaustion sets in. This treatment still finds just favor
with many practical authorities, although it is not ajiproved by Dr.
Graves. It is considered that free purgation in scarlet fever prevents
severe sore-throat, glandular swellings, discharges from the nose and
ears, with many other disagreeable sequelte.

In measles, purgatives must be given with caution, the bowels being
generally irritable, and diarrhrea often present.

Eutherford, from his experiments with fasting dogs, finds that
jihosphate of soda is a powerful cholagogue, not merely emptying the
gall-bladder and biliary ducts, but actually increasing the secretion of
bile. Sulphate of potash and Eoelielle salts he finds moderate chola-
gogues, whilst sulphate of soda is only a feeble he^^atic stimulant.
Strange to say, he finds that sulphate of magnesia produces no effect on
the liver. It is interesting to observe that sulj^hate of soda is the chief
ingredient in Carlsbad water, so largely used for its action on the liver.

Dr. Bartholow sj^eaks highly of j)hos2Dhate of soda in catarrhal jaun-
dice; a drachm three times a day to adults, ten grains for children. He
commends it also in hepatic colic, to prevent the formation of gall-
stones. In biliary colic the treatment should be persisted in for several
months. He also strongly recommends ten grains several times a day in
milk, passing the pasty white stools of ill-conditioned children.

On account of the low diffusion-power of these salts, very little passes
into the blood, the greater part, especially when they purge, passing
from the system with the freces. Small doses, if they tarry long in the
intestines, ultimately pass into the blood, and are separated by the kid-
neys. They are reputed to act as diuretics. The tartrates of this group
are highly esteemed as excellent diuretics in Brighfs disease, and are
often employed in doses short" of purging. The tartrates and bitartrates
are converted into carbonates partly in the intestines and partly in the
blood. They thus lessen the acidity of the urine or even render it alka-
line. Except in the case of phosphate of soda, the action of these salts
on the constituents of the urine, either in health or disease, has not yet
been worked out.

The salts of this group most frequently employed are the bitartrate
of potash, sulphate of magnesia, and ])hosphate of soda. This phosphate,
well-nigh tasteless, may be given to children, unsuspected, in a little broth.

Like other purgatives these salts often act quicker and with greater
certainly in small and frequently-repeated doses. Hence, when the

NITRATES. 165

bowels are tightly locked up, having resisted the action of a full dose of
Epsom salt, it is a good practice to give the same remedy in small and
often rejjeated quantities, as a drachm every hour or two hours.

It should be mentioned that sulphate of potash must be given with
some caution, for, although usually a safe and mild purgative, it has
proved in some cases poisonous, potash salts being far more poisonous
than soda or magnesium salts.

NITRATE OF POTASH, NITEATE OF SODA.

These salts possess a very high diffusion-power, and are freely solu-
ble in water. They lower the temperature of water, an effect very con-
siderably increased if sal ammoniac is mixed with the nitre. This com-
bination of salts used to be aj)plied to the skin as a refrigerator, though
now it is rarely so emi^loyed, and is to be especially avoided if the skin
is broken, as solutions of the nitrate are very irritating to the wounds.
Ice is in every way a better refrigerator.

The inhalation of the fumes of burnt nitre paper will sometimes
avert the paroxysm of asthma. According to Dr. Hyde Salter this treat-
ment is most effectual in pure uncomplicated asthma. He points out
that the paper must not imbibe too much nor too little nitre. If the
bibulous paper is too thin, it absorbs insufficient nitre; if too thick, it
takes up excess of nitre, and the fumes are too carbonaceous, the paper
burning too fast, with a sudden explosive flame. There should be no
brown smoke, but clear white fumes. Red blotting paper of moderate
thickness and loose texture is best. Dr. Salter gives the following di-
rections for the manufacture of nitre-paper: — Dissolve four ounces of
nitre in half a pint of boiling water; pour the liquid into a small waiter
and soak the paper, then drain and dry it. Cut it into pieces four inches
square, and when required burn one or two of these pieces, or a piece
may be burnt nightly in the bedroom. The prepared paper mast be
kept in a dry place. In the Pharmacopoeia of the Throat Hospital, Sir
Morell Mackenzie gives the preparation of three papers of different
strength, one made from a solution containing sixty grains, another forty
grains, and the third thirty grains of nitre to an ounce of water. He
directs the paper to be cut into pieces three inches long and half an
inch broad, and one to six of these pieces to be used successively at each
inhalation. The paper is buriied in a Jar, and the fumes inhaled by tak-
ing deep inspirations from the fuming vessel. Variotis substances may
be added to the solution which appear in some instances to heighten
the effect of the nitre, such as compound tincture of benzoin, spirits of
camphor, oil of cassia, and tincture of sumbul. It is a singular circum-
stance, affording a marked example of the " caprice " of asthma, that a
paper prepared with nitre only will relieve one patient, yet will utterly
fail to relieve another, although a nitre paper prepared in a different
manner may be quite successful. It must be borne in mind, therefore,
that although one kind of nitre-paper has failed, it does not necessarily
follow that another sort of nitre paper will also fail. Sometimes a thin

106 NITRATES.

paper fails where a thick one succeeds, or vice verHd. It appears, indeed,
that very slight differences in the mode of manufacture influence the
therapeutic effects. Many quack papers said to contain other substances
besides nitre, or besides nitre and clilorate of potash, often succeed ad-
mirably.

A considerable recent experience leads me to conclude that these
papers would prove much more relieving if somewhat differently pre-
pared, and if pieces were burned sufficiently large to fill the room with
fumes. The most efficacious paper is made by dijjping ordinary white
blotting jDajDer in a boiling saturated solution of nitrate of potash and
chlorate of potash. Paper thus j^repared burns with a flame. A large
piece, the size of course depending on the dimensions of the room, often
succeeds when other prepared papers fail. A piece ten inches square,
and sometimes two or three jiieces are required. When ordinary papers
have failed, I have recently used in some cases with advantage a pastile
compounded of two parts of nitre, one part of chlorate of potash, with
two parts of lycopodium jjowder. Dr. Murrell uses with much success a
thick paper soaked in a boiling saturated solution of nitre and chlorate
of potash. This thick paper, made by the adhesion of six sheets during
crystallization, contains, when dry, twice its own weight of salt, and a
piece of paper six inches square* takes up nearly half an ounce of the
mixed salt. Certain cases require a greater quantity of nitre smoke than
others. I am convinced that the reason why papers appear in so many
cases to fail, is that they are not adequately imjDregnated with nitre, and.
are consumed too sparingly.

The crystals of nitre have a cooling saline taste, and in acute inflam-
mation of the throat are sometimes sucked, but other remedies are j^ref-
erable.

In large doses the nitrates inflame the stomach. Even when taken
for some time in moderate quantities they considerably disorder diges-
tion, producing nausea, vomiting, and a coated tongue: consequently
their action must be carefully watched.

From their high diff'usion-power these salts speedily enter the circu-
lation. Unless, indeed, large quantities are taken they pass but a short
way along the intestines, and therefore do not purge, and. indeed, so far
as we know at present, exert little or no direct influence on either the
small or large intestines.

Much conjecture has been hazarded regarding the action of the nitrates
on the blood. It is well known that they prevent the coagulation of the
fibrin in blood withdrawn from the body, or, when coagulated, dissolve
it. Scherer, however, asserts that they will not dissolve the fibrin of in-
flammatory blood. These facts have led to the supposition that the
nitrates may possess a like influence over fibrin in the circulation, and
th;it they are indicated when this substance is in excess, as in inflamma-
tions and acute rheumatism. There is no proof, however, that the ni-
trates possess any such power, and, indeed, unless employed in consider-
able quantities, they exert very little influence upon fibrin out of the body.
Hence it cannot be expected that after its dilution with the fluids of the
circulation, harmless doses can in any Avay influence the fibrin of the
blood. But, indeed, this notion is no longer tenable, for it has been
ascertained that blood withdrawn from the body, both before and after
the administration of nitrate of potash, contains in each case the same
quantity of fibrin.

NITRATES. 1G7

These salts are considered to be liiglily useful in acute rheumatism,
and are supj^osed to jirotect the valves of the heart, or to restore them
to their natural state when damaged by rheumatism, a supposition
founded on a misapprehension of the morbid j^rocesses which lead to
valvular contraction and incompetency. These structural changes, it
was imagined, resulted from the depositions of fibrin on the surface of
the valves, and the subsequent contraction of this substance rendered
them shrunken and inefficient, the truth being that these changes in
the valves are owing to inflammatory products formed in their own sub-
stance. Occasionally, it is true, fibrin is deposited on thickened and
roughened valves, but even this, as has just been pointed out, these salts
can neither prevent nor remove.

While it must be admitted that these salts do not act in the way
supposed, many high authorities consider that nitre mitigates and short-
ens an attack of rheumatism. The advocates of nitre administer it in
large doses, freely diluted in water, giving as much as half an ounce to
an ounce of the salt in the course of the day in lemonade or barley-water
agreeably sweetened. The urine, it is said, becomes very abundant when
the fever declines, and the pains abate. At present there are no obser-
vations sufficiently exact to determine this point, Nitrates are now
quite superseded by salicylate of soda in acute rheumatism.

The same discrepancies of opinion prevail regarding the influence
of the nitrates on acute inflammation.

Large doses produce pains in the stomach, with vomiting and diar-
rhoea, great weakness, faintings, loss of consciousness, and death. The
same symptoms are witnessed in a minor degree when less immoderate
quantities are used. The patient becomes languid, disinclined to exert
either body or mind, and the pulse is feeble and slow.

These salts readily pass from the body through the kidneys with the
urine, and in their passage may irritate and inflame the urinary organs,
and in large doses may even produce bloody urine.

Nitrate of potash has been recommended in the incontinence of
urine of children.

In some quarters they enjoy a very high reputation as diuretics, and
in certain cases appear to be of considerable service. Their diuretic
action is well displayed in lumbago and chronic rheumatism; accom-
panied by scanty high-colored urine, which becomes turbid on cooling.
Ten grains of the salt dissolved in water, taken hourly or every two
hours, in some cases will soon increase tlie urine, rendering it clear and
limpid, when the rheumatic pains generally decline.

168 CHLORATE OF POTASH.

CHLORATE OF POTASH.

In many of its chemical properties Chlorate of Potash corresponds
to the preceding group of nitrates; like them, endowed with a high dif-
fusion-power, it differs in its sparing solubility.

A solution of the chlorate, used as a wash, is said to clean and stim-
ulate foul ulcers; but other remedies are more effective.

This salt appears to increase the flow of the saliva, and, according to
Hutchinson and others, to produce ulceration of the mucous membrane
of the mouth. It is largely used in various affections of the mouth, and
is of signal service in mercurial and simple salivation, in ulcerative sto-
matitis and aphthae. It is particularly useful in the ulceration of the
edges of the gums, generally limited to one side of the mouth, affecting
both the upper and lower Jaws, also that part of the tongae and cheeks
coming in contact with the ulcerated gums. Although not at all dan-
gerous, it is often a very obstinate complaint, especi;illy Avith adults,
though children are most prone to it. The influence of the chlorate on
this form of ulceration is almost magical; in one or two days it cleans
the dirty looking ulceration, and heals it in a day or two more. It is
said to cure follicular and phagedenic ulceration like a charm. Dr. Lloyd
Eoberts says that chlorate of potash, taken internally, and used as a
lotion, is useful in the teazing dryness of the mucous membrane of the
throat left after diphtheria and scarlatina.

It is largely used in full doses in diphtheria, acute sore-throat, and
scarlatina.

Dr. Leonard Sedgwick speaks highly of chlorate of potash in catarrh;
he says it quickly relieves stuffing of the nose, rawness of the throat,
and thickness of voice. Taken early and frequently, it will stop many a
cold. Eight or ten lozenges should be sucked in the twenty-four hours.

Some assert that the action of chlorate of potash is simply local, and
that its good effects are all due to its topical application. AVhen ad-
ministered by the stomach, it is largely excreted by the salivary glands;
hence after absorption its to^ncal action in the mouth and throat j^ersists.

Chlorate of soda is more soluble than chlorate of potash, and appears
to be equally serviceable.

Chlorate of potash seems to produce but little effect oii the stomach,
unless taken in considerable quantities, when, like the nitrates, it in-
flames the mucous membrane, and produces both vomiting and diarrhcea.
It is not employed in diseases of the stomach.

Owing to its high diffusion-power it passes readily into the blood,
but owing to its slight solubility, a large quantity of this salt cannot
find its way quickly into the circulation. Nevertheless, it has proved
poisonous, especially in children. In poisonous doses, as half an ounce
to an adult, it inflames the gastro-intestinal canal and excites violent
vomiting and profuse diarrhoea, acting like nitrates and some other sub-
stances. It profoundly modifies the blood corpuscles, changing the
oxyhsemoglobin to methtemoglobin, and induces cyanosis with cardiac
weakness, sometimes delirium, coma with cramps, and a peculiar stiffness
of the extremities. It also disintegrates many of the red corpuscles,
and the coloring matter with albumen, and some blood corjmscles, es-
cape Avith the urine, the coloring matter existing in part as metha?mo-
globin and in part as oxyha^moglobin. The urine also contains the col-
oring matter in the form of granular red or brownish-red casts. The

ALUM. 1G9

quantity of the urine is diminisliecl; it therefore induces a condition
quite similar to paroyxsmal liaemoglobinuria. Small ecchymoses some-
times appear in the skin, and general jaundice sometimes occurs. Owing
to the gastro-intestinal catarrh the patient complains of pain and ten-
derness of the abdomen. The liver is also enlarged. At the post-mortem
the blood is found of a chocolate color, the liver and spleen are enlarged,
and with the marrow of the bones, contain much debris of the disinte-
grated red corpuscles. Nephritis is also present, and the kidney tubules
are full of brown casts.

As this salt easily parts with oxygen, it was at one time supposed
that, by yielding up this element to the blood and tissues, it might pro-
mote oxidation; but careful observations have conclusively proved the
erroneousness of this view, as the salt can be obtained unaltered from
the urine.

It has been recommended in facial neuralgia.

Its influence, if any, on the organs of the body is unknown. Half
an ounce to an ounce of a saturated solution containing five to ten drops
of laudanum is very useful as an injection for inflamed and painful piles.

ALUM, DEIED ALUM, ACETATE OF ALUMINA.

These salts are employed almost exclusively as topical astringents.

They act as astringents in virtue, it is supposed, of their capacity to
unite with albumen, and coagulate it.

They produce no effect on the entire skin; but when applied to sores,
they coagulate the albumen of the pus, mucus, or of the tissues them-
selves, thus coating the sore with an impermeable layer, and protecting
it from the action of the air. Like the salts of many other metals, alum
may be used to form this protective coating. These agents have a further
action than that just described; for, as just stated, they act as astringents
by combining with and condensing the tissues. The topical application
of alum contracts the blood-vessels, and lessens the supply of blood to a
sore. By constringing the blood-vessels, and by condensing the tissues
themselves, the members of this group will depress the vital action of a
sore, and so check the secretion of mucus or pus. For this purpose alum
is applied dry, or in solution, to relaxed and abundantly secreting sores.

In such cases other astringents generally succeed better.

Alum solutions may be applied to free- weeping eczematous surfaces
to check profuse discharge, and to bring the eruption into a condition
suited for other remedies. Like other astringents, alum is generally in-
sufficient to heal ecezma.

Owing to their property of condensing tissues and coagulating albu-
men, these substances may be used to control the milder forms of bleed-
ing, and alum in an emergency has the advantage of being almost always
at hand. In severe haemorrhage other treatment is of course required,
but to check the bleeding of the gums, of piles, leech-bites, or slight cuts,
alum dusted on the affected part, first wiping it dry, or applied in a pretty
strong solution, is generally sufficient.

170 ALUM.

In opistaxis, alum may be injected into the nose, or may be snuffed
up as the dried powder.

In strong solutions (six grains to the ounce) alum has been recom-
mended, though it is little used, in prolapsed anus or uterus.

In vulvitis of children, few remedies can be compared to alum used in
the strength of sixty grains to a pint of water, and frequently applied,
every hour or oftener, by the help of a syringe^ to the secreting surface,
first washing away the pus with warm water and then applying between
the parts a piece of Ihit soa^ked in the lotion. Although generally success-
ful, this treatment sometimes fails to check this troublesome complaint,
even when it cannot be traced to any irritation, as worms, constipation or
teething. In some cases the discharge, besides comiiig from the surface
of the vulvae, is poured out from the lining membrane of the vagina,
when it is necessary to take care to pass the injection up the vagina.
Want of attention to this fact explains the occasional failure of treatment
and ap])arent obstinacy of the case. The solution just recommended may
sometimes prove too strong, increasing both the inflammation and the
discharge, when, of course, its strength must be reduced.

Similar solutions are useful in chronic otorrhcea, but alum is far in-
ferior to glycerine or tannic acid.

A solution of alum, of the strength of eight grains to the ounce of
water, is an excellent solution in simple, and especially in purulent, oph-
thalmia of children. The conjunctiva must be well washed with it eveiy
quarter of an hour, for success depends on the frequency of the applica-
tion. Simple water, as frequently applied, is a useful, although inferior,
substitute.

Few substances are as useful as alum in certain diseases of the mouth.
Thus, in simple ulcerative stomatitis — that form which, beginning at the
edge of the gums, and never spreading far beyond, is often limited or
most marked over one-half of the jaw — gives way in a few days to dried
alum applied with the finger many times a day. It is not merely astrin-
gent; but from its attraction for water (which it has lost by being heated)
it is also slightly escharotic, and gently stimulating to the indolent tissues.
Ulcers like these produce ulceration by contact with the contiguous
mucous membrane of the tongue or cheek.

Aphthous ulcers, showing but little disposition to heal, or indeed,
tending to spread, may be touched with dried alum a few times a day with
the best effect. Usually, no such application is required, and chlorate of
potash, and perhaps a purgative, are all that is necessary. Other forms
of ulceration may be treated in the same Avay, Alum is recommended to
be applied to the throat, either dry or in solution, in simple or scarlatinal
sore-throat, in tonsillitis, and even diphtheria. Alum being now little
used in any of these cases, its advocates', perhaps, exaggerated its good
effects.

It is asserted that ten grains of powdered alum, placed dry on the
tongue, will sometimes arrest a paroxysm of asthma.

Gargles of alum are more useful in chronic inflammations of the throat,
when the mucous membrane is relaxed and covered Avith a grey mucus or
with pus; but although alum is highly useful, tlie glycerine of tannin is
a surer and less disagreeable application.

Many cases of chronic ozaena speedily yield to a solution of alum, a
drachm to the pint, applied by an irrigating tube. About a foot above
the patient's head is a jug containing the solution, and in this jug one

ALUM. 171

end of an elastic tube is placed. The solution is then sucked or manipu-
lated into the tube, when the free end is placed in one nostril, and the
ala of the nose pressed on it to secure it in position. Here we have a
syphon, and the fluid runs from the vessel through the tube, up one
nostril, round the septum, and down the other nostril, washing the sinu-
osities of the nasal membrane most thoroughly. The head is bent a little
forward, and the mouth must be kept open, and, i'f properly managed,
none of the solution escapes by the mouth, or runs down the throat.
Even when this irrigation fails to eradicate the disease, it checks the dis-
charge, and removes the offensive smell depending on decomposing
matters. Some prefer acetate of alumina as more efficient in correcting
the fcetor than simple alum. If the foetor persist, the application should
be used twice a day, or oftener. If the foetor is very great, a weak solu-
tion of j)erma.nganate of potash or carbolic acid may be used. A wash of
a solution of glycerine of tannin in water is often useful; also a saturated
solution of boracic acid.

A strong solution of alum is sometimes useful in pruritus vulvae.

Ten grains of alum to the ounce of water is used in the form of spray
for chronic coughs and hoarseness.

Alum behaves in the stomach as on the denuded skin; it coagulates
the albumen, and constringes the mucous membrane; and it hinders diges-
tion by each of these processes. It will often check bleeding from the
stomach, but it is inferior to other astringents. It sometimes controls
vomiting. In six to ten-grain doses it sometimes checks obstinate forms
of vomiting, occurring in phthisical patients, especially that form excited
by coughing.

Dr. ]\leigs speaks very highly of alum emetics for children, and he
prefers it to other emetics in croup. He gives a drachm in honey or syrup
every ten or fifteen minutes till the child vomits; but a second dose is
not generally required. Alum, he says, does not weaken, and does not
lose its efi'ects so soon as antimony or ipecacuanha, but my experience by
no means confirms this statement. Dr. Meigs strongly advocates the em-
ployment of emetics in true croup, and thinks that many lives might be .
saved were they more commonly used and repeated oftener. In severe
cases, he produces vomiting three or four times a day or even oftener-
This treatment must be begun early.

Alum checks secretion from the mucous membrane of the intestines,
and constipates by rendering the contents of the canal more compact and
more difficult of propulsion. Alum is sometimes usetl in both acute and
chronic diarrhcea, and it has proved useful in the diarrhoea of typhoid
fever and of dysentery.

It is uncertain how far the members of this group pass down the intes-
tinal canal, but probably not far, without being decomposed and rendered
inert. Alum, extolled by many high authorities in lead colic, is said to
remove the spasm and the pain, and at the same time to unload the bowels
more speedily and certainly than other remedies. It is given in consider-
able quantities, as much as ten grains every hour. The few trials I have
given this treatment have not been rewarded with success.

The long-continued administration of these substances produces loss
of appetite, constipation, and at last chronic catarrh of the stomach and
intestines. Large doses cause gastro-enteritis at once, with its usual
symptoms.

When the acute stage of whooping-cough is over, and when there is
no fever nor inflammation of the lungs, nor any irritation of the teeth.

172 PREPARATIONS OF IRON.

alum is an excellent remedy. In fact, it is useful only in uncomplicated
cases; but in these, few remedies give more satisfactory results. It
speedily reduces the violence and frequency of the paroxysms, often,
indeed, at once lessening their recurrence one-half, and, in fact, it often
straightway cures.

Alum checks the troublesome vomiting so often met with in whooping-
cough, and much improves the appetite — effects observed sometimes even
before the cough undergoes any diminution. Constipation rarely happens.

Alum may control whooping-cough simply by its astringent action on
the throat, and in support of this conjecture, other astringent substances,
as tannin, etc., are likewise useful (see Tannin), even when applied to the
throat only. Alum itself acts best when mixed with some tenacious fluid,
as gum, glycerine, or honey, so that the solution is made to cling some
time about the fauces.

The alum should be given in doses varying from two to six grains
every three hours, or it may be given hourly in corresponding doses.
Alum is generally beneficial in the paroxysmal cough, which may continue
a long time after the characteristic whoop has disappeared, and in other
coughs having the same spasmodic character.

It is unknown how much of these substances is absorbed by the intes-
tines, and conveyed into the blood, but probably not a large quantity.
The chief part escapes by the fasces, which the alum is said to make firmer
and odorle'ss.

Dr. Justin finds that a grain and a half of sulphate of alumina, one
grain of bismuth, with enough extract of gentian to form a pill, to be
taken night and morning, is useful in chronic constipation.

It is doubtful if alum has much effect as a remote astringent to check
bleeding from the lungs, uterus, kidneys, etc., and to check profuse
sweating and discharges. Alum injections, one drachm to a j^int, employed
in the manner directed for the injection of carbonate of soda (see Potash
Group), are very useful to check leucorrhoeal discharges. The alum solu-
tion constringes the parts, and sometimes causes severe cramp-like pains
in the belly.

PEEPARATIONS OF IRON.

Ikon is a constant and necessary constituent of the body, and must
be regarded as an important food.

None of the preparations of this metal applied to the skin produce any
change in it. Several of the soluble salts combine with albumen on raw
surfaces, sores, and mucous membrane, condensing the tissues, and con-
stringing the blood-vessels; and, besides this astringent action, they at the
same time act as stimulants or irritants, according to the strength of the
application or the condition of the sore.

The organic salts are less astringent and stimulating than the inoi-ganic;
while of the inorganic, the ferric salts possess these properties in a greater
degree than the ferrous salts.

Several compounds of iron may be employed as astringents and stimu-
lants; but, when a stimulant is required, other metallic preparations are
j)referable. The sulphate, and especially the ferric chloride, solid or in

PREPARATIONS OF IRON. 1 7o

solution, are employed to check haemorrhage. The chloride is a powerful
styptic, and readily controls the hleeding from small vessels, but it has the
disadvantage of irritating the surface of wounds, and preventing union by
first intention. Carbolic acid will probably supersede perchloride of iron;
for this acid, properly employed, does not hinder the immediate closure
of a wound.

The soluble preparations of iron have a metallic astringent taste, and
act on the mucous membrane of the mouth as on the abraded skin.

Iron salts are never employed as topical agents in diseases of the mouth;
and, as they often discolor the teeth and stain the tongue black, especially
when the breath contains sulphuretted hydrogen gas, arising from carioiis
teeth, etc., they may he taken through a quill, glass tube, or reed.
They are conveniently given in the form of pill.

Tincture of iron, painted over an erysipelatous surface, is a useful
application. This treatment is commended in the erysipelas following
vaccination.

Solutions of astringent preparations of iron, as a drachm of the solu-
tion of the subsulphate in eight ounces of water, are recommended as a
sjoray in bleeding from the nose or lungs, and even insufflation of the
powdered sulphate has been successfully employed; though one would
expect this 'treatment would excite cough, and favor bleeding. This
spray also is useful in chronic oza?na.

The effects of these salts in the stomach differ according to their prop-
erties. Some are astringent, stimulating, and in large doses irritating to
the mucous membrane, as the pernitrate, the perchloride, the iodide, and
the sulphate, while the remaining preparations with respect to this mem-
brane are almost inert. If the stomach is irritable, bland preparations
of iron must be chosen. It is often stated that chlorotic or anaemic
patients with Aveak stomachs must be treated with bland unirritating
preparations of iron. In some instances, no doubt, the astringent jtrepa-
rations are unsuited, but in most cases they produce far bettor results
than the bland forms of iron, A pale, flabby, broad, and teeth-indented
tongue, indicates almost always the need of large doses of the astringent
preparations of iron. Thirty drops of the tincture, or three or four
grains of the sulphate, may be given three times a day. Weak anaemic
girls, suffering from pain and vomiting after food, with perhaps tender-
ness of the skin at the epigastrium, are often effectively treated by large
quantities of the tincture of the perchloride.

The soluble preparations of iron combine with the albumen in the
stomach, forming soluble protosalts, persalts and insoluble albuminates,
which, however, are soluble in dilute acids and gastric juice, while the
insoluble pre])arations are dissolved to a variable extent in the acids of
the gastric juice. The reduced iron is pretty freely soluble in the gastric
juice, but gives off hydrogen gas; or, if the preparation is impure and
contains a sulphide, sulphuretted hydrogen, either gas causing eructa-
tions, and the sulphuretted hydrogen a very disagreeable taste. The per-
oxide, if strongly heated, is soluble in the stomach with great difficulty;
the more slightly heated forms should therefore be preferred. The car-
bonate and the magnetic oxide are more easily dissolved than the sesqui-
oxide.

The astringent preparations, as the perchloride, acetate, pernitrate
or sulphate, are employed to check ha?moirhage from the stomach. In
proportion to their astringency these preparations confine the bowels.

174 PREPARATIONS OF IRON.

Since after quitting the stomach tliey are soon clianged into an insohi-
ble and inert sulphide, their astringency must extend itself on the upper
part of the small intestines.

The sulphate, acetate, perchloride, pernitrate, in common with otlier
astringent metallic preparations, may he given in diarrhoea. The perni-
trate, much praised in the chronic forms of diarrhoea, is probably an effi-
cient preparation.

In bleeding from the stomach small doses of the astringent prepara-
tions in iced water should be given hourly.

Owing to the astringency of iron salts, it is well to combine each dose
with some laxative, as a quarter of a grain of aloes, a few grains to half a
drachm of sulphate of magnesia, soda, or potash. Some authorities con-
sider that the combination of iron with a laxative markedly promotes the
absorption of the iron. Iron salts, however, by no means always consti-
pate, and, indeed, large doses of the astringent preparations, as the
sulphate, often relieve constipation.

In their course along the intestines, iron salts, as we have said, are
changed into a sulphide of the metal, giving to the iivces a black and
characteristic appearance. A very small quantity of an iron salt is suffi-
cient to stain the motions deeply, and to keep them darkened for several
days after its discontinuance. Iron salts have no direct influence on the
pancreatic or biliary secretions.

In the treatment of the small thread- worms infesting the rectum, the
tincture or the sesquichloride, in the strength of a drachm of the tincture
to half a pint of Avater, is an efficient injection; it coagulates the albumen
and destroys the thread- worms.

It is an interesting and important question — How much iron is absorbed
into the blood ? Probably but little of the insoluble forms, as the quantity
of acid in the stomach is not adequate to dissolve them; and as regards
the soluble preparations it is hard to say how much gets into the blood.
The increase of the iron in the urine being very slight, after administer-
ing a soluble iron salt, it has been concluded that very little passes into
the blood; and the fact that almost all the iron taken by the mouth may
be re-obtained from the fieces, seems to strengthen this view; but an ex-
tended knowledge concerning the elimination of metals from the body
shows this conclusion to be fallacious. Probably most metals, but cer-
tainly iron, are eliminated from the system through the intestines, and
make their exit with the faeces; for, when iron salts are injected into the
blood, almost all the metal is ultimately recoverable from the fa?ces. That
much more is absorbed than is appropriated by the blood corpuscles is
shown by the coloration iron produces in all the albuminous secretions of
the body, the fluids Ijathing the various cavities becoming colored reddish-
brown. Still, the quantity absorbed is probably not very large, for when
an iron salt is injected into the blood, much of it passes out by the urine.

Oxide of iron possesses an ozonizing power. " Thus, a spot of iron-
mould, i.e., iron oxide, on linen, will in time destroy the fabric. From
a similar cause a fleck of rust on a bright surface of steel will steadily
enlarge and deepen." (Horatio Wood.) Hence it is argued that the
iron of the blood corpuscles acts in the same way, converting oxygen
into ozone, thus promoting oxidation, ozone being the active form of
oxygen in the system.

In the treatment of ansemia many physicians advocate the use of

PREPARATIONS OF IRON". 175

large doses of iron salts; others, instancing the beneficial effects of fer-
ruginous waters, strenuously maintain that all the good effects are ob-
taiualile from very small doses. In many instances, no doubt, anemia
is curable by the employment of small quantities of iron, but it is like-
wise certain that large quantities, when they can be borne, act far more
jn'omptly. Half drachm doses of the tincture, or six to eight grains of
the sulphate, may be given two or three times daily. The following j^ill,
originally employed by Bland, and strongly recommended by Niemeyer,
is no doubt very efficacious, but the iron without the carbonate appears
to answer as well. Sulphate of iron, carbonate of potash, of each half
an ounce; tragacanth, as much as is required to make ninety-six pills;
three to be taken three times a day, an additional pill being added
daily.

A convenient pill is made with five grains of the dried sulpliate of
iron, equal to about nine grains of the ordinary suljjhate, with a drop of
syrup. This sets into a firm pill, easily dissolved in the stomach. A
small quantity of extract of belladonna may be added to prevent consti-
pation, but when given alone this pill seldom constipates. Larger doses
of iron, while rarely upsetting the stomach, or j^roducing headache, often
cure anaemia with astonishing rapidity. This pill is especially useful in
chlorosis, but when this pill cannot be borne I obtain excellent results
by giving five grains of the reduced iron three times a day.

The experiments of Drs. Cutler and Bradford, conducted after Mal-
assez's method of counting the blood corpuscles, show that in health iron
does not increase the number of blood corpuscles, though it does in
anaemia.

Iron salts are largely used in ansemia; they are especially useful in
chlorpsis. Cases of ansemia, apart from those forms due to loss of blood
or exhausting organic diseases, fall into two classes, though both forms
may be combined. In chlorosis, the number of corpuscles is but little
reduced, but their haemoglobin is very deficient in quality. In perni-
cious anremia, on the other hand, the number of corpuscles is greatly
reduced, but the coloring matter in each is normal in amount. Iron is
chiefly beneficial in chlorosis, where haemoglobin is deficient without
much diminution in the number of corpuscles, and is much less service-
able, and, indeed, is very often useless, in pernicious anaemia, in which
serious condition arsenic is very useful.

In chlorosis the production of corpuscles is but little diminished, but
they contain too little coloring matter. There is also excess of the larger
and especially of the smaller corpuscles, the smaller being newly formed
and ill-developed and easily acted on by re-agents. There is indeed in
chlorosis *' imperfect evolution of blood." (Wilcocks, Moriez.) Iron
improves the condition of the blood discs, increasing their color and less-
ening the amount of small-sized discs.

In pernicious anaemia the production of red corpuscles is reduced, and
in such cases iron has very little influence, arsenic being a much more
potent remedy; hence it is argued that iron exerts little or no influence
on the formation of red corpuscles.

It is true that in chlorosis the number of red discs may be somewhat
reduced, and iron salts will then augment their number; but it is argued
tliis is not due to an increase in the production of discs, but to the fact
that iron improves the vitality of the red corpuscles by increasing their

176 PREPARATIONS OF IRON.

hsemoglobin, and by prolonging the life of the red discs increases their
total number.

In many cases of anaemia the combination of iron and arsenic is useful.

Iron salts are also useful in angemia from haemorrhage, and to a much
less extent in anaemia dependent on organic disease.

The long-continued use of iron is highly beneficial in scrofula and
rickets.

Iron-salts are commonly administered in amenorrhoea; as there is
usually much anaemia conjoined Avith this affection, the iron, in remedy-
ing the ana?mia, assists in restoring the uterine functions.

It must be remembered that anaemia is dependent, not on deficiency
in the supj^ly of iron, but on its scanty assimilation; hence iron must
be conjoined with well-regulated hygienic conditions, otherwise it does
comparatively little good.

In anaemia iron suits possess other important proj^erties besides their
influence over the growth of the corpuscles. They act bracingly on the
relaxed mucous membrane of the digestive canal and probably in this
way tend to restore its functions. Moreover it is highly probable that
after its entrance into the blood the iron exerts an influence beyond that
of merely increasing the quantity of red corpuscles; hence iron salts
are useful not only as a food to promote the formation of blood discs and
so improving general nutrition, but likeAvise on account of their beneficial
influence on the tissues. Iron therefore must be regarded as a food as
well as an important curative agent. When it is desired to benefit toni-
cally the mucous membrane of the digestive canal and the tissues, large
quantities of the soluble astringent preparations should be administered.

The exjoerience of physicians of the last generation accorded with
these views, and so does that of many highly practical men of the present
day; but on the introduction of the bland and almost tasteless prepara-
tions of iron, they were assumed to be in every way superior to the as-
tringent forms. Their comparative tastelessness is certainly in their
favor. It used to be considered, mainly on speculative grounds, that
the astringent preparations must disorder digestion; and these theoreti-
cal, and as I believe unfounded, opinions still prevail. In a certain class
of ansmic patients the astringent jareparations, even in large doses, are
preferable, and a large share of their efficacy is due to their direct action
on the mucous membrane of the stomach and intestines, and on the
organs Avhich stud them. It has been experimentally shown that sul-
phate of iron does not check the solvent action of the gastric juice, and
experience justifies the conclusion that in weak anaemic patients it does
not lessen, but rather increases the formation of this secretion.

If the digestive mucous membrane is in an irritable state, then, as
has been previousl}^ pointed out, the astringent iron preparations, in full
doses, may do harm.

Individual peculiarities must be taken into account. Some persons
cannot take iron in any form, not even a single dose of a weak ferru-
ginous water. Iron upsets the digestive organs of some patients, or it
induces fulness and pain in the head; others again take it not only with-
out inconvenience, but Avitli great benefit.

It is sometimes advisable to humor the stomach by occasionally chang-
ing the preparation of iron.

In a case of neuralgia with anjfiifiia Avhen no organic cause can be dis-
covered, salts of iron are especially recommended, although it is true

PREPARATIONS OF IRON 177

their action is uncertain. The huge doses of these salts sometimes given,
especially of the sesquioxide, are probably injurious, and are less service-
able than smaller ones.

Large doses of perchloride of iron are of great benefit in diiDhtheria.
Better use the solution rather than the tincture, and to give the medi-
cine very frequently — every hour, or even oftener. It is uncertain
whether the effect on the throat depends on the topical action of the
medicine, or after its entrance into the blood. The solution should be
frequently painted on the throat, taking great jDains to apply it very
gently, lest by increasing the inflammation it may do more harm than
good; this process appears to arrest the spread of the disease, and it is
said to maintain the patient's strength. The solution may be applied
with the atomizer, so as to penetrate into the trachea and bronchial tubes.
Large hourly doses of perchloride have been found of great use in ery-
sipelas, though with some observers this treatment has altogether failed,
a result perhaps due to the long intervals between the doses. The fre-
quent repetition of the medicine is one of the most necessary conditions
of success.

In the so- culled hysteria of middle-aged women, occurring especially
at the cessation of menstruation, they often experience distressing flut-
tering of the heart, a sensation of fulness of the head, with heat and
weight on the vertex, frequent flushings of the face, and " hot and cold
perspiration." This combination of symptoms is generally removed by
considerable doses of the sesquichloride of iron, given three times a day.
If the symptoms are limited to the head and face, other remedies are
more successful, as nux vomica, opium, belladonna, bromide of potas-
sium, nitrite of amyl.

Salts of iron sometimes excite irritation of the bladder, witli frequent
desire to pass water, wliich may contain a considerable quantity of mucus.
With children they may cause nocturnal incontinence of urine, yet iron
salts not unfrequently cure this troublesome complaint, even when not
dependent on worms in the rectum, or other irritation. Astringent
preparations of iron contract somewhat the blood-vessels, and are em-
ployed to arrest hsemorrhages from the lungs and kidneys.

Salts of iron appear to lessen profuse secretions, such as occur in
chronic bronchitis and leucorrhoea. Dr. Graves gave the compound
iron mixture, in doses of one or two fluid drachms, to check excessive
bronchial secretion.

The iodide of iron may be given where both iron and iodide are indi-
cated, for instance, in syphilis complicated with angemia. It is a ques-
tion of much interest whether it is better to administer these two agents
separately or combined in the iodide of ^iron, and whether the constit-
uents continue in combination in their course through the stomach and
circulation, or whether the salt is decomposed. Viewing this question
simply from a chemical point of view, it would seem that an iodide of
sodium and albuminate of iron must be formed in the stomach or blood,
though some observations, made I believe by Bernard, throw much
doubt on this conclusion ; for it was found that if iodide of iiotassium
and a salt of iron were injected into the blood, no iron appeared in the
saliva, but when an iodide of iron was injected, then both iodine and
iron were found in this secretion.

The iron of the effete red corpuscles probably escapes with the bile,
and when iron salts are swallowed this fluid contains an excess of the
12

178 SALTS OF MANGANESE.

metal. This, therefore, is one way by which iron may be separated from
the body. To Dr. Barnes Ave are indebted for having suggested thu
injection of perchloride of iron into the uterus in grave cases of flood-
ing after deliver}'. In such cases, obstetricians are well-nigh agreed
that this procedure is effective and life-saving. Dr. Barnes recom-
mends four ounces of the liquor ferriperchloridi mixed with twelve of
water, to be slowly injected into the uterus with a Higginson's syringe,
furnished with a long uterine tube, taking care to avoid the introduc-
tion of air.and to allow a free outlet of the fluid.

In chronic uterine catarrh with clear white-of-egg-looking discharge
issuing from a patulous uterus. Dr. Lloyd Koberts recommends swab-
bing the interior of the organ with a solution composed of one part of
perchloride of iron to four of water; or the injicction of a few drops of
the solution.

The tincture of the perchloride of iron, in the proportion of half a
drachm to half a pint of water, with a drachm of laudanum, makes a
caj^ital injection for gonorrhoea or gleet, often speedily checking the
discharge, and easing the pain on micturition. The following injection
is useful : — Sulphate of iron twelve grains, tincture of opium half an
ounce ; water eight ounces, use three times a day.

The syrup of the phosphate of iron is a good form, if there are any
indications for the employment of phosphoric acid. (See Phosijhate of
Lime.)

A teaspoonful of lemon-juice covers the taste of iron preparations
and tincture of steel.

Milk, too, covers the styptic taste of iron.

Iron salts to act as food should be administered soon after a meal.

SALTS OF MAXGANESE.

The sulphate of manganese in large doses, acting on the mucous
membrane of the stomach, excites vomiting and purging. It is said to
increase the flow of bile, but Rutherford says it is a powerful irritant to
the mucous membrane, but not a cholagogue. Manganese is generally,
and according to some investigators always, found in the blood corpus-
cles, and has come to be regarded as a normal constituent of the red
discs, which has led to the administration of its salts in ana?mia, though,
in the hands of trustAVorthy observers, without any benefit.

Leared gave ten to fifteen grain doses of the black oxide in gastrody-
nia and pyrosis. Manganese salts long persisted in produce, according
to BartholoAv, wasting, feebleness, staggering and paraplegia. They are
said to cause acute fatty degeneration of the liver.

The permanganate is a powerful oxidizer, yielding ozone, and is
widely used as a disinfectant and deodorizer.

Bartholow recommends this preparation in dyspepsia with flatulence,
and to assist the conversion of uric acid into urea. It has been given
internally in scarlet fever, diphtheria, erysipelas, puerperal fever, and

SALTS OF MANGANESE. 179

pyaemia; but the permanganate can act only on the mucous membranes
with which it comes in contact, and must be decomposed in the stomach.

Kobert finds manganese salts are more poisonous to frogs than salts
of cobalt, iron, nickel or tin. Small doses susjjend voluntary motion,
larger doses slow the reflexes, and render the heart weak; still larger
doses arrest the heart in systole, but the excitability of the nerves and
muscles by direct stimulation lasts for hours.

In cases of deficient, delayed or arrested menstruation I find perman-
ganate of potash very efficacious.

Otlier salts of manganese would, in all probability, act equally well,
but I have not yet had time to test their action. The permanganate
itself cannot pass into the blood undecomposed.

The permanganate is useful in amenorrhoea of young women. It will
restore menstruation after the lapse of two years or longer; sometimes
it restores the discharge in a few days, or the succeeding period may be
missed till the next period is due, or sometimes six weeks or iven two
months will elapse before the drug succeeds.

I find this salt useful also in the very common case of scanty, perhaps
delayed, menstrual flux, the interval varying from six weeks to two
months. The permanganate in a case like this brings on the period at
its proper time, with increase in the quantity.

It is useful, too, when a chill prevents or delays the menstrual flow.

A woman prevented menstruation by taking a cold bath on the day
it should have appeared, and she suffered from the usual symptoms aris-
ing from arrest of the catamenia. Three doses of permanganate restored
the flux. On its appearance she discontinued the drug, when tke dis-
charge ceased. She returned to the medicine, and after another three
doses the flow reappeared and progressed naturally.

I find it successful in cases of anaemia, and in plethoric patients. It
certainly does not act by improving the quality of the blood.

I usually 'give the salt daily till the catamenia appear, and then dis-
continue; but I recommence it four days before the access of the next
period and continue it till the flow ceases.

Dr. Fordyce Barker found j^ermanganate useful in girls who suffer
from arrested menstruation on leaving the country and coming to town
for their education; also in amenorrhoea induced by sea sickness; and
with women, between thirty and forty, generally married, who rapidly
increase in weight while menstruation decreases.

Dr. Murrill and I in our investigations did not find that permanga-
nate produced abortion, but some cases of abortion apparently due to
the drug have been published.

At first I gave the solution of permanganate from 3 ss. to 3 j, thrice
daily, but the disagreeable taste often provoked nausea and vomiting,
especially after taking it for some time. I now give one, two or more
grains in pill form thrice daily. Mr. Martindale makes the pills accord-
ing to the following formula: — Permanganate of potash gr. 1, kaolin and
petroleum cerate in equal parts q. s.

180 BISMUTH.

NITRATE OF BISMUTH, CARBONATE OF BISMUTH.

These powders are commonly used as harmless cosmetics; they are
useful in intertrigo, and sometimes in eczema, as dusting jJOAvder; but
in eczema other remedies are to be preferred.

Applied to the broken or unbroken skin, these substances, being in-
soluble in any fluid they may then meet with, are not absorbed.

Trousseau employed equal parts of bismuth and Venetian calc in
chronic non-syphilitic ozaena, ordering the j)atient, after clearing the
nasal passages by strongly blowing the nose, to snufl! up some of this
powder. He, however, prefers mercurial powders. (See Mercury.)

Being insoluble, they are tasteless, but they sometimes occasion a dis-
agreeable sensation of roughness, and sometimes blacken the tongue.
This rough taste may be covered in a great degree by administering the
drug in milk.

Little is known at present of the changes these medicines undergo,
and of their behavior in the stomach. Whether they are dissolved or
not, or whether their efficacy depends on physical or chemical j^roperties,
are questions yet unsolved.

In many diseases of the stomach, these preparations, especially the
nitrate, are very valuable, easing the pain incident to many affections of
this organ, whether depending on organic or so-called functional disease.
In cancer, chronic ulcers, and chronic inflammation of the stomach, bis
muth is often serviceable, and is especially useful in the chronic gastritis
of drunkards, subduing the pain, checking the vomiting, and enabling
the stomach to tolerate food. It is also useful in gastrodynia and
cramp of the stomach. Many forms of vomiting in children, and notably
that kind depending on acute or chronic catarrh of the stomach, yield
speedily to bismuth. The various forms of pyrosis, whether acid, alka-
line, or neutral, are very amenable to this drug, although our limited
knowledge concerning the causes of this form of indigestion fails to en-
able us to lay down precise rules respecting the particular form of it
most benefited by bismuth.

Dr. Graves treated acidity of the stomach witli nitrate of bismuth,
and experience confirms his practice. He generally mixed it with opium
or morphia, and sometimes with magnesia. Flatulent dyspepsia, in
some of its forms, yields more or less to bismuth; and it is well some-
times to mix it with an equal quantity of vegetable charcoal.

These remedies often succeed in some forms of chronic diarrhoea,
especially Avhen other drugs fail, in the exhausting purging of phthisis.
It is necessary to give as much as half a drachm to a drachm of the ni-
trate several times a day, and this large quantity, taken with milk, does
not disturb the stomach. It often subdues intractable diarrhoea, effect-
ing occasionally so great an improvement in the general health that
l^atients whose speedy death seemed inevitable rally and recover.

In the various forms of diarrhoea peculiar to young children, bis-
muth, in large doses, is freely used on the continent. A dose of thirty
to sixty grains hourly is recommended, milk being at the same time
withheld. Much smaller doses, however, are often useful, and may be
given with milk: a grain hourly is very efficacious, niul tlie addition of
a sixth of a grain of grey powder often enhances its efficacy.

LEAD SALTS. 181

Bismuth preparations are not employed to act on the remote organs
of the body.

Large doses of sohible ^^reparations, as the citrate of bismutli and
ammonia, act much like antimony or arsenic, causing gastro-enteritis
and fatty degeneration of the liver (Brunton).

A bismuth injection, consisting of bismuth half an ounce, glycerine
half an ounce, water three ounces, is very useful in gonorrhoea, especially
iu its chronic state, and sometimes proves serviceable in gleet.

The chief part, if not all the bismuth swallowed, is evacuated with
the faces, and stains the motions a dark slate color. A portion, indeed,
may be absorbed, but the quantity entering the blood is probably ex-
tremely small.

Hans Meyer finds bismuth salts are eliminated by the mucous mem-
brane of the intestine, especially of the large intestine, for after subcuta-
neous or intravenous injection of a bismuth salt, the mucous membrane
becomes blackened, and bismuth can be detected. Sometimes the mucous
membrane of the intestine was found ulcerated, Meyer suggests, from
blocking of the arteries by sulphide of bismuth.

LEAD SALTS.

Lead added to albuminous fluids, forms a precipitate composed of
albuminate of lead. Like other metals, the soluble salts of this group,
when applied to the abraded skin, or to sores, or to mucous membranes,
coat them with an impermeable air-proof covering; if, however, a pro-
tecting covering is required, other metallic salts are generally employed.
Any excess of lead solution, after combination with the albuminous part
of the secretion, will unite with the tissues themselves, in which manner,
probably, lead salts condense these structures, and constringe the blood-
vessels. The soluble lead salts are used as lotions to unhealthy and over-
secreting sores, and to eczematous eruptions; lead lotions in some forms
of eczema being very useful. When there is much inflammation, and
when the surface is raw and weeps copiously, a lead lotion allays inflam-
mation, checks the discharge, and quells the itching, burning, and ting-
ling so often accompanying eczema. Two or three drachms of liquor
plumbi in ten ounces of water are generally sufficient; but a stronger
lotion, consisting of two ounces of liquor plumbi, two ounces of glycer-
ine, and four ounces of water, is sometimes more successful. When the
inflammation is great, and the weeping abundant, the rash must be con-
stantly covered with rags soaked in the lotion. In some cases it is use-
ful to apply a poultice at night, and the lotion during the day. The
stronger lotion is especially useful in difi'used eczema, without weeping,
but with excessive itching and tingling, and the diseased skin should be
sponged with the lotion several times a day. A weak alkaline, or a sul-
phur bath, greatly assists the action of the lotion. The fluid oozing so
abundantly in eczema being strongly alkaline, the property of these
lotions to check this discharge may be owing to their weak alkaline reac-
tion {vide the Chapter on the Topical Influence of Acids and Alkalies on

182 LEAD SALTS.

the Secretions). The stronger lotion very effectually allays the itching
of pityriasis. Lead lotions occasionally ease the itching of urticaria.

A lead lotion is often of great service in pruritus pudendi, especially
when the mucous membrane is red and excoriated. A weak lotion
sometimes fails where a strong one succeeds. It may be necessary to
use equal parts of liquor plumbi and glycerine, on application which
may excite a little very temporary smarting. AVhen pruritus pudendi
depends on ascarides, haemorrhoids, or a tumor in the urethral passage,
it is obvious that these applications are useless.

A lotion of one part of liquor plumbi,^ with one or two parts of glyc-
erine, applied warm after the crusts have been entirely removed, is use-
ful in the milder forms of lupus.

While lead salts have many properties in common with those of
other metals, they are distinguished by their unirritating, soothing
character, whence they are used only as astringent and calming appli-
cations. The soluble lead j)re])arations may be used to check bleeding
from small vessels; but other astringents are more effective.

Solutions of the acetate and diacetate are employed as injections and
washes in chronic otorrhoea and vulvitis of cliildren. They lessen the
production of pus, and ease pain, by virtue of their astringency and their
soothing qualities. They are of most use when the acute stage has just
subsided, the tissues remaining irritable and painful. In the later
stages stronger astringents are needed.

Bland, unirritating plasters made of lead are in common use.

These j^lasters and lead applications generally, are sometimes objec-
tionable, owing to the black discoloration they produce from the forma-
tion of the black sulphide, with the sulphuretted hydrogen gas evolved
by the decomposition of the discharges.

A stout plaster often relieves pain in the loins, due to weakness.

Burgundy ])itch on leather is generally used, but it is very liable to
produce a crop of itching papules, which may spread over the greater
part of the body, while lead plaster, though somewhat less adhesive, is
comparatively free from this objection. Plasters sometimes relieve back
pains due to uterine disease or piles.

For sweating feet, Hebra employs an ointment composed of equal
parts of lead plaster and linseed oil spread on linen, and wrapped round
the feet, renewing the application every third day for nine days.

The same ointment applied on soft linen twice daily is sometimes
invaluable in the subacute stage of eczema. Dr. Matthews kindly draws
my attention to the fact that this ointment must be used fresh since it
becomes rancid in a few days.

In ulceration and sloughing of the cornea, lead washes must be
avoided, lest a white compound become deposited in the structures of
the ulcer, leaving a permanent opacity.

Mr. Alfred Aspland recommends the local aj^plication of white paint
for burns. He claims that it relieves pain in two minutes.

Lead injections are sometimes employed in gonorrhoea, gleet, and
leucorrhoea.

Insoluble lead salts are tasteless; the soluble have a sweetish acid
and astringent taste.

The soluble preparations are astringent to the mucous membrane of

'When liquor plumbi is mentioned we refer to the strong' solution.

LEAD SALTS. 183

the mouth, and combine with the albuminous substances they meet
with tliere.

Tliat portion of the soluble compounds of lead which escapes com-
bination with albumen in the mouth is converted into an albuminate in
the stomach.

The soluble lead preparations are sometimes used in htematemesis,
and have been recommended to check jiyrosis.

Albuminate of lead in the intestines is probably speedily decomposed
into a sulphide of lead, an insoluble an^l inert compound. The soluble
salts act powerfully as astringents of the intestines, and cause constipa-
tion ; they control many forms of diarrhoea, even that dependent on
disease of the lower part of the small or even of the large intestine.

The effects of lead on the parts of the intestines distant from the
stomach and duodenum, can be manifested only through the nervous
system or blood; and we know the intimate sympathy existing between
the different parts of this canal.

In summer diarrhoea, a few grains of the acetate with a small dose
of morphia is a sure and speedy remedy.

The acetate has been recommended in cholera, especially in its early
stages. In the purging from dysentery and typhoid fever, and from
tubercular disease of the intestines, few remedies are so useful. The
acetate should then be combined with opium.

It increases the efficacy of a starch injection, used to check various
forms of diarrhoea; and it may be used for similar purpose as a sup-
pository.

In large doses, the acetate acts as a weak irritant poison, bat the
symptoms it produces differ from those of other irritants, chiefly by
constipating instead of purging.

It is by no means common to meet with a case of acute poisoning
with lead salts, and even the most soluble salts rarely cause death.

Acute poisoning by the acetate induces the following symptoms : —
Dry burning sensation in the throat, thirst, vomiting, colic (the pain
of which is generally relieved by firm pressure), tenderness of the abdo-
men, obstinate constipation, dark slate-color motions from the presence
of plumbic sulphide, great prostration of strength, cramps of the ex-
tremities, cold sweats, giddiness, numbness and even paralysis of the
lower limbs; sometimes coma; and high-colored scanty urine. In one
case it is reported that in less than five hours the extensor muscles of
the extremities became paralyzed, and the flexors rigidly contracted.
The sub-acetate is even more powerful than the acetate. The carbonate
has no irritant action.

The treatment of acute poisoning is to promote vomiting by luke-
warm drinks, to give sulphate of soda, or sulphate of magnesia, or fresh
precipitated sulphide of iron, which is rarely at hand; the stomach-
pump should be used, and milk, with white of egg, may be given with
advantage.

Small, nay, even minute quantities, taken for a long time, will pro-
duce chronic lead poisoning, which may happen in various ways, owing
to the manifold uses of lead compounds. Oxide of lead is used to
sweeten wines, the soluble salts are used as hair-dyes, and wafers are
often colored with red lead. In grinding the carbonate, the basis of all
paints, unless great care is taken, the liner particles are inhaled. Snuff
is sometimes adulterated with lead, and sufficient may be snuffed into

184 LEAD SALTS.

the system to produce chronic poisoning. Dr. Garrod has lately narrated
an instructive case of chronic lead poisoning, through the decomposition
of the leaden envelope of a packet of snuff. Painters become poisoned
by eating their meals with unwashed hands, and so introducing lead
into the system. Drinking-water sometimes becomes contaminated with
lead dissolved from the lining of tanks. Certain conditions of the water
either favor or retard the solution of lead. Thus, pure water, and waters
containing carbonic acid, carbonate of lime, and sulphate of lime, act
but little on lead. But, on the other hand, waters containing much ox}'-
gen, organic matters, nitrites, nitrates, and chlorides, act freely on this
metal. Carbonic acid is very protective of lead ; it crusts the metal with
an insoluble covering of carbonate, and protects it from the further
action of the water.

A very small quantity of lead in water is adequate to produce all or
some of the symptoms of lead poisoning; even one-fortieth to one-fif-
tieth of a grain per gallon. But there aj)pear to be individual differences
in respect to the action of lead, some persons becoming sooner affected
by it than others: differences sometimes susceptible of explanation, as
will be shortly shown. Acetate of lead, in five grain doses, may be given
for weeks or even months, without inducing lead poisoning, as has been
abundantly proved at the Brompton Hospital, where the acetate is largely
employed to check the diarrhea of consumption; yet it is extremely
rare to meet with any lead symj^toms, even after the medicine has been
continued for months.

Cosmetics and hair-dyes containing lead may cause chronic j^oisoning.

The .symptoms indicative of chronic lead poisoning are briefly — con-
stipation, and, it may be, imiDaired digestion, accompanied with a
sweetish taste. A blue line is soon observed at the edges of the gums,
produced by the suljihuretted hyrdogen developed from the tartar of the
teeth penetrating the tissues of the gums and uniting with the lead,
forming a black sulphide, consequently the blue line is most marked
in persons who do not clean their teeth. It is seen only at the edge of
the gums, where they come in contact with the teeth; where the teeth
are absent, the blue line is absent. It is first observed, and is always
most marked, in the gums in the neighborhood of the incisors. This
blue line is one of the earliest indications of the effect of lead, and is one
of the slowest to disappear. Dr. Garrod says this blue line is never ab-
sent if there are any teeth, and that it may extend to the whole gums,
and sometimes it is observed on the j^arts of the lips and cheeks corre-
sponding to the gums. More recent observers have seen cases without a
blue line. The nutrition is impaired, the skin becomes very sallow, and
sooner or later severe colic, with obstinate constipation and sometimes
vomiting, sets in. Colic may occur without any premonitory signs. In
lead colic the abdominal walls are retracted, and very rigid. The pain,
as in acute lead poisoning, is mostly eased, though it is sometimes aggra-
vated, by firm pressure. The pulse is small and incompressible (high
tension).

Frequent and often severe cramps occur in the calves, sometimes in
the uterus, penis, and scrotum; and sometimes the patient is harassed
with pains about the joints, generally of the extremities, increased by
movement or wet weather, and closely simulating rheunuitic })ains.

Sometimes paralysis takes place, generally affecting the extensors of
the forearm.

LEAD SALTS. 185

The muscles first affected are those supplied by the musculo-spiral nerves (pos-
terior inteix)ssens) in the forearm, and especially the extensor communis digitorum.
The supinator longus therefore escapes. The supinator longus is almost always
supplied by a branch from the musculo-spu'al nerve before it divides into the
posterior interosseus and radial nerve. This fact often enables us at once to dis-
criminate between lead-poisoning, and paralysis from disease of the musculo-
.si)iral nerve. If the supinator longus is paralyzed, this fact points to the disease
of the musculo-spiral nerve, and then the paralysis is not due to lead. If this
muscle is not paralyzed, this fact shows that the disease is limited to the posterior
interosseus, and that the paralysis is probably clue to the action of lead. The con-
dition of the supinator longus is easily tested in the following way: Extend the
paralyzed forearm on the table, with tlie radius upward, then, press down the
wrist, and tell the patient to trj' to raise it from the table. The supinator longus,
if not paralyzed, immediately becomes hard, contracted, and stands out promi-
nently. (Erb.)

The muscles of the ball of the thumb waste greatly, and in severer
cases the deltoid, and even the muscles of the neck and trunk are simi-
larly affected. Indeed, in the worst cases, general paralysis may occur,
with wasting of the muscles of the whole body, even the voice becoming
weak. The paralysis mostly affects motion only, but sometimes there is
also loss of sensation; great loss of electric excitability in the muscles
occurs early, sometimes before loss of voluntary jDower. Epilepsy, delir-
ium, convulsions, or coma, may destroy the patient; but death from
chronic lead poisoning is uncommon.

The muscles are wasted, grayish -red or whitish and tough, with considerable
increase of tlie interstitial connective tissue. These changes are similar to those
which occur in injury to nerves, in progressive muscular atrophy, and in spinal
pai'alysis of children.

How does lead produce paralysis? On this point various views are held.
Some maintain that lead directly affects the muscles ; others that it arrests n,utri-
tion by exciting- strong contraction of the blood-vessels supplying- the wasted
muscles. The existence of the " reaction of degeneration," as tested bj- electricity,
shows that the atfection is seated either in the nerves or in the spinal cord; and
probably in the spinal cord, for the reaction of degeneration and atrophy pursue
exactly the same course as in the spinal paralysis of children.

In the nervous system it causes hypera^mia and proliferation of neuroglia with
consequent contraction, causing degeneration of tlie cellular elements.

The cramps are not confined to the muscles of the extremities. The
intestines are also affected, sometimes almost throughout their length,
but generally only a limited extent is involved. If the finger is jDassed
up the rectum, the contractions can sometimes be felt. The blood-ves-
sels, like other parts of the body, are said to be subject to cramps. The
kidneys are found to be cirrhotic, indeed, in many fatal cases the reis
more or less general fibrosis.

The colic is generally dependent on constipation; for when this is set
right the colic generally disappears.

In large doses lead, like the other heavy metals, may induce inflam-
mation of the grey matter of the cord, and later of the white matter, in-
ducing symptoms like acute general myelitis, with rajjid wasting of the
muscle. Chronic lead poisoning causes chronic neuritis and myelitis.

Chronic lead poisoning excites cirrhosis of the kidney, due, it is said,
to the deposits of lead carbonate in Henie's Ioojds, these deposits acting
as irritants.

The influence of lead on the urates in the blood is most singular. Dr.
Oarrod, in his remarkable investigations concerning gout, has elucidated
this subject, and shown the intimate connection existing between lead-

18G LEAD SALTS.

poisonint^ and gont. In jifont, as tliis philosophical observer has shown,
the urates, probal)ly with increased formation, are retained in tlie blood.
In gout, especially during the acute attacks, scarcely any uric acid is to
be found in the urine, while an abundant quantity is detectable in the
blood. The urates dissolved in the blood manifest special affinity for
particular structures, as the cartilages, bursa?, and fibrous tissues, particu-
larly of certain parts, and during the deposition of the urates in the joints,
acute inflammation is excited, and this constitutes gout. (See Colchicum.)

Now, lead checks the separation of urates from the blood by the
kidneys, diminishes the uric acid of the urine, thus greatly augmenting
that of the blood, and thus we have the pathological condition which
excites the gouty inflammation. Dr. Garrod has further shown — and his
experience is corroborated by all Avho have investigated this subject — that
gout very frequently occurs among lead-workers, and that gouty patients
often exhibit the characteristic blue lead line on their gums.

There, too, is the fact, in further confirmation of Dr. Garrod's dis-
coveries, that if to a gouty person, free at the time from an acute attack,
a salt of leacl is administered, it developes acute gout, with its accompany-
ing symptoms of severe pain and high fever. The author has repeatedly
verified this fact, first pointed out by Dr. Garrod, which affords an ex-
planation, in part at least, of the good effects of iodide of potassium on
gout, since as we have shown already, this salt promotes the excretion of
lead.

Lead is used for a variety of purposes, but cliiefly for its astringent
action on the tissues, as in profuse discharges of the mucous membrane,
from the lungs in bronchitis, and to check bleeding from the nose, lungs,
kidneys and uterus.

It has been conjectured that lead in Bright's disease might check the
escape of albumen from the blood, and therefore lessen the amount of it
in the urine, and George Lewald has published some experiments instituted .
with a view of testing this point. He does not mention the form of kidney
disease his jDatients suffered from, but it was probably the pale, flabby,
fatty kind. He observed at the same time the influence of the lead on the
amount of urine voided. These experiments, too few perhaps to decide
the question, showed that lead constantly diminished the albumen of the
urine, though only to a very small extent, namely, to about nine or ten
grains in the twenty-four hours. The diminution appeared to hold no
relation to the quantity of lead administered. The quantity of water was
simultaneously increased on an average by 200 c.c. in the twenty-four
hours. Here again, the increase held no projDortion to the quantity of
lead, employed.

M. Paul, who has investigated the influence of lead-poisoning on the
foetus, says that women working in lead factories frequently abort; and
that the father may cause abortion, even when the mother is not a lead-
worker. In 123 pregnancies, seventy-three children were 1)orn dead; and
of these, sixty-four w^ere abortions, four premature births, and five born at
the full time. Of the fifty born alive, twenty died the first year, eight the
second, seven the third; one later, and only fourteen reached the age of
ten.

We know but little concerning the elimination of lead. Only a little
lead passes off with the urine: iodide of potassium, however, increases its
elimination.

]SriTRATE OF SILVER. 187

NITRATE OF SILVER, OXIDE OF SILVER.

The soluble preparation of silver, when painted on the skin, colors
it first an opaque white, which changes gradually to brown and black.
The application of a strong solution Avill produce vesicatio]i. Nitrate of
silver is sometimes applied as a destructive caustic to warts and other ex-
crescences, but its action being too superficial it is useless for this purpose.

Applied to the abraded skin, or to sores, the soluble silver salts form
an albuminate which coats the surface with a thin layer and protects the
tissues beneath from the irritation of the air. The nitrate of silver acts
as a powerful excitant of the tissues and destroys tliem, but only very
superficially. It is frequently applied to induce healthier growth in un-
healthy and unclean ulcers, giving much smarting pain, which, however,
soon passes away.

Like most other soluble metallic preparations, the nitrate causes con-
densation of the tissues as well as contraction of the blood-vessels, on
which account it is used to stay haemorrhage; being liable, however, to
excite much inflammation and pain, other blander astringents should first
be tried. Sometimes it is used to check the bleeding from leech-bites by
touching them with a stick of nitrate of silver.

Nitrate of silver will prevent the pitting of small-pox, if each vesicle is
opened as soon as formed, and the raw surface beneath touched with a solu-
tion of the salt. Dr. F. Bowen has recorded an instructive case showing
the efficacy of this treatm^t. He treated the vesicles on one side of the
face and neck in the way described, leaving untouched the vesicles on the
opposite side, with the result that on recovery the untreated side was
deeply pitted, while the opposite side remained smooth and scarless. Dr.
Bowen, who has devoted much attention to this subject, states that a nurse
can easily carry out the process. At an early stage of the eruption — at
the latest on the fourth or fifth day — he punctures the vesicles with a fine
needle dipped in a solution containing twenty grains of nitrate of silver to
an ounce of water. Mr. Higginbottom finds it unnecessary to puncture
the vesicles, and says it is enough to paint the skin in the manner recom-
mended by him in erysipelas, which subdues inflammation and prevents
suppuration.

Bed-sores are best prevented by painting the threatened but unbroken
skin as soon as it becomes red, with a solution of nitrate of silver {20
grains to an ounce), with the effect of dispersing the redness, hardening
the skin, and preventing the bed-sores, unless, as in the ease of paralysis,
there is a great proneness to this lesion.

That species of boil which, beginning first as a papule, maturates into
a pustule, and inflames and extends till a large dead core is produced, may,
it is said, be arrested in its early pustular stage by painting it over at its

188 IvlTEATE OF SILVER.

Tery commencement with a strong solution of nitrate of silver. I have
had no experience of this method, but of the beneficial influence of collo-
dion on similar boils, to be mentioned in another place, I can speak with
great confidence.

Nitrate of silver will arrest herpes labialis and the vesication of shingles,
if the warning patch of erythema is painted over lief ore, or as soon as, the
vesicles begin to form.

We sometimes meet with a patient with a patch of lichen, the size of
the palm of the hand, affecting almost any part of the body, the irritation
from this patch being sometimes so excessive as even to break the sleep
and injure the health. The painting the patch with the nitrous ether
solution of silver every day, or second day, as the itching may require,
will generally cure this affection.

Limited patches of eczema are sometimes benefited in the same way.
Nitrate of silver proves most serviceable after the weeping stage.

The occasional application of nitrate of silver or sulphate of copper is
serviceable in psoriasis of the tongue and mucous membrane of the mouth,
but if it depends on syphilis mercurial applications are Ijest. A Aveak solu-
tion of nitrate of silver, gradually strengthened, is stated to be useful in
the superficial kinds of lupus.

Higginbottom very strongly recommends the local application of nitrate
of silver in erysipelas. No agent, he says, is so safe or so efficacious in
subduing external inflammations; but he points out that the success of
this treatment depends entirely on the manner of conducting it. He
directs the skin to be well washed with soap and water, then with simple
water, then to be wiped quice dry; next a solution of four scruples of the
brittle stick of nitrate of silver, in four drachms of water, is to be applied
two or three times to the inflamed surface, extending two or three inches
beyond it.

Nitrate of silver often cures the intolerable itching of pruritus puden-
di. A large camel-hair brush, saturated in a solution containing from
two to five grains to the ounce, should be painted three or four times a
day over the vulva, and be thrust up to the os uteri. A stronger solution
used less frequently will not answer so well. ,

A weak solution of nitrate of silver often relieves pruritus ani.

Pruritus of the meatus auditorius, occurring without any eruption,
should be treated by the application of a strong solution of nitrate of
silver, carefully avoiding the membrana tympani. If the itching arises
from undue dryness of the ear, from deficient secretion of Avax, almond
oil or glycerine should first be tried.

When used as an outward application, nitrous ether is by far the best
solvent of nitrate of silver, for, by dissolving the fatty matters of the
skin, this solution forms a uniform layer over the surface, unlike a Avatery
one, which runs into drops, leaving the intermediate skin dry. This solu-
tion is not available in erysipelas, as nitrous ether will not dissolve the
quantity of silver required. It is important to bear in mind that a nitrous
ether solution acts much more strongly than an aqueous solution of corre-
sponding strength. The ether solution must, therefore, be made weaker,
five to ten grains to the ounce being generally strong enough. Five
grains to the ounce is sufficiently strong for threatened bed-sore, a
stronger solution often blistering, particularly on applying several coats.

Solutions of nitrate of silver are used to blacken the hair of the head.
The hair is first washed with the solution of nitrate of silver, and then a

NITRATE OF SILVER. 189

comb, dipped into a solution of snlpliide of potassium, is passed through
it; a process resulting in the production of a dull, lustreless, ghastly,
black-bhiish color=

In obstinate tinea tarsi, the solid nitrate of silver stick is sometimes
passed over the edges of the e3'elids, first removing the eyelashes and the
scabs.

In conjunctivitis, a few drops of a sohition of nitrate of silver, varying
in strength, is inserted -with the aid of a quill several times a day into the
eye, exciting in the membrane a healthier inflammation, which soon
subsides.

The nitrate may be applied to ulcers of the mouth. When a milder
application than the ordinary caustic is required, it is convenient to use
the sticks composed of equal parts of nitrate of silver and nitrate of potash.

The soluble salts have an astringent metallic taste.

In the early stages of inflammation of the throat, when the inflamma-
tion is superficial, and there is only a little swelling, the application of a
strong solution, or of the solid stick of nitrate of silver, subdues and some-
times even extinguishes the inflammation.

In chronic sore throat, when the tissues are relaxed and covered with
pus, solutions of the nitrate are serviceable; but the author does not think
they are superior in any way to strong astringent and unirritating applica-
tions. Even ulcers are best treated by the glycerine of tannin; but if in
a sloughing and unhealthy condition, then the irritant nitrate must be
preferred. The nitrate of silver is also applied with doubtful benefit in
diphtheria. Most authorities are agreed that the application should be
limited to the inflamed patches; for if applied beyond their area, it excites
an extension of the inflammation, on which the false membrane may
readily implant itself.

Nitrate of silver, m powder or solution, is sometimes applied by means
of a probang, l)rush or sponge, to the chronically inflamed larynx, as in
phthisis; or solutions of nitrate of silver, in the proportion of gr. -^ to gr. v
to the ounce of water, may be brought to bear on the pharynx and lar^'nx
by the spray-producer.

Dr. Horace Green injects a solution of nitrate of silver into the_ trachea
in asthma, bronchitis, and phthisis, after deadening the sensibility of the
glottis, by applying to it for one or two weeks a solution of nitrate of silver.
He passes a No. 10 or 12 catheter, which produces only a sensation of
warmth, through the rima glottidis, down even to the bifurcation of the
trachea, and injects the solution. The late Dr. Hughes Bennett, who en-
dorsed this treatment, injected either two drachms of a solution contain-
ing half a drachm of nitrate of silver to an ounce of water, or even half
an ounce of a solution consisting of forty grains of nitrate of silver to an
ounce of water. While introducing the catheter, the head is thrown
back, and the tongue drawn forward, when the instrument glides along
the laryngeal surface of the epiglottis, Avhicli is nearly insensible, through
the rima glottidis itself.

Sponging out the throat with a solution of nitrate of silver greatly
diminishes the violence and frequency of the paroxysm in whooping-cough,
renders the cough but half as frequent, makes the fits much less severe,
and enables a child harassed with broken sleep to obtain a good night's
rest. But there is a formidable drawback to this treatment; for the ap-
plication generally produces, especially with very young children, so vio-
lent an attack of coughing, as to excite fears lest suffocation should ensue.

190 ]S'ITRATE OF SILVER.

Instead of si^onging the throat, the nitrate of silver may be applied in the
form of spray by the atomizer. Very young children, however, cannot
be inducetl to open their months, and allow the inlialation of the spray;
hence its use is restricted to children more than two or three years old.
These applications, being apt to excite retching, should be employed when
the stomach is empty.

Any part of the salt ha\'ing escaped conversion in the mouth is changed
into an albuminate when it enters the stomach; and if sufficient albumen
is not present to effect this, the salt attacks the mucous membrane, and
excites active inflammation. The best antidote for a poisonous dose is
common salt, a fact useful to bear in mind, if, as sometimes happens, the
solid stick of nitrate breaks off and is swallowed.

Xitrate of silver acts as an irritant in the stomach, and may be used in
precisely the same class of cases for which arsenic is applicable. It often
checks the pain and vomiting of chronic inflammation, of chronic ulcer,
and even of cancer of this organ. It should not be given in the form of
a pill, but in solution.

The nitrate acts as an astringent in the intestines, and, in common
with several other metallic preparations, may ])e used in diarrhoea, both
of the acute and chronic kind.

Peptones readily dissolve the nitrate, and the solution does not coagu-
late albumen. Probably it enters the blood in this form and collects in
the red corpuscles, as other metals tend, to do if not speedily deiiosited in
the organs or separated by the secretions. The red corpuscles are said to
become paler and the haemoglobin to be converted into ha?matin, and it
is conjectured that this change explains the slight fall in temperature after
large doses of silver salts. These salts, being absorbed, are supposed to
be astringent to the tissues to which they are conveyed, but this is a doubt-
ful supposition, and they are never used to check either bleeding or secre-
tion from the distant organs of the body.

In poisonous doses nitrate of silver excites in animals convulsions and
paralysis, probably central in origin; the convulsions, being very similar
to those produced by strychnia, are excited by the least peripheral irrita-
tion. Death is said to be due to asphvxia, and the lungs are found con-
gested and oedematous and the bronchial tubes choked with mucus. In-
jected into a vein nitrate of silver desti'oys contractibility of the cardiac
muscle.

Chronic poisoning by nitrate of silver produces loss of appetite, im-
paired nutrition, albumen in the urine, rapid and irregular action of the
heart, and after death there is found general fatty degeneration, especially
of the kidneys, liver, and heart.

Both the oxide and nitrate are employed in chorea and epilepsy, ap-
l^arently with occasional benefit. The oxide has been given to check
profuse sweating. Xitz'ate of silver is sometimes very useful as an injec-
tion in acute and chronic dysentery ( 3 j to three pint's of injection). If
administered too long, these substances, in some form, probably as the re-
duced metal, are deposited in all the tissues of the skin, except the rete
malpighii, and most abundantly Avhere the skin is finest and most vascu-
lar; but, once deposited, the metal remains as a permanent discoloration,
of a deep leaden hue, either by time or treatment irremovaljle, unless it
should prove true that large doses of iodide of potassium, as has been
lately stated, will wash out the stain. Dr. W. Pepper finds that the
staining of the skin is always preceded by a dark line upon the gums.

MERCURY. 191

Silver appears to be chiefly eliminated by tlie intestines and bile, very
little escaping by the urine.

The nitrate, in solutions of various strength, is used as an injection in
gonorrhoea. Some advocate a very strong solution (twenty grains to the
ounce), averring that in many instances the disease may at once be cut
short by it; others prefer a much weaker solution of one or two grains to
the ounce of water, repeating the injection several times a day.

MEECURY AND ITS PREPARATIONS.

The salts of mercury possess very various physical as well as chemical
properties; but as in every instance their effect on the system is well-nigh
the same, probably all mercury compounds ultimately assume the same
form in the blood.

The nitrates of the oxide and suboxide are escharotic; but much of
this action is due to the free nitric acid of the salt. They are used to
remove warts, condylomata, and other slight excrescences. Mercurial ap-
plications Avill completely allay the annoying itching of certain skin affec-
tions. Solutions of bichloride, black-wash, yellow-Avash, or mercurial
ointment, may each prove useful, but the application must be a strong
one. Trousseau highly recommends bathing the part with a solution of
about twelve grains of bichloride in a pint of very warm water. After
much experience of these applications, I believe that far the best applica-
tion is an ointment composed of a drachm of calomel to an ounce of lard;
but this ointment, in common with other mercurial applications, is not
useful in all kinds of itching; for instance, it is unavailing in the irritation
of urticaria.

Calomel ointment often immediately removes the itching of pruritus
ani and neighboring parts. This irritation may be due to rashes, as
psoriasis, lichen or eczema, or no eruption may be visible, yet the oint-
ment will prove equally efficacious. This application is less frequently
useful in pruritus pudendi. In obstinate cases of pruritus ani and pruritus
pudendi, blisters to the thighs, or the application of a few leeches, some-
times afford relief.

The ointment in many instances improves the rashes themselves, but
this is in some measure due to the cessation of the scratching, on the dis-
appearance of the itching.

Sometimes a little scabbiness of the head, looking like mild eczema,
occurs in children, accompanied by a degree of itching, sufficient to prevent
sleep, and to cause constant restlessness. The calomel ointment speedily
appeases this irritation.

The inunction with calomel ointment allays the distressing itching of
the scalp sometimes accompanying pityriasis. It may be profitably added
to other ointments used for the removal of pityriasis, as oxide of mercury
or of tar.

192 MERCURY.

It may be objected that so strong an application of mercury, especially
when applied to soft and absorbing parts, as the inner surface of the vulva,
and the skin around the anus, must surely produce salivation. No doubt
care should l)e exercised, and no more ointment used than is needed.
Yet the risk of salivation seems to be extremely slight, for, with a very
large experience of the ointment, I have never seen salivation produced by
it. Properly applied, a very small piece of ointment is generally sufficient
to allay the irritation at once, and even to remove it altogether in a few
days, although it is very apt, after a variable time, to return, when it
again yields to a renewed employment of the unguent. Its grateful effects
are often almost instantaneous, though sometimes it takes a few davs to
give ease. Having many times seen it succeed when other remedies have
entirely failed, I am convinced of the value of this ajiplication in these har-
assing and perverse diseases. An ointment composed of five to ten grains
of menthol to an ounce of s^Dermaceti ointment is also very useful. The
smaller quantities must be first tried, as the larger may be too irritating.

The white precipitate, or nitrate of mercury ointment, or corrosive-
sublimate wash, will destroy the various kinds of lice and their nits, which
infest different parts of the body. For lice on the pubes it is necessary
to apply the ointment or lotion to the scrotum, hair on the perineum,
and around the anus. The nits can be dislodged by washing the hairs
with spirits of wine, which dissolves the gluey matter so strongly attach-
ing the nit to the hair. The body-louse may be killed by the essential
oils, as the oil of rosemary, or by powdered pyrethrum, or by an ointment
of staphisagria. Through the groundless fear of inducing salivation some
prefer these to mercurial applications. The under linen should be boiled
to destroy any hidden lice.

The irritant ointments of mercury are useful in that obstinate and
disfiguring affection, tinea ciliaris. The eyelashes should be cut short,
and the ointment, either of nitrate or oxide of mercury, applied night and
morning, picking off the scabs before each dressing. It is a common
practice to dilute the unguentum hydrargyri nitratis with from four to
six parts of simple ointment, Avhether used for rashes or tinea ciliaris, but
in many instances the undiluted ointment is best, and it seldom requires
to be reduced more than half the officinal strength, for the failure of the
ointment in eczema, psoriasis, lichen, and tinea ciliaris, is often due to its
employment in too weak a form. Mr. Hutchinson and others assert that
epilation ensures the speediest cure. Should these stimulating applica-
tions fail, others more powerful should be tried, as nitrate of silver, or
sulphate of copper, the last-named salt being preferable, as it gives less
pain.

Patches of obstinate lichen and psoriasis, especially of the hands, even

Avhen not syphilitic, will sometimes yield to mercury ointment when milder

, treatment fails. The calomel and nitrate of mercury ointment may be

mixed, and the addition of tar ointment sometimes increases the efficacy

of this combination.

Citrine ointment is also very useful in some cases of eczema, even in
the weeping stage, if there is but little inflammation, but it is esj)ecially
useful in the stage of desquamation when the skin has healed. It is
markedly serviceable when eczema affects the hairy parts of the face,
often curing this obstinate form when other remedies have been tried in
vain, and even when it fails to cure, it generally in great part subdues
the disease. The same ointment is very beneficial too in pityriasis of the
hairy part of the face. In both eczema and pityriasis it is better to mix

MERCURY. 193

it with tar ointment, though this combination is sometimes more irritating
than the simple citrine ointment. Not unfrequently this mixture cannot
be borne, whilst the citrine ointment, pure or diluted, proves very useful.

In the early stages of acne, a lotion composed of corrosive sublimate,
one part; alcohol, enough to dissolve it; water, 100 parts, is said to be of
use. A teas})oonf ul is to be added to a quarter of a pint of water, and the
face sponged with the lotion night and morning. The bichloride lotion
after a time produces a " scaliness and hardness of the cuticle."

Bichloride of mercury, one of the best parasiticides, is useful in favus,
tinea sycosis, tinea tonsurans, eczema marginatum, and pityriasis versicolor
(chloasma). A lotion containing two grains of bichloride to an ounce of
water is generally sufficiently strong. In favus, and tinea sycosis, and tinea
tonsurans, the lotion should be applied after each epilation, and should
be continued for some time after epilation is stopped. This treatment
is highly spoken of by McCall Anderson.

It is tauglit, on high authority, that the application of mercury oint-
ment in paronychia is very useful, repeated for ten minutes every hour,
applying poultices at other times. Dr. Scott reports several striking cases
of cures by dusting nitrate of lead on the diseased tissues night and
morning.

^lercurial preparations are used as local applications in chronic in-
flammation; for instance, Scott's ointment is often employed in chronic
inflammation of the knee-joint. Mr. John Marshall has introduced a
mercurial preparation, oleate of mercury, varying in strength according
to the needs of the case, and variously combined with other remedies.
Mr. Marshall's paper is so practical and valuable, and so insusceptible
of condensation or abridgment, that we have deemed it best to reproduce
the larger portion of it. " These preparations," he says, " are cleanly
and economical, and have a much greater diffusibility or penetrating
power than the old mercurial ointments, for they are absorbed by the
skin with remarkable facility, and manifest the remedial effects with
great promptitude."

" They should not be rubbed in hke ordinary liniments or embrocations, but should
be merely applied with a brush, or be spread lightly over the part with one finger; other-
wise they may cause cutaneous irritation, or even produce a few pustules on the skin,
especially in certain persons. This result may, however, be obviated by the addition
of a small quantity of olive oil, or puritied lard, according as an oleaginous or an unc-
tuous preparation is required. Any of these forms may be scented by the addition,
of essential oils.

" In employing these mercurial solutions for combating persistent inflammations of
joints, I soon found that the addition of morphia was of very great advantage. For this
purpose the simple alkaloid must be used, as neither the liydrochlorate, the acetate,
nor the mecouate, is soluble in oleic acid. For every drachm of the solution of oleate
of mercury in oleic acid, one grain of morphia may be added. Being, as well as the
mercury, completely dissolved, it quite as rapidly penetrates the skin, comes quickly
into contact with the extremities of the nerves, and thus, even within a few minutes,
acts upon them at their most sensitive points, and speedily produces a soothing eifect.

The oleates of mercury and morphia, thus united in one preparation, represent, as
it were, a liniment, ointment, or plaster of mercury and opium; but they are far more
elegant, economical, and efficacious. As a rule, according to the size of the part
affected, from ten to thirty drops are sufficient for one application. This should be
repeated twice daily for four or five days, then at night only for four or five other
days, and afterward every other day until a cure is obtained. The morphia immedi-
ately begins to relieve pain, allays the nervous irritation, and consequent vascular tur-
gescence; and thus arrests the progress or ' persistence ' of the inflammatory process;
whilst the mercury probably promotes the death and degeneration of the morbid prod-
ucts, and so facilitates their subsequent removal by absorption. Unless used in excess-

1 04 MERCURY.

ive qllantit}^ the oleate of mercury does not salivate, or produce any marked constitu-
tional disorder."

Mr. Marsliall says " their applicability and utility appear to me to ]je
almost co-extensive with the occurrence of ' persistent ' or chronic inflam-
mations, provided only that the seat of the disease be in, or sufficiently
near to, the skin."

" I may first mention that not only in persistent articular inflammation, hut also in
simple synovitis, these remedies rapidly relieve the tenderness and pain, and promote the
absorption of the fluid elf used into a joint. They are also of decided benefit in the rheu-
matic, the arthritic, and the mixed forms of joint disease; but in these they do not, of
course, supersede the necessity for general treatment. In inflammation of tlie mam-
mary gland, occurring during or after lactation, or altogether independently of that
secreting process, their efficacy is unequivocal; for I have seen, not only the induration
left after previous abscesses speedily disappear under their use, but a tendency to re-
current svippuration in the site of old abscesses, and the threatened formation of new
ones, entirely controlled and arrested. I have also seen a threatened aljscess in the
perinajum from inflammation of one of Cowper's glands, and likewise the froul)lesome
indurations left after ordinary perinteal abscess, rapidly disappear on the use of these
preparations. In obstinate and painful tonsillitis, in epididymitis, in periostitis, and
in inflammation with imminent or actual suppm-ation in or around lymphatic glands,
I have similarly employed them with decided advantage. In hyiirocele they have
not appeared to l)e useful. I have used equal parts of the 20 per cent, ointment and
purified lard applied outside the eyelid with success, in hordeolum, and in palpeljral
conjunctivitis.

" In raanjr cutaneous affections the oleate of mercury solutions, without morphia,
form elegant and powerful remedies. It was in a case of obstinate sycosis menti that
I first used, and with excellent results, an ethereal solution of the perchloride of mer-
cury mixed with oleic acid; but I now much prefer, as equally efficacious, and far less
irritating, the 5 per cent, solution of oleate of mercury in oleic acid, with the addition
of an eighth part of ether. (Dr. Alder Smith employs a 10 per cent, solution.) Tliis,
when applied to the skin with a camel-hair pencil, is a most diffluent and penetrating
remedy. It enters the hair follicles and the seljaceous glands, penetrates the hiurs
themselves, and carries everywhere with it its powerful metallic constituent. Besides
sycosis, it will cure chloasma and the various forms of tinea; it is useful in porrigo,
and in pruritus ani et pudendi; but I have not found it serviceable in non-specific
psoriasis, or in eczema. The solution of oleate of mercury destroys pediculi immedi-
ately; and, owing to its singular power of permeation, simultaneously kills the ova —
a result not always certain when ointments containing undissolved luercury are used.

"Again, in man}' of these syphilitic affections for the cure of which mercury is ap-
plicable, the oleate of mercury preparations offer some advantages. Thus, in congeni-
tal syphilis, a piece of the 20 per cent, ointment, about the size of a pea or bean, placed
in the child's axilljio night and moi'ning for five or six days, rapidly and easily, and
without any signs of uncleanliness, produces constitutional effects. Even in the adult
this mode of introducing mercury into the system, either for the cure of syphilis or
other disease, may be often preferalile to, and less troublesome than the bath, and it
certainly gets rid of the o):)jections to the ordinarj' mode of inunction. As a topical
remedy for certain local manifestations of syphilis, such as the non-ulcerated forms of
syphiloderma, especially when these disfigiu-e the head, face, neck, or hands, the 10
per cent, solution is a most valuable adjimct to other treatment, the spots rapidly disap-
pearing under its use. This, or the 20 per cent, preparation, diluted -with equal parts
of purified lard, may also be applied to non-idcerated syphilitic indurations and con-
dylomata, but it gives pain if applied to surfaces much excoriated or ulcerated, to
moist warts, or to mucous membranes. In syphilitic iritis, and also in non-siu'citic
forms of that disease, this diluted oleate ointment smeared over, not within, the eyelid,
evidently ])romotes the absorption of the effused lym])h. Lastly, in some of the re-
moter kinds of syphilitic affections, which iodide of" potassium will usually cure, such
as very hard nodes and certain forms of syi)hilitic testicle, the external application of
the oleate of mercury is very valuable. I have seen a case of enlarged testicle, epi-
didymis, the syphilitic origin of which iiad not been suspected, and for which no mer-
curial course had been prescribed, ))ut which, during a period of six years had been,
from time to time, relieved by enormous do.ses of iodide of potas.sium, speedily and
decidedly benefited by the inunction of the 20 per cent, mercurial oleate.

MERCURY. 195

■'In reference to other uses of the combined oleates of mercury and morphia, I
may remark that I cannot doubt their value in the treatment of ' persistent ' inflamma-
tion of certain internal parts and organs — as, for example, of obstinate pleurisy, pneu-
monia, pericarditis, and endocarditis; for they would here also allay pain and nervous
Irritation; would thus contribute toward the arrest of progressive disease, and would
likewise promote the process of absorption. Moreover, I may state that a solution of
morphia in oleic acid (one or two grains to the drachm without mercury), is an excel-
lent topical remedy in neuralgia, and in that exquisitely painful affection, herpes zoster,
care being taken not to produce cutaneous irritation by friction. I have also used,
endermically, with advantage, a solution of atropia in oleic acid, and have had pre-
pared for me the oleates of zinc and copper. Each of these preparations will probably
come to have its uses, to which, however, I have now only time thus generally to refer.
Oleic acid is likewise a ready solvent of cantharidine and croton oil. It is itself aperi-
ent, and permeates fieces more readily than olive oil. Indeed, I fully anticipate that
this acid, as well as its compounds with mercury and with morphia, besides other
preparations made by its aid, will eventually be admitted into the Pharmacopana. An
ointment of the oleate of mercury would almost supersede the old-fashioned blue
ointment, Avhilst the solutions of tlie oleates might replace the liniment of mercury.
The remaining mercurial ointments of the Pliarmacopo?ia, of which the nitrate may
contain a little oleate or some allied salt, will, however, still have their special uses.

" The oleate must be prepared with the oxide precipitated by caustic potash or
soda from a solution of Lhe metal in nitric acid recently made and well dried. The
solution of mercury by oleic acid is assisted by a temperature of 300° Fah.

" The 5 per cent, solution is a perfectly clear, pale yellow liquid, resembling olive
oil, but thinner; the 10 per cent, solution is also fluid and perfectly clear, but as dark
as linseed oil; whilst the 30 per cent, preparation is an opaque, yellowish, unctuous
substance, closely resembling in appearance resin ointment, melting very readily at
the temperature of the body, and forming a kind of transparent, viscid, colorless var-
nish when applied to the skin. The chief care to be observed in the manufacture of
these solutions is not to hurry the process, and not to employ a high temperature, or
the mercury will be Immediately reduced. ' '

Baths of corrosive sublimate and chloride of ammonium, in the pro-
portion of half an ounce of sublimate to one ounce of the chloride, are
sometimes useful in the treatment of obstinate syphilitic and non-s3qjliilitic
rashes.

An ointment of l^iniodide of mercury has been largely employed in India
with remarkable success in the treatment of goitre. The action of the
ointment is aided by the effects of the sun's rays, to which the tumor is
exposed after inunction. The ointment is prepared in the following way:
— Melt three pounds of lard or mutton suet, strain, and clean; when
nearly cool, add nine drachms of biniodide of mercury, finely triturated;
work the mixture well in a mortar till no grains of red are visible, and
keep it in pots, protected from the light. In India this ointment is ap-
plied to the swelling at sunrise by means of an ivory spatula, and is
then well rubbed in for at least ten minutes.

The patient then sits with the goitre held up to the sun as long as he
can endure it. In six or eight hours there will probably be some jniin
from the blistering action of the application, although no pustules will
have arisen. At about two o'clock in the afternoon a second application
is made, the ointment being rubbed in with a light hand; the ointment
is then allowed to remain, and its absorption is completed about the third
day. In ordinary cases one such course cures the patient, but in bad
cases it may be necessary to repeat the treatment in six or twelve months.
In countries where the sun is less powerful, the patient sits before a fierce
fire; or the ointment may be rubbed over the swelling night and morning,
afterwards covering it Avith oil-skin. The full effect is produced in a few
days, when a mild ointment like spermaceti is substituted. (Stainthorpe.)

Mercurial ointments are useful in erythematous lupus. I have seen

196 MERCURY.

great advantage result from the use of calomel ointment or black -wash in
scrofulous and tubercular lupus of children, and in open scrofulous sores.
Scrofulous sores that had resisted other treatment I have often seen yield
speedily to the application of calomel ointment.

In tubercular lupus, Xayler advises touching the summit of the tuber-
cles with the solution of acid nitrate of mercury, repeating the application
till they are reduced to the level of the skin, but not deeper, or a scar will
result. Each application excites a good deal of inflammation and pain;
but the pain may be allayed by covering the spot with collodion. Xayler
uses the mercurial vapor bath in general eczema.

Mercurial preparations, especially black-wash, are very useful applica-
tions to syphilitic sores. Thus mucous tubercles soon yield to black-wash.
Black-wash is useful, too, for those elevated indurations occurring at the
anus of children, differing from mucous tubercles, Ijeing of much larger
size, of irregular shape, often limited to one side, and generally extending
some Avay up the rectum. This eruption, which may bleed and smart
severely each time a motion passes, often disappears but slowly under the
influence of mercury administered by the mouth, and may, in spite of it,
continue increasing slightly for months; while, if kept constantly moist
with black-wash, its removal may be assured in ten days or a fortnight.
Black- wash is very useful in other syphilitic sores.

When it is not convenient to apply black-wash, calomel or citrine
ointment well rubbed in may be substituted.

Calomel, dusted over syphilitic condylomata, generally removes them.

Cyanide of mercury in solution, in the proportion of five, ten, or fifteen
grains to an ounce of water, is useful as a local application to syphilitic
rashes and sores, as those of the throat, tongue, anus, penis, etc. For
sores on the prepuce or glans a solution of five grains to the ounce is gen-
erally strong enough, and even this strength sometimes excites a good
deal of smarting. It should be well rubbed in with a camel-hair brush,
once, or at most twice a day, carefully avoiding the neighboring healthy
tissues. In case of chancres it is a good plan to apply this lotion daily,
or to keep the sore moist with lint soaked in black-wash. Mercurial oint-
ments rubbed into the skin of the penis are often apt to bring out a crop
of eczema, with considerable swelling.

Mercurial applications mixed with other substances, as tar, are very
useful in syphilitic psoriasis.

Mercurial fumigations are very successful in syphilis: calomel, which
is undestroyed by heat or moisture, and gives constant results, is em-
ployed. Some employ dry fumigation; others maintain that the thera-
peutic effects of mercury are increased by steam. This mode of adminis-
tering mercury is considered the best and surest way of eradicating syphilis.
Moreover, it affects the general health less deleteriously, disturbing
neither the functions of the stomach nor the intestines. Ten to twenty
grains of calomel are used at each fumigation. The fumigations some-
times produce so much weakness and prostration that they cannot be
continued. There can be no doubt that many cases of syphilis, rebellious
to other treatment, yield to these fumigations. Sometimes only a portion
of the body affected with syphilitic rash is sul)jected to calomel fumigation.

Mercurial applications, but especially the mercurial and calomel oint-
ments, are rubbed into delicate parts of the skin, so as to mercurialize the
system by their absorption. This method has the advantage of not dis-
ordering the digestive canal.

MERCURY. 197

Bichloride of mercury has been injected under the skin, and a much
smaller quantity aifects the system than when administered by the mouth;
but this painful mode of treating syphilis is not likely to become general.

At one time the application to the face of mercurial ointment or of
mercurial plaster was in vogue to prevent the pittiiig of small-pox. It is
a question of interest whether the mercury itself plays any part in arrest-
ing the maturation of the pustules, or whether other applications are not
as effective. A good deal has been said on each side of the question, but
I think that, since several instances of very severe salivation have followd
this plastering in small-pox, other safer remedies may be used, perhaps
not with equal benefit, yet with sufficiently good results to render it de-
sirable to employ them in preference to the mercurial compounds.

The exclusion of light and air probably thwarts the development of
the pustules and prevents pitting. The exclusion of air and light can be
perfectly effected by collodion and india-rubber dissolved in chloroform;
this, or other means, should therefore be employed in preference to mer-
cury compounds. {Vide Nitrate of Silver.)

In non-syphilitic ozaena Trousseau employs the following snuff-
powders: — White precipitate, 4 grains, sugar in fine powder, 232 grains;
or red precipitate, 4 grains, sugar in fine powder, 232 grains. The nose
is first cleared by blowing it strongly, and then a pinch of either powder
is snuffed up a i'ew times daily for a few days. They quickly remove the
stench, and modify the state of the mucous membrane, though sometimes
they produce a rather powerful irritating effect on the mucous membrane,
and, unfortunately, they do not cure this very intractable complaint.

In the syphilitic oztena of children mercurial ointments, as nitrate of
mercury ointment partially melted applied twice a day after the nose has
been well cleared, will arrest the secretion, remove the obstruction, and
improve the condition of the mucous membrane; the child's health im-
proves, for the nasal obstruction prevents sucking, during which the
child is unable to breathe. It is well known that a child, especially in
sleep, breathes only through the nose, consequently the health must suffer
through inability to sleep when the nasal passages are blocked.

Half a grain of bichloride of mercury in six ounces of water, applying
it every two, three, or four hours, is a good injection in gleet.

Sternberg shows that mercuric bichloride is a very powerful germicide.
In regard to its power to destroy the micrococcus of pus, he thus ranks
it relatively to other germicidal agents. Mercuric bichloride active 0.005
per cent., potassium permanganate 0.12 per cent., iodine 0.2 per cent.,
creasote 0.5 per cent., carbolic acid 1.0 per cent., zinc chloride 2 per cent.
This germicide power has led to the use of weak mercuric bichloride solu-
tions in antiseptic surgery and as a topical ajjplication in diphtheria.
Some use a solution of 1 in 200Q to 1 in 1000.

Potassio-mercuric iodide is a germicide four or five times more pow-
erful than mercuric bichloride. It may be used in the strength of 1
part in 12,000. (Levis.)

]\Iercurial medicines, if administered at an undue time, severely injure
the mucous membrane of the mouth and salivary glands. The first
symptom is a disagreeable metallic taste; the gums around the teeth
become swollen and tender, of a dark- red color, the mucous membrane
investing the incisor teeth being the first affected, whence the inflamma-
tion spreads; the tongue swells and is thickly coated, the breath is exces-
sively fa'^tid, the secretion from the buccal mucous membrane is aug-

198 MERCURY.

men ted, and the saliva is increased in quantity even to the extent of one
or two pints daily. At first the stiliva is richer than natural in epithelium
and solid constituents, but after a time becomes clearer, more watery, and
contains fat and mucous corpuscles. The salivary glands become swollen
and painful; at last the inflammation of the mouth reaches such a point
that ulceration sets in, and progresses till large portions of the gums and
cheeks may be destroyed, the teeth becoming loose, and the bones of the
jaw carious. Some are much more prone to become salivated than others;
weak persons are more easily aifected than strong; children are rarely
salivated. Disease, too, influences the operation of mercury; for in inflam-
mation it is often well borne, while in granular disease of the kidneys or
in scrofula, patients are very liable to become salivated. It is stated that
salivation has occurred three hours after a dose of mercury, that it may
last a few hours only, or endure for several 3'ears, and even disappear for
a time and then return.

There are persons who can never take even a small dose of mercury
without provoking toothache, generally in a carious tooth.

In a certain stage of tonsillitis the influence of mercury is most marked,
owing probably to its absorption in the circulation. In quinsy or scarla-
tina, when the enlarged tonsils almost meet and block the passage, and
when the difficulty in swallowing is nearly insuperable, with even danger
of suffocation, at such a crisis a third of a grain of grey powder taken
every hour, greatly reduces the swelling in a few hours, and obviates the
distress and danger; and, even if an abscess has formed, its maturation
and evacuation appear to be effected more quickly.

The same powder, administered in the same dose three or four times
dailj^, is useful in mumps, speedily relieving the swelling and pain.
Probabh", as in the last case, the drug acts only after its absorption.

The soluble preparations of mercury combine with the albuminous
matters in the mouth, and any j^ortion left uncombined attacks the
mucous membrane, and may excite in it acute inflammation.

They act in a similar manner in the stomach.

A form of vomiting is sometimes met with in very young children —
generally only a few weeks old — which yields in many instances to grey
j)Owder or calomel, but especially to grey powder. The chief, and to a
great extent characteristic feature of this vomiting is its suddenness and
instantaneousness; for immediately the milk is swallowed it is forcibly ex-
pelled, curdled or uncurdled, apparently without any retching or effort on
the part of the child. The milk literally shoots out of both mouth and
nose. Diarrhoea may exist, but more generally there is constipation.
This affection often proves both obstinate and dangerous, as all the food is
ejected, till the child, reduced almost to a skeleton, dies actually of starva-
tion. At the pod moi'fein it often happens, either that nothing is found
to account for death, or the mucous membrane may be much softened,
and like water arrowroot in consistency and appearance. One-third of a
grain of grey powder, repeated every two or three hours, will in many
instances quickly stay this vomiting, which resists all other remedies. A
twelfth of a grain of calomel also every two hours sometimes succeeds.

The soluble preparations act as purgatives, increasing the secretion
from the mucous lining and the contractions of the muscular coat of the
intestines. Xot all, however, are employed as purgatives; and when pur-
gation is needed, our choice falls either on calomel or gre}' powder; either,
being tasteless, is a useful preparation for children.

MERCURY. 199

Most purgatives act more efficiently when given in frequent small
doses, at every hour; but this does not hold with calomel. Moreover, ac-
cording to my experience, we do not much increase the purgative effect
by augmenting the size of a dose, a grain acting as energetically as
five grains. Again, where a nightly purgative is needed, calomel does not
answer, for the dose adequate to produce four or five motions the first
night, will act only twice or three times the second, and often not at all
the third.

The influence of mercury salts on the pancreatic and biliary secretion
is still undecided. Seeing the influence of mercury on the salivary glands,
some conceive it probable that it exerts a similar influence on the pancretis,
a gland with a structure and a secretion very similar to those of the saliv-
ary glands.

Most opposite statements have been made concerning the action of
mercury on the secretion of bile. From experiments on animals it has
been concluded, though not without dissentients, that mercury in health
diminishes the secretion of bile. In his report, as secretary of the Edin-
burgh committee appointed to investigate this matter, the late Dr. Hughes
Bennett arrived at somewhat the same conclusion. This report states:
(1) That neither blue pill, calomel, nor corrosive sublimate, aifect the
bile unless they purge, or impair the health, when the quantity of bile is
diminished. (2) That during an attack of dysentery, both the solid and
fluid constituents of the bile are diminished. (3) Purgation from any
cause lessens the amount of bile and the proportion of its solid constitu-
ents. (See Podoph>illum.)

Kohrig and Rutherford have re-investigated this subject, and they
conclude that calomel does not increase the secretion of bile, nay, in pur-
gative doses, it may even decrease it. Rutherford finds that bichloride of
mercury does increase the secretion of bile.

Dr. H. Bennett's committee experimented on dogs regularly fed. Rutherford and
TJohrig, on fasting dogs, in every instance tirst paralyzing the animal with curare.
Tliey first inserted a glass caniila into the common bile d\ict near its junction with
the duodenum; tlieu compressed tlie gall bladder to fiUtlie tubewitli bile, and clamped
the cystic duct. They then closed the wound in the abdomen, and collected the bile
as it tiowed througli the canula.

In some experiments Rutlierford placed the calomel in the duodenum, unmixed
with bile, in others mixed with it; and in others he administered the calomel by the
stomach.

Yet the experience of generations strongly supports the general con-
viction that in some diseases calomel, as well as other preparations of mer-
cury, does increase the bile. Moreover it is not difficult to conceive that
in a given disease mercury may set aside some condition hindering the
formation of bile, and thus act as a cholagogue, though possibly in health
it may even check this secretion. It is certain that small doses of mer-
curous salts will restore color to colorless stools. Their efficacy may be
over and over again tested in children, for we often meet with a child
that for weeks passes quite colorless stools. In some cases grey powder
will restore the color, and this can be repeated many times in the same
patient, for it often happens that some time after the discontinuance of
the mercury the color again leaves the motions.

When given to promote the secretion of bile, the common practice is
to give a purgative dose for one or two nights; but if there is no constipa-
tion there is no need to purge, and a small dose, say one-sixth to one-half
grain of grey powder twice or three times a day, will answer better. The

200 MERCURY.

administration of small doses frequently is especially advantageous in cases
where the illness is apt to recur frequently from slight and scarcely pre-
ventible causes, and Avhere the frequent employment of purgative doses
would favor after-constipation, and produce depression and possibly sali-
vation. For these reasons it is common to hear highly practical doctors
decry mercurial preparations, whereas were they to employ the minute
doses now recommended they would obtain the desired effect and exclude
the bad results they fear. Given in the doses just mentioned, mercurial
preparations in certain cases which I will now indicate are signally useful: —

I. A patient voids pale clayey stools and suffers from acidity, flatu-
lence, or vomiting, occurring sometimes only before breakfast. Half a
grain of grey powder given three times a day will often restore color to
the stools, when the d3'speptic symptoms cease at once.

II. Small doses of mercury yield excellent results in a form of diarrhoea
common in children. The child's health is bad; the digestion is imper-
fect, generally with annoying flatulent distention; and three or four pale,
clayey, pasty, stinking motions are passed in the day. A single grain of
bichloride dissolved in half a pint of water, and a teaspoonful of this solu-
tion given each hour; or, still better, one-third of a grain of grey powder
every hour or two hours, will in one or two days limit the number of the
stools, and restore their natural bilious color, even though they have been
clay-colored for weeks.

III. Again, we frequently meet with a case like this: — A patient,
generally of nervous temperament, on exposure to cold, or after fatigue or
excitement, or even without any discoverable cause, feels sick, perhaps
vomits, has a coated tongue, and in a few hou.rs becomes jaundiced, the
discoloration sometimes affecting only the conjunctiva, in other cases dye-
ing the skin of the whole body yellow. The stools are pale or colorless.
The attack lasts three or four days, and is accompanied by great depres-
sion. The patient may undergo many attacks, so frequently indeed, that
before the discoloration of one attack has passed away, another has begun
to assail him. Here one-sixth or one-third of a grain of grey powder,
taken at the very onset and repeated three or four times a day, allays the
sickness, cuts short the illness, increases the intervals between the attacks,
and after a time cures the patient, though he may have suffered thus for
several years. If, however, there is obstinate constipation, a course of
Carlsbad waters is then sometimes more efficacious.

IV. The same weak bichloride of mercury solution of a single grain in
ten ounces of water in doses of a teaspoonful, is very efficient in another
serious form of diarrhoea common in children. The characteristics of this
form are very slimy stools, especially if mixed with blood, accompanied
by pain and straining. The salient indication for employing the bichloride
is the slimy character of the motions. Sometimes the slime is very tena-
cious, and, being colored with blood, is described by the mother as " lumps
of flesh." This affection may be acute, or it may be chronic and last for
months; but in either case the bichloride cures with remarkable speed
and certainty.

V. A similar treatment relieves the dysentery, acute or chronic, of
adults, provided the stools are slimy and bloody. A hundredth of a
grain of the bichloride given hourly, or every two hours, according to the
severity of the case, is generally sufficient, rarely failing to free the stools
from blood and slime, although in some cases a diarrhoea of a different
character may continue for a short time longer, requiring perhaps other
treatment to control it.

MERCURY. 201

YT. A sixtli of :i gi-ain of grey powder given liourly is of great service
in infantile cholera, characterized by incessant sickness, with profuse and
almost continuous diarrhoea, very offensive and copious motions, watery,
almost colorless, or of a dirty muddy aspect. Under this treatment the
vomiting generally soon ceases, and the diarrlnea shortly afterwards.
Infantile cholera is an extremely fatal disease, running so rapid a course
that in a very brief space a child is reduced to a death-like aspect and dan-
gerous condition. It is essential then to check the diarrhoea as speedily
as possible. In urgent cases a starch injection, with a minute quantity of
laudanum, assists the action of grey powder.

YII. We often see in infants a chronic diarrhea, characterized by
watery, very offensive, muddy-looking or green-colored stools, often to the
nnmber of ten or twelve daily. This diarrhoea Avill generally yield to grey
powder, in doses of a sixth of a grain, given at first hourly, and then
every two or three hours, according to the frequency of the stools.
Vomiting is an additional indication for this treatment. Although this
drug may check the diarrhoea and vomiting, yet, if the disease has endured a
iong time, so serious may-be the injury inflicted on the mucous memljrane
of the stomach, that food can neither be digested nor absorbed, and the
child gradually wastes away. The appearance of thrush in the mouth is
an unfavorable sign, as it generally indicates profound damage to the
mucous membrane of the digestive canal. So also it is a bad sign always
in the chronic diarrhoea of children when the stools change in character
from time to time — now watery, then slimy, at another time curdy, and
at another green. It is far easier to cure a diarrhoea when the motions
are of a uniform character. In most of these cases full doses of nitrate
of bismuth increases the curative action of the mercury.

It is important to treat the severe forms of infantile diarrhoea promptly,
for being generally inflammatory, the mucous membrane of the large, and
even that of the small intestine, soon becomes seriously affected, the
mucous membrane of the large intestine extensively ulcerated or consider-
ably thickened and granular-looking, whilst the mucous membrane of the
small intestine, a part of the tube less commonly affected, may be much
softened. It will be readily understood that disease so extensive must
take some time to cure.

Mercury, as we have seen, proves very serviceable in most of the forms
of infantile diarrhoea, both acute and chronic. I have endeavored to
point out categorically the circumstances when one mercurial preparation
is preferable to another. It may be urged that, as in both severe acute
and chronic diarrhoea the same pathological conditions are found, the
same form of mercury suitable for one case would equally benefit another.
But although the pathological state is held to be identical, still some
hitherto undetected differences there must be, either in the nature of
the disease itself, or of the part it affects; for surely it requires a different
pathological condition to produce in one case slimy stools, in another
watery, and in another green curdy stools. These differences displayed
in the symptoms, though at present not discriminated pathologically,
require somewhat different treatment. Hence, thoiigh in each kind of
diarrhoea all forms of mercury are useful, it is found that in some cases
bichloride of mercury is greatly to be preferred, and in other cases grey
powder. In the treatment of chronic diarrhoea, mercurial preparations
are often required for many days, and it frequently happens that, though
they alter the character and lessen the frequency of the motions, yet the

202 MERCURY.

diarrhcea may persist, and may require for its cure other remedies, like
lime, arsenic, and nux vomica. In the treatment of chronic, as well as
in that of acute diarrhoea, too much attention cannot be paid t)otli to the
quality and quantity of the food. Acute diarrhoea is often aggravated,
and made chronic, by over-feeding; a short time after eacli meal the child
is violently purged, and the mother seeing it wasting rapidly is apt to
think she can sustain her child by giving as much food as possible; Ijut
it must be borne in mind that digestion is greatly impaired, so that but
little food is digested; the excess, lodging in the intestinal canal, under-
goes decomposition, and, acting as an irritant, increases the disease. Not
only should the quantity of food be small, but it should be given fre-
quently in very small portions. It is also important to clothe the child
warmly, and to put a flannel roller round the belly. In most forms of
diarrhoea in children I am satisfied that it is wiser to cut off milk and sub-
stitute some artificial food like Nestle's, Savory and ]\Ioore's, Mellin's, or
Robinson's prepared barley, etc.

There is a form of diarrhcjea, in which the child passes large, acid,
offensive, curdy stools, evidently consisting of decomposing curds. Mer-
curial preparations, and, indeed, the other usual remedies for diarrhcpa,
are of little avail in this form of diarrhoea, which is best treated by with-
holding milk entirely and substituting animal food or an artificial food of
the kind just referred to.

The chronic diarrhoea of adults, independent of serious organic change
of the intestines, with watery pale stools, often yields to the hundredth of
a grain of corrosive sublimate every two or three hours. The same treat-
ment answers sometimes in the diarrhoea of typhoid fever and phthisis.

With one-third of a grain of grey powder three or four times a day, a
thickly-coated creamy tongue occurring in dyspepsia, in the coarse of
chronic disease, or in early commencement of convalescence from an
acute illness, will generally rapidly get clean, with simultaneous improve-
ment of the appetite and digestion, and removal of disagreeable taste in
the mouth. If thex'e is constipation, then it is better to give haM a grain
of calomel with three grains of extract of hyoscyamus repeated for three
nights. The first pill generally purges twice or thrice, the second less,
and the third not at all. Grey powder should be given if there is either
diarrhoea or tendency to it, for, besides its effect on the tongue and stom-
ach, it will generally control the diarrhoea, at the same time restoring their
natural color to the motions, if too light or too dark.

With the exception of the sulphide, all mercury compounds enter the
blood, and are employed in a variety of diseases on account of their action
on distant organs.

Small doses of corrosive sublimate increase the weight of healthy
men and animals ; increasing also their red corpuscles. Mercury given
in excess decreases the red corpuscles. In small doses in simple ana?mia,
the corpuscles increase for about fourteen days, when a slight reduction
follows. The haemoglobin increases till the twenty-fourth day, and then
falls again. The haemoglobin increases in greater proportion than the
corpuscles. In syphilis accompanied by ansemia, mercury in small doses
increases the red corpuscles and their haemoglobin, and diminishes the
white corpuscles.

The prolonged and undue employment of mercury produces serious
mischief, the body wastes, the blood becomes much impoverished, and
" mercurial fever " may be induced, sometimes accompanied by pustular

MERCURY. 203

or vesicular eruptions. A rise of temperature occurs with sensation of
heat, thirst, loss of appetite, nausea, vomiting, purging, sometimes bloody-
stools. In mercurial tremors weakness in the upper extremities is first
noticed, then voluntary movements begin to lack their usual precision,
and soon slight tremors set in, and gradually increase in severity and
extent till the whole body becomes affected, the legs being attacked before
the trunk. These tremors are easily excited, cannot be controlled, and
persist for some time. In severe cases almost every part of the body is
affected by severe spasmodic movements, so that respiration is spasmodic,
and the sufferer may be unable to walk, talk, or masticate. There may
be neuralgic pains ; loss of memor}', headache, delirium, and even con-
vulsions may occur. Salivation is sometimes absent, for the mode of
poisoning greatly influences the effect of mercury, inhalation generally
jaroducing tremors, inunction producing salivation. Inunction, however,
has produced tremors. Complete recovery generally takes place, provided
the patient is removed from the influence of mercury before the disease
has greatly advanced. The nervous symptoms are usually slowly pro-
duced, but they may occur after only a short exposure to mercurial vapor,
for Dr. Christison narrates a case where one night's exposure to the
vapor from a pot of mercury on a stove produced tremor which lasted
for life.

The treatment of mercurial poisoning consists in the use of simple or
sulphurous baths, and of iodide of potassium. The influence of iodide of
potassium on mercury in the system has been spoken of elsewhere.

Mercury is preeminently useful in syphilis. The following I believe
fairly represents the views now most generally held :

That it is good in both jnimary and secondary syjihilis.

That it is of use in the treatment of the hard chancre only, and does
harm in the soft chancre.

That by the aid of mercury the hard chancre is more speedily cured,
and the patient is less liable to secondary symj^toms, which, when they
do occur, are milder in character.

That most forms of secondary syphilis yield quickly to mercury.

The following propositions are extracted from the admirable lectures
by Mr. Jonathan Hutchinson, to whom medical science is in so many
ways indebted : —

" That mercury is probably a true vital antidote against the syphilitic
virus, and that it is capable of bringing about a real cure.

" That in practice, a good many cases are really cured by mercury ;
the cure being proved by the restoration to good health, and in some
cases by renewed susceptibility to contagion.

" That the probability of cure depends upon the stage of develop-
ment attained by the disease when the remedy is resorted to, and upon
the perseverance with which it is used.

" That in order to secure the antidotal efficacy of mercury against
syphilis, it is desirable to introduce a considerable quantity into the
system, and to protract its use over a very long time.

" That ptyalism and other evidences of the physiological action of
mercury, so far from being beneficial, are, if possible, to be care-
fully avoided, since they prevent the sufficiently prolonged use of the
remedy.

*" That in cases in which the patient shows an idiosyncrasy peculiarly

204 MERCURY.

susceptible to mercury, the indication is to reduce the dose, rather tlian
to omit the drug.

" That it is impossible to begin tlie administration of mercury too
soon, and that it should be resorted to without loss of time in all cases
in which a chancre shows a tendency to indurate.

'* That many cases of indurated chancre, treated early by mercury,
never show any of the characteristic symptoms of the secondary stage.

" That in other cases of mercurial cure of the chancre, in which yet
secondary symptoms do occur, they are usually milder than if allowed
to develop without specific treatment.

" That when mercury does not wholly abrogate the secondary stage
it exhibits a remarkable jjower in delaying it.

" That delayed outbreaks of secondary syphilis are to be regarded
rather as proof that the administration had not been suflticiently perse-
vering, than that the remedy was not efficient.

" That it is probable that the risk of tertiary symptoms, is in ratio
with the severity and prolonged duration of the secondary stage.

"That there are some grounds for believing that the tertiary symp-
toms of syphilis are both less frequent and less severe in those who have
been efficiently treated by mercury, than in others.

" That mercury, cautiously given, does not, in a great majority of
cases, do any injury to the general health, and that its local inconven-
iences may usually be prevented.

" That the doctrine of the re-id antidotal character of mercury in
respect to syphilis, ought to lead to much more prolonged administration
of it, with the hope of destroying utterly all lingering germs of the
malady.

" That most collected statistics as to the duration of treatment and
freedom from relapse, are misleading and worse than useless because
usually the treatment was far too short to be effectual.

'■ That it has not yet been proved that there are any special forms of
syphilitic disease in which mercury ought to be avoided, although, as a
rule, it is acknowledged that it must be used with more caution in all
forms which are attended with ulceration than in others.

" That iodide of potassium possesses little or no efficacy against either
the primary or secondary forms of syphilis.

" That the efficacy of mercury is often most signally proved in cases
which have utterly resisted the action of iodide of potassium.

" That it does not much matter whether the mercury is given by the
mouth, by inunction, or by the vapor bath, provided that whatever
method is selected, care is taken to avoid salivation, purging, etc.

" That the doses usually resorted to for internal administration, are
for the most part too large, and thus often necessitate a premature dis-
continuance of the remedy.

" That if one method of administration does not proceed satisfac-
toriljf, another should be tried; and that in no case of difficulty should
the vapor bath be forgotten."

Many other writers agree with Mr. Hutchinson. Dr. Keyes of Xew
York recommends the unremitting use of mercury for at least two years,
and sometimes longer, in small doses incapable of producing physiological
effects. Dr. Keyes entertains the belief that syjdiilis can be eradicated.

Most of the forms of congenital syphilis of children succumb to mer-

MERCURY. 205

cury with singular rapidity. It is a common practice to give to children
small doses, as a quarter of a grain of gray powder, and to add to it a
small portion of Dover's powder to prevent relaxation of the bowels. But
I am convinced that much larger doses of gray powder are more beneficial,
and remove the disease far more quickly, and succeed, indeed, where the
smaller dose fails. Thus one, or ^ven two, grains of gray powder may
be given three times a day, unguarded with opium, for it is the rarest
thing for even these doses to purge ; nay, if any diarrhoea exists, a not
imcommon complication, these doses check it. Moreover, they may be
continued for a considerable time, till every symptom has vanished, witli-
out producing any of the toxic effects of the drug. As a rule, however,
one grain of gray powder thrice daily is sufficient. Those comparatively
rare forms of congenital disease, where the periosteum is affected, usually
near the articulation of some of the long bones, yield best to iodide of
potassium, though, as far as my experience goes, it is still necessary
in most cases to resort to mercury to remove the other evidences of
syphilis.

While admitting the validity of these views, it is necessary to say that
sometimes syphilitic patients are apparently completely cured without
mercury, by mere general treatment tending to improve the health ; and
further, if the health is kept in good order, the secondary symptoms will
be of a mild character. Oases of syphilis occur which are entirely un-
influenced by mercury, and are curable only by diligent attention to
those hygienic circumstances which mend the general health.

When other means fail, mercurial fumigations, with steam, often
cure certain obstinate syphilitic rashes.

The firmest believers in the effica.cy of mercury in syphilis, are unani-
mously agreed that to give it in quantities sufficient to produce saliva-
tion, is not only undesirable, but pernicious; yet it appears that those
preparations which salivate quickest, manifest the greatest power over
the disease, and hence the metallic and mercurous preparations, as gray
powder and calomel, are preferred by some to the mercuric, as corrosive
sublimate.

To prevent or to mitigate an attack of sick headache, it is a common
and often successful practice, to take a mercurial purge, generally in the
form of a blue pill.

For further suggestions as to the employment of mercury in this
troublesome affection, the reader is referred to the section on podo-
phyllum.

It was formerly thought that mercury salts were endowed with the
power of controlling inflammation, and to this end they were constantly
given, even to salivation ; now, however, their use under such circumstan-
ces is much less general. Bichloride of mercury certainly appears to be
of great use in iritis and inflammations of the deep-seated parts of the eye;
and in other inflammations, especially of the serous membranes, it is prob-
ably of service in checking the inflammation and jjromoting the absorji-
tion of effusfcd products.

According to very high authorities, among whom may be mentioned
Dr. Parkes, small doses of calomel may be very beneficially given in ty-
phoid fever. It should be given at the commencement, some think it
useless after the ninth or tenth day. It is considered to lessen the
height of the fever, to shorten its course, to render the intestinal de-
rangement much milder, and to check the diarrhoea. Some push the

206 COPPER.

medicine till the gums are slightly touched ; but this practice, not only
unnecessary, but harmful, should be carefully avoided.

Calomel administered several times a day is strongly recommended
as a i^owerful diuretic in cardiac dropsy, and, according to some 'writers,
also in renal droj)sy. It has been recommended in cirrhotic ascites.
Sometimes its effects are only temporary.

Mei-cury remaius a long time in fhe body, and may accumulate, so it
is said, in globules in the cancellous structures of bone.

Mercury salts are to some extent eliminated by the urine, by the mu-
cous membrane of the intestines, and with the bile; indeed, it has been
found in every secretion, physiological and pathological.

PREPARATIONS OF COPPER.

Applied to the unbroken skin, the soluble salts of copjoer produce no
visible effect. They unite with the soluble albuminous substances on
sores, forming an insoluble albuminate, which coats the surface, and, in
an imperfect manner, may take the place of the lost cuticle. The thin
Ijellicle thus formed protects the delicate structures from the air, and the
substances floating in it, and so jn'omotes the healing process. Like many
other metals these salts condense the structures and constringe the blood-
vessels, and so lessen the supply of blood to the part, and may even arrest
hfemorrhage from the smaller vessels. They act as irritants to the deli-
cate tissues, producing slight inflammation, with some smarting pain.

To arrest bleeding, and as an irritant to indolent sores, the sulphate
is most employed, either in stick or solution, or as an ointment.

Indolent forms of impetigo, after resisting the more usual ajjplica-
tions, will sometimes yield to sulphate of copi^er.

In tinea tarsi the solid sulphate may be rubbed, often with conspicu-
ous advantage, along the edges of the eyelids, the eyelashes having been
previously cut off closely, and the scabs carefully removed. Indeed, in
every case where slight stimulation is required, this salt may be used.
Milder in its action than nitrate of silver, it excites much less pain.

The soluble snlts combine in the mouth with the liquid albuminous
substances of this cavit}', and precipitate them more or less completely;
but if used in quantity more than sufticient to do this, the mucous mem-
brane itself is attacked in a manner altogether similar to the abraded skin.
These salts possess a metallic styptic taste.

The sulphate in the solid form may be applied with advantage to
the spots of jjsoriasis, simple or specific, or to indolent sores aff'ecting
the tongue. Painted in solution over the edges of the gums in ulcera-
tive stomatitis, it generally quickly heals tlie ulcerated surfaces, but on
the wliole dried alum is to be preferred.

A weak solution of this salt painted over the mucous membrane will
remove the white curdy-looking coating of thrush, and prevent its re-
newal.

ZINC. 207

The soluble salts in the stomach behave in the same manner as in
the mouth, and if taken in large quantities, act as jJowerful irritant
poisons.

These salts are emetic; the sulphate, being speedy, and mostly effect-
ual, is not unfrequently i^rescribed. A good Avay to give this salt as a
vomit is to administer it in small and frequently-repeated doses. It gen-
erally produces one copious evacuation, neither purging nor producing
much nausea or prostration. It is supposed to exert an especial action
on the larynx, hence it is sometimes given in croup, and when it is nec-
essary to expel any obstructive substances from the glottis by the me-
chanical efforts of vomiting.

Copper salts, like zinc salts, alum, mustard, common salt, warm water
and bitter infusions, act topically on the stomach, and but slightly
through its direct action on the centre of vomiting after its absorption
into the blood.

In moderate doses the salts are astringent to the mucous membrane of
the intestines. The sulphate, administered either by the mouth or by in-
jection into the rectum, is often effectual in staying severe chronic or acute
diarrhoea, whether or not depending on serious organic disease.

Copper salts, taken for a considerable time in small quantities, are
said to give rise to a condition not unlike that produced by lead ; for
example, colic, with alternating constipation and diarrhoea, and, it is even
said, paralysis of the upper extremities, undistinguisbable from that of
lead.

Salts of copper find their way into the blood, existing there probably
as albuminates.

Drs. Levi and Barduzzi find that small doses of sulphate of copper
promote assimilation, and increase strength and " flesh" in man and ani-
mals. They are used with benefit in erythema, ecthyma, eczema, scrof-
ula, tuberculosis. Copper, therefore, appears to act physiologically and
therapeutically much like arsenic, and, like it, should be taken with, or
soon after, food.

Copper salts have been given in cholera and epilepsy.

Solutions of the sulphate are employed in gonorrhoea, gleet and leu-
corrhoea.

Copper is eliminated both by the urine and fasces.

PREPARATIONS OF ZINC.

The members of this group are employed in various ways as external
applications.

Even in dilute solutions chloride of zine destro3^s low organized forms,
and is thus a disinfectant and antiseptic.

Their common action is astringent and irritant : but on account of
their different degrees of solubility, their varying affinity for water, and
perhaps for the tissues, the several members of this group manifest these
properties in unequal degrees.

The chloride and iodide, from their high diffusion-power and great
affinity for water, are the most energetic; yet even these remain almost
inert on the skin, unless the cuticle is first removed, when they perme-

208 ZINC.

ate tlie tissues, and destroy tliem for a considerable depth. The chloride
at first produces a sensation of Avarmth, which increases to a burning
pain, lasting seven or eight hours, by which time the tissues are destroyed,
and a white eschar is formed, which separates in from seven to twelve
days. The chloride and iodide, as Ave have just said, have hitherto been
regarded as the most energetic salts of this series, but recentlv Mr. ^lar-
shall, of University College, has shown by experiments that the nitrate
penetrates deeper than the chloride, destroying the tissues to a greater
depth, and, according to the same authority, possesses the further advan-
tage of producing less pain than the chloride. These three preparations,
but especially the chloride, are applied to nsevi, warts, condylomata, the
skin affected Avith lupus, and the tissues of syphilitic ulcers.

The sulphate having a loAvcr diffusion-poAver, its action is much more
superficial. In common AA-itli the other soluble salts of zinc, it forms an
insoluble compound Avith albumen, and by virtue of its astringency con-
denses the tissues, and contracts the blood-vessels. As a stimulant aiul
astringent it lessens the secretions, and promotes healtliier groAvth of ill-
conditioned, free-secreting sores or eruptions. In common Avith the chlo-
ride it is used as an injection in gonorrhoea or gleet.

A grain or tAvo grains of chloride of zinc dissoh'ed in a pint of Avater,
and a little of this solution injected hourly during the day, is often use-
ful in gonorrho'a, if treated at its very beginning, removing the disease in
twenty-four to forty- eight hours. Rest, if possible, should be observed;
but this is not indispensable. If the frequent injection causes any pain in
the testicles, they should be suspended and frequently fomented with hot
water; if, notAvithstanding, the pain continues and the SAvelling increases,
the injection must be employed less often.

A solution so weak as the one recommended is no better, it may be
said, than simple Avater; but the fact is, simple AA-ater does not cure
with anything like the same rapidity. If some of this solution is taken
into the mouth, and retained there a fcAv seconds, it Avill produce a de-
cided roughness of the mucous membrane; noAV, if the solution is strong
enough to affect the mucous membrane of the mouth, it can certainly
influence, in at least an equal degree, a similar, but more sensitive, struct-
ure in the urethra.

The carbonate and oxide are insoluble, or but very slightly soluble, in
the animal fluids ; and as these salts i^ossess no affinity for Avater, their
action on the tissues is very Aveak. They are, hoAvever, slightly astringent,
and are useful on account of this property, in ointment, or in poAvder.
The ointment of the oxide is used as a mild stimulating ap2:»lication in
eczema and impetigo, when mflammation having suljsided the raAV surface
is left in an indolent state, Avitli very little disposition to heal. Both the
oxide and carbonate are used as dusting poAvder, and are, perhaps, the best
poAvders for this purpose; but, as a rule, greasy applications are preferable.
In inflamed conjunctiA-a, a weak solution of the sulphate dropped into the
eye several times a day is often very useful. The same salt is occasionally
employed as a gargle in relaxed sore-throat, and is sometimes added to
alum injections for leucorrluea.

The more soluble preparations possess a metallic styptic taste. Xone
are employed in diseases of the mouth. The chloride has been used to
destroy the exposed painful pulp of decayed teeth.

The carbonate in large doses produces some nausea and vomiting; but
a full dose of the sulphate acts much more speedily, is a safe emetic, pro-

ZINC. 209

ducing little prostration or nausea, and generally empties the stomach in
one complete evacuation. It is, therefore, the best emetic in cases of
poisoning, being far preferable to the slow and unsure action of ipecacu-
anha. It maybe employed as an emetic in bronchitis or croup; in bron-
chitis, to expel the mucus from the bronchial tubes; in croup, the false
membrane from the larynx ; but other emetics are mostly preferred. The
suljjhate may be employed as an emetic, or in doses short of the induction
of vomiting, in painful affections of the stomach, dependent on chronic
inflammation of the mucous membrane. Injected into the blood, the
sulphate excites vomiting. It acts, however, chiefly by its topical action
on the stomach.

On account of its slight solubility, the oxide exerts but slight action
on the stomach, little being dissolved unless much acid is present. Like
most other metallic preparations, the oxide and sulphate of zinc are useful
in acute or chronic diarrhoea.

Dr. Brackenridge strongly recommends oxide of zinc in two to foui
grain doses every three hours in the diarrhoea of children.

The chloride is a corrosive poison. The sulphate, on account of its
astringency, like most other metallic salts, may be employed in diarrhoea.
Its action must take effect on the upper part of the canal, since the por-
tion escaping absorption must be speedily converted into an inert sulphide.
The stomach may become habituated to the ingestion of very large doses of
the sulphate, to the extent even of forty grains thrice daily, without ob-
vious bad results, or without inducing either nausea or vomiting, or appar-
ently any alteration in the mttcous membrane of the digestive canal. As
it has been shown that stiperficial itlceration of the stomach may be pro-
duced, the prolonged employment of sitcli doses is imprudent.

Zinc colic has been described with symptoms including constipation,
vomiting, prostration, with disagreeable taste in the mouth.

Zinc finds its way into the blood, and exists there probably as an albu-
minate.

The oxide and sulphate have been employed w^lth advantage in epi-
lepsy and whooping cough. In bromide of potassium we now possess a
better remedy for epilepsy.

Sulphate of zinc is often very useful in chorea. Like tartar emetic, it
sticceeds best when given in doses stifiicient to produce nausea, or even
vomiting, daily. To effect this, however, the dose must be rapidly in-
creased, sometimes to the extent of two grains every two hottrs daily, and
it is astonishing how much of this drug can be borne, for I have given
fifteen and sometimes twenty-two grains eyery two hours withotit produc-
ing nausea. Thus administered this salt often effects striking improve-
ment, but these heroic doses after a time excite pain at the pit of the stom-
ach with loss of appetite, and when this happens, another emetic, like
tartar-emetic, may be substituted. When given to excite nausea, it is a good
plan to administer a dose before breakfast.

It is a noteworthy fact that most emetics are useful in chorea. Do
they act by exciting the physiological state of nausea, or by their opera-
tion on the nervous centres through which emetics produce nausea ? As
improvement occttrs in many cases independently of the induction of nau-
sea, the latter suggestion is probably the more feasible.

Zinc salts are reputed to be powerful " nervine tonics," a somewhat
vague expression, meant, I suppose, to imply that they promote the nu-
14

210 ANTIMONY.

trition of the nervous system, and some authorities attribute to this prop-
erty the influence of these salts in chorea. In certain forms of hysteria
zinc salts are useful, especially in the shape of the valerianate.

These substances are reputed to be antispasmodic. "When they pro-
duce nausea no doubt they indirectly act thus ; but it is doubtful whether
non-emetic doses are efficient antispasmodics.

The oxide in two to four grain nightly doses often controls profuse
colliquative sweating. It is said also to check the profuse secretion from
the bronchial mucous membrane in some forms of bronchitis.

Dr. Hammond recommends oxide of zinc, in two to five grain doses,
for nervous headache.

This metal does not become fixed in the body, nor does it, like lead or
mercury, produce chronic affection. Zinc salts are eliminated from the
body less rapidly than some other metals, passing out in small quantities
only by the urine. It has been asserted that very little of the salts pass into
the blood, which may be true ; but the fact that the chief part may be re-
obtained from the faeces is no proof of this statement, as zinc, like many
other metals, is probably excreted by the mucous membrane of the intes-
tines, and with the bile.

Zinc chloride, even in dilute solution, is a powerful poison to low forms
of life. Hence it is antiseptic and disinfectant, and is used to destroy the
contagiousness of typhoid stools. A strong solution should be jjoured
into the bed-pan before, or immediately after, an evacuation.

PEEPAEATIONS OF ANTIMONY.

Tartar-emetic in the form of ointment, excites in the skin a charac-
teristic inflammation, at first papular, then vascular, and lastly pustular.
The rash thus runs the course of the eruption of smallpox, and in each
stage simulates it very closely, though there are points of difference dis-
tiuguishable to a practised eye. Like smallpox eruption, this rash often
scars ; moreover, the capricious and j^ainful action of this ointment ren-
ders it an unsuitable external ap]ilication.

Tartar-emetic ointment used years ago to be employed, though now
very rarely, as a counter-irritant to obtain a powerful persistent action;
for instance, to the scalp in tubercular meningitis.

Chloride of antimony is a powerful escharotic, but it produces an ill-
conditioned slow-healing sore.

Tartar-emetic being the most used member of this group, our remarks,
except Avhen the contrary is stated, will apply to this preparation.

After small medicinal doses the stomach experiences a slight sensation of
soreness — a sensation easily mistaken for hunger. Pushed yet further,
the drug produces increased secretion of -mucus from the stomach and
intestines, to the extent of inducing numerous moist motions ; and,
diarrhoea with colic may set in. The bronchial mucous membrane also
yields an increased secretion, and probably the secretion of the whole mu-
cous tract is augmented.

Antimony is never used as a purgative ; in fact, opium is frequently
given in combination with tartar-emetic, expressly to prevent purgation.
Large doses excite nausea and vomiting. As an emetic, tartarized anti-

ANTIMONY. 211

mony produces considerable depression, with much nausea, in a greater
degree than those other emetics; and the repeated vomiting is accom-
panied by great straining. Its action is somewhat tardy, sometimes
twenty minutes to half an hour, hence in cases of poisoning it is an un-
suitable emetic.

Majendie has shown that when injected into the veins tartar-emetic
excites nausea, even after the removal of the stomach and its substitution
by a pig's bladder; hence it has generally been held that this salt pro-
duces vomiting, not by its effects on the stomach, but on the nervous
centres. Grimm finds that when injected into a vein it excites vomiting
more slowly, and a larger dose is required than when administered by
the stomach, whence he concludes that it produces vomiting by its effects
on the termination of the nerves of the stomach. He disposes of the
difficulty raised against this view by Majendie's experiment, by assuming
that tartar-emetic excites nausea by its effects on the termination of the
nerves of the oesophagus and intestines. Other observers explain the
foregoing facts by the supposition that tartar-emetic acts both through
the terniinations of the nerves of the stomach and directly on the centre
for vomiting.

Tartar-emetic was formerly employed to induce muscular weakness and
relaxation of spasm, to facilitate the reductions of dislocations and hernia;
but in such cases chloroform has now completely superseded it.

Trousseau taught that food influences greatly the action of antimony, a
low diet favoring the production of its constitutional effects, and a full
diet its emetic and purgative effects. Its action is further modified by the
quantity of water administered Avith it, this being small, vomiting takes
place, if large, diarrhoea. Trousseau further observed that certain sub-
stances modify the effects of antimony ; for wine and acid fruits, both
fresh and preserved, develop its emetic and purgative properties.

The soluble antimony compounds easily enter the blood, but the form
they assume there is unknown. Possibly the oxide of the metal, either
in the stomach, intestines, or blood, combines with albumen, forming an
albuminate. Antimony compounds, it is said, do not combine with albu-
men, except in acid solutions, when an insoluble compound is formed.

In antimonial poisoning there is great motor and sensory paralysis, and
loss of reflex action. The loss of reflex action and motor power Radzie-
jewski shows is clue to the effect of the tartar-emetic on the cord. This
salt also powerfully affects the heart in the frog, slowing and then arresting
it in diastole; and it affects the heart of warm-blooded animals in the
same Avay. The arterial pressure falls greatly. "Whilst the pulse is slow
the diastolic pauses are long, but each beat influences the mercurial column
of the cardiometer five times more than normal. After a large dose the
pulse at last becomes very frequent and feeble, and the heart stops in dias-
tole. Tartar-emetic directly affects the heart; affects it even when the
heart is removed from the body. Radziejewski has shown that the ends
of the vagi are paralyzed, and Ackermann that the contractility of the
cardiac muscle is destroyed.

In the Journal of Physiology, I have published, in conjunction Avith
Mr. Murrell, some experiments showing that tartar-emetic, like potash-
salts, arsenious acid, aconitia and hydrocyanic acid, is a protoplasmic
poison which destroys the functions of all the organs of the body in the
order of their vital endowments. We have shoAvn that the general paral-
ysis which ensues in a frog in the hypodermic injection of tartar-emetic is

212 ANTIMONY.

due to the action of the drug on tlie spinal cord, thus confirming previous
experimenters : and tliat tartar-emetic is also a direct paralyzer of the
motor nerves, and of the muscles. Our experiments confirm the conclu-
sions of previous observers concerning the action of tartar-emetic on the
muscular substance of the heart.

We have thus shown that tartar-emetic paralyzes the central nervous
system, the motor nerves, the muscles, and destroys sensation, and there-
fore we are led to infer that probably tartar-emetic is a protoplasmic
poison, destroying function in all nitrogenous tissue. Our experiments,
however, fail to show whether it manifests for all nitrogenous tissues an
equal affinity, or whether it has a special action on some.

As in the case of potash salts, arsenious acid and aconitia, tartar-emetic,
we suggest, weakens or parlyzes the heart through its action on all the tis-
sues, ganglia, nerves, and muscular substances of this organ, affecting first
the ganglia, then the nerves, and last the muscular substances.

Tartar-emetic is a general as well as a cardiac depressant. The gen-
eral depression is usually attributed to the action of the drug on the heart;
but, as antimony is a poison to all nitrogenous tissues, I would suggest that
its depressing action is due also to its effects on the central nervous sys-
tem, the nerves, and the muscles.

We noticed a peculiar effect of tartar-emetic on the skin. In a few
hours the cuticle of a poisoned frog became softened and gelatiniform, too
soft to be stripped off, though it could be easily scraped off every part of
the bod}'. Even small noses soon produce this remarkable effect, for in
one experiment the skin, after a small dose, became in this condition even
whilst the animal could still crawl pretty well.

Miss Nunn, under the direction of Dr. Michael Foster, has carefully
worked out the effect of tartar-emetic on the skin, and the results are
published in the Journal of Phifsiology, 1878; and to her investigation I
shall refer in the article on arsenic. Malcolm Morris highly praises tar-
tar-emetic in 32-grain doses in acute eczema. It is less successful in the
chronic forms.

Like arsenic and phosphorus, tartar-emetic destroys the glycogenic
function of the liver, and induces fatty degeneration of this and other
organs. It splits up the nitrogenous matter into fat and some compound
wherefrom leucin. tyrosin, and urea are formed, so that in case of anti-
mony poisoning there is incre^tsed formation of urea in the urine, and
increased elimination of carbonic acid in the expired air; moreover, tar-
tar-emetic increases both the insensible perspiration and the vapor from
the lungs, but chiefly the secretion from the skin. Tartar-emetic wine
is commonly given as a diaphoretic in fevers.

Many cases of ague may be cured by tlie impression emetics make on
the system. An emetic administered each morning will help the action
of quinine, for cases rebellious to quinine alone often yield immediately
to the joint action of quinine and emetics. Ipecacuanha and other
emetics should be preferred to antimony.

Antimony will not lower the temperature of the body of a healthy
person, if one experiment may be accepted as sufficient to settle this
point. To a strong young man I gave tartar-emetic in half-grain doses
every ten minutes for nearly seven hours, inducing great nausea and
vomiting, with profuse perspiration; but during the whole time his
temperature remaiiied remiirkably constant, varying not more than 0.4°
Fahr. an amount of deviation quite within the limits of health.

ANTIMONY. 213

Tartar-emetic acts in many respects like aconite; given in 3V ^o g-^
grain doses each hour to a fever patient it produces copious perspiration
and slows the pulse, and with the perspiration, restlessness, etc., disappear.
In 3V) gi*ain doses it often excites troublesome sickness, even in adults, and
it is better therefore to begin with a -^\ to g-^ grain. In my experience
aconite, tartai'-emetic, and carbonate of ammonia are the most powerful
diaphoretics in fever, and next, though a long way inferior, acetate of
ammonia.

Tartar-emetic is highly useful in catarrh of any part of the respi-
ratory tract. A dose of -gV of a grain hourly induces perspiration and
secretion from the mucous membrane, and cuts short the attack. Small
hourly doses are preferable to larger doses at longer intervals, for larger
doses may excite nausea and even vomiting with much depression. Be-
ing tasteless, this is an excellent treatment for children, for the drug
may be made quite palatable by the addition of syrup of orange peel.
The addition of a small dose of potassium iodide, as one-sixth of a grain
in each dose, heightens its action.

Antimony administered in the same way will shorten and moderate
attacks of feverish cold, tonsillitis, pleurisy, orchitis, bronchitis, puer-
peral peritonitis, inflammation of the breast, whitlow and other inflam-
matory affections.

Antimony is serviceable in chronic bronchitis, when the expectora-
tion is copious, frothy, and difficult to expel.

In the following disease tartar-emetic is invaluable : —

A child six to twelve years old on the slightest exposure to cold is
attacked with much wheezing and some difficulty of breathing, some-
times so urgent as to compel him to sit all night propped with pillows.
The expectoration may be pretty abundant, but a child of this age does
not generally expectorate. On listening to the chest there is heard much
sonorous and sibilant, with perhaps a little bubbling, rhoncus; but this
last is often absent. The wheezing is audible for a considerable distance,
and sometimes the noise is so great as to be heard many rooms off. Oc-
casionally the cough is troublesome, and on each exposure to cold the
voice may become hoarse, and the cough hollow and barking. Some
children become thus afflicted whenever the weather is cold, even in
summer and may not be free the whole winter : with others the attack
lasts only a few weeks or days. This affection sometimes follows
measles. It is compared by the mother to asthma, with which, if not
identical, it is certainly allied.

The best way to administer this salt is to dissolve a grain of it in
half a pint of water and to give a teaspoonful of the solution every
quarter of an hour for the first hour, afterwards hourly. If the wheez-
ing comes on at night it is sufficient to give the medicine at this time
only.

The good effects of the medicine become speedily evident; for
on the very first night it often greatly benefits the child. So small a
dose, it may be thought, must be inefficacious, but when first given it
generally produces vomiting once or twice in the day, and as it is not
necessary to produce sickness, the dose in this case must be still
smaller.

There is, however, an affection unaffected by tartar-emetic somewhat
similar to that Just described, which it is necessary to discriminate from
it. It occurs in children a few months old, and consists of a loud

214 ANTIMONY.

rattling, wliich is obviously caused by niuous in the throat or larynx.
In some cases the rattling is worse in the day, but is usually worse at
night.

There is no bronchitis, or if there is, this is a mere coincidence; n;iy,
sometimes on the occurrence of bronchitis the complaint in question
ceases for a time. It is brought on and aggravated by cold, and may
last, with some fluctuations, many months.

Antimony in small hourly doses is very useful in the acute catarrh of
children, sometimes accompanied by vomiting and diarrhcea, probably due
to catarrh of the intestines. The intestinal canal is sometimes the first
attacked, but most frequently the lungs are first implicated. The tartar-
emetic generally quickly stays the vomiting and diarrhoea, but often
takes a longer time to control the bronchitis.

Antimony in large doses was formerly freely used in acute pneu-
monia. In some cases small hourly doses certainly seem very useful
when administered at the onset of the disease.

Graves employed antimony in typhus and other fevers when there
is much excitement and furious delirium, symptoms which are generally
subdued by the exhibition of this drug. As wakefulness is a concomi-
tant symptom, being, indeed, the cause of the excitement and delirium,
opium should be added to the antimony. The combined influence of
these remedies calms the excitement, and induces refreshing sleep, out
of which the patient wakes refreshed and free from delusions. Judi-
ciously employed, these remedies may save an almost hopeless life.
Each drug appears to assist the action of the other, and the relative doses
must be determined by the circumstances of the case. In furious de-
lirium the tartar-emetic must be given in full, and the opium in small,
quantities; while, if wakefulness predominates, with not very boisterous
delirium, the dose of tartar-emetic must be reduced, and the opium in-
creased.

Graves advises one-fourth to one-half a grain of the salt every hour
or two hours, to be discontinued when it produces bilious stools. This
treatment is very useful in the delirium which usually sets in about the
ninth or tenth day of t3q3hus.

The mania and sleeplessness of delirium tremens generally give way
to the same treatment.

Puerperal mania may be treated in the same way, although probably
bromide of potassium and cliloral give better results.

Tartar-emetic given to the extent of producing nausea and vomiting
once or twice a day is sometimes useful in chorea. (See Sulpliate of
Zinc) Increasing doses must be given, as the system aj^pears soon to
tolerate it. Other remedies, however, are more efficient.

In strumous ophthalmia tartar-emetic may be given with advan-
tage, in doses of l-3Gth to l-48th of a grain three or four times a day.
Sharp purgation at the commencement of the treatment is highly
useful.

In acute poisoning by tartar-emetic violent and continuous vomiting
occurs, accompanied with a diarrhoea of bilious and bloody stools, and
sometimes the common symptoms of gastro-enteritis, and sometimes of
peritonitis, are present. The prostration is intense and jn-ofound. and
repeated faintings take place. The respirations and the pulse are said
to be reduced both in frequency and in strength; otheis assert that the
pulse is more frequent.

ARSENIC. 215

The post-mortem appearances are inflammation of the stomach and
intestines, but not often of the gullet. The peritoneum may be, and,
according to Harley, the rectum often is, inflamed, and some inflamma-
tion of the lungs is usually observable, tending to make it probable that
tartar-emetic exerts an especial action on these organs.

In the treatment of poisoning by tartar-emetic the vomiting should
be promoted by warm demulcent drinks, while strong tea or colfee, tan-
nin, or decoction of oak bark should be diligently administered.

The statements concerning the influence of antimony on the urine
are conflicting.

The probable effect of tartar-emetic on this excretion is to lessen
the amount of water and of chloride of sodium, owing to increased per-
spiration.

The urea is greatly increased, apparently in proportion to the dose
of the antimony; so is the pigment and uric acid, but in a less
degree.

Antimony is separated chiefly by the kidneys; some, however, passes
with the bile, and by the stomach and intestines. A portion is retained
in the body.

PREPAEATIONS OF ARSENIC.

Aesenious acid is poisonous to many of the lower forms of animal life,
but it does not impair the action of animal ferments, as pepsin, pancrea-
tine, etc.

Dry arsenious acid produces no changes in the unbroken skin, but in
wounds or sores it excites very active ijiflammation, with much pain, suffi-
cient, if the application is a strong one, to destroy the tissues for some
depth. Arsenious acid has long been used to destroy warts, condylomata,
cancerous growths, the nerve of a carious tooth, etc.

It may be applied pure, or mixed in variable quantities with some bland
powder, as starch. At times this application has enjoyed a high reputa-
tion, whilst at other times it has fallen into almost complete disuse.
Some have fallen victims to this treatment, it is said, through the absorp-
tion of arsenic in sufficient quantity to destroy life; but an untoward re-
sult like this can occur only when certain well-known precautions are dis-
regarded. Absorption can be effectually prevented if sufficient arsenic is
employed to excite active inflammation; for inflamed tissue loses the
power of absorption more or less completely. Produce active inflamma-
tion, and the patient is safe; but if, through fear of poisoning, too little
arsenic is used, that is the most efficacious way of doing what it is desired
to avoid. Surgeons experienced in the employment of arsenic recommend
that, if the tissues to be destroyed are extensive, the arsenic shovild be
applied to a part only of the surface at a time. When employed to re-
move large growths, like cancer, the skin being unbroken, incisions are
first made, and into these the arsenical paste is laid, which soon stirs up
active and deep-seated inflammation, and the growth dies for a considerable

21(5 ARSENIC.

depth. The whole tumor often sloughs away from the healthy tissues —
is in fact enucleated — leaving a clean and healthy sore, which heals with-
out trouble in fifteen to thirty days.

Lupus and other obstinate skin affections may be treated in the same
way.

Arsenious acid and powdered acacia, of each an ounce, blended with
five fluid drachms of water, form an arsenical mucilage much used by
Doctor Marsden to remove epitheliomatous growths. Some of this arseni-
cal mucilage is to be painted over the tumor night and morning, great
care being taken to limit its employment to the diseased tissues. Each
application, covering not more than a square inch, is to be several times
repeated, and the separation of the sloughs aided by poulticing.

The following powder may also be used: — Fresh lime, half an ounce;
yellow sulphide of arsenic, 20 grains; starch, 180 grains. The arsenic
should constitute one-fifth or one-sixth part of the arsenical powder, so as
to insure the excitation of sufficient inflammation to prevent poisonous ab-
sorption. This powder may be also cautiously used as a depilatory.

Liquor arsenicalis painted over warts is said to cause them to disappear,
and a limited experience leads me to believe that the arsenic does appear
to disintegrate the wart, so that pieces of it drop off, or can be picked out.
If very large it must first be dissolved away with liquor potassae, to allow
the liquor arsenicalis to come in contact with the softer tissues below. It
has appeared to me to be also a useful application to corns. The corn
should be well pared down and the liquor arsenicalis applied thrice daily.
This treatment I have seen greatly improve even hard corns on the sole
of the foot. Salicylic acid is a very useful apjDlication to corns.

An arsenical bath is useful in some forms of rheumatoid arthritis. It
is made by adding to the water in an ordinary general bath four ounces
of common washing soda and twenty grains of arseniate of soda.

Arsenic has a sweetish taste. In moderate doses it apparently neither
undergoes nor produces any changes in the mouth. Dentists employ it
as an escharotic to destroy the exposed sensitive pulp of decayed teeth, or
to destroy the pulp before stopping the tooth. If used to quell pain, the
arsenic may be mixed with opium; it sometimes fii'st aggravates the pain.

We see, chiefly in children and occasionally in adults, a circular rash
on the tongue, which begins at a point, then enlarges, and separate rings
may coalesce. Sometimes the edges are not raised, and the patch looks as
if due merely to separation of epithelium, leaving the surface unduly clean
and smooth ; in other cases the edges are raised, and have a gelatinous aspect.
This affection is often very obstinate, frequently recurring, and is generally
connected with stomach or intestinal disturbance; some cases being always
associated with diarrhaa. Other cases are associated with a rash over the
body, like lichen urticatus. In this affection of the tongue arsenic has
appeared to me to be useful.

The vapor of arsenical cigarettes drawn into the lungs is sometimes
useful to prevent or to lessen attacks of asthma, and in acute and chronic
coryza and chronic i)roncliitis. They may be made by saturating paj^er
with a solution containing fifteen grains of arsenite of potash in an ounce
of water. (Stille. )

These cigarettes may be used in chronic phthisis.

Arsenic given in medicinal doses is very effective in sloughing of the
mouth or throat, malignant sores, as cancrum oris, malignant sore
throat and the like. It is also useful in chronic coryza.

ARSENIC. 217

There are certain curious complaints of the respiratory tract more
or less allied to asthma, which I will now refer to. In these cases of
qnasi-asthma a close of one, two, or three drojis of the solution of arsenic
three times a day often proves serviceable.

I. A patient is seized, perhaps daily, or even several times a day,
generally in the morning directly on rising, or soon after, with an attack
of persistent sneezing, with profuse running from the eyes and nose,
accomjianied sometimes with severe frontal headache. Each attack may
last several hours. Several days sometimes elapse before the recurrence
of an attack, which is then usually severe, lasting twenty-four hours, or
even longer. The sneezing is generally accompanied, and sometimes pre-
ceded, by itching at a small spot situated inside one or both nostrils, not
far from the orifice, but in some cases the itching affects the whole of
the inside and outside of the nose, extending even to the face, sometimes
even to the lips and external meatus. The throat and soft palate may
itch or feel rough. These attacks are excited by exposure to cold, by
dust, strong sunlight, and sometimes from unascertainable causes.

II. We occasionally meet with cases, apparently identical with that just
described, but with this difference— the attack is excited by food, is most
severe after the larger meal, and lasts from twenty to forty minutes. One
]iatient felt itching in the nose, throat and ears, in distinctly periodic
monthly attacks, worse in summer. This attack was brought on by food,
but a chill sometimes brought on a paroxysm.

III. Arsenic is invaluable, too, in another more developed and severer
form. We not seldom find a patient, prone to catch cold, attacked Avith
severe and repeated fits of sneezing, accompanied with profuse clear nasal
discharge, and severe frontal headache. Each attack, generally worse in
the morning, lasts a few days; but, owing to the great susceptibility to
cold, it frequently recurs. Severe itching of the ala of one or both nos-
trils often forewarns the patient of an approaching attack. A simple ir-
ritant like dust may be adequate to excite paroxysm. Continuing in this
form for some time, occasionally for years, the affection may then extend
from the nose, along the throat, to the lungs, j)roducing sore throat, soon
followed by much difficulty of breathing, great wheezing, and free expec-
toration. The lung affection may last for some weeks. When this severe
form has become established the lungs may be attacked without any pre-
liminary affection of the nose or throat.

IV. Again, among children, we not uncommonly meet with a similar,
and perhaps identical, disease. A child, perhaps six months old, under-
goes a severe attack of bronchitis, and thenceforth becomes very prone to
catch cold. Then, on catching cold, he is seized with frequent and inces-
sant sneezing, lasting a variable time, sometimes a few hours, sometimes
three or four days, and resulting in bronchitis, accompanied by much
fever, wheezing, and great embarrassment of breathing, severe enough
even to compel the patient to sit up in bed. The coryza may sometimes
precede the dyspnoea three or four days, the shortness of breath continu-
ing for many days, or even weeks after the cessation of the coryza. It is,
indeed, a form of asthma. The child encounters many attacks in the year,
especially during the winter, and may continue liable to them for years,
and then, perhaps, lose them, or they may engender life-long asthma.

V. Or we meet with cases like the following: — A patient suffers from
asthma for several years, and then is seized with severe attacks of sneez-
ing. These attacks, strange to say, may not occur coincidently with
the paroxysm of dyspnoea, the sneezing takes place in the morning on

218 ARSENIC.

rising, whilst the difficulty in breathing comes on in the afternoon, or at
night.

These cases appear related on the one hand to broiichitic and dyspeptic
asthma, and on the other hand to hay fever. They are allied to the bron-
chitic form of asthma, being excited by dust, cold, and direct irritants;
and to bronchitic asthma, through those cases where the paroxysmal coryza
is always accompanied by a bronchial asthma; and again, to bronchitic
asthma, through those cases commencing as paroxysmal coryza, the disease
extending and becoming complicated with bronchial asthma, or vice verm.
To the peptic forms of asthma this paroxysmal sneezing is related through
those cases where the attack is excited by food; and those where the
patient, a confirmed asthmatic for many years, then becomes afflicted with
paroxysmal coryza, induced by food, the asthma at last ceasing, the coryza
alone remaining. This typical case further illustrates the connection
between ])aroxysmal sneezing and dyspeptic asthma; a child since six
months old is subject to attacks occurring every few months, most com-
mon in winter, beginning with not very severe sneezing, lasting from a
day to a week, often, but not invariably, followed by an attack of bron-
chitis, with much difficulty of breathing, and fever. Even when free
from an attack the child, after a full meal, suffers from stuffy breathing.

The following cases, occurring in the course of four generations in the same family,
show the intimate connection between the intermittent sneezing and astlima, for astlima
was followed in the grandson by hay-asthma, and he begot an asthmatic child, Avho
suffers all the year round from severe attacks of itching and sneezing, not due to pollen,
as was the case with his father; one patient showing that even hay-asthma may be
intiuenced by climate, whilst his son especially exemi^litied the intimate connection
between intermittent sneezing and asthma, for in his case both co-existed, and both
were peptic in kind, being each greatly and mainly intiuenced by diet, and in the case
of his father also by climate.

Mr. H. , aged 35. His grandfather was asthmatic for years, dying clgse upon eiglity
years of age. Mr. H. himself suffered from hay-asthma from babyhood. The attacks
occur only in the .spring during the hay season, and last six weeks. If he goes into a
hay -field, nay, near one, he is stricken immediately with a .severe attack of intense
itching of tlae whole inside of the nose, and of the entire conjimctiva of both eye.%
(though not over the frontal sinus), and of the throat, accompanied b}' violent sneez
ing, and profuse discharge from the eyes and nose. His eyes become bloodshot, and
the lids swell sometimes to such an extent that he can scarcely see. His breathing is
very dilhcult, and without expectoration. So intensely su.sceptible is he, that a field
a great distance off will affect him; nay, if his children play in a hay-field, and then
come indoors he will have an attack. Other flowers besides grass or roses, etc., at this
time will bring on a mild attack, but at no other time of the year. Strong sunlight
also induces them unless protected by large dark-glassed spectacles. Strange to say that
whild severely affeetedin Sussex-, Ms native county, he is quite free in Windermere, in Scot-
land, and in Devonshire, even tliough the grass is in full bloom. Thus, on one occasion when
suffering from a .severe attack, he started for Linton, in North Devon, and after leav-
ing Barnstaple, he began to improve more and more, and while at Linton he was quite
free, though tlie hoiise he lived in was close to a grass field in full lilossom. On one
occasion, whilst yachting in St. George's Ciiannel, but not till the fourth day from
land, he was seized with a severe attack. For the last four years he has inhaled cpii-
niue spray through his nose with marked l)enefit. His sister, twenty-four years old,
has had hay-asthma for the last four years. His son, aged ten, has suffered from
severe asthma since a sharp attack of bronchitis when three years old. He suffers all
the year round almo.st continuously from severe itching inside the nose, in the eyes,
throat, ears, and under the chin. When these .symptoms are aggravated, he has severe
sneezing, with rather free discharge of clear tluid from his nose. Any kind of dust
aggravates the symptoms, but not especially pollen. He suffers also from wheezing,
and when the itching and sneezing are aggravated, from much difficulty of breathing
and violent cough.

All these symptoms are very greatly influenced hy food, thus, the itching, etc., and
the dyspnoea, are always aggravated by pastry, sweets, and especially by a heavy meal

ARSENIC. 219

taken in the evening or late at night. He has been much worse since an attack of the
measles tliree months ago, and subsequently any food, even bread and butter, increases
botli the itching and tlie ditficulty of breathing. He does not easily catch cold at Brigh-
ton, where he is always free from all his troubles, and on one visit to Linton he lost all
his symptoms during his .sojourn there. His stomach has lately been very delicate, so
that he vomits very readily. He is very flat-chested and round-shouldered, he wheezes
loudly, and his expiration is very greatly prolonged.

The following interesting and instructive family history throws much
light on the affinities of these ciirions complaints. A woman when young
suffered from bronchial asthma, which left her for some years, and then
she became affected with hay-asthma. She bore two sons. One, aged
nineteen, has suffered for two years every morning during the summer
from violent attacks of sneezing, and profuse watery discharge. These
attacks are not excited by hay nor the smell of flowers.

Another son, aged thirty, has been subject to asthma and bronchitis
since five years of age. It began, and for a long time continued, of the
same character as that so often seen in the commencement of asthma, es-
pecially in young children, beginning by an attack of cold in the head,
with fever, lasting ai)out three days, followed by about nine days of
asthma. (See Aconite.)

The bronchial asthma of the mother was most severe in the winter. From this she
quite recovered, and remained well for several years; but during the last ten years
she has suffered from well-marked hay-asthma, the attacks being apparently solely due
to hay.

Her son, aged 19, for two years has sutfered from violent attacks of sneezing and
much running from the nose, the paroxysms lasting sometimes for hours. They are
accompanied by much itching of the whole inside of the nose. There is no dyspncea
or wheezing. These attacks occur chiefly in the morning, directly he gets up, but they
may seize him at any hour of the day. He can go into a hay-field, or smell flowers,
without producing the slightest trace of an attack. They are brought on by dust and
strong sunlight; these being the only causes he has detected, but he cannot account
for those attacks beginning directly he gets out of bed. The complaint lasts the whole
summer, leaving him in the winter. The attacks are not affected by food.

His brother, aged 80, has suffered from bronchitis and asthma since five years old.
At first the attacks began with cold in the head and fever, without much sneezing.
This stage lasted about three days, when his throat became slightly sore, and next
bronchitis set, in. To use his own words, he has generally three days' cold in the
head, and nine days asthma, tlnnigh sometimes the asthma lasted much longer,
indeed, sometimes continuing for mouths. As he has grown older, the attacks have
undergone considerable modification. The chest symptoms begin with a cold in the
head, or may occur without it. He is obliged to take the greatest care, for the chill
brings on an attack. Strange to say, conditions which at one time induce an attack are
inoperative at another. Thus, he can sometimes join a hay party without being
affected, yet at otlier times, going into a stable, or passing a hay-cart, not to mention
going into a hay-field, brings on a violent attack. Dust, as house dust, builders' dust,
excites an attack; so does strong sunlight or flowers. An attack induced by any of
these agents, consists in itching of the nose, violent sneezing, with jirofiise discharge
from eyes and nose, the itching and discharge being usually most marked in the left
nostril, though sometimes the right nostril is implicated. In addition, he suffers from
dyspnoea. The coryzal symptoms always occur in the day, the dyspnani at night.
When troubled with asthma, the dyspna?a is considerably aggravated by food, which,
however, at any other time does not produce any tightness of tiie breath.

Strong black coffee, even the smell of it, immediately relieves the dyspnoea, but is
without effect on his coryza.

The fumes from Ilimrod's powder wonderfully relieve both the coryza and dysp-
noea. All inhalations, with the foregoing exception, "tighten him up everywhere,
even in his nose and throat. ' '

In some cases the irritability appears to be limited to the nasal mucous
membrane, or even to a very limited portion of it. In other cases, after

220 ARSENIC.

continuing in this form for some time, tlie mucous membrane of the tliroat
may become involved, and subsequently the bronchial mucous mem-
brane; or vice versa, beginning at the bronchial mucous membrane, the
irritability may involve the nose. In either case the disease may quit
the portion of mucous membrane originally affected, an incident" most
common when the attack first affects the territory of the fifth nerve.
Indeed, in my experience, this is not an unusual way for asthma to be-
gin in children; and as they grow u]), the coryzal symptoms cease, and
ordinary bronchitic asthma alone remains.

On the other hand, these cases of paroxysmal coryza are related to hay-
asthma, which, indeed, appears to be the same disease, but, owing to the
patient's idiosyncrasy, the attack is induced only by the pollen of plants;
the similarity between these affections being shown by the fact that in
each the mischief may be limited, to the nose, frontal sinuses, and. eyes,
or extending further, may involve the lungs.

Mr. Blackley, in an admirable paper, sliows that in his own case, and
in some other instances, hay asthma is solely due to the irritant effects of
the pollen of plants. He conducted an extensive series of experiments
with the pollen of many grasses, cereals, etc., and found that all are capa-
ble of exciting an attack, although some kinds of pollen are more active
than others. The pollen of poisonous plants is not more virulent than
that of harmless plants; indeed, he finds that pollen of solanaceous plants
will excite a slight fit, while the pollen of wheat excites a very severe
attack. In his own person, and some other cases, he clearly shows that
all the agents hitherto supposed to be severally productive of asthma, as
ozone, heat, strong sunlight, the volatile principle on which the odor of
plants depends, oleo-resins, dust, unless it contains pollen, are powerless
to produce a paroxysm. In other cases it appears that one or more kinds
of pollen only will produce the attack. Thus, rose-pollen excites the at-
tack only in some patients; and it is said that in America Koman worm-
wood is a freqiient cause. Hay- asthma and the diseases just described are
indeed identical, but, owing to individual idiosyncrasy, the attack is in-
duced in one person b}^ one irritant, and in another by a different irritant.
In some cases the attack, as we have seen, is induced by pollen, in other
cases by ipecacuanha, or by animal emanations, as from rabbits, cats,
horses, the smell of mustard, feathers, or a /privet hedge, etc. Dr. W.
Smith, of Preston, narrates a case in which a linseed poultice provoked
the symptoms of hay-asthma. In one case an attack was alwa3's induced
by porridge. Simple dust will occasionally excite these symptoms, and
sometimes one kind of dust only. Thus, a middle-aged man, an iron-
monger, had suffered from paroxysmal coryza and asthma for two years,
the attacks being brought on only by the dust of his shop; Avhilst other
kinds of dust, as that of a road, failed to affect him; nor did flowers,
grasses, etc., nor sunlight. This case was singular in this respect, that
whilst only the dust of his shop excited coryza and asthma, yet in certain
localities he suffered at night irom simple asthma without coryza. Xot-
withstanding Mr. Blackley's careful and elaborate experiments, I cannot
help believing that sunlight and great heat will in some persons bring on
an attack without the intervention of pollen. I have known persons who
could never look at the sun without it inducing violent sneezing. It is
well known, of course, that strong sunlight and great heat will much ag-
gravate the attack induced by poflen.

The itching and tingling Avhich generally accompany paroxysmal
sneezing, no matter Avhat their exciting cause, may affect the whole or any

ARSENIC. 221

part of the nose. Sometimes tlie tingling and itching are felt near the
orifice, or inside under the bridge, and may extend to the cheek or to the
eyes, how and then only to the inner canthus, and maybe limited to this
part, or they may affect also the palate or throat. I remember the coryza
in one case was accompanied and prob'ably excited by itching of the nose
and soft palate, and that iodine inhalations at once removed the coryza
and nasal itching, but left unaffected the itching of the palate, which
ceased at once on the application of a little nitrate of silver.

It is interesting to observe the very different degrees of development
of the disease. In certain cases the attack in some seasons appears to
be limiied to paroxysmal severe itching of the inner canthus. In other
cases, even of true " hay-fever," the irritant excites only this itching of
the inner canthus ; though at other times it also excites paroxysmal sneez-
ing, or the attack may at first be limited to the itching, but as it goes on
sneezing and profuse watery discharges are superadded. In other in-
stances, besides the itching and sneezing, the i)atient suffers from bron-
chitis and dyspnoea. In another group of cases the irritant only excites
bronchitis and dyspnoea. In yet another set of cases a patient has vio-
lent attacks of sneezing, generally occurring in the morning without any
itching.

Arsenic in many of these cases is most efficacious, quickly affording
relief in some, but in others requiring ten days or a fortnight to mani-
fest its remedial effect, while in yet other cases it altogether fails. I find
it of little or no value in true hay fever, that is, where the paroxysmal
sneezing is excited by pollen. Where there is fever, aconite (see x\.co-
nite), if given early, curtails the course of the attack considerably. Cases
unyielding to arsenic are sometimes benefited by iodine inhalation, by
the administration of iodide of potassium, or by veratrum viride. The
case of a young woman, twenty-two years of age, who for several years
had suffered with attacks of sneezing like those described, well illustrates
the value of local applications. The fits occurred in the morning, lasted
several hours, were accompanied by considerable pain over the forehead,
and the saeezing was so violent that she be-^ame quite exhausted, and so
remained the greater part of the day. She complained also of great itch-
ing over the whole of the inside and outside of the nose and part of the
face, which continued as long as the sneezing. Her health was failing
her, and her hair was growing very thin. Arsenic benefited her very
slightly, while iodine inhalations, the internal administration of verat-
rum viride, pulsatilla, iodide of potassium, bromide of potassium, and
cod-liver oil were found useless. Then aconite liniment to the outside
of the nose and itching part of her face, immediately subdued the attack,
removing both the itching and the sneezing. The attacks of sneezing
recurred very slightly, and a fortnight's persistence with the treatment
cured them. Cocaine applied to the nose will, in most cases, cut short
an attack, and some patients derive benefit by snuffing up hazeline.

The changes which arsenical compounds undergo in the stomach are
at i:)resent unknown. There is no proof that, like most other metals,
arsenic combines with albumen to form an albuminate. The uniform-
ity of action of all soluble arsenical compounds renders it probable that
either in the stomach or the blood, they ultimately become identical in
composition. Metallic arsenic, like the oxide, is poisonous; it is proba-
bly first oxidized before it becomes active. Pure sulphide of the metal
is inert, but, as it generally contains a not inconsiderable quantity of the
oxide this admixture renders it poisonous.

222 ARSENIC.

The condition of the stomach is said to control the action of arsenic;
for example, when food is present, the medicine becomes absorbed by the
lacteals, and throngli them mixed with tlie blood, while if the stomach is
empty the arsenic is absorbed by the veins, and, passing into the liver, is
separated with the bile.

In small medicinal doses, arsenic excites a sensation of warmth at the
epigastrium, and gives rise to a sensation of hunger; indeed many main-
tain that arsenic, while increasing appetite, promotes digestion, which
others as strenuously deny. Arensic, as we shall see hereafter, by remov-
ing or lessening a morbid condition of the stomach, promotes digestion and
appetite.

In certain diseases of the stoQiach few remedies are more useful than
arsenic. In the so-called irritative dyspepsia, where the tongue is furred,
and its papillse red and prominent, a drop of the sulution of arsenic, taken
shortly before food, will be found of great benefit. Administered in the
same manner, it will arrest the distressing vomiting of drunkards with
almost unfailing certainty, and simultaneously improve the state of the
stomach, and restore both appetite and digestion. This vomiting, accom-
panied by great straining and distress, usually occurs in the morning
before breakfast; and mostly very little, and sometimes nothing, is ejected,
and then it is called dry vomiting. The vomit is generally intensely
bitter, sour, and of a green color.

Arsenic is valuable in chronic ulcer and cancer of the stomach, allaying
the pain and checking the vomiting; and I have seen this metal give relief
in chronic ulcer, after failure of the commonly-used remedies. It is
sometimes useful in the vomiting of pregnancy.

Arsenic sometimes removes heartburn, and other distressing sensations
of the stomach, and is very useful in gastralgia. It is probable that some
of the cases reported to be cured by arsenic and supposed to be cases of
ulcer of the stomach, were really cases of gastralgia.

Small doses of arsenic are serviceable in that form of chronic vomiting,
when, after eating, the patient mostly rejects his meal without pain, and
with scarcely any naiisea, the food simply regurgitating into the mouth.

It has been recommended in the vomiting of cholera. It is often
useful in the vomiting of pregnancy.

The solution of arsenic is always of service in that form of chronic
dyspepsia and diarrhoea characterized by the following symptoms: — A
sinking at the pit of the stomach, which is relieved by food; but imme-
diately on taking it, nay, even during mastication, an urgent desire seizes
the patient to relieve the bowels, which may constrain him to quit the
table. The motions are solid, or se}ni-solid, usually containing lumps of
half -digested food. The disease appears to depend on excessive peristaltic
action of the stomach and intestines whereby the food, before it is di-
gested, IS driven from the stomach to the intestines, and thence expelled.
This form of diarrluiea is common with children, eight or twelve years of
age, and may last many months. Arsenic in a few days will prolong the
interval between the meal and the evacuation, and in a week or ten days
the disease will give way. I always give one or two drops shortly before
each meal. (See Opium.) Arsenic often proves useful in other chronic
forms of diarrhoea, even Avlien due to serious organic disease, as the bowel
ulceration of phthisis, etc.

Arsenic has been strongly recommended in cholera; especially in the
later stages, when there is much collapse.

Arsenic enters the blood freely, but the effects of this metal on it are

ARSENIC. 223

unknown. It has been detected not only in tliis fluid, but in most of the
organs of the body.

In frogs, according to Sklarek, in about five minutes after poisoning
by arsenic acid, the animal lies flat, with extended extremities and without
breathing. Pinching, or other irritation, excites neither reflex action nor
voluntary motion, though much voluntary power remains, since, on lift-
ing the animal, or withdrawing a leg, or turning the frog on its back, it
displays active voluntary movements. In a short time, however, the animal
becomes completely paralyzed. Arsenic, therefore, paralyzes first sensation
and reflex action, and some time afterwards voluntary power. This account
of Sklarek's corresponds Avith my observation of the order in which the
symptoms occur after poisoning by potash, or in mechanical arrest of the
circulation during the summer months. My experiments with arsenious
acid, dissolved with the aid of a small quantity of soda, made in October,
do not agree Avith Sklarek's account; for I found that sensation and reflex
action persisted as long, or longer, than voluntary power.

Sklarek attributes the general paralysis to the action of arsenious acid
on the cord. My own experiments, conducted with Dr. Murrell, confirm
this statement; but they show also that arsenious acid is a paralyzer of
the motor and sensory nerves, and of the muscles; in fact, like potash,
tartar-emetic and aconitia, it is a protoplasmic poison, destroying the
functional activity, first of the central liervous system, next of the nerves,
and last of the muscles.

Arsenious acid quickly arrests the heart of cats and frogs, and probably
of other animals when administered in large doses. This effect is due to
the direct action on the heart; for arsenious acid arrests the frog's heart
when removed from the body. As arsenious acid is a protoplasmic poison,
I suggest that it stops the heart by alfecting all its structures, its ganglia,
its nerves, and its muscle. Arsenious acid lowers arterial tension; partly,
it is thought, by its influence on the vaso-motor nerves, but also owing to
its action on the heart. Bolim and Unterberger find that arsenic especi-
ally reduces arterial pressure in the abdominal vessels.

Lesser concludes from his experiments that paralysis of the heart is preceded by
slight and transient increased irritabihty, accelerating the heart's beats in warm-blooded
animals. Large doses, however, at once decrease the heart's action, and the blood-
pressure at once falls in the aorta. He attributes the increased frequency of the pulse
to depression of the vagi and stimulation of the cardiac ganglia. The depression from
large doses he ascribes to depression of cardiac ganglia and stimulation of vagi. The
vagi, he believes, are first stimulated and then depressed. Arsenic, he finds, does not
affect the accelerator nerves, nor the vaso-motor centre, nor vaso-motor nerves, nor the
muscidar tissues of the vessels.

Arsenic at first stimulates, but larger doses soon extinguish the irritability of the
respiratory centre. The primary stimulation is never great. Small dosgs stimulate
the terminations of the pulmonary vagi. Arsenic increases peristalsis of the intestines
by direct action on the ganglia in the intestinal walls.

He finds also that arsenic diminishes the irritability of the motor nerves and mus-
cles, and first stimalates and then paralyzes the spinal cord. His experiments, then,
for the most part confirm my conclusions that arsenic is a protoplasmic poison; but
he finds tliat it first sliglitly and transiently stimulates many structures.

Dr. Murrell and I noticed that in ten to twenty minutes after injecting
a small quantity of arsenic under the skin of a frog the animal gapes,
keeps its mouth open, and sometimes puts its paws into its mouth; it
looks as if sick, and some frogs actually vomit. Arsenic, therefore, acts
as an emetic to frogs.

Dr. Murrell and I were astonished to find how very fatal arsenious

224 ARSENIC.

acid is to frogs, for ^of g-o ^^ ^^^^ weiglit of the animal produced complete
paralysis in lOS minutes, and ^jroTTo killed the frog on the third day. \Ve
found that frogs are much more influenced by arsenious acid dissolved in
a small quantity of soda than by arseniate of soda; one-fifth of a grain of
arseniate of soda requires eleven hours to produce complete paralysis.

The statonents as to the effects of arsenic when taken for a prolonged
period are sti-angely conflicting; yet probably all are true, though at
present it is impossible to reconcile the opposing statements.

Some animals, as the horse and sheep, can take considerable quantities
of arsenic, not only without harm, but with apparent benefit.

It is now established beyond reasonable doubt, that in some parts of
Lower Austria, as Styria, many of the inhabitants are accustomed to take
considerable quantities of arsenic, sometimes as a condiment with food.
It is said they often eat it with cheese. They usually begin with a small
dose, once or twice a week, the quantity being gradually increased, until
half a grain, or a grain, or even more, is taken at one time. This habit
seems to induce no untoward symptoms. Arsenic is eaten for a twofold
purpose. The women, and even the men, take it to clear the complexion,
and to improve the personal appearance; and it is said to effect these
objects. The men more frequently use it to enable them to undergo
great exertion without fatigue, and they maintain that it enables them to
climl) mountains and accomplish fatiguing tasks, impossible to accomplish
without it. The experience of most countries is opposed to the Styrian
practice; for it is generally found that the long-sustained administration
of arsenic fails to niduce tolerance of the drug, but, on the contrary,
entails serious consequences. Even in the arsenic-eating countries, the
habit is not without risk; for there it is a general opinion that many fall
victims to the drug. It has been supposed that, taken in an insoluble
form, the arsenic is not absorbed at all, but passes out with the motions,
leaving the system unaffected by it; but Dr. Maclagan's investigations
effectually disposed of this supposition, for after witnessing a Avell-known
arsenic-eatei eat arsenic and afterwards collecting his urine, a considera-
ble quantity of the poison was obtained from it.

Ordinary experience, however, shows that the long-continued use of
arsenic produces serious symptoms, evidenced first in the eyes and stomach.
The eyelids become slightly oedematous, the lower before the upper;
while usually at the same time, or soon after, slight conjunctivitis occurs
with suffusion and smarting of the eyes, and sometimes dimness of sight.
The mucous membrane of the nose, mouth and throat may be reddened
and inflamed, giving rise to thirst and dryness of the mouth and throat.
In some, the digestion becomes deranged nnich sooner than in others. The
appetite fails, and at the pit of the stomach a sensation of weight or sore-
ness is felt, aggravated each time on taking" food or the arsenic. Some-
times the stomach is affected before the eyes. On the appearance of any
of these symptoms the drug must be given in smaller quantities, or be
discontinued. The skin becomes dry and dirty-looking, and a slight
"branniness" maybe noticed, most marked where the skin is covered
with clothes. Eczema or urticaria may arise, or perhaps vesication or
mere desquamation with tenderness of the palms of the hands or soles of
the feet. Arsenic is said to have produced pityriasis and lichen and aching
pains in the head, and swelling and inflammation of the joints. Sleep
may be much broken, or disturbed by dreams. Still more serious symp-
toms set in. The voice becomes rough, and in some cases salivation takes

AESENIC. 225

place. Ulcers may form in the mouth. Nausea, vomiting, and diarrhoea
set in with slimy and bloody motions, voided with much straining and
pain. The hair, and even the nails, sometimes fall olf. Cough with
bloody expectoration, may occur. With these serious symptoms the
patient wastes away, the skin becomes dry and hot, the pulse frequent,
especially at night. Pains in the limbs, neuralgic pains, anaesthesia,
tremblings, and even paralysis, come on; till at last the memory fails,
sensation is lost, and death soon follows. The susceptibility to arsenic
varies; some being speedily affected by two-drop doses of the arsenical
solution, while others can take ten to tAventy drops without injury for a
considerable time. ' Dr. McCall A.nderson states that patients while taking
arsenic are liable to bronchitis, and should therefore be cautioned against
exposure to cold.

In some persons very small doses inhaled for a long time will induce
serious symptoms, and many cases are recorded, where serious symptoms
arose from the use of wall papers whose pigments contained arsenic.
Arsenic is largely used in the formation of pigments other than green.
Arsenical pigments are largely used in cretonnes,

Gies finds that the prolonged use of arsenic in increasing doses con-
tinued for months, has the same effect on the bones of rabbits, pigs and
fowls, as phosphorus. The bones become more compact; these changes
beginning in about three weeks. The animals became heavier and fatter,
and there occurred fatty degeneration of the heart, liver, kidneys, and
spleen.

A large dose induces the symptoms of acute poisoning. The arsenic
acts as an irritant to the whole digestive canal, exciting very active in-
flammation in its delicate mucous membrane; accordingly the symptoms
to be expected from severe inflammation of this tract set in. But, strange
to say, the symptoms following a large poisonous dose are not invariable;
the symptoms arising from acute inflammation of the digestive canal are
most common, and prove fatal in four or five days; but sometimes the
symptoms are almost or entirely absent, and instead of the patient running
the usual course of arsenical poisoning, profound coma sets in, from which
he never wakes, but dies in a few hours, the mucous membrane of the
stomach and intestines being free from all inflammation. Sometimes the
symptoms are very like those of English cholera.

At the post-mortem the intestines are filled with rice-water fluid, with
epithelial flakes, the epithelium being in a state of advanced fatty de-
generation. The solitary and agminated glands are much swollen.

Dr. Biachez describes another form of arsenical poisoning character-
ized by choleraic symptoms of the intestinal canal, with suppression of
urine, cramps, and progressive coldness of the body, convulsions, and
localized paralysis especially attacking the extensors. If the patient
survives long enough, a petechial, papular, vesicular and wheal-like rash
often appears from the second to the fifth day.

A fatal does of arsenic lowers the temperature of dogs and rabbits
4° to 7° Fah.

Even when injected into the blood, or applied to a wound, arsenic
produces its local effects on the digestive canal, being found in the intes-
tines, showing that this is one outlet by Avliich the poison is eliminated.
When the metal is injected into the blood, or absorbed by a wound, the
effects on the stomach and intestines are said to be as severe as when it is
swallowed. This is perhaps hardly true. It is evident from the foregoing
15

2l>(; AESENIC.

facts that arsenic manifests an especial affinity for the mucous membrane
of the intestinal canal.

The post-mortem examination in acute arsenical poisoning shows much
inflammation of the stomach, often in patches, in which arsenic powder
is visible, embedded in the thick viscid mucus. Spots of ecchymosis are
sometimes seen, and less commonly ulcerations. Perforation is rare.
The oesophagus and intestines may undergo inflammation, often most
severe in the rectum. Occasionally the mouth, throat, and even windpipe
and bladder, become inflamed. The curious fact has been pointed out,
that notwithstanding the existence of symptoms of inflammation, yet
sometimes no traces of it are apparent after death. This al)sence of in-
flammation cannot be explained by want of time for the arsenic to act;
for in cases ending in death yet more rapidly, severe structural changes
are to be found. Death may occur in two hours. Ecchymosis is com-
monly met with under the lining of the cavities of the heart, and if the
patient survives long enough, a petechial, papular, or pustular rash, or
wheals of urticaria may occur. Neuralgic pains, anesthesia, and paralysis
are sometimes seen. Like phosphorus, it produces extreme fatty de-
generation of the liver, heart, kidneys, and other structures. Ether, and
even chloroform are said to jiroduce similar effects. Both in arsenical
and antimonial poisoning the glycogenic function of the liver is said to
be destroyed. Arsenic retards putrefaction.

Drs. Cutler and Bradford, from their experiments conducted accord-
ing to Malassez's method, are led to conclude that "arsenic given in
health causes a progressive decrease of the number of the red and especi-
ally of the white corpuscles. In simple anemia, on the contrary, there
seems to be an increase at first of both red and white corpuscles. After
a certain point there is a steady diminution of both." Arsenic is useful
in chlorosis and ana?mia, sometimes succeeding when iron fails and dis-
agrees. Some hold that the addition of arsenic increases the efficacy of
iron. It is the most successful remedy in pernicious antemia, and some
recommend it in leucocythajmia and lymphadinosis. Large doses will,
in some cases, entirely reduce the excess of white corpuscles in leucocy-
thffimia, but apparently have little influence in increasing the quantity
of red corpuscles. Arsenic, in moderate doses, it is said, gives fulness
and increased strength to the pulse. Some give arsenic in prostrating
acute febrile diseases, with the effect, so they aver, of strengthening the
pulse, moistening the skin, and invigorating the patient. Arsenic is
useful for the swelled feet of old or wenkly persons; or for old j^eoi^le
with a weakly acting heart and feeble circulation, who often suffer from
breathlessness on exertion.

Arsenic has long been recommended as an excellent remedy in spas-
modic diseases of tlie lungs; it is often useful in asthma, whether or not
dependent on emphysema.

Arsenic often gives great relief to a class of emphysematous persons
who, on catching cold, are troubled with a slight Svheezing at the chest,
difficulty of breathing, especially on exertion, or at night time, and are
obliged to be partially propped up in bed; it appears, however, to be of
little service when there is very much bronchitis, or when the paroxysms
of dyspnoea are very urgent. In this contingency lobelia or belladonna
answers better. Arsenic is especially useful in the foregoing cases, where
the difficulty of breathing can be connected with the retrocession of a rash,
as eczema. Arsenic generally relieves the wheezing with oppressed
breathing, which affects some children for months and even years, and is
probably tlie commencement of asthma.

ARSENIC. 227

Arsenic lessens the carbonic acid of respiration.

The beneficial influence of arsenic in certain skin diseases, particularly
in the scaly eruptions and in chronic eczema, is universally recognized.
Lepra almost always yields to it, and its efficacy over other forms of
psoriasis is hardly less marked. Many cases it cures, others it improves,
but a few it leaves unbenefited.

Hunt, who has had more experience of this remedy than perhaps any
other person, laid down excellent rules for guidance. He recommends
small doses as capable of effecting all that is possible by arsenic, and dis-
countenances the practice of gradually increasing the dose. If toxical
effects arise he advises, not the discontinuance but the diminution of the
dose.

Arsenic is hurtful during the inflammatory stages of eruptions.

Children above tive years will bear a dose nearly as large as adults; and it is curi-
ous that girls often require a larger dose than boys.

The largest dose ever required is five minims, repeated three times a day; but some
practitioners give double or even treble this quantity. As a rule it should never be
given on an empty stomach.

Arsenic, if mixed with food, does not usually irritate the bowels. In the course of
a few days or weeks it will produce an itching or smarting in the conjunctiva, and
this membrane will appear slightly inflamed, the lower eyelid becoming a little puffed
or swollen at this point. The cutaneous disease will now begin to decline, and the dose
must be reduced one-fifth.

Should the conjunctiva continue much inflamed, the dose must be still further
reduced, but the conjunctiva should be kept affected throughout the whole course.

If the skin become more inflamed, the course must not be interrupted, but an occa-
. sional aperient must be taken.

The arsenical treatment must be continued for as many months after the final dis-
appearance of the eruption as it has existed years before.

These rules closely correspond to the advice given by Dr. Graves in
his clinical lectures. "With two statements made in this " code of regula-
tions," my experience does not quite correspond, for I have not found
that smarting of the eyes and swelling of the lower lid occur so often as
IMr. Hunt implies, nor do I find it necessary to induce these toxic symp-
toms to insure the beneficial influence of the remedy.

The first influence of arsenic on psoriasis is to make it redder, more
inflamed, and to look worse than before treatment, a fact which, if not
known, would lead to the suspension of the drug just when it commenced
to do good; but the exaggerated redness soon declines, the eruption heals
in the centre, leaving in a short time only a slight redness.

Chronic eczema, although perhaps not so amenable to arsenic as psori-
asis, is generally benefited Ijy it, especially the obstinate chronic forms.
It sometimes removes the rebellious eczema which infests the vulva, the
verge of the anus, and the scrotum.

Arsenic will generally cure that troublesome disease pemphigus, as
Mr. Hutchinson has shown; and although after a variable interval the
eruption is liable to recur, it will again yield to a renewed course of the
drug.

Arsenic sometimes relieves lichen and other obstinate skin affections.

In our experiments on arsenious acid and tartar-emetic, published in
the Journal of Phi/siologi/ for 1878, Dr. Murrell and I found that these
two substances produced desquamation in frogs. Thus, after poisoning
by arsenious acid, even with only ^ ,. ^ o „ part of the weight of the animal,
desquamation begins on the trunk in about five hours, in the legs in about
eight hours. The cuticle strips off in large pieces, so readily that mere

228 ARSENIC.

handling the animal detaches it. Tartar-emetic affects the cuticle appar-
ently in a somewhat different way; it changes the cuticle into a pulp or
jelly, so that even whilst the frog is alive it can be scraped but not torn
off. We conclusively showed that these effects are due to the direct
action of arsenious acid and tartar-emetic on the skin.

Does arsenious acid affect all epithelial structures in this way ? I think
so. Miss Nunn has shown that it affects the cornea. And after acute
poisoning the bow^els are found filled with a rice-water fluid, consisting of
epithelial flakes, and the epithelial cells are choked wnth granules, and
some in a state of advanced fatty degeneration, and these changes occur
even when the poison is injected into a vein.

Miss A. Xunn, Lecturer on Biology in the Wellesley College, Boston,
U. S. A. , under the direction of Dr. Michael Foster, kindly investigated
microscopically the action of arsenious acid and of tartar-emetic on the
skin. Miss Xunn shows that the peculiar effect of these substances is
limited to the epidermis and leaves unaffected the corium, with the ex-
ception of increasing the quantity of blood it contains. Miss Nunn says:

"An examination of a series of sections taken from different parts of
the body at different intervals after the (hypodermip) introduction of the
poison, "shows that the general effect of arsenious acid on the epidermis is
to cause a degeneration, and partial solution, of the protoplasm of the
cells, Avhereby (1) the whole epiderm becomes loosened from the subja-
cent derm, (2) the cells of the malpighian become incoherent, so that the
whole layer collapses, and its well-known architectural features become
obseurcdj and (3) the intermediate layer separates from the malpighian
laver below, and at times from the corneous layer above. The corneous
and intermediate layers are th"s desquamated, sometimes separately, some-
times, and perhaps most frequently, together. In no case, even in those
of most extreme or most lengthened poisoning, have I ever seen the mal-
pighian layer actually cast off during life; it always remains attached,
though loosely, to the" derm in a manner which I shall presently describe.
In preparing sections, however, it frequently becomes wholly detached.

" It is obvious from the foregoing account that the arsenic first attacks
the lowermost or innermost portions of the epiderm, and that its action
advances from the derm outwards. This may be in part due to the simple
fact that the innermost cells are those which are nearest to the blood-
vessels carrying the poison; but this can hardly be the whole reason, since
diffusion must be very rapid tbrough a thin membrane of such a nature
as the epidermis. It seems more natural to attribute the phenomena to
the fact that the cells of the malpighian layer next to the derm (the colum-
nar layer) are composed of more active, more irritable protoplasm than
that of the rest of the derm, the irritability diminishing in the series of
cells from within outwards in proportion as the metamorphosis of the
protoplasm into keratin becomes more and more pronounced.

" I never observed any excess in the fluids excreted by the skin gener-
allv as the result of arsenic poisoning, and it is impossible to explain the
changes described above as merely due, or as chiefly due, to an excessive
discharge of fluid from the cutaneous blood-vessels or lymphatics loosen-
ing and separating the cells. All the facts go to prove that the changes
are the result of the arsenic acting directly on the epidermic cell, which
Avith its diminished cell-substance and shrunken nucleus, presents a strik-
ing analogy with the secreting cell (of a salivary gland) Avhicli has ])een
stimulated' to exhaustion; and I shall probably not go far Avrong in regard-

ARSEisric. 229

ing the changes of the former as the consequences of an action of the poi-
son not wholly unlike an excessive, in fact, a lethal stimulation, by which
the destructive stages of the metabolism of the cells are hurried on beyond
the reparative power of the constructive stages.

" The stimulation is obviously of a peculiar kind. One marked effect
of the stimulation of undifferentiated protoplasm is to forward and accel-
erate processes of growth. I have looked diligently for indications, such
as double nuclei, etc., of multiplications in the epidermic cells, but always
in vain. One would naturally expect that the changes which I had de-
scribed would, if the animal lived and recovered from the poison, be fol-
lowed by a rapid renewal of the epidermis, but I have not as yet suc-
ceeded in xeeping the animals long enough to see even the first trace of
it. I may remark incidentally, that the fact of the columnar layer being
the first to be attacked by the poison may perhaps be regarded as an indi-
cation that the growth of the epidermis does take place from this layer,
and not, as recent researches on the structure of the mammalian epiderm
have suggested, from the cells of the intermediate part.

" The characteristic vertical arrangement of the undermost cells, the
columnar layer of the epiderm, is a phenomenon for which it is very diffi-
cult to account. Embryologically considered, this feature seems to be a
continuation of the condition of the primary epiblast, the cells of which
are always vertical; but it is difficult to see what purpose is served by the
preservation of this ancestral feature. It is obvious, however, from the
results which I have given, that this vertical position is maintained (for
whatever reason) by some exertion of the protoplasm of the constituent
cells. Immediately that the arsenic damages the protoplasm, the vertical
arrangement is lost: indeed this is the most obvious effect of the arsenic,
and the one most readily recognized."

Concerning the action of antimony she says: '' The structural changes
in the epidermis brought about by antimony are essentially the same as
those produced by arsenic. There is (1) the same marked degeneration
and partial solution of the columnar layer which causes the e^iidermis to
be held less firmly to the dermis; though previous to the hardening, the
extreme softness of the cells prevents it from being stripped away as can
be done in the case of arsenic. There is (2) the same degeneration and
separation of all the cells of the malpighian layer, and (3) the same des-
quamation of the corneous and intermediate layers. The principal differ-
ence is the greater softness, or more complete isolation of the cells, and
the somewhat more marked change in the intermediate layer. The cells
of this layer appear more thoroughly detached from one another, and
hence cavities are more frequently found between them: but their proto-
plasm is never formed with threads and processes enclosing spaces, as in
the columnar cells. It is this separation of the constituent cells of the
intermediate and also of the malpighian layer which is the chief determin-
ing cause of the pulpy or mucilaginous condition of skin in antimony poi-
soning mentioned by Ringer and Murrell. Altogethei*, the action of
antimony is more rapid than that of arsenic, and the changes produced
by it bear evidence of more violence. But the marked change in the
columnar cells remains the most characteristic feature among the struc-
tural changes produced by both arsenic and antimony poisoning.

" Both these drugs, then, have a specific effect upon the cells of the
epidermis, the one differing slightly only from the other in their funda-
mental action, though the results appear to the naked eye to diverge so

230 AKSENIC.

largely. The skin, under the influence of either drug, presents a striking
contrast to one which has been left to disintegrate in a natural manner
after death. I have examined the skin of frogs at intervals of one to
seven days after death, but I have never observed the peculiar changes
which I have described above as taking place in the columnar cells. The
cells of the whole epidermis become granular and more opaque, and the
outlines of the cells become indistinct; the corneous layer may be thrown
off, and the features of the malpighian layer become, eventually, very diffi-
cult to recognize; but at no stage does either the protoplasm of the cells
become softened in the peculiar manner described, nor do the nuclei
become shrunken. The desquamation under antimony and arsenic is
obviously a specific effect." Miss K^unn finds that arsenious acid and
tartar-emetic affect the cornea in a similar manner to the skin, but the
effects are never so marked as in the skin. It is interesting to observe
how these exjjeriments confirm the conclusions previously arrived at by
clinical study. These investigations show that arsenic affects the epi-
dermis mainly, if not exclusively, and leaves the dermis unaffected. Dr.
Duhring, in Wood's " Therapeutics," says that diseases affecting the
more superficial parts of the skin are most amenable to the influence of
arsenic, and that it possesses little or no influence ujjon diseases seated
in the deeper structures of the skin. It has no effect upon infiltrations
of the corium. If long continued, arsenic turns the skin a dirty brown,
and this discoloration is especially marked around the orifices of the hair
follicles. The color is very like the discoloration of Addison's disease.

Few, if any, remedies are so successful in chorea as arsenic. If there
is much anaemia, iron is required; if fever or rheumatism, these must be
subdued by appropriate treatment. But in simple uncomplicated cases of
chorea, arsenic is far the best remedy. Its occasional non-success is some-
times owing to the undue smallness of the dose, and decided improvement
often begins simultaneously with a freer administration of the medicine.
When chorea has resisted smaller quantities, children may take four, five,
or more minims of the solution. In one case which rapidly improved, I
quickly increased the dose till the boy took twenty minims of liquor arsen-
icalis six times a day, and in another successful case the girl took fifty
minims of liquor daily. Dr. Seguin gives two to five minims at first and
quickly increases, adding a drop to each dose daily. If arsenical symp-
toms arise, he intermits the arsenic for forty-eight hours. He finds that
with most patients, doses of 20, 25 or 30 drops thrice a day may be
reached. Perrorid uses arsenic hypodermically with great success. Arse-
nic is well borne this way and does not derange the stomach.

Arsenic is often useful in neuralgia. Dr. Anstie speaks highly of it
in various neuralgias; and in angina pectoris, a disease he regarded as a
neuralgia, he states that it will lessen the severity of the attacks, and in
time reduce them to mere " tightness of the chest."

Arsenic has been found serviceable in epilepsy. It not unfreqnently
ciires dull throbbing pain affecting one brow.

With the exception of quinia, no drug subdues intermittent fever like
arsenic. Some indeed, with large experience, count arsenic equal, if not
superior, to bark in ague. The greater number of observers, however,
do not credit arsenic with such pre-eminent virtues, maintaining that cin-
chona cures tlie disease more quickly and more certainly, and that it is
especially to be preferred in those malignant forms which, unless at once
arrested, speedily destroy life. A concurrence of testimony tends to show
that arsenic is most useful in long-standing agues, especially of the quar-
tan type.

ARSENIC. 231

A long-continued course of arsenic is recommended in epithelioma,
and even scirrluis and rodent ulcer.

Arsenic has lately been extolled in phthisis and tuberculosis. It
improves the apjjetite, increases assimilation, lessens expectoration and
cough, and promotes the cicatrization of cavities. It is stated that it
will reduce the temperature in tuberculosis, and after carefully investiga-
ting this subject, I am inclined to believe so; at least I have frequently
observed a steady and sustained fall of the thermometer follow the use of
arsenic in cases when the undue temperature had continued unchanged
for a considerable time, and this I have known happen twice or three
times in the same case on reverting to arsenic after it had been discon-
tinued. The decline generally takes place gradually, and may begin soon
after taking the arsenic, or the fall may be postponed for ten or twelve
days. Moreover, I have seen children in a hopeless state, with severe
tuberculosis involving lungs, intestines, and peritoneum, steadily and
slowly improve and ultimately recover under arsenic treatment, and I
have observed a like result in adults with phthisis, in the subacute and
chronic forms. It must, however, be admitted that this is a very intricate
subject, seeing how irregular a course the fever of tuberculosis runs, and
how sometimes cases the most desperate recover by means of other treat-
ment, or indeed through little or no treatment. Still, I am sure that the
action of arsenic in phthisis and tuberculosis is well worthy investigation.
In my experience it is especially useful in fibroid phthisis and chronic
phthisis with much fibroid induration. I have generally given from two
to four minims every two to four hours. In a few cases it is ill-borne,
producing sickness, pain in the stomach and bowels.

Arsenic is often serviceable in rheumatoid arthritis and nodosity of
the joints, but the indications for its employment are unknown. The
pains of this troublesome affection are sometimes increased, sometimes
benefited, by heat, some cases being worse in summer, others in winter;
some are worse during the day, others at night. All these forms of arse-
nic will sometimes cure, yet its action is capricious, for in cases apparently
identical it sometimes fails and sometimes cures. Its effects are some-
times astonishing, for stiffened joints, for a long time considerably en-
larged, become reduced to their natural size, and regain their suppleness.
Large doses are necessary, given for a considerable time, and it must bo
borne in mind, that if improvement does not speedily ensue it must not
be concluded that the medicine will fail. Some consider it necessary to
produce the toxic effects of arsenic; but in many cases improvement cer-
tainly results without pushing the remedy to this extent.

Dr. Simpson employed arsenic in that peculiar affection of the bowels
prevalent among women, characterized by the copious discharge of mem-
branous shreds, accompanied by much emaciation, and a long train of
neuralgic and other nervous symptoms — an affection occasionally co-
existing with dysmenorrhcea, the membranous shreds being discharged
both from the bowels and uterus. Like other metals, arsenic, though
more quickly eliminated than some metals, as lead, is retained a long
time in the body. Some maintain that arsenic is to be found in the
bones as arseniate of lime, a statement denied by others. It may be de-
tected in the milk, and has induced serious symptoms in suckling infants.

It is found in the blood chiefly with the red corpuscles. It is sepa-
rated from the body by the urine, the stomach, and intestines, and per-
haps by the liver. After arsenical j)oisoning, the metal is found in the

232 PHOSPHORUS.

liver in quantities larger than elsewhere. It may he that, like many
other metals, it is separated from the body with tlie bile.

We know nothing of its influence on the composition of the urine.
Some experimenters assert that the urea is lessened, and, as the carbonic
acid separated by the lungs is diminished, they conclude that arsenic
diminishes tissue metamorphosis to a considerable extent. Vogel ob-
served hajmato-globulin in the urine of an individual poisoned with ar-
seniuretted hydrogen.

Dr. Garrod states that arsenic acid is less irritating to the stomach
than arsenious acid. Arseniates, we liave seen, are much less poisonous
than arsenites. The additional oxygen appears to saturate the molecule
of arsenic more completely, and so lessen its effects on the tissues.

Home persons are highly intolerant of arsenic, so that even one minim
of liquor arsenicalis will produce violent action on the stomach and in-
testines. (Schiifer, Bohm.)

PHOSPHORUS.

In large doses it is an irritant poison, but the symptoms are sometimes
delayed for hours, or even days, and they occur early if the drug is given
in solution as in ether, slower when given in the solid form. The patient
complains of burning in the throat, with intense thirst and severe burning
pain in the stomach, followed by distention of the abdomen and vomiting
of a dark green or black substance with the odor of garlic, and sometimes
phosphorescent. There are the usual symptoms of collapse. In less
Severe cases, vomiting ceases on the second or third day, but on the oc-
currence of jaundice, which often happens, the sickness returns, and the
rejected matter contains dark-colored blood. There is now pain and ten-
derness over the liver, generally diarrhaa, and later the stools become
clay-colored. At first, it is said, there may be fever, the temperature
rising even to 102°, but subsequently the temperature sinks below the
standard, and in one case it fell to 89° Fall, in the rectum. Jaundice
sets in from the second to the fifth day, and at first the liver is apparently
enlarged, but afterwards its size diminishes considerably. Jaundice may
be absent even with advanced fatty degeneration of the liver. The urine
is generally scanty, albuminous, and sometimes bloody. It deposits epi-
thelium cells, and when there is jaundice it contains biliary acid and
coloring matter with leucine, t}Tosine, and para-lactic acid. Urea dis-
appears almost entirely towards the termination of a fatal case. Haemor-
rhage and purpura often occur. Wounds bleed inordinately and some-
times uncontrollably. Later, either delirium sets in, or coma, which
may terminate in convulsions. The post-mortem reveals most of the
tissues in a state of advanced fatty degeneration. In the stomach and in-
testines, there is general inflammation of the glandular structures; hence
the mucous membrane is thickened and whitish. The epithelium is
granular or fatty and much degenerated, or even broken iip. The liver
is either enlarged, with its cells in a state of advanced fatty degeneration,
or is contracted from destruction of the cells. The kidneys are similarly
affected, the epithelium being swollen, granular, fatty, or broken up.
The heart, the voluntary muscles, and other structures are also impli-
cated. The fatty degeneration affects likewise the whole of the arterial
system, down to the microscopic arterioles (AVegner), and the number of
the blood discs are said to be lessened.

PHOSPHORUS. '2 S3

Fatal doses of phosphorus lower the temperature of dogs and rabbits
8° to 12° Fah.

The main stress of the poison sometimes falls on the gastro-intestinal
mucous membraiie; sometimes on the nervous system, and at other times
on the blood and blood-vessels, and in this case gives rise to haemorrhages.

The duration of acute poisoning is very variable, the patient may die
in two or three days, but generally he survives from one to three weeks.
Eecovery is slow.

Jnrgensen claims to have saved several lives by direct transfusion of
human blood.

The effects of chronic phosphorus poisoning have lately been elabor-
ately worked out on animals by Dr. George Wegner, with most singular
results. It has long been known that workmen esposed to the fumes of
phosphorus are liable to necrosis of the jaw, and Dr. ^Yegner believes
that this results from the direct action of the phosphorus on denuded
bone, and that necrosis will not set in unless through wounds or carious
teeth there is some destruction of the soft tissues, thus enabling the plios-
jihorus to reach the exposed bone; in support of this view he adduces the
following reasons: — 1. If the periosteum of an animal is severely wounded,
and phosphorus is given in the form of a pill, even for months, the peri-
osteal changes do not take place. 2. When the tibia of a raljbit is par-
tially bared, a healthy granulating wound is soon established, but under
exposure to a phosphorus atmosphere, periostitis is set up similar to that
in the jaw. 3. Many workers in phospliorus escape, whilst those who do
suffer have carious teeth.

The lower jaw is more often affected, but the upper is liable to attack;
and in rare cases even the ])alate and frontal bones.

Dr. Wegner found that gradually increasing doses of phosphorus or
phosphorus fumes administered to rabbits produced congestion of the
mucous membrane of the stomach, this membrane becoming of a lirown
color and three times its natural thickness. The liver is chronically in-
flamed, with great increase of the interstitial tissue, affecting earliest that
portion surrounding the acini. This new tissue contracts, producing atro-
phy of the liver-cells, and obstruction of the vessels and ducts. The
organ, at first enlarged and livid in color, sometimes gradually changes
into the hob-nailed liver, or into a shrunken irregular mass, deformed by
contracting bands.

Given in doses too small to affect the stomach and liver, phosphorus
modifies the bones, especially in growing animals. Thus, where spongy
tissue should be formed in the growing bone, dense solid tissue takes its
place, which, examined by the naked eye and microscope, is found to
consist of well-formed bone, and, if the administration -of the phospho-
rus is continued, the proportion of dense bone increases, and the cancel-
lous structure, in accordance with a natural process, becomes absorljed
to make room for marrow tissue, till at last no cancellous structure is left,
and afterwards the solid, newly-formed tissue itself also undergoes absorp-
tion. Changes occur likewise in the bony substance formed by the perios-
teum. The new bone looks natural, but the microscope reveals that it is
dense, and compact masses of it encroach on the Haversian canals, pro-
ducing in them at last a general narrowing which affects even bone
formed previous to the admhiisti*ation of phosphorus. If phosphorus is
given for a long time to adult animals, the spongy tissue thickens, and
the compact tissue becomes still more dense, and after a time new bony

234

PHOSPIIOKUS.

tissue is deposited on the inside of the shaft, incre.asinjy till the Ijone
actually becomes solid. The chemical composition of the bone remains
natural.

Dr. Wegner found also that under the influence of phosphorus, callus
after fractures or resection becomes more dense, and the formation of
new osseous tissue is favored. Kassowitz has very successfully treated
5 CO cases of rickets with phosphorus in doses of gV gi". dissolved in oil.

The changes above described are produced by ])hospliorus as such, and
not after its conversion into phosphoric acid. For phosphoric acid does
not produce the pe :;uliar changes in the stomach and liver. It does, how-
ever, att'ect the bones similarly, in very large quantities, larger than could
be produced by the phosphoric acid generated from phosphorus intro-
duced into the system; Wegner considers that it acts as a food, pro-
moting natural growth.

In acute poisoning, phosphorus itself is absorbed unchanged, for in
some cases the breath, the urine, and, after death, the tissues themselves,
are luminous; moreover, it has been chemically detected in most of the
tissues.

The jaundice occurring in acute phosphorus j)oisoning has been vari-
ously explained. Dr. Ebstein holds that it is not due to destruction of
the liver-cells, but to catarrh of the small biliary ducts, causing obstruc-
tion and leading to absorption of the bile. The ductus communis chole-
dicus has sometimes been found occluded by a tenacious plug of mucus,
thus greatly assisting the obstruction of the smaller ducts in the produc-
tion of jaundice. The presence of biliary acids in the urine, when jaun-
dice occurs, certainly supports the view that the jaundice depends on
absorption from obstruction of the ducts, rather than from suppressed
secretion owing to the destruction of the liver-cells. Sometimes the con-
tents of the intestines are found destitute of bile.

According to Mr. Ashburton Thompson, the effects of repeated
medicinal doses are improved appetite, increased rate of circulation,
a heightened temperature, perspiration, irritation of the skin, abundant
urine, sometimes loaded with deposit, a sharpening of the mental facul-
ties, increase of muscular power, sensation of well-being, sometimes ner-
vous excitement shown by hesitation and trembling (effects more readily
induced in some persons than in others), even slight clonic convulsions,
occasionally some venereal ardor, and, less frequently, a more acute tactile
sensibility.

Sometimes, even after doses now considered medicinal, as for instance
-sjygv., we get sickness and jaundice which may last weeks or months.
The drug appears to affect some persons much more readily than others,
and this uncertain action, long known, used to be ascribed to "idiosyn-
crasy." It has been asserted that phosphorus in medicinal does some-
times causes haematuria and albuminous urine, but this must be unusual,
for having employed phosphorus in a very large number of cases, I have
never seen this result.

Phosphorus has been given lately in neuralgia with consideable suc-
cess. It appears to be efficacious in neuralgia of any part of the body.
Some regard phosphorus as well nigh a specific. As might be expected,
chronic cases take longest to cure, but in all the instances susceptible of
benefit relief follows the first few doses. Mr. Thompson employs large
doses, giving never less than one-twentieth, and generally one-twelfth, of
a grain every three hours. Some writers think one-hundredth of a grain
a sufficient dose.

PHOSPHORUS. 235

The most intractable and severe cases generally occui', as Dr. Anstie
pointed out. in the degeneration period of life; but even in these in-
stances phosphorus may prove useful. My own experience hardly Avar-
rants me in speaking so enthusiastically of this drug as did Mr. Thomp-
son. Yet, though it not uncommonly fails in the severe forms of neuralgia
of middle and advanced life, still it must be considered one of the most
valuable remedies. In my hands it has yielded less satisfactory results
in sciatica than in many other forms of neuralgia. Phosphorus is probably
most eflficacious in typical neuralgia, and much less useful, according to
my experience, in those imperfectly-developed cases where the neuralgia
appears to be allied to, or passes into, sick headache of pleurodynia, and
in those instances of nerve pain which lack many of the more distinctive
characters of neuralgia. Phosphorus is often serviceable in angina pec-
toris, a disease closely allied to, if it be not a true, neuralgia.

Dr. Richard Hughes recommends phosphorus in chronic inflammation
of the rectum, and Dr. Fleishmann, of Vienna, approves its use in pneu-
monia, especially if accompanied by typhoid symptoms.

Dr. Bartholow recommends phosphorus in wakefulness depending on
cerebral anajmia and in the wakefulness of the aged. It is useful in the
degenerative changes due to age, and under its use I have seen many
cases improve. Cod-liver oil, too, is beneficial in the same cases and
should be given simultaneously.

Phosphorus is said to stimulate the sexual functions, and patients
have told me that they were constrained to discontinue this drug, be-
cause it gave them trouble in this way. Old men, while taking phos-
phorus, have told me that it had produced a return of sexual capacity.

Mr. Thompson held that phosphorus, unless given in large and un-
safe doses, is neither an aphrodisiac nor useful in spermatorrhoea, but
that in small tonic doses, -gV to ^V gi'-j it will remove the physical and
mental debility induced by spermatorrhoea. A large dose, Thompson
taught, acts as a stimulant to the brain, and fits it for unusual exertion,
and so obviates physical and mental exhaustion or depression from over-
work. *

Phosphorus is certainly useful in over-taxation oi! the nervous system
by too arduous or too anxious work. In these patients brain po\yer is
weakened, the mind sooii becomes weary and fatigued; they are irritable
and depressed, and sexual capacity in many instances is much impau-ed.
Here a prolonged course of several months of 3V to ^^o gi"'^"^ thrice daily
is often very useful. It appears to promote the nutrition of the nervous

system. . i • i i. •

Hammond commends phosphorus in cerebral softening and m hysteri-
cal paralysis, and Anstie in chronic alcoholism, and Thompson recom-
mends it strongly in migraine.

Phosphorus is recommended in melancholia. Bartholow highly recom-
mends it in acne indurata.

It has been asserted that phosphorus largely increases the cpiantity of
urea of the urine, splitting up, it is said, the nitrogenous tissues and con-
verting them into fat and a compound which ultimately forms urea;
others hold that the fatty degeneration is due to deficient oxidation. In
men the products of nitrogenous disintegration appear in the urine as
leucin and tyrosin. Phosphorus gives to the urine a smell of violets or
of sulphur. (See Turpentine.)

Phosphide of zinc 1 gr. to h gr. doses, has been strongly recommended

236 COLLODION.

in place of phosphorus. In compounding phosphorus it must not be
mixed with turpentine, since wit.li this, and probably with other essential
oils, it combines and forms an inert compound; indeed, turpentine itself
is used as an antidote in phosphorus poisoning. Eulenberg and Gutt-
mann point out that with a solution of a copper salt phosphorus immedi-
ately forms a phosphide of copper; and Bamberger's experiments lead
him to conclude that copper salts are far more efficient antidotes tlian
turpentine. The sulphate being strongly emetic is especially useful.
Three to five grains should be given every five minutes till vomiting en-
sues. (See Turpentine.)

Eed allotropic phosphorus is inert. The disagreeable eructations which
occur when taking phosphorus are due to the oxidation of phosphorus,
and the liberation of hydrogen, the nascent gas uniting with phosphorus
to form phosphide of hydrogen.

COLLODION.

CoLLODiox is useful in many ways. It is used to adjust accurately
and bind together the edges of cuts and wounds, and to exclude air. It
is sometimes applied to chapped hands and chapped nipples; but for these
affections there are better applications, as glycerine of starch, arnica
cerate, or two parts of eau de Cologne to one of glycerine. For chapped
nipples, often so difficult to heal, equal parts of sulphurous acid and glyc-
erine is a useful comljination.

Collodion, painted over "suj^erficial erysipelas, slight burns, or patches
of herpes before vesicles are developed, subdues inflammation, eases pain,
and checks vesication. L'nfortunately the collodion coating often cracks,
admits air, and ceases to be efficacious; hence collodion is inferior to a
solution of nitrate of silver in water or nitrous ether. ( Vide Xitrate of
Silver.)

Dr. Hare, we believe, first employed collodion for boils. There are
many kinds of boils. The common form begins as a pimple or pustule,
whence the inflammation spreads, producing a hard, painful swelling, the
centre of which dying forms a core. Xow if collodion is applied at the
papular or pustular stage, the swelling around the pustule suljsides, and
the further development of the boil is arrested in the pustular stage, col-
lodion appearing to he useless if the pustule has burst. The matter must
not be let out after the collodion application, or inflammation recommen-
ces, and the boil follows the usual course. It is desirable to apply fresh
coatings of collodion over the old ones, allowing them to remain till the
pustule has dried up, and the sore has healed. If much pus accumu-
lates beneath this covering, causing considerable pain, the collodion should
be incised under carbolic acid and the pus allowed to escape, the subsequent
treatment being conducted on Lister's carbolic-acid plan. This treat-
ment allays the great irritation often accompanying the early stages of
boils. Dr. Hare prefers the contractile collodion, attributing its success
mainly to the pressure it exerts. I have succeeded with flexible collo-
dion, but perhaps the contractile would have answered still better.'

' The extension of a carbuncle, may sometimes be limited by ti£rhtly strapping vrith
strips of adhesive plaster, appUed concentrically from the borcler inward, aromid and

OILS. 237

Some doctors add a drachm of spirit of turpentine to each ounce of collo-
dion.

Collodion solutions of gutta-percha, or india-rubber in chloroform,
prevent the pitting of small-pox, and the flexible variety of collodion is
better for this purpose.

A mixture of collodion and carbolic acid is useful in toothache due
to an exposed ai^ inflamed pulp. A jelly is made by melting in a test-
tube some crystamzed carbolic acid, then adding an equal quantity of col-
lodion. A portion of this preparation on a small piece of cotton-wool is
inserted into the hollow painful tooth, with sometimes aggravation of
the pain, but in a few seconds it begins to diminish and soon ceases.

Contractile collodion, with which some mix iodine, painted over the
inflamed part in acute gout, will speedily relieve the pain, although for
a brief space the application increases it. Too many coats must not be
applied, or the contraction is too great and dragging on the skin, excit-
ing a good deal of pain, or even producing vesication.

Sir I). Corrigan treats the incontinence of children with collodion.
The prepuce is drawn forward by the left hand, and the little cap thus
formed at its extremity is smeared over with collodion, which contract-
ing, draws closely together the edges of the prepuce, and effectually pre-
vents the exit of urine. A fortnight of this plan, which gives no pain
and does not prevent sleep, sometimes suffices for the cure. When it is
needful to pass water, the little cap of collodion can be easily chipped off
with the nail. The prepuce in the morning is found distended with
urine. Sir D. Corrigan thinks that it would answer as well to paint the
collodion over the orifice of the urethra. This plan I find unsuitable for
girls, as it excites smarting, and induces them to pick off the collodion.

Two parts of glycerine to a hundred parts of collodion sets without
contracting or dragging the skin.

COD-LIVER OIL. DUGONG OIL.

ALMOND OIL. PALM OIL.

POPPY OIL. LAED.

HExMP-SEED OIL. SUET.

LINSEED OIL. WAX.

COCOA-NUT OIL. Etc.

Fats, in one form or other, are found abundantly in both the animal
and vegetable kingdoms, showing their great importance in organic life.

Fats are necessary foods to the animal body, being heat-giving, force-
supplying, and plastic. Their combustion contributes mainly to the gen-
eration of the heat of the body. They are essential to tissue formation,
for without them nutrition and growth would be very imperfect, if not
impossible.

Their combustion, moreover, supplies most of the force appropriated

over the swelling. I)r. Planat highly recommends the application of arnica ointment
(one part of extract of fresh arnica flowers to two of honey) spread on diachylon plaster
and placed over the boil, the application being renewed once or twice a day. He finds
the internal use of arnica benelicial.

238 OILS.

by the nitrogenous structures, and through them to be converted into
muscular force, secretive force, nerve force, etc.

For the most part, all fats, so far as we know, have the same physi-
cal properties, differing only in the melting point. In their chemical
nature, however, they differ much, but after entering the blood they are
probably converted into a fat of uniform composition.

Oils and fats are iised to lubricate and to supple the skin Avhen it has
lost its elasticity, and become dry, hard, and liable^o crack; for in-
stance, in many scaly diseases, as psoriasis and xeroderma. They should
be employed in conjunction with warm baths.

Fats, moreover, are applied to the surface of the body to prevent irri-
tation from such excreta as urine or fa?ces, or b}^ acrid discharges, as in
eczema, and when used for this protective purpose, some stimulating sub-
stance, as oxide of zinc, is generally incorporated with them.

Simple oils are used to soften and facilitate the removal of scabs, as
of impetigo, eczema, and favus. Poultices are likewise useful in favus
preparatory to epilation.

Oils are sometimes, with occasional success, rubbed in to the skiu of
the whole surface, to prevent the debilitating sweating accompanying
exhausting disease, as phthisis; but this process is inferior to that of
sponging the skin with a Aveak acid Avash, and to other means. AYith the
ancient Komans, during the decline, when warm baths Avere so much in-
dulged in, it was the custom to anoint the bod}^ Avith fats, to check the
j^rofuse SAveating caused by this enervating habit.

Fats are sometimes rubbed into the skin Avith a vicAV to their absorp-
tion, so as to minister to the nutrition of the body.

Fats and oils are in general use as excipients for the application of
various agents to the skin.

It has been asserted that the inunction of the bod}' with fatty sub-
stances Avill induce a considerable fall in its temi^erature; but in a solitary
testing instance I found this statement to be incorrect.

Rubbing the hands and feet with some firm fat will remove the irk-
some sensation of heat and tightness produced b}' the rashes of scarlet
fever or measles.

Some practitioners treat scarlatina solely by inunctions, anointing
thoroughly the skin of the whole body tAvice or three times a day Avith a
bland fat, or oil, Avhich is not to be Aviped off during couA'alescence from
scarlatina. Dr. Budd, of Bristol, recommends the inunction of oil; the
jiatient takes a bath at night, and after being Aviped quite dry, a bland
oil, like almond oil, is rubbed over the whole body. This treatment is
said to assist desquamation, and to prevent sequels: moreover, it proba-
bly lessens the risk of contagion by preventing the diffusion of the branny
particles of the skin by currents of air.

In cases of ringAvorm it is a useful practice to prevent the extension
of the disease by greasing the head very freely to hinder the sporules
reaching the unaffected hair. The uncontaminated members of the fam-
ily should also use grease to the hair freely for the same purpose, and
probably it Avould be more i:)reventive to use a mild mercurial pomade,
or quinine dissolved in glycerine, so that the sporules may alight on some
substance destructiA^e to them.

Oils and fats are not used topically in diseases of the mouth, nor do
fats undergo alteration in this cavity, and they are almost as little affected
in the stomach. If enclosed in albuminous walls, as in the form of cell.

OILS.

239

these being dissolved, the fat is set free. Although themselves not acted
upon by the stomach, fats, however, act npon the other forms of food:
they certainly promote the fermentation of sugar and starch; and it is
generally accepted that fats, by assisting those chemical changes which con-
stitute digestion, aid the conversion of the nitrogenous food. For exam-
|3le, fats assist the fermentation of milk, and promote the process of arti-
ficial digestion; and this action of fats upon food can be demonstrated
outside the body. But how fats effect these changes, and whether at the
same time they themselves are in any measure modified in constitution,
are questions at present quite unsettled. The importance of this property
of fats must be sufficiently apparent, and needs no further comment.
In large quantities they hinder digestion, possibly by their decomposition,
and the formation of acids foreign to the stomach.

Fats are mainly, if not exclusively, digested and absorbed in the in-
testine. The pancreatic ferment steapsin causes some of the fat to take
up a molecule of water and produces glycerine and fatty acids. Pancrea-
tic secretion also emulsionizes fats. The further absorption is due to bile.
Bile also emulsionizes fats.

It has been surmised that fat may become saponified, and so pTiss
through the walls of the intestines into the blood, and jirobably a small
j)art does pass into the circulation in this form; but, as much unsaponi-
fied fat is visible in the epithelium cells covering the villi, and much can
be extracted from the chyle, the chief part must undergo absorption in
another manner.

The passage of fats through the moist animal membranes forming the
intestinal canal, is probably justly ascribed to the action of the bile; and
in support of this proposition, apart from other evidence possible to
adduce, it may be advanced that —

I. In capillary tubes moistened with water, fats rise scarcely at all;
but if the tubes are moistened with bile the fats rise from twelve to four-
teen times higher.

II. While fats pass with extreme difficulty through moist animal mem-
branes, if these are moistened with bile the fats, as may be shown experi-
mentally, pass readily.

Fats pass, to a small extent, into the blood by the agency of the intes-
tinal juice.

The chief part of the fat passes into the lacteals; a little into the
veins, to be conveyed to the liver, there to be converted into cholic acid;
or, at least, it is probable that the oleic acid undergoes this change. The
cholic acid, uniting with the soda set free when the hydrochloric acid of
the gastric juice is poured into the intestines, forms a kind of soap,
namely, the taurocholate and glycocholate of soda. These again find
their way into the intestines, and after serving their destined purpose
there, the base reunites with the acid of the gastric juice from which it
has been separated.

The influence of fats on the secretion of bile varies according to cir-
cumstances; if taken on an empty stomach, fats lessen the biliary secre-
tion; if taken with, or after food, they increase it.

As food greatly augments the flow of bile, we have here an indication,
abundantly corroborated by experience, to give fats either with or soon
after a meal.

The melting point of a fat must mfluence its absorption; for if this

240 OILS.

point is above the temperature of tlie body, the fat, unless dissolved in the
more liquetiable fats, must remain unabsorbed.

The stomach tolerates animal far better than vegetable fats: moreover,
animal fats may be given in larger doses, and for a longer time; circum-
stances which, in some measure, explain the medicinal superiority of
animal over vegetable fats.

There is a limit to the quantity of fats absorbable by the body. In
regard to cod-liver oil, at first only a small quantity is taken up, and
often for some weeks some of it appears in the motions: however, more
and more of it becomes absorbed, till full doses are borne, and find
entrance into the circulation; but in too large a quantity this oil is liable
to decompose, and to form hurtful acids, exciting nausea, vomiting, colic,
and diarrhoea. This limitation to the quantity absorbed as well as the ir-
ritation caused by an excess remaining in the intestines, are sufficient
reasons, to say nothing of economy, to make it undesirable to give more
fat than can be appropriated. Too large a dose is both wasteful and
harmful. By examining the motions day by day we can at any time
ascertain if too much is administered.

Catarrh of the intestines is a condition unfavorable to the absorption
of fat. Oils are sometimes given after a poisonous dose of a corrosive
substance,* with the intention of forming a protective sheathing to the
mucous membrane, but it is impossible to give a coating of oil to a mem-
brane moistened with water. Cod-liver oil sometimes overcomes obstinate
habitual constipation in children. Figs kept in Lucca oil, and one or two
eaten daily, are gently relaxing.

Fat is speedily saponified in the lacteals and blood-vessels, and most of
it in the blood-vessels appears to collect in the blood-corpuscles, and may
contribute to their formation, growth, etc.

Fats, as we have said, are heat-giving, force-supplying, and plastic.
In common with other combustible substances, they, through oxidation,
u])hold the temperature of the body. This, though an important, is not
their only, nor their most valuable, function.

Fats, like phosphate of lime, are necessary both to growth and nutri-
tion; for in the most vitally-endowed organs fats are found in excess, and
abound wherever cell -growth proceeds rapidly; it abounds even in disease,
for much fat is found in fast-growing cancer; it is found, moreover, asso-
ciated with the more highly-organized constituents. Thus the fat existing
in pus is chiefly associated wdth the corpuscles, comparatively little being
found in the serum. More fat is found in plastic than in non-plastic
formations: in fact observations day by day demonstrate more and more
the importance of fats as tissue-forming substances. Facts like these ob-
viously bear on the use of the members of this group in disease; but to
this subject Ave shall return shortly.

Observations tend to show that fats are force-yielding substances, and
that tlie peculiar forces of the body are mainly derived from the fats we
consume. Only a short time ago it was considered that the forces of tlie
body were derived from the combustion of the nitrogenous structures, but
many circumstances tell conclusively against this hypothesis.

1. After severe and prolonged exercise, the urea of the urine is scarcely increased;
and as this substance is a measure of the consunijition of nitrogenous materials, it fol-
lows that at such times but little of it is consumed.

2. Under exertion, enormous quantities of carbonic acid are exhaled from the lungs,
pointing indubitably to the combustion of carbo-hydrates, or of fatty substances, the
urea at the same time not being increased.

OILS. 241

3. The combustion occurs chiefly, not in the blood, but in the muscles themselves,
for when these are separated from the body, and made to coniract under a bell-glass,
they are found to yield, during the time of their activity, an enormous quantity of car-
bonic acid.

4. It has been found by experiment that when only starchy and fatty foods are
eaten, great exertion and prolonged labor can be endured, while at the same time the
urea of the urine is but little increased.

Drs. Cutler and Bradford, using Malassez's method of connting the
red eorpnscles, find tliat in health cod-liver oil causes an increase in the
number of red corpuscles, and a slight increase in the white.

Dr. John Day's (of Geelong) higenious experiments show that fats
possess considerable power in converting oxygen into peroxide of hydro-
gen; also that the coloring matter of the blood rapidly decomposes this
into water and nascent oxygen with its characteristic active properties;
and he suggests that fats may play this important part in the blood,
making inert oxygen of the atmosphere into active oxygen. His experi-
ments show that the iron of the coloring matter of the blood is probably
the agent decomposing the peroxide of hydrogen. Ether also possesses
great power to form oxygen into peroxide of hydrogen; and Dr. Day
suggests that the efficacy of etherized cod-liver. oil may be due to the large
quantity of peroxide of hydrogen it contains.

Fats being necessary to growth, nutrition, and the due performance of
the bodily functions, are peculiarly suited to convalescents from acute
general diseases. Fats are also useful in many chronic affections. On
the subsidence of many acute inflammations, as of the kidneys, heart, or
lungs, a chronic, but not less fatal, condition may be left, a condition the
danger of which is in proportion to the health of the patient previous to
the acute attack. If the patient's health has been impoverished, or if he
is the subject of tuberculosis, or of scrofula, many sequela? are apt to
occur. Middle-aged and old people, in whom the nutritive process
begins to flag, are more liable to chronic diseases after acute attack. A
like danger threatens cliildren whose previous health has been damaged
by unhygienic conditions. It benefits the chronic degenerative diseases
of old age. These and other maladies depend on deficient nutrition, and,
as fats are peculiarly promoters of this function, they are especially useful
in such chronic maladies.

The dependence of chronic affections on the state of general nutrition
may be shown in another way. Persons are found to suffer from some
slight local affection, but little troublesome while the health is unbroken,
but as the weakest link of the chain is the first to yield, so if the health
gives way, the local mischief becomes immediately developed or aggravated.
Thus many individuals are able to measure the state of their general
health by the conditions of a local disease. Here, again, any treatment
restorative of the general health will reduce the local affection to its
former unimportant state, and in such a case cod-liver oil is often indi-
cated.

Thus experience confirms the efficacy of cod-liver oil in many chronic
inflammations, as of the heart, lungs, and kidneys, and in the sequelse of
the acute specific diseases, as the chronic discharge from the ears or nose
so often left by scarlet fever or measles.

Cod-liver oil is of special service in scrofula, tending to remove the
various manifestations of this disease, as chronic discharges from the ears
and nose, strumous ophthalmia, strumous disease of the bones, strumous
abscesses, etc.

242 OILS.

In the treatment of phthisis cod-liver oil stands pre-eminent. The
term phthisis, however, includes sevei-al distinct diseases. For our purpose
it is sufficient here to divide them into the febrile and non-febrile varieties:
— those forms manifesting preternatural heat of the body, and those in
which the temperature is natural, or rises only occasionally, and for a
short time. The existence of fever in the febrile forms of phthisis is by
no means an indication of the uselessness or harmfulness of cod-liver oil,
for in this condition many patients derive considerable benefit from it. In
this form of phthisis, as, indeed, in all cases, we must Ije guided, in the
emplovment of this remedy, not only by the nature of the disease, but
also by the state of the patient in other respects. If the digestion is
good, cod-liver oil may generally be given with advantage, but if the
stomach is irritable, then cod-liver oil does harm by still further dis-
ordering it.

In the chronic, or non-febrile forms of phthisis, cod-liver oil is gener-
ally well borne, and does great good; but, as with the more acute varieties,
it sometimes upsets the stomach. It is generally held that diarrhcjea in
. phthisis is a decisive indication against the employment of the oil ; but
this is only partly true. Cod-liver oil, no doubt, sometimes increases
diarrha^a, but this chiefly arises when the dose is unduly large, or too
frequently administered; if only a teaspoonful is given at a dose once or
twice a day, the oil often even controls diarrhoea. In cases of phthisis
with diarrhoea, it is 'a good plan to begin the cod-liver oil with cautiously
small doses, and if it suits it may be given with greater freedom. An ex-
cellent method is to give a teaspoonful the last thing at night, immediately
before sleep, when it may often be borne without producing either nausea
or diarrhoea, though previously it had occasioned one or both of these
symptoms.

In the early stage, as might be expected, j^hthisis is most benefited by
the use of oils.

Phlegmatic persons with sallow skins and dark complexions, benefit
more, it is siiid, by cod-liver oil than persons of sanguine temperament
and florid complexion.

Cod-liver oil is often very serviceal)le in chronic rheumatism, rheu-
matoid arthritis, chronic gout, chronic skin affections, syjihilitic or other-
wise. It is also particularly useful in emphysema of the lungs, and
chronic bronchitis; in the former checking lung degeneration, in the
latter controlling the expectoration.

Many persons, especially the aged, complain of much sinking, or a
sensation of "craving" at the epigastrium, relieved for a short time only
by food, a condition sometimes connected with atonic dyspepsia, some-
times dependent on the general state of health. If the intestinal canal
is not in an irritable condition, cod-liver oil will remedy this sinking.
Middle-aged patients suffering from that anomalous group of symptoms
called hysteria, sometimes complain of the same irksome symptoms. In
this case oil will remove the sinking, while it often simultaneously relieves
the other symptoms of the group.

Cod-liver oil and quinine is the best treatment for giddiness in the
aged, that is, when this symptom is not ascriljable to serious organic brain
disease, but probably to atheromatous changes in the brain-vessels, or to
a weak heart. Indeed cod liver oil, since it promotes nutrition, is highly
useful in the suffering due to old age.

Fats are of special use in the chronic diseases of children, arising from

OILS. 243

mal-]iutrition, and Jiny local malady will generally disappear on restoring
nutrition and growth to the healthy state.

Cod-liver oil often favorably modifies the course of laryngismus stridu-
lus, rickets, chorea, the middle and after stage of whooping-cough, and
chronic coughs.

The obstinate constipation of children sometimes yields to cod-liver
oil.

The chronic diarrhoea of a few pale, stinking, pulpy motions daily will
reduce a child a few months old almost to a skeleton. The skin becomes
leathery and wrinkled, food is, perhaps, rejected, and, when brought to
this dangerous pass, thrush breaks out. While combating the diarrhoea
or vomiting, a teaspoonful or half a teaspoonful of cod-liver oil, given to
the child nightly before sleep, gradually increasing the quantity and fre-
quency of the dose, will neither increase the vomiting nor the diarrhoea,
but, on the contrary, will promote nourishment, growth, improve the
general health, and rescue the patient from a perilous condition.

Hitherto, fats have been spoken of, for the most part, in common, but
they certainly are not all equally useful therapeutic agents.

As we have seen, animal fats are to be preferred to vegetable fats; and
liver fats are generally esteemed beyond all others. Whether cod-liver
oil is superior to that derived from the livers of other animals is difficult
to decide — since much of the cod-liver oil of commerce is procured, not
only from the livers of various fish, but likewise, it is said, from those
of other marine animals.

The superiority of cod-liver oil has been thought to depend on the
minute quantities of iodine, phosphorus, or bile it contains — a conjecture
clearly wrong, for the effect of these substances in disease is dissimilar to
that of the oil.

The su])eriority of liver oils is ascribable to their easy toleration by the
stomach. They generally can be taken without inconvenience for months
or years, while other fats and oils often produce nausea, loss of appetite,
and diarrhoea. There is reason to think that cod-liver oil is more easily
absorbed than other oils.

Cod-liver oil, at first, often excites nausea, vomiting, and disagreeable
eructations. Occasionally, the difficulty in overcoming the distaste for
this medicine is almost insuperable; yet disgust is generally overcome, and
in a short time the oil is taken even with relish, and children, indeed,
often come to regard it as a treat. Sometimes at the commencement of
the course, a child becomes languid, appetiteless, and appears worse;
but usually, after a week or ten days, the oil begins to be tolerated, and
then improvement sets in.

The nausea and vomiting sometimes caused by this remedy may be
produced by too large a dose. At first a teaspoonful only, or even less,
is enough; and should the stomach manifest intolerance, one dose only
should be given daily; and it is a good practice to give it at night-time,
just before lying down to sleep.

Cod-liver oil is often administered in such quantities that it can scarcely
be borne, even Avhen the stomach is accustomed to it. Weeks, and even
months may elapse, before full doses of oil can be digested and absorbed;
hence, if swallowed in iindue bulk, it merely passes off by the motions,
and by its decomposition is liable to disorder the intestines. An examina-
tion of the motions will show whether the oil is given in excess.

Cod-liver oil should be taken after food, on orange, or ginger-wine or

244 OILS.

weak brand^'-and- water, or some agreeable tincture of orange-peel, and
should be so poured as not to touch the glass, but to float on the surface
of the wine or the brandy as a srlobule, and thus tossed off. A little salt
taken immediately before and after the dose often removes the taste, and
prevents nausea, and it is said that a few drops of ketchup added to the
oil will cover its taste.

A mixture composed of equal parts of cod-liver oil and fresh mucilage
of gum acacia and water, has very little taste, and the addition of two
minims of oil of lemons to each ounce of this mixture effectually conceals
the fishy flavor.

A cod-liver oil jelly has recently been prepared, which is said to contain
70 per cent, of oil. Bolted like jelly it is almost tasteless.

Xotwithstanding such ingenious devices, it is not uncommon to meet
with patients who, even after repeated trials, cannot tolerate the oil on
account of the eructations, loss of appetite, nausea, or vomiting. In some
cases this intolerance is due to dyspepsia, but it is generally due to that
inability to digest and absorb fats so commonly noticed in consumption,
even before its development. This fact has been much dwelt on by Dr.
Balthazar Foster, who, led by some suggestive experiments of Claude
Bernard — in the case of patients intolerant of oil, uses ether as a means of
assisting the digestion and absorption of fat.

Claude Bernard has shown that the action of ether "is twofold —
(1) it stimulates the pancreas and glands of the duodenum to pour out
their secretions freeh-, and (2) at the same time facilitates the absorption
of those very substances which these secretions are designed to digest. In
other words, ether not only obtains for us the secretions required to digest,
but promotes the absorption of these fats when digested." Bernard
maintains that fats are chiefly absorbed by means of these secretions.
After a prolonged investigation of the influence of ether. Dr. Balthazar
Foster finds that oils and fats, which otherwise cause nausea and sick-
ness, are, by means of this combination, letained and digested, thurs in-
creasing appetite, nutrition, and weight. Dr. Foster employs ether purus
of the Pharmacopffiia in doses of from ten to fifteen minims to every two
drachms of oil. The ether may be given either separately, or with the
oil; but as the ether masks the unsavoriness of the oil, it is better to
combine them.

I,ime-water mixed with the oil sometimes obviates nausea, and even
the diarrhoea induced by the ingestion of cod-liver oil.

Fats are consumed in the body, but sometimes a small quantity es-
capes Avitli the fasces and urine. The quantity escaping by the urine is
insignificant, except in the disease called chylous urine, in wliicii fat is
often present in considerable amount. In Bright's disease, a little fat
is voided with the uriniferous casts in the urine.

CASTOR OIL. CROTOX OIL.

These oils consist of a bland oil. Avith a variable quantity of an acrid,
irritating, purgative matter, which imparts to them their characteristic
properties. This irritating substance exists in a small proportion in
castor oil, and in a larger degree in croton oil. Croton oil irrit- tes the

OILS.

245

skin, produces redness, vesication, and, with a strong application, even
pustulation, followed by scars. The irritating effect is increased by the
admixture of alkalies; hence, liquor potassas is sometimes added, to in-
tensify the effects of croton oil.

Its action is very variable; several applications on successive clays may
produce but slight vesication, whilst sometimes a single moderate applica-
tion sets up great irritation, much vesication, and even pustulation.
Caution is therefore needful. When applied too energetically or too per-
sistently, croton oil liniment sometimes produces superficial papilliform
white round scars, with a hair follicle in the centre. These scars gradu-
ally disappear. Croton oil liniment applied to the chest of phthisical and
bronchitic patients, is highly esteemed as a counter-irritant, but, owing
to the vesication it produces, it cannot generally be repeated more than
once or twice on successive days, and sometimes, only one application can
be borne. In bronchitis and phthisis, croton oil liniment is sometimes
preferred to mustard poultices, and, indeed, certain patients aver that
croton oil gives them greater relief than mustard poultices. The vesica-
tion, being a decided disadvantage, the patient must carefully avoid con-
veying any of the croton application to tender parts of the skin, lest it
should provoke troublesome or severe inflammation of the face or scrotum.
Dr. Tilbury Fox states, that croton oil sometimes produces a symmetrical
erythema of the face, lasting for a few days, where no direct application
of the drug could have occurred; and I too have seen this erythema of
the face occur during the employment of croton oil. It is hard to say
whether this erythema depends on the action of the croton oil after its
absorption into the blood, or on the volatile acrid principle, reaching the
face tlirough the air, or by means of the hands.

As is the case sometimes with iodine liniment, and now and then from
a bellndonna plaster, I have known croton oil liniment produce a crop of
itching papules which have spread over the chief part of the body, reach-
ing even to the feet.

Dr. Alder Smith employs croton oil as an application in obstinate
ringworm. He says, '*' I generally put it on a patch about the size of a
shilling, with a small camel's hair brush, and order a poultice to be ap-
plied at night, then, if it has not set up severe inflammation and pustula-
tion by the next dav, which is very rare, I apply it again, keeping
poultices on constantly day and night. A pustular rash occurs at once,
biit the oil can be applied over this, and a daily application of it for three,
six, or ten days, together with constaut bathing with warm water, and
frequent poulticing with linseed meal, will generally set up such inflam-
matory exudation, that the patch resembles true kerion." Dr. Thin
draws attention to the risk of this treatment causing j^ermanent bald-
ness. The daily application of castor oil is reputed to remove warts in
a month or six weeks.

Pure castor oil is almost tasteless. Croton oil has an acrid burning
taste.

These oils, apart from their acrid principle, behave in the stomach
and intestines, for the most part, like other oils. Croton oil in a large
dose inflames the stomach. If not quickly expelled from the intestines,
they become absorbed into the blood, and serve the same purposes as
other oils.

The acrid matter of these oils, irritating the mucous membrane of
the intestine, excites slight catarrh, and by this means purges. As alka-

246 OILS.

lies intensify the action of the acrid principles, the purgative effect of
these oils is heightened by admixture with the alkali of the bile.

Tliese oils, especially castor oil, are commonly used as j^urgatives.
Castor oil is a speedy, certain, and somewhat mild purgative, producing
only one, two, or three motions, with little griping. It is said to purg-e
when injected into the veins, or even when applied to the skin, and if
this statement is true, the oil must have an esj^ecial affinity for the intes-
tines. It is commonly used as a purgative for children, women with
child, after parturition, in fever, piles, and fissure of the anus. It is not
a good purgative in habitual constipation, as it increases the torpid habit
of the bowels, an effect constantly witnessed in children.

Dr. Soper recommends castor oil and glycerine in equal parts, and finds
wath this combination that half a drachm of oil is sufficient. The oil
must be added slowly to the glycerine in a mortar, and the mixture must
be well rubbed together. The taste of the oil is covered.

Croton oil is a powerful purgative, producing watery stools, with much
depression. It is an uncertain purgative, sometimes acting in half an
hour, at other times requiring much longer. Large quantities, even six
or eight drops, may be required; hence it is seldom used, unless, as in
apoplexy, coma, and mania, when it is important to administer a purga-
tive of small bulk. It is sometimes employed in obstinate constipation
when other purgatives have failed. It is a good plan to give a quarter
or a third of a minim every hour, by which means a much smaller total
quantity often succeeds better than a larger quantity given in one dose.
Owing to its acrid taste it is generally administered in the form of a jiiH,
except to patients in a state of insensibility, when it is mixed with a lit-
tle butter or lard, and conveyed to the back of the tongue, and is swal-
lowed involuntarily, or trickles down the throat.

Kohrig, from experimental evidence, is led to conclude that croton
oil given to fasting animals is a powerful stimulant to the liver, but
Kutherford and Vignat did not get this result in their experiments.

As these oils remain but a short time in the intestines, the greater
part passes out with the motions. Probably little of the acrid matter
passes into the blood, since unless croton oil is swallowed in large quan-
tity, those serious symptoms seen after its injection into the veins do
not occur. Like other purgatives, these oils may infiueuce distant organs,
as the kidneys, and act as diuretics.

Croton oil has been used in hydrocephalus, and it is said to have re-
moved the excess of fluid from the ventricles of the brain.

Diarrhoea in children often yields to eight or ten drops of castor oil
suspended in mucilage; but unfortunately, the indications for this treat-
ment being unknown, it often fails.

In the early stages of diarrhoea it is a common practice to administer
a dose of castor oil, to carry away the irritant exciting the discharges.

A drop of castor oil introduced into the eye will often allay pain and
intolerance of light produced by a fine irritant, as sand.

Castor oil may be taken almost if not quite tastelessly in beef-tea,
highly peppered and well salted; or the oil may be beaten up Avith an
equal quantity of the froth of porter, and tossed off* before the constitu-
ents have separated. A mixture consisting of castor oil, half an ounce;
fresh mucilage of acacia, three drachms; distilled water, five drachms,
has very little taste. It may be flavored with oil of peppermint or oil of
lemons. It is a good plnn to pour into a wetted glass the required dose,
and then toss it off' without letting the oil impinge upon the teeth.

GLYCEKIJSTE. 247

GLYCERINE.

The api^lications of glycerine are endless. It is antiseptic, and pre-
serves lymph vaccine indefinitely. It is a nseful application for cliapped
lips and hands; and for rough, furfuraceous, and inelastic skin, left after
eczema, or other skin complaints. It restores suppleness to the tissues,
and allays burning, tingling, and smarting. Undiluted glycerine may
cause inflammation and smarting, hence it should be mixed with an
equal quantity of rose-water or eau de Cologne. Glycerine of starch acts
still better in renderng the skin soft and supple. In xeroderma, a bath
should betaken daily, and the ointment rubbed in after wiping the body
thoroughly dry. Glycerine is a good application for dryness of the
meatus of the ear; and when the tymj^anum is ruptured, it covers the
opening in the tym^iiuium with a thin film, supplying for a time the
j^lace of the lost membrane.

Dr. M. Rosenthal recommends glycerine as a solvent for alkaloids
employed hypodermically. One drachm of glycerine will dissolve ten
grains of muriate of morphia, twenty grains of sulphate of quinia, and
only one grain of curare.

The lips, tongue, and gums, when dry and coated with dried mucus
in acute diseases, should be washed and kej)t moist several times a day
with glycerine, Avhich greatly improves the comfort and appearance of
the patient. If the sweet taste of glycerine is unpleasant, it will answer
as well if diluted with an equal quantity of w^ater or lemon-juice.

In the last stage of chronic diseases, as phthisis, when the mucous
membrane of the mouth becomes dry, red, shiny, and glazed, a condi-
tion which causes much distress, and is usually accompanied by great
thirst, a wash of glycerine and water, to rinse the mouth, will relieve
this harassing condition. Undiluted, glycerine is apt to make the mouth
clammy and sticky. Glycerine will sometimes cure thrush.

Glycerine of carbolic acid is a useful application to foetid sores and
open cancers of the surface of the body, or of the uterus. It removes
the offensive odor of the discharge, and improves the condition of the
sore.

A pledget of cotton-wool, saturated with glycerine, and ajoplied for
several hours to the congested neck of the womb, will induce a copious
serous discharge, and will give as much relief as the apj)lication of
leeches. The pledget should be fastened with a piece of twine, so that
the patient herself can readily withdraw it.

Glycerine of borax is a good application in pityriasis of the scalp,
aphtha? and thrush.

Glycerine is much used now in the manufacture of medicated pessaries.

Glycerine has been used in place of sugar as in diabetes, but saccha-
rine is far preferable. It has also been recommended as a substitute for
cod-liver oil, but experience has shown its inferiority.

One of the best preventives of bed-sores is glycerine or glycerine
cream. The part exposed to pressure should be washed morning and
evening with tepid water, and carefully dabbed quite dry with a soft
towel, and then gently rubbed over with a little glycerine or glycerine
cream. If the skin is sore or tender, the glycerine cream is best. A

248 TANNIN.

draw-sheet made of linen, and sufficiently large to be firmly tucked in
at both sides of the bed (as any folds or creases are very apt to produce
tenderness, and eventually sores), will prevent soiling of the bed-clothes.
This preventive treatment should be commenced before the on-coming
of redness or tenderness.

It relieves greatly when ajoplied to the mucous membrane; in acute
coryza vaseline is preferable.

Glycerine I find useful in stomach flatulence and acidity, a drachm
to two drachms should be taken several times a day in tea, coffee, or
water,with food.

A teaspoonful of glycerine neat, or added to water, is often useful in
coughs, even the cough of phthisis. It may be added to a little lemon-
juice, which makes it more efficacious in some cases. This taken at
night often lessens morning cough. It also is useful in dry throats. A
drachm used as an anal injection is useful to relieve the bowels in con-
stipation. A very large dose produces hgemoglobinuria, from destruc-
tion of the red corpuscles.

TANNIN AND ITS COMPOUNDS. ON GALLIC ACID.

These substances produce little or no change on the unbroken skin,
but act as astringents to sores and mucous membranes, checking secre-
tion by contracting the vessels and condensing the tissues. Rossbach,
however, maintains that the vessels are dilated but not paralyzed, for
they contract on stimulation. They precipitate albumen, and thus coat
over wounds, in some measure protecting them from the injurious action
of the air, whence tannin-containing substances are applied to excoria-
tions, profusely-discharging sores, and luxuriant granulations. Tannin
is conveniently employed in the form of glycerine of tannin. This com-
bination is useful in oza^na. After measles, scarlet fever, and some other
diseases, the inside of the nose not uncommonly becomes excoriated and
reddened, and discharges freely a thin sanious or thicker purulent fluid,
which, on drying, scabs up the nose, and often excites eczema of the
upper lip; now, if the inside of the nose is well brushed out with glyc-
erine of tannin, the discharge will cease, even after a single application;
but if the scabs are thick, they must be thoroughly removed, to enable
the application to act on the secreting soi'e surface. Glycerine of tan-
nin is useful in syphilitic oza^na of cliildren; it arrests tlie discharge, re-
duces the swelling of the mucous membrane which produces the charac-
teristic sniffling, and, by enabling the child to breathe through the nose,
permits sound refreshing sleep and effective suckling.

Occasionally among adults we meet with an impetiginous eruption
of the inside of the nose, most severe near the orifice where the hairs
grow, but extending higher in a milder form. Scabs block up the nose,
especially at night, and the ala?, and sometimes tlie whole of the nose, is
tliickened, dusky red, and very painful. The swelling may extend to
the ad ji) cent structures, and may merge into repeated attacks of erysip-
elas of the face. Glycerine of tannin, ap])lied once or twice daily to the
whole cavity of the nose, speedily reduces and even cures this disease.
The upper part of the nose is the most easily cured, but the disease situ-

TANNIN. 249

ated iu the hairy part is much more obstinate, and is very prone to recur
again and again. Epilation is useful in obstinate cases. Glycerine of
starch or zinc ointment, applied several times a day, keeps the tissues
moist and supjile, and is a serviceable supplementary application.

Glycerine of tannin will generally cheek the nasal discharge of thick,
hnnpy, greenish-black, and stinking mucus, and, even when it fails, it
ordinarily removes the offensive smell. In other forms of oza?na, esjje-
cially when the disease aifects the upper and back part of the nose with
its numerous recesses, it is preferable to flush the nose with a deodoriz-
ing and astringent wash; which, besides benefiting the mucous mem-
brane, washes away the inspissated putrefying discharge on which the
stench of ozasna generally depends.

Glycerine of tannin is very valuable in otorrhoea, acommon compLiint
of weak, unhealthy children after severe illnesses. The external meatus
must be filled with it, and retained there by cotton-wool. One applica-
tion usually suffices, but a slight discharge may remain, or return in a
few weeks, when a repetition of the treatment is called for. This treat-
ment is inaiiplicable in the acute stages of inflammation of the meatus.
This affection is much more difficult to cure when the tympanum is de-
stroyed and the small bones are exposed; indeed, in such cases, the tan-
nin only restrains and deodorizes the discharge, which generally returns
when the application is stopped. Glycerine of tannin will often cure the
chronic vaginitis of children, a complaint generally more obstinate than
either oza3na or otorrhooa.

Glycerine of tannin is useful in some stages of eczema. After the
removal of the scales, if the inflamed, red, swollen, and weeping raw sur-
face is painted with this prejmration, it notably abates the discharge,
redness, heat, and swelling. A jDoultice must be applied at night: if the
glycerine of tannin excites much pain, the j^oultices must be continued
night and day. In a less active stage, when the tissues are not so red,
swollen, and weeping, eczema yields still more readily to glycerine of
tannin, applied twice or thrice daily. A poultice is useful at night.
Tannin glycerine quickly allays the trouldesome itching, tingling, and
burning, so common in eczema; hence it prevents tearing with the nails
and rubbing, which hinder healing, nay, even cause the eczema to spread.
It may not entirely remove the disease, but only reduce it to the desqua-
mative stage, with a tendency to crack and ooze, when tar, carbolic acid,
or other ointments become necessary to complete the cure. The same
treatment is useful in impetigo. A poultice must be ajiplied each night
fo remove the scabs, and the tannin application should be employed dur-
ing the day. While treating these skin diseases, the state of the digestive
organs must not be overlooked.

Eczema of the ears, common in middle-aged and old people, readily
yields to glycerine of tannin, unless the inflammation runs high, with
great swelling, heat, and weeping. This remedy is also very efficacious
in eczema behind the ears of children, one or two applications speedily
drying up and healing the eczema, although it niay have lasted for weeks
or months. The gums must be lanced, if red and swollen, and other ir-
ritations removed.

Glycerine of tannin sometimes benefits intertrigo.

Equal parts of tincture of catechu and liquor plumbi is a useful ap-
plication to prevent bed sores.

The following is an excellent pomatum for dandruff'. — Tannic acid.

250 TANNIN.

3j; glycerine, 3 ss; prepared lard, 3j; balsam of Peru, 20 drops; oil
of bitter almonds, four drops.

Glycerine of tannin is very useful in many throat diseases. Imme-
diately after acute inflammation, when the mucous membrane grows
less red, less swollen, becomes moister, and is covered with mucus or
pus, glycerine of tannin painted on the pharynx, hastens recovery, pre-
vents chronic inflammation with relaxation of the mucous membrane,
which often follows the acute disease, heals superficial ulcerations occur-
ring as the acute inflammation subsides, and cures hoarseness. It causes
dryness of the mouth and lessens the sensitiveness of the nerves, both
of ordinary and special sensation.

Glycerine of tannin is useful on the appearance of ulceration in
aphthous sore throat. In chronic inflammation of the throat when the
mucous membrane is relaxed, swollen, granular-looking, and covered
with mucus or pus, a few ajiplications of glycerine of tannin brace up
the tissues and lessen or remove the hoarseness. This kind of throat,
often with slight enlargement of the tonsils, is common in children,
and sometimes produces deafness, and still more often a frequent hack-
ing cough, which may keep the child awake the greater part of the
night. In children, this is so commonly the cause of cough, that it is
well always to examine their throats. Glycerine of tannin ajjplied daily
speedily allays the cough and cures the deafness. Throat deafness is
the most common form of that inflrmity in childhood; and when not
due to enlarged tonsils, generally depends ujjon the kind of morbid
throat just described.

Many coughs depend on the state of the throat, a fact accepted in
theory, but little regarded in practice. Glycerine of tannin is very use-
ful to allay the cough and frequent deglutition excited by an elongated
uvula, and the frequent hacking cough in phthisis , due to inflammation
or ulceration of the throat. A good night's rest may be often obtained by
painting the throat shortly before bedtime, and a small quantity of mor-
phia added to the glycerine of tannin increases its soothing effect, Mop-
2)ing the pharynx, epiglottis, and adjacent structures with this applicci-
tion will much reduce the frequency and violence of the paroxysms of
whooping-cough. It is of little use if the case is complicated with
catarrhal or other inflammation of the lungs, tuberculosis, or any irrita-
tion, as that from teething; but in simjole uncomplicated whooping-cough
it is very useful. The paroxysmal cough often left by whooping-cough,
which readily returns on catching cold, yields to this treatment. Ii^
whooping-cough and the foregoing throat diseases, glycerine of tannin
is better than a solution of nitrate of silver, as it excites less pain, and is
less disagreeable to the taste. (See Nitrate of Silver). Glycerine of
tannin is more efiicacious than tannin lozenges.

Glycerine of tannin is useful in ulcerative stomatitis, especially in
that form affecting only the edges of the gums; but dried alum is a bet-
ter application. (See Salicine.)

In diphtheria and croup, Trousseau successfully employed a solution
containing five per cent, of tannin, in the form of spray several times a
day, for fifteen or twenty minutes.

Tannin unites with albuminous matter in the stomach, forming an
insoluble substance, and any tannin left uncombined constringes the
mucous membrane, and lessens its secretions. As tannin likewise dimin-
ishes the solvent power of the gastric juice, it is inadvisable to give tan-

TANNIIST. 251

nin-containing substances close to meal times. It is asserted that taimin,
by virtue of its astringeiicy, cures slight catarrh of the stomach; hence
tannin preparations are occasionally employed in irritative dyspepsia.
Some give tannin for pyrosis, but they do not discriminate whether it
checks neutral, alkaline, or acid pyrosis, or all these forms of the com-
plaint. In poisoning by alkaloids, as strychnine and, morphia, tannin is
given to render them less soluble. Tannin controls bleeding from the
stomach ; it should be given in large doses of gr. x to gr. xx. The mem-
bers of this group are astringent to the intestines, lessening their secre-
tions and probably their contractions : hence they constipate, and tan-
nin-containing substances, as catechu, kino, red gum, rhatany, and
ha^matoxylnm, are very useful in most forms of acute and chronic diar-
rhoea. The members of this group are employed as anal injections to
check diarrhoea, to destroy thread-worms and to restrain prolapsus ani.

Few applications are so useful in irritable piles as gallic-acid and
opium ointment. The combination quickly relieves pain, and after a
time even reduces the size of the ha3morrhoidal tumors. Calomel oint-
ment, too, is highly useful.

Owing to their low diffusion power, the members of this group must
pass but slowly from the intestines into the blood. For topical action
on digestive mucous membrane tannin is best, but gallic-acid is best to
influence distant organs. After, if not before, absorption into the cir-
culation, they must become neutralized with albumen, and for this rea-
son some authorities maintain that tannin and its allies do not act as as-
tringents to organs distant from the intestines. Nevertheless, tannin
and gallic-acid are frequently em2)loyed with considerable benefit to clieck
bleeding from the lungs, uterus, and kidneys. Bartholow states it is es-
pecially useful in bleeding from the kidneys, and is less beneficial in
checking over-abundant secretion of milk, and profuse sweating.

Tannin is sometimes administered to diminish the loss of albumen
in chronic Bright's disease, and George Lewakl has experimentally tested
its power in this respect. In a few carefully-conducted experiments, he
found that the albumen was always lessened to an inconsiderable
amount, the daily average diminution amounting to about 0.66 gramme.
Tannin produced a much more decided increase in the quantity of urine.

An injection of glycerine of tannin is very beneficial in the after-
stages of gonorrhoea, and in gleet, but, as the undiluted preparation
commonly excites much pain, it should be mixed with an equal quantity
of olive oil or mucilage. Two drachms of this mixture is enough for
each injection. Too much Avill excite frequent and painful micturition;
the discharge in many instances ceases only during its employment.
Urethral injections should be persevered with eight or ten days after
the cessation of discharge, and as they are apt to excite seminal emissions,
should not be employed at bedtime.

Tannin, either alone or blended with other astringents, is a useful
injection in leucorrhoea. In obstinate cases, and when the os uteri is
ulcerated, a suppository of tannin and cocoa-nut fat applied to the mouth
of the uterus is very beneficial. Glycerine of tannin checks the great
discharge of cancer of the uterus, and destroys the stench : but a mixt-
ure of glycerine of tannin and glycerine of carbolic acid is still more
useful.

The effect of the members of this group on the natural constituents
of the urine is unknown. Gallic-acid ''passes unchanged into the urine.

252 HAMA.MELIS VIKGINICA.

and liiis been detected one hour after being taken." Tannic acid " passes
off by the urine in the forms of gallic and pyrogallic acids, perhaps of a
saccharine body." (Parkes.)

HAMAMELIS VIRGINICA.

Two preparations of this plant are largely used. A tincture and a
preparation called hazeline. Pond's extract, too, owes its virtues to this
plant.

Various preparations of witch hazel have long been in vogue in
America among the natives, who introduced it to the English settlers.

It is largely used in haemorrhage, and is most serviceable in passive
hsemorrhage, or in bleeding (oozing) from small vessels.

Applied on lint or cotton wool, it is useful for bruises, also for oozing
from wounds and sores.

It is also very useful in various ha3morrhages when taken by the
stomach, and thus administered is useful often in epistaxis, lia3moptysis,
and hsematemesis. It has been recommended in the hajmorrliagic dia-
thesis; but in the case of a lad with this peculiarity, I employed it on
several occasions in~vain in nose bleeding.

It is useful in purpura, and I have seen severe cases much benefited
by a drachm of the tincture given hourly, though, in most cases, half
this dose is sufficient. Dr. Hill recommends it in dysentery, when the
discharges contain much blood. I have known it in several cases arrest
hsematuria when other remedies had failed.

It is very useful too in some forms of menorrhagia. The dose is two
drachms of hazeline twice or thrice a day. It often relieves the pain of
dysmenorrhoea.

An obstinate case of bleeding from the bladder, due probably to a
vascular growth, was cured by injecting twice daily into the bladder half
an ounce of hazeline.

It is very valuable for piles. It rarely fails to check bleeding from
piles, even when administered by the mouth. But its effect is much en-
hanced by injecting half a drachm to a drachm of the tincture in an
ounce of cold water daily, as in the morning before rising.

It not only checks bleeding, but if this treatment is persisted in for
several months it permanently relieves or even cures piles that are not
very large. It has been employed successfully in varicocele, and one case
I have seen in which, during the employment of the drug, the varicosi-
ties entirely and apparently permanently disappeared.

Dr. Preston extols it in phlegmasia dolens.

It is useful, too, in catarrh of the mucous membrane, and snuffed up
the nose it is beneficial for colds in the head and in hay fever.

Dr. Hector Guy investigated the pliysiological action of this useful
and interesting drug, and found that it is not tonic in very large doses,
and that it has no action on the heart, arteries, or veins. The active
j)rinciple is probable an essential oil. It contains no alkaloid. Drs.
Wood and Marshall, experimenting with a strong distillate, were unable
to obtain any jDhysiological effects. It contains much tannin and gallic

TAR, CREASOTE. 253

acid, and some ascribe its virtue to these substances; but tlie distillate
is efficacious, and this contains only the volatile oil.

In the earlier editions of this work I recommended one or two min-
ims of the tincture every two or three hours, and this, in many cases, is
quite sufficient to check bleeding, but much larger doses will succeed
when these small quantities fail. But large doses sometimes cause severe
headache.

GOTO BAKK.

Of this plant the tincture in ten-minim doses, or the alkaloid cotoin in half-gi*ain
to two-gn-ain doses, or the powder in one to ten-grain doses several times a day is
the usual dose.

It is highly recommended, especially by Albertini, in all forms of diarrhoea, acute
and chronic, even the diarrhoea of phtiiisis. It is larg-ely used by some in the diar-
rhoea of infants. Said to be useless in the diarrhcea of drunkards and from cirrhosis.

Albertini says it increases appetite and augments venous pressure, and excites
active hj^pertemia of the abdominal organs. It is reputed to check salivation and
the sweating of phthisis.

The powder irritates the nose. From an allied bark, paracotoin is obtained;
which is used in similar cases and employed in similar doses as cotoin.

PETROLEUM. VASELINE, &c.

Since vaseline remains unchanged by exposure to the air, it is highly
useful for lubricating the skin when it is dry or hard, as in psoriasis,
chronic eczema, xeroderma, chapped hands, sunburn. It is excellent in
many cases of chronic eczema where the skin is dry and scaly. 01 delena
I have seen very useful in these cases.

As it is not absorbed by the skin it is not the best vehicle for medi-
cines, like aconitia, veratria, etc., and is used only with those substances,
as lead, mercury, zinc and iodide of sulphur, which make lard rancid.

Petrolettm, or benzin, are jDopularly used as local applications in
chronic rheumatism, and appear to be of considerable service.

TAR. CREASOTE, &c.

The empyreumatic oils, and their derivatives, are very useful in many
chronic skin affections, as chronic eczema, psoriasis, erythema. The odor
of oil of cade, or oleum rusci, is less disagreeable than that of tar, liquor
carbonis detergens, and carbolic acid. Dr. McCall Anderson strongly
recommends these oils, especially liquor carbonis detergens, oil of cade,
and oleum rusci. In most cases they afford immediate relief from the
tormenting itchiu/g of chronic eczema, psoriasis, erythema, and prurigo,
but if too long continued they excite inflammation of the hair follicles,
forming papules and pustules, with a black spot in their centre. Hebra

254 TAR, CREASOTE.

terms this eruption tar acne. They often excite considerable inflam-
mation in delicate skins. The topical effect of the vapor even sometimes
produces acne. The parts protected by clothes escape, showing that this
effect is not induced througli absorption by the lungs.

These oils are useful in chronic eczema, after the subsidence of in-
flammation, especially Avhen only a little redness, itching, and some des-
quamation remain. Sometimes pure tar succeeds better than its oint-
ment ; but if there is inflammation, or if the surface is raw and weeping,
it will then excite great pain and inflammation. In some instances the
application of undiluted petroleum much improves local forms of eczema,
as that kind occurring on the back of the hands; but as this apj^lication
is generally very painful, other and milder remedies should first be tried.

The external apjilication of tliese remedies in psoriasis is often very
serviceable. Tar, or its ointment, seldom fails to benefit chronic jDsoriasis ;
and some of the most obstinate forms of this disease may often be cured
by jiainting the patches of the eruption with pure undiluted tar, allow-
ing it to remain till it wears gradually away. If the unsightliness of the
tar ointment is objectionable, the creasote ointment, composed of two or
three jDarts of creasote to one part of white wax, recommended by Mr.
Squire, may be substituted. This powerful ointment must be applied
only to the patch of psoriasis, not on the adjacent healthy skin, otherwise
it will blister. To avoid staining exposed parts, Dr. McCall Anderson
sponges the eruption three or four times daily with a wash composed of
crystallized carbolic acid, two drachms; glycerine, six drachms; rectified
spirits, four ounces; distilled water, one ounce. But he considers car-
bolic acid inferior to tarry preparations. He strongly insists on the
necessity of rubbing in the ointments till they have nearly disappeared,
and, lest they become rancid, of washing them off with soajD and water
before each fresh apjilication.

Petroleum soap, cade soap, and carbolic soap are useful in both chronic
eczema and psoriasis. As these soaps are made of different strengths, if
one kind prove too strong and irritating a milder form may be substituted.

The inhalation of creasote or carbolic acid, ten to twenty drops in
boiling water, is useful in bronchitis, lessening in some cases over-abun-
dant expectoration. It will generally remove the breath fcetor occasion-
ally met with in bronchitis, and sometimes even the fcetor due to gan-
grenous lung. The inhalation of even ten drops produces in some
l^ersoas giddiness and sensation of intoxication. Inhalation of carbolic
acid with steam, or in spray, is useful in whooi3ing-cough. Used in an
oro-nasal inhaler, twice or three times a day, for a quarter to half an
hour, creasote in 5 to 10 minim doses is very efficient in easing the cough
of chronic johthisis and chronic bronchitis. It seems especially useful
where the cough is violent and protracted, and out of all proportion to
the amount of expectoration, when, indeed, the cough seems largely to
depend on an excitable state of the nerves. Its effect is often rapid and
complete; in fact I know of no remedy that affords in some cases so
much and such rapid relief. I have seen it relieve the violent cough
accompanying plastic bronchitis.

Creasote, mixed either with tannin or opium, introduced into the
hollow of a decayed and painful tooth, often gives relief.

A creasote or carbolic gargle or wash proves very efficacious in
sloughs of the mouth or throat, removing the offensive odor, and pro-
ducing a healthier action in the sore.

TAR, CREASOTE. 255

Small closes of creasote excite no particular symptoms in the stomach,
but a large quantity produces a sensation of burning at the epigastrium,
with nausea and vomiting.

During its transit through the intestines, creasote aj^pears not to un-
dergo any cliange in composition, as its characteristic odor may be de-
tected in every part of the canal. It checks the vomiting of various
diseases, as that of pregnancy, sea-sickness, cancer, ulcer of the stomach,
Bright's disease. It often promptly relieves stomach pains occurring
after food.

Creasote has been given in cholera and typhus fever, but apj^arently
without much benefit.

Creasote passes into the blood, and its odor is detectable in most of
the organs, showing that it probably remains in chief part, if not en-
tirely, unaltered in the blood.

Tar, creasote, and carbolic acid are used in bronchitis and in phthi-
sis to check both the quantity of the expectoration and its offensiveness.
They are especially useful in chronic bronchitis. Tar-water is an old-
fashioned and approved remedy in bronchial complaints. The frequent
and popluar use of tar-water, both by the profession and by the laity in
Trance and Belgium, led me, in conjunction with Dr. Murrell, to try its
elfects. Patients so susceptible to cold that they were obliged to remain
indoors the whole winter informed us that this remedy curtailed con-
siderably the duration and lessened the severity of their catarrhal attack,
and that, by an occasional recourse to the tar, they became less prone to
catch cold, and could more freely expose themselves to the weather.

We employed tar in two-grain doses, in a inll, every three or four
hours. From October to January, inclusive, we carefully watched its
effects on twenty five patients, whose ages varied from thirty-four to
seventy, the average being forty-four. All these patients had suffered
for several years from winter-cough, lasting the whole winter. They
were out-patients, and visited the hospital weekly, or oftener. Most of
them were much exposed to the weather, while some, being so ill, were
obliged to stop work, and therefore were less exposed.

These patients suffered from the symptoms common in winter cough
— paroxysmal and violent cough, the paroxysms lasting from two to ten
minutes, recurring ten to twelve times a day, and in the night spoiling
sleep. The expectoration, frothy and slightly purulent, was generally
rather abundant, amounting in some cases to half a pint or more in the
day. The breathing was very short on exertion, but most of them could
lie down at night without propping. The physical signs showed a vari-
able amount of emphysema with sonorous and sibilant rhonchus, and
occasionally a little bubbling rhonchus at the base.

These patients usually began to improve from the fourth to the
seventh day; the improvement rapidly increased, and in about three
weeks they were well enough to be discharged. The improvement was
so decided that the patients returned to their work; even those who, in
previous years, had been confined to the house the whole winter. The
cough and expectoration improved before the breathing. In several cases
the expectoration increased during the first three or four days ; but its
expulsion became easier, and with the improvement in the cough and ex-
pectoration, appetite and strength returned.

On discontinuing the tar, a relapse often occurred in a week or two,
and the patient returned with a request for more of the same medicine.

25G CARBOLIC ACID.

and then a second time the symptoms quickly subsided. AVe found it
useless in bronchial asthma, and its effects were more evident in cases
where expectoration and cough were more marked than dyspnoea.

We have no doubt that tar is a good, useful, though, perhaps, not a
striking, remedy in these troublesome affections; and certainly it is more
efficacious than the drugs generally employed.

It may be remarked that tar is useful in the same cases for which the
spray of ipecacuanha wine is serviceable. The spray, we find, acts much
more quickly and, unlike tar, it lessens dyspnoea even before it improves
cough, or diminishes expectoration.

Creasote in full doses is strongly recommended in phthisis, especially
for the non-febrile or only slightly feverish cases. It is said to diminish
expectoration, imi^rove appetite, and increase weight.

Dr. Anderson gives tar m chronic eczema. He begins with three or
four minims in treacle, pill or capsules, gradually increasing the dose to
ten or fifteen minims three times a day. In gangrene of the lungs crea-
sote is employed to obviate the foetor of the expectoration, and as an in-
halation it certainly succeeds, though when swallowed it is of doubtful
efficacy.

Oppression of the head, epigastric jiain, vomiting of dark colored fluid,
and black motions sometimes occur after the application of tar, though
rarely except when applied over a large area.

Tar and creasote are reputed to be diuretics; and, as some of the in-
gredients of tar pass off with the urine, changing its color and odor, they
may possibly act on the urinary tract. Thus tar, creasote, and carbolic
acid, administered either internally, or applied externally, cause some-
times at first dark-colored, and sometimes black urine, which gradually
becomes lighter in tint. It is said that the urine is colored dark more
frequently from the external than from tiie internal use of carbolic acid;
and Ferrier suggests that this is owing to its becoming oxidized before
its absorption. Sometimes the urine is natural in color when first passed,
but becomes dark on standing. On the addition of sulphuric acid, the
odor of tar is readily perceived, and chloride of iron develops a beautiful
blue color. The local application of ol fagi, ol rusci, ol cadini, occasion-
ally affects the urine in the same manner. The urinary changes are es-
pecially marked within the first few days, but after a time these changes
become scarcely perceptible. The urine remains clear throughout, rarely
contains albumen, and does not exhibit an excess of iron, showing that
the discoloration is not due to disintegrated blood corpuscles. The urine,
in health, contains a trace of carbolic acid. Carbolic acid and creasote
sometimes excite strangury. Carbolic acid and sulpho-carbolates admin-
istered by the stomach prevent, as we have shown, decomposition of the
urine; possibly these drugs may prove useful agents to preserve the urine
sweet in cystitis, enlarged prostate, and paralyzed bladder.

CARBOLIC ACID AND SULPHO-CAEBOLATES.

Carbolic acid destroys the lowest forms of animal and vegetable
life, and j)revents fermentation and putrefaction. While it ])revents the
fermentation of sugar, it is said not to prevent the conversion of starch

CARBOLIC ACID. 257

into sugar, nor the decomposition of fimygdiilin. Dr. Brunfon, however,
in his work states that strong solutions will prevent these changes. It
is largely employed to prevent tlie stenches of drains, water-closets, dis-
secting rooms, and hospital wards. Unlike chlorine and permanganate
of potash, carbolic acid is incapable of destroying offensive gases; it only
prevents their formation. Its destructive influence over the low forms
of animal and vegetable life has led to its being employed as a disinfect-
ant. It is a good plan to hang a sheet, kept moist with a solution of
carbolic acid, and large enough to cover the doorway of the sick cham-
ber, and to extend a little beyond.

Koch finds that chlorine, bromine, and corrosive sublimate are de-
cidedly more efficacious in destroying the bacilli spores of splenic fever
tJian carbolic acid, sulphurous acid, or zinc chloride ; and where gases or
heat cannot be employed he recommends a mercuric salt, as mercuric
chloride, sulphate, or nitrate. One part in a thousand of these solutions
killed the resting S2)ores in ten mintues, and one part in fifteen thou-
sand is strong enough to kill micro-organisms.

Creasote and carbolic acid act energetically on the skin, producing
opaque, white patches, and exciting active inflammation, followed, in a
few days, by desquamation. They coagulate albumen, and are stimulant
and astringent; hence they may be emjjloyed to check bleeding.

Carbolic acid, locally applied, is an anaesthetic. Dr. A. H. Smith
painted on his forearm a spot an inch in diameter, with an 85 per cent,
solution of carbolic acid. For a minute it caused slight burning, then
the skin became quite numb, whitened and shrivelled; at this point he
made an incision half an inch long Avithout even feeling the knife, the
wound healing as usual. Three hours afterwards he thrust, without
pain, a needle into the skin, and next he applied a blister to the carbon-
ized skin without causing pain or vesication. He found that in incising
two whitlows this application greatly lessened the pain.

Professor Erasmus Wilson employed carbolic acid as an anaesthetic,
to diminish the pain arising from caustics, as potassa fusa. Brushed
over the delicate part or raw surface several times, the acid coagulates
the albumen, "benumbs the surface, and iDcrmits the caustic action with
a great reduction of pain." Mr. Wilson employed this method in lujjus,
epithelioma, and in disease of the glans and prepuce.

A solution of carbolic acid or glycerine of carbolic acid is often use-
ful as a topical application to relieve itching; even the itching due to
jaundice. Dr. Squibb says that the anaesthetic action is useful in burns
and erysipelas, for a one per cent, solution applied on lint and frequently
renewed relieves pain of burns in ten minutes, and its influence, pro-
vided the application is used from the first, is persistent for twenty -four
hours.

Carbolic acid applied as a stimulant and antisei^tic to gangrenous and
ill-smelling sores prevents the stench, and improves the condition of the
wound.

Provided inflammation runs not too high, carbolic acid ointment,
composed of ten minims of the acid to an ounce of simple ointment,
moderates the weeping stage of eczema and allays the tingling and itch-
ing. It is useful in the eczema of the heads of children.

Carbolic acid has the great advantage of being free from color. It
is useful in eczema, psoriasis, and prurigo, but it is generally considered
inferior to tar.
17

258 CARBOLIC ACID.

Dr. Alder Smith finds glycerine of carbolic acid very useful in the
early stages of ringworm.

Dr. Eade recommends the use of carbolic acid for carbuncles and
carbuncular boils. He employs a solution of one part of carbolic acid in
four of glycerine or oil, and soaks in this small pieces of lint, and thrusts
them through the opening of the broken skin to the bottom of the holes
and sinuses in the carbuncle, and keeps the surface of the carbuncle cov-
ered with lint soaked in the solution. This application he maintains
prevents the extension of the carbuncle. This treatment is only useful
in that late stage of the carbuncle when the skin is broken and the car-
buncle discharging.

Professor Iliiter employs carbolic acid hypodermically in erysipelas.
He uses the following formula: — Carbolic acid and alcohol, of each 3 ss;
distilled water, 3 ij. Of this six to eight syringefuls should be in-
jected at different points where the inflammation is most intense, and
should be repeated next day, or in a few days, if the disease spreads.

Carbolic acid topically applied is very useful in malignant pustule
(anthrax). It may be injected into the neighborhood of the pustule;
two minims in a two per cent, solution, repeated twice a day for two or
three days, or compresses soaked in a five per cent, solution, are to be
frequently a^ipl led. Some paint the diseased part with concentrated car-
bolic acid.

Glycerine of carbolic acid appears to me to be highly useful as a topi-
cal application in the throat in diphtheria. It should be applied only
to the diseased portions of the mucous membrane twice a day.

Carbolic acid sjH'ay to the nose or a gargle of one per cent, solution is
recommended in contagious coryza or sore throat.

A weak solution of carbolic acid is a very useful injection or wash for
the cavities of large abscesses, or in empyema, after the evacuation of
pus. A like injection will correct the iVetor arising from cancer of the
womb, or other uterine diseases. Carbolic acid removes the stench and
lessens the discharge in ozsna.

A lotion consisting of one part of carbolic acid to one hundred parts
of water is useful in pruritus ani. Dr. J. Thompson employs marine lint
soaked in carbolic lotion. He pushes every night a small plug into the
anus, a part being left as a pad outside. Carbolic acid is useful in pru-
ritus pudendi. It may cause considerable irritation both in pruritus ani
and pudendi, the skin sometimes being so delicate that even a weak aj)-
plication causes considerable burning and smarting.

The investigations of Dr. Sansom, who first employed sulpho-carbo-
lates in medicine, prove that these salts arrest fermentation in different
degrees, sulpho-carbolate of soda being most efficient; then follows a salt
of magnesium, then of potassium, then of ammonium. Administered
to animals, they prevent putrefaction and decomjjosition of urine, al-
though Sansom could not detect any of the salt in this excretion. He
gave sulpho-carboltite, and then collected and preserved the urine, which
after six months had not undergone decomposition.

Sulpho-carbolate of soda and carbolic acid are very useful in flatulence,
especially when there is great distention, unaccompanied by pain, heart-
burn, or other dyspeptic symptoms. Sulpho-carbolate of soda will gener-
ally relieve extreme flatulence, producing copious eructations and con-
siderable distention, symptoms not unconjmon in middle-aged women
and phthisical patients. When flatulence occurs immediately after a

CARBOLIC ACID. 259

meal ten or fifteen grains of sulpho-carbolate of soda should be taken
just before food: when it occurs some time after meals, the medicine in
the same dose should be taken half an hour after food.

We often meet with patients, generally women, who suffer from what
is ordinarily called "spasms." The patient complains of considerable
flatulence and distention, often limited to one part, or sometimes more
marked in one part, of the abdomen, generally on the left side under
the ribs, accompanied by severe pain, which, like the flatulence itself, is
often most marked under the left side of the chest. The pain, tempo-
rarily relieved by the eructation of a little wind, soon returns and may
endure many hours, and may frequently recur. In some cases the com-
plaint is evidently a neuralgia of some of the abdominal nerves, the pain
being chiefly excited by flatulence. Sulpho-carbolates, in doses of fifteen
grains, or carbolic acid in one to two minim doses immediately before or
after food, prevent the formation of wind, and they often afford consid-
erable relief.

Carbolic acid is readily absorbed by the skin. Internally and even
externall}'^, even in small quantities, it may produce sometimes serious
symptoms, some patients being affected much more readily than others;
it may excite severe vomiting, giddiness, delirium, contracted pupils, ir-
regular breathing, ha^moglobinuria, even coma or collapse, with weak
pulse and cold sweat, lowered temperature, even to several degrees.
These toxic symptoms are, it is said, best combated by the free use of
diluents; so, doubtless, the symptoms arising from tar would be bene-
fited by the same means. Injected under the skin of a frog, carbolic
acid causes weakness, passing into complete paralysis, convulsions and
death. Slight irritation of the skin induces violent convulsions. These
convulsions are central. Some believe they depend on the action of the
poison on the spinal cord; others conclude on experimental grounds
that the convulsions are due to the effect of the poison on the central
basal ganglia.

The convulsions are tetanic in frogs, but chronic in warm-blooded
animals; as with the spinal cord so with the respiratory and vaso-motor
centre, they are first stimulated and then paralyzed. Carbolic acid
stimulates the sweat and salivary centres.

Professor Czerny describes a chronic carbolic poisoning which attacks
surgeons much exposed to the spray. There is a slight headache, bron-
chial irritation, languor, diminished appetite. The legs feel heavy, there
is nausea, especially in the morning. The patient complains of insom-
nia, and is anaemic, and his skin itches. These symptoms disappear with
a few days' absence from the exciting cause.

Carbolic acid is recommended to reduce temperature in fevers, but it
is inferior to many other antipyretics. Like other antipyretics it has a
greater effect on the febrile than on the non-febrile temperature.

Carbolic acid is useful as a sedative to the stomach, and also to check
fermentation. Thus, in one to two minim doses it is useful in many
forms of vomiting due to irritation of the stomach ; it is likewise very
useful in flatulence, especially when it is copious.

Carbolic acid as spray or administered internally is useful in coughs,
especially where the secretion is abundant. A four per cent, spray with
administration of half a minim to two minims every three or four hours
is highly efficacious in whooping-cough.

Dr. Lloyd Eoberts, of Manchester, was one of the earliest to draw at-

260 MUSK CASTOREUM.

tentiou to tlie virtues of carbolic acid, now commonly employed in ulcer
of the OS and cervix uteri, in chronic inflammation of the uterus and
cervix with excoriation, and in chronic uterine catarrh. " I use," says
Dr. Roberts, "invariably the pure acid. A capital plan for maintaining
the fluidity of the acid, devised by Mr. Weir, of Dublin, and recom-
mended by Dr. Roe, is to add a few grains of camphor to a little of the
acid. In simple ulceration a free application of the acid drawn over the
surface twice a week is sufficient. When it is necessary to apply the
acid to the interior of the cervical canal I use a charged camel-hair jien-
cil, or a gum elastic catheter, having previously removed, with a piece of
lint or injection of water, any impeding mucus. In applying it to the
interior of the uterus by injection, it is very important to have the cer-
vical canal freely open, so that any superfluous injection may pass freely
out. Care should also be taken to ascertain the direction of the uterus;
as in cases of retroflexion any of the injection passing beyond the curved
portion of the organ and retained there Avould be certain to produce un-
toward consequences. When injected into the uterine cavity the acid
should be diluted Avith glycerine and water, commencing with a weak
solution, gradually increasing the strength as circumstances require. I
also use this acid freely as an ordinary injection in vaginal leucorrhoea,.
uterine ulceration, and cancer; and it will be found an excellent cleanser,
healer, disiufector, and allayer of pain Although its action does not
penetrate below the diseased surface, it possesses, in equal degree with
the stronger caustics, the proj)erty of changing the vitality of the tissues,
and produces rapid cicatrization, dissipates the inflammation and hyper-
trophy, and relieves pain."

An injection comjjosed of twenty grains of sulpho-carl)olate of zinc to
eight ounces of water, used twice or thrice daily, is useful in gonorrhoea.

It is said that sjDonging the exposed part of the body with a weak
solution of carbolic acid will drive away mosquitoes.

MUSK. CASTOREUM.

These medicines, although once highly esteemed, especially musk^
by Graves and Cullen, are but seldom used. Their peculiar and charac-
teristic odor is o^jpressive and sickening, and sometimes causes headache,
giddiness, and even fainting ; hence musk is ill adapted for the sickroom.

These substances have a bitter taste.

Jorg asserts that musk, in two to five-grain doses, causes weight at
the stomach, eructations, dryness of the oesophagus, heaviness of the
head, giddiness, headache, followed by sleepiness, faiutness, and a sensa-
tion of heaviness in the whole body ; and in very large doses, trembling
of the limbs, and even convulsions. It is said they strengthen and
quicken the pulse. Trousseau and Pidoux failed to obtain these symp-
toms, noticing only headache with giddiness, the pulse being unaffected.

These remedies are employed in melancholia, and for many of those
anomalous but distressing svm])toms grouped under hysteria. They
have been given in chorea, epilepsy, whoo])ii>g-cough, nervous palpitation,
cramps of various parts of the body, and even in tetanus. Dr. Graves

ALCOHOL. 261

employed musk in typhus and other fevers, to prevent jjrostration, and
to strengthen a weak and feeble pulse.

Professor Horatio "Wood highly commends musk in delirium tremens
and acute specific fever. He gives ten grains with ten to twenty drops
of laudanum per anum, the laudanum being added to secure its reten-
tion. He draws attention to the fact that by repetition it soon loses its
effect.

In cardiac dyspnoea, ten drops of tincture of musk given every quar-
ter of an hour, for four or six doses, is recommended to remove the op-
pression of breathing and to induce good sleep.

ALCOHOL.

FoK many reasons alcohol might be grouped conveniently with chloro-
form and ether, there being much similarity in the action of these three
medicines. Each, at first, produces much excitement, with increased
strength of the pulse, tbis stage after a time giving way to another of uncon-
sciousness, Avhich may be profound; but with this general similarity there
is an important difference between alcohol on the one hand and chloro-
form and ether on the other. With chloroform and ether the stage of
excitement is brief, soon passing into that of insensibility, which may
endure a long time without danger to life. But with alcohol the early
stage of excitement and intoxication is of considerable duration, insensi-
bility and unconsciousness not coming on till large quantities have been
taken, and some time has passed. In this stage of insensibility the
danger of death is imminent from paralysis of the heart and of the move-
ments of respiration. It will be easily understood, therefore, that while
chloroform and ether are used as ana?sthetics alcohol is inadmissible for
this purpose.

Alcohol, owing to its volatility, is sometimes employed to abstract heat,
and cool the surface of the body, as in inflammation of the brain, etc.,
but it is not a very effectual refrigerator, and ice is preferable.

If its evaporation is prevented, it penetrates the skin, owing to its
tolerably high diffusion-power and excites the tissues beneath the cuticle,
causing a sensation of heat and some inflammation. It may be thus em-
ployed as a counter-irritant.

It coagulates albumen, and is sometimes used to cover sores with a
thin, protective, air-excluding layer, which promotes the healing process.
Alcohol, in the form of brandy or eau de Cologne, is often applied to
harden the skin of parts exposed to pressure, and to obviate the occur-
rence of bed-sores, an excellent practice, which should be adopted before
the occurrence of abrasion, or even before redness occurs. It is a
useful practice to bathe the nipple with brandy, each time after a suck-
ling, then carefully to wash the part, and dab it dry. It is well to apply
the brandy some days before delivery, so as to harden the tissues, and
prevent the formation of cracked nipples, which give rise to so much
pain and distress.

In virtue, probably, of its power to coagulate albumen, and perhaps
of other properties, it constringes, to a small extent, the mucous mem-

262 ALCOHOL.

branes of the month, and is sometimes nsed, dilnted with water, as an
astringent gargle in relaxed throat, scnrvy, salivation, etc.

In the stomach it exerts a double action. Thus it may affect both the
gastric juice and the secreting mucous membrane. Its action in these
respects will be considered separately. The effect of a small quantity of
alcohdl on the pepsine of the gastric juice is insignificant; but a large
quantity precipitates the pepsine, but adding water redissolves it.

As with the gastric juice so with the mucous membrane, the topical
effect of alcohol differs according to whether the dose is large or small.
It has been experimentally proved that, taken very moderately, it in-
creases the secretion of the gastric juice, and every day experience con-
firms this fact; whilst undue quantities destroy the appetite, upset the
stomach, inflame its mucous coats, cover it with a thick tenacious mucus,
and abolish its secreting power.

Owing to this influence on the functions of the stomach alcohol is a
remedial agent, as the following examples will illustrate:

I. Some persons, after undergoing considerable fatigue, are apt to lose
all appetite and digestive power, and on taking food to suffer from an un-
digested load on the stomach; but a glass of wine or a little brandy -and-
water, taken shortly before food, will restore appetite and digestion.

II. In the convalescence from acute diseases, when digestion and
strength may remain a long time depressed, alcoholic stimulants, taken
just before or at meal -times, are often serviceable.

III. Many dwellers in towns, who lead a sedentary life, and suffer
often from weak digestion, find that only by the help of alcohol in some
form can they properly digest their food.

IV. Stimulants are most serviceable in the prostration from aciite
illness, when, in common Avitli the other functions, digestion is much de-
pressed, at a time when it is most important to support the strength until
the disease has done its worst. Strength, no doubt, is best supported by
food; yet the weakened stomach can digest but sparingly; but at this
critical juncture alcohol spurs the flagging digestion, and enables the
patient to take and assimilate more food.

Next, the time of giving the alcoholic stimulant is a matter of great
importance. It should not be given at haphazard, as is too commonly
the case, but should be given with the food. To a patient laboring under
great prostration, in whom digestion is very feeble, food and stimulants
should be given together, in small quantities, frequently repeated; but a
strong patient had better take food at the ordinary meal-times, when,
from habit, the stomach digests better.

It is necessary to insist on this point, as it is common with both doc-
tors and patients to trust to alcohol alone, forgetting that while it bene-
fits by stimulating the heart, it at the same time effectually aids the
digestive process, and thus supports the patient in the best and most
natural manner.

It has been mentioned that large quantities of alcohol excite catarrh
of the stomach, but it is singular how large a quantity a patient pros-
trated by fever can take without producing this result. The same fact
may be noticed in convalescence from exhausting diseases. Still, care
must be exercised, since stimulants, if too freely given, will sometimes
upset the stomach, so that the food is vomited, an untoward circumstance
gi'eatly adding to the patient's danger.

After a variably time the prolonged indulgence in alcoholic drinks

ALCOHOL. 263

seriously damages the stomach by producing chronic catarrh. The
mucous membrane, coated with tenacious mucus, excites unhealthy fer-
mentation of the food, while the structure of the membrane itself
undergoes considerable alteration, through great increase of the connec-
tive tissue, which by its contraction obstructs and destroys the secreting
follicles and their lining cells. The mucous membrane thus becomes
thickened, hardened, and uneven; and, owing to obliteration of the ori-
fices of the follicles, cysts form in its substance, and these enlarge from
the accumulation of cells within them. In consequence of these serious
changes little gastric juice is j^oured out in response to the demand made
by the food, while the unhealthy mucous coating of the stomach, by
exciting morbid fermentations, induces the production of much gas, with
various acids, as butyric, acetic, etc., whence acidity and heartburn.
Morning vomiting of a scanty, sour, bitter, and tenacious fluid is a char-
acteristic symptom of this condition. Owing to its high ditfusion-power,
alcohol passes readily into the blood, so that but little can reach far into
the intestines. Spirits, especially brandy, are often successfully employed
after the removal of the exciting irritant, to control the after stages of
acute simple diarrhoea, when the relaxed condition of the mucous mem-
brane allows the liquid parts of the blood to pass into the intestines, pro-
ducing frequent watery stools. In the vomiting and diarrhoea of children
small doses of brandy, added to food, are very useful. Brandy often in-
duces refreshing sleep in children. Even in large quantities alcohol ap-
pears neither to promote nor to hinder the conversion of starch into sugar.

01)servations on the influence of alcohol on the blood and organs, have
yielded contradictory results, the most recent and elaborate investigations
of Drs. Parkes and Wollowicz clashing in most ^particulars with those of
previous experimenters. Hitherto it was held that alcohol diminishes
the oxidation of the body, but Parkes and Wollowicz's observations are
opposed to this conclusion. Dr. G. Harley found that alcohol in small
quantities added to blood withdrawn from the body, lessened its absorp-
tion of oxygen and its elimination of carbonic acid.

As the result of a great many observations taken in conjunction with
Dr. Rickards, every quarter of an hour, for several hours, on persons of
all ages, we found that alcohol, brandy, and wine, diminish the body
temperature. After moderate doses the fall was slight, amounting to
not more than 0.4" to 0.6° Fall., but after poisonous doses the depression
in one instance reached nearly three degrees; in rabbits the fall was much
greater, reaching to ten or more degrees. These observations have been
confirmed by Professor Binz, of Bonn, and by Dr. Eichardson, who asserts
that all alcohols redaice the animal temperature. Drs. Parkes and Wol-
lowicz, whose observations are opposed to the foregoing, gave to a healthy
young man, in divided quantities, for six days, a daily amount of absolute
alcohol, varying from one to eight ounces, and, on a subsequent occasion,
twelve ounces of brandy daily for three days, observing meanwhile the
temperature of the body every two hours. The average temperature of
the alcohol and of the brandy -drinking days, was found to be almost iden-
tical with that on days when only water was taken. These conflicting
results it is difficult to reconcile; but it must be granted that a consid-
erable quantity of alcohol, repeated several times a day, does not perma-
nently reduce the body temperature. Dr. Parkes has recently re-investi-
gated this question, and he finds that dietetic doses (two fiuid ounces of
absolute alcohol) given to a healthy fasting man at rest often reduces the

264 ALCOHOL.

rectal temperature rather less than half a degree; hut when the alcohol
is given with food, even in doses of four to eight ounces of absolute alco-
hol, it produces no effect on the temperature. In a boy aged ten. who
had never in his life before taken alcohol in any form, I found through a
large number of observations a constant and decided reduction of tem-
perature. It is possible that alcohol given in repeated doses may soon
lose its power of depressing the temperature. Excessive habitual indul-
gence appears to have this effect; for Dr. Rickards and I gave to an
habitual drunkard, making him " dead drunk," twelve ounces of good
brandy in a single dose, without the smallest reduction of the tempera-
ture. The effect on the body temperature was formerly ascribed partly
to the increased loss of heat through the skin by dilatation of the blood-
vessels, and in a lesser degree from diminished oxidation and lessened pro-
duction of heat; but Dr. B. Lewis and Drs. Wood and Reichert find that
alcohol increases both heat production and heat dissipation, but whether
the increased loss leads to the increased production, or vice vernd, they are
unable to decide. The time of greatest heat production coincides with
the lowest bodily temperature ; which suggests that increased loss leads
to increased formation of heat. This increased production of heat proves
that alcohol does not influence temperature by lessening oxidation.

In their experiments on the urine Bocker and Hammond found that
*' the formation of urea, of the extractives, and of sulphuric acid and
phosphoric acid, Avas lessened by alcohol and beer, and the water and free
acidity of the urine was diminished ; " but in Parkes' and Wollowicz's ob-
servations, alcohol, brandy, and claret produced no decreased elimination
by urine of the urea, phosphoric acid, or free acidity. They, however,
increased the amount of urinary water.

Edward Smith found that brandy and gin diminish, while rum in-
creases, the pulmonary carbonic acid. These conflicting statements it is
impossible to reconcile; but Parkes' observations were so carefully con-
ducted, and are so complete, that they must be accepted as authoritative.

How much alcohol is consumed in the Ijody ? The results of investi-
gations to determine this point are so contradictory that it is impossible
to decide the value of alcohol as a food. Bouchardat, Sandras, and
Duchek conclude that alcohol is freely consumed in the body, little escap-
ing by the urine, iinless very large quantities are taken. On the o'ther
hand, Perrin, Duroy, and Lallemand deny that alcohol is consumed
in the smallest degree in the body. Anstie concludes from careful ex-
periments that the greater part of the alcohol is consumed, and he has
undoubtedly proved that only a little escapes with the urine, while Parkes
and Wollowicz believe that a considerable quantity escapes with the sweat
and breath. Dupre's recent observations confirm those of Anstie, prov-
ing that only a fractional part of alcohol escapes from the body; and
Anstie believes that this never occurs except with a narcotic dose, which
varies in different persons.

Even if the greater part of alcohol is consumed, and thi;s ministers to
the forces peculiar to the body, yet alcohol, by depressing functional
activity, favoring degeneration, etc., may do more harm than can be
counterbalanced by any good it may effect by the force it sets free dur-
ing its destruction; even if taken in quantities too small to do harm, yet
it can scarcely be classed as an economical food for the healthy. Granted
that dietetic doses check oxidation in the healthy, and thus economize
the blood and tissues, still, unless it can be shown that in health there is
constantly an excess of consumption over and above that required by the

ALCOHOL. 265

body, such a diminution of oxidation could only result in lessening the
amount of force set free and put at the disposal of the organs, entailing
of course a diminution of the functional activity of the body. Physiology
failing to guide our steps amid these conflicting statements, it is obvious
that in estimating the value of alcohol in health or disease we must rely
solely on experience, which plainly shows, that, for the healthy, alcohol
is not a necessary nor even a useful article of diet. Varied, repeated, and
prolonged experience, and the testimony of army medical men, prove
that troops endure fatigue and the extremes of climate better if alcohol
is altogether abstained from. The experience of the celebrated Moscow
campaign showed this ; and, a few years ago, the Red Eiver expedition.
During arduous marches it has always been found that, without alcoliol,
the health of the men is exceptionally good, but as soon as spirits are
allowed disease breaks out. Modern trainers recognize the fact that the
power of sustained exertion and resistance to fatigue is best promoted by
abstaining from alcohol, and the ill-health of many athletes depends,
not on the rigor of the training, but on the excesses they indulge in after
the contest.

There can be no doubt that healthy persons, capable of the fullest
amount of mental and physical exertion Avithout the stimulus of alcohol,
not only do not require it, but are far better without it.

It must be recollected, however, that these remarks apply to pure
alcoholic drinks, as spirits, and not to beers and wines, which contain in-
gredients useful as food. The amount of alcohol in the lighter beers
and wines is small, and can hardly be prejudicial to the robust, while
they seem to brace up and sustain the flagging functions of the weakly,
as town-dwellers, especially those who pass mucli of their time indoors,
in an unhealthy atmosphere. Some, indeed, cannot properly digest food
without a stimulant.

Dr. Anstie highly extolled alcoholic stimulants in the debility of old
age, especially in the " condition of sleeplessness, attended often with
slow and ineffectual digestion and a tendency to stomach cramps." He
employs "a generous and potent wine," containing much ether.

Alcoholic drinks, especially those containing a large quantity of vola-
tile ether, often relieve the pain of neuralgia, the alcohol removing the
temporary nervous depression which produces the paroxysm; alcohol for
a time relieves the distressing symjjtoms occurring in so-called hysteria,
generally met with in middle-aged Avomen; but, as the stimulant after a
time must be taken in increasing quantities, there is great danger lest the
patient should acquire the habit of taking alcohol to excess. Nervous or
neuralgic patients are often prone to imbibe alcohol in excess, and thus
many women become confirmed tipplers. It behoves the doctor then to
be very guarded and precise in prescribing alcoholic stimulants.

AVhatever doubt may exist concerning the usefulness of alcohol in
moderate quantities, there can be no question of its pernicious and
poisonous effects when taken in excess. It then injures and degenerates
the tissues of all parts of the body and produces premature old age, for it
produces increase of the connective tissue (fibrosis) and fatty degeneration
of parenchymatous tissues (steatosis). The lungs become prone to em-
physema; there is diminution of both physical and mental vigor; the
kidneys, liver, and stomach may become cirrhosed. Even in a state of
so-called health, when the effects of hard-drinking are not very apparent,
they become at once evident on the occurrence of illness or accident, when

266 ALCoiioi..

tlie constitution manifests its undermined condition and its diminished
power to resist disease. Thus drunkards succumb to accident or illness
which temperate men easily pass through.

Delirium tremens may arise in different ways; sometimes through a
single debauch, Imt commonly it attacks those who habitually take an
excessive quantity of wine or spirits, without perhaps ever getting drunk.
In an attack arising from an exceptional debauch it is merely necessary to
withhold spirituous drinks for a time, to allow the system to get rid of the
alcohol. On the other hand, delirium tremens is often excited in habitual
topers by altogether withholding intoxicating drinks, so that in treating
these chronic drinkers a moderate quantity of some alcoholic drink for a
time must generally be allowed. It is right, however, to add that many
excellent ooservers contend that it is wiser to cut off alcohol altogether,
maintaining that the symptoms are due to the paralyzing action of alcohol
on the nerve centres.

The influence of alcohol on the heart is most noteworthy. It
strengthens the contractions of the heart, especially when this organ is
weakened by debilitating diseases, which are always attended by a
quickened and weakened pulse. In health, alcohol dilates the arterioles and
makes the pulse larger and softer; in disease, or when from other causes
the arterioles are relaxed, it contracts them, rendering the pulse smaller,
slower, less frequent, and more resistant; alcohol strengthens the pulse,
and reduces its frequency and must be considered one of the most powerful
cardiac tonics. This tonic property, combined with its influence in pro-
moting digestion by increasing the gastric juice, explains the great use-
fulness of alcoholic beverages in debilitating chronic and acute diseases.

In most diseases accompanied by weakness or prostration alcohol in
one or other form often proves a valuable remedy. It is of conspicuous
service in acute diseases running a limited and definite course, in the
treatment of Avhich the cardinal point is to sustain the vital force beyond
the critical stage.

Brandy or wine are the best remedies when the heart is suddenly en-
feebled, from fright, loss of blood, accidents, or other causes."

Great as are the beneficial effects of alcohol in disease yet it may do
harm as well as good. Certain precautions must therefore be observed,
and its effects on the functions must be carefully watched. Althougli
the heart affords the most trustworthy information on this }ioint, yet the
influence of alcohol on the other organs must not be overlooked, as it
may happen that wdiile alcohol may benefit one part of the system it may
injure another, doing good in one respect, yet on the whole inflicting
more harm.

The following rules regarding the use of stimulants in fever were laid
down by Dr. Armstrong, endorsed by Dr. Graves, and will receive the
assent of all practical men:—

1. If the tongue become more dry and baked, alcoholic stimulants
generally do harm; if it become moist, they do good.

2. If the pulse become quicker, they do harm; if it become slower,
they do good.

3. If the skin become hot and parched, they do harm; if it become
more comfortably moist, they do good.

' In threatened fainting, it is a good plan to direct the patient, whilst sitting down
to lean forward and jilace the head between the legs as Ioav down as possible, so that
the blood may gravitate to the brain.

ALCOHOL. 267

4. If the breathing become more hurried, they do harm; if it become
more and more tranquil, they do good.

These excellent rules might be supplemented by a fifth; alcohol does
good Avlien it produces sleei?, and quells delirium. (See Opium.)

In judging of the influence of alcohol on the pulse, its compressibility
is of more importance than its volume. Under the action of alcohol a
soft and yielding pulse of large volume often becomes much smaller and
less compressible, changes indicating an increase in the tonicity of the
arteries, and in the strength of the heart.

Such are the rules which must guide us in the employment of alcohol
in disease, giving us data as to the quantity we should administer, and
whether we should continue, increase, or withhold it.

There are other circumstances which we must carefully regard in
respect to the employment of alcoholic drinks. At the two extremes of
age, the powers of the body being easily depressed, stimulants are accord-
ingly called for early, and must be freely used. In the aged, especially,
it is of great importance to anticipate prostration by the early employment
of alcohol; for it is very difficult to overcome this condition. Young
children prostrate from disease take stimulants with benefit, eveii in large
quantities. Xext, the knowledge of the course a disease ordinarily runs
gives us timely indications in respect of this question. In some acute
diseases, as typhus, in which the depression is often very marked, es-
pecially at the extremes of life, stimulants should be employed early.

Alcohol is sometimes given to fever patients in very large quantities.
It is given to reduce fever, and to check waste. In fevers, no doubt,
there is greatly increased destruction of the nitrogenous tissues, shown
by the large quantity of urea eliminated by the urine; at the same time,
all the functions of the body are much depressed, and can appropriate
less of the force set free by oxidation than in health. From these two
causes, and partly likewise from diminution of perspiration, so that the
heat fails to pass off duly by the skin, jareternatural temperature of the
body occurs in fevers. Alcohol in large doses, it is maintained, lessens
oxidation and prevents Avaste, and thereby lowers the temperature of the
body, and diminishes the amount of urea in the urine; but to effect this
very large doses must be given — doses which, in some cases at least, I
should imagine might do harm in other ways ; hence, the influence on
the pulse, respiration, etc., according to the rules just laid down, must
be very carefully watched.

Several years ago I made a large number of observations concerning
the influence of alcohol on the temperature of fever, and found that as
in health, so in fevers, alcohol slightly reduces the temperature; but its
efficacy in this respect is so insignificant, and doses so enormous must be
taken to produce even trifling results, that it is useless to give alcohol
solely with this intention.

In my judgment, there can be 210 doubt that alcohol is not required
in all febrile diseases ; on the contrary, many cases are best treated Avith-
out it. Children and young persons previously healthy rarely require it,
and in no instance should it be given unless special indications arise.
The enormous quantities of alcohol which used to be given a short time
ago, and are indeed now sometimes administered, are, I believe, rarely
needed, although very large doses are occasionally needed, and are un-
doubtedly the means of saving life.

The kind of alcoholic stimulant employed is perhaps not a matter of

268 ALCOHOL.

great importance, provided its quality is good. It is undesirable to give
several kinds of stimulants at about the same time, or they may derange
the stomach; but they may be changed from time to time according to
the jiatient's desire. Anstie recommends strong alcoholic drinks in fevers,
as brandy, in the earlier and middle stages; but when the heart flags, and
the nervous system becomes weakened, he prefers wines containing plenty
of compound ethers. Stimulants should not be given in large quantities
to weakly persons at distant intervals of the day; it is far better to give
them in small and frequent doses. A large dose at one time strongly
stimulates the heart; then, as the alcohol is decomposed or eliminated,
the heart is left unsustained, when great weakness may set in; whereas,
the frequent administration of smaller quantities keeps the heart more
uniformly supported.

Some easily digested food in small quantities should be given with the
stimulant, which, by promoting digestion, supports the patient's strength
in the most natural and most effectual way. As a rule, when food is
freely taken and digested, stimulants are little needed.

Weakly children derive more benefit by taking stimulants about an
hour before, rather than with food, which plan enables them to take more
food, and to digest it better, than the more common one of giving the
stimulant Avith food.

In common with ether and chloroform, alcohol is an antispasmodic,
but in this respect ether and chloroform are more effective.

It does sometimes happen that one alcoholic stimulant is harmful,
while another is found useful; a fact especially noticeable in coughs,
which are aggravated by porter or beer, but are unaffected or even re-
lieved by brandy or Avine. Beer or stout sometimes produces sleepiness,
heaviness, even headache, and flushing of the face, while the same person
can take wine or brandy without inconvenience. Individual peculiarities
abound in respect of wines; for example, one person cannot take sherry
without suffering from acidity, Avhile another, on taking port, is seized
with gouty pains.

The wish of the patient for any particular form of stimulant is often a
correct indication of its desirability. A free draught of the weaker beers
will often gratefully slake the urgent thirst of fever.

Stout is supporting and nourishing to persons brought low by ex-
hausting discharges, and to women weakened by suckling, though in
many cases unfortunately it disagrees, producing headache and sleepiness.
The good old-fashioned remedy, rum or brandy and milk taken before
breakfast, is useful in phthisis and in exhausting diseases. A little rum
and milk an hour before rising is a good prop to town-living women, to
whom dressing is a great fatigue, who, without appetite for breakfast,
suffer from morning languor and exhaustion, often lasting till mid-day,
and to couA^alescents from acute diseases.

The ill-effects of alcohol in gonorrhoea are well known. A cure is
much more readily effected if the patient Avill abstain altogether from
alcoholic beverages. Even Avlien the cure seems near completion a single
indulgence in spirits, wine or beer, will bring back the scalding and dis-
charge.

In some persons, alcohol, unless in a very dilute form, and in very
moderate doses, quickly affects piles. Beer, champagne, port, strong
claret, even in a few minutes cause burning pain and aching in the
rectum, lasting for hours. With some persons coffee or pepper act in the
same rapid way.

CHLOROFORM. 269

CHLOROFOEM.

Chlopofokm, when applied to the surface of the body, speedily vola-
tilizes and cools the skin; but it is seldom used as a refrigerator, being in
this respect inferior to other agents.

Owing to its high dilfusion-power chloroform readily penetrates the
animal textures. If evaporation is prevented, it penetrates the cuticle
and excites inflaramation, and thus becomes a rubefacient.

In quantity insufficient to excite inflammation, chloroform deadens
sensation, and acts as a local anaesthetic. It is sometimes applied to relieve
pain, and occasionally with good effect, although it often fails, and is
inferior for this purpose to many other external applications. It has
been used in neuralgias, sometimes effectively, but it generally fails, and
even when successful, the relief is ordinarily very temporary, the pain soon
returning.

In faceache or toothache, two or three drops, on a small piece of cotton-
wool, introduced into the ear, give occasionally complete and permianent
relief; but if too large a quantity is used it Avill excite inflammation, even
vesication, and give much annoyance. The pain of cancer, when the
skin is broken, leaving a painful, irritaljle sore, is relieved by playing
vapor of chloroform on the raAv surface, and often the immunity from
pain lasts several hours; a like proceeding relieves the pain of cancer of
the uterus, of ulceration of the os uteri, of neuralgia of the uterus, and,
in a less degree, the annoyance of pruritus pudendi. The vapor must be
made to play on the os uteri for some minutes. I think that chloroform
vapor might be useful in cancer of the rectum, spasm of the intestines,
etc. , re-collecting, however, that chloroform is easily absorbed b}'' the large
intestine.

According to Sir J. Simpson, a few drops of chloroform whilst evapo-
rating from the palm of the hand held close to a photophobic eye will
enable it to bear the light without pain.

Dr. Churchill lessens the violence of the paroxysms of whooping-cough
by the simple plan of directing the nurse to pour about half a drachm of
ether or chloroform over her hand, and to hold it before the child's
mouth. The child at first dislikes this treatment, but soon appreciating
its benefit, will run to the nurse on the first warning of an attack.

An ointment, composed of half a drachm of chloroform to an ounce
of lard, will often allay the itching of urticaria, lichen, and true prurigo,
but, like most other ointments, it loses its effect in a short time; hence
anti-itching applications require to be changed from time to time.

Dr. Augustus Waller has shown that chloroform promotes to a con-
siderable extent the cutaneous absorption of many substances. The
absorption of watery or alcoholic solutions is far less rapid. The chloro-
formic solutions of aconite, atropia, strychnia, or opium, applied to the
skin, speedily destroy an animal, with the characteristic toxic symptoms
of the alkaloid employed. He ascribes this property of chloroform to its
property of passing rapidly through animal textures, carrying with it the
dissolved alkaloid. The addition of a certain amount of alcohol to the
chloroformic solution does not hinder the absorption of the alkaloid —

2 70 CHLOROFORM.

indeed, it appears to liasten it; for when an equal quantity of alcohol is
added to the chloroformic solution, the absorption is more rapid than
when simple cliloroform is used. This property, either alone or mixed
with alcohol, should be borne in mind in employing alkaloids as external
applications.

Chloroform produces in the mouth a sensation of warmth, and if un-
diluted excites inflammation. Being a stimulant to the mucous mem-
brane it excites a flow of saliva. A few drops on cotton-wool inserted into
the hollow of a decayed aching tooth often gives permanent relief, but
when the anfesthetic effect has passed away the pain is sometimes aggra-
vated, the chloroform having irritated the inflamed pulp. It is a good
plan to fold over the hollow tooth a piece of linen moistened with chloro-
form, so that the vapor may remove the pain. Equal parts of chloroform
and opium, or of chloroform and creasote, constitute a useful application
in toothache.

Chloroform excites a sensation of warmth in the stomach, but in
large doses it induces nausea and vomiting. One to three drop doses of
pure chloroform are beneficial in flatulent distensions of the stomach,
sea-sickness, and other vomitings.

Its high diffusion-j^ower enables it to pass rapidly into the blood, lit-
tle, if any, finding its way into the intestines. The ph3'sical and chemical
changes produced in the blood by its admixture with chloroform are at
present unknown.

When given in medicinal doses to a healthy jDerson it produces very
little change, either in the frequency or strength of the heart's contrac-
tions, though when inhaled, judging by the hasmadynamometer, it is said,
at the very first, slightly to increase their force. In disease, on the
other hand, when the heart beats feebly, especially if due to some sudden
and transient cause, chloroform certainly strengthens the heart's con-
tractions, so relieving such symptoms as syncope, etc. ; but it is in noway
preferable to a glass of brandy-and-Avater or wine. It no doubt acts more
ouickly and evanescently than alcohol, and its cardiac effect certainh'
declines more speedily than that of alcohol. It is frequently adminis-
tered to hysterical patients and others suffering from weakness, depres-
sion of spirits, nervousness, etc. Like all stimulants, if habitually in-
gested, it soon loses its effect, and this es2:)ecially happens with chloroform
and ether, so that from time to time the dose requires to be increased,
and even then these drugs soon lose their efficacy.

In diarrhoea, after the removal of the exciting irritant, spirit of chloro-
form may be given with much benefit, combined with astringents and
opium. It is useful in intestinal and summer colic, from whatever cause
arising, and in renal and biliary colic, in hiccup, hysteria, and asthma,
both primary and secondary ; and from the relief it gives in these affec-
tions it is ranked among antispasmodics. In the treatment of any of the
foregoing diseases it is usually combined with ojnum, and this combination
succeeds admirably. No doubt much of the effect is due to the opium,
its action, it appears, however, being increased and sustained by the chloro-
form. Its mode of action is at present unknown. Fossibh-, by restoring
the weakened muscular or nervous system to its natural physical condi-
tion, it controls inordinate muscular action and removes pain, thi;s be-
coming a true stimulant. Chloroform, combined with small doses of
morphia, or opium, given with a drachm of glycerine, honey, sugar-
and-water, syrup of lemons, syrup of Virginia prune, or treacle and water,

CHLOROFOEM. 271

is often conspicuously beneficial in certain coughs. It is useful when the
cough is paroxysmal and violent — violent out of proportion to the amount
of expectoration; when, indeed, there appears to be much excitability or
irritability in the respiratory organs, and when a slight irritation induces
a distressing fit of coughing. In such circumstances the chloroform is of
more service than the opium, and should be given in a full, while the
opium should be given in a very small, dose. This combination allays
the cough in the fibroid form of phthisis, so frequently paroxysmal, wear-
ing, and exhausting. In this form of lung disease there is often such ex-
tensive induration, with thickening of the pleura, as to prevent any
expansion of the lung, and consequently of the chest walls, so that little
or no air enters the consolidated part of the lung, and no expulsive force
can be brought to bear on the mucus. Here our attention should be
given to check the abundant secretion, to lessen its tenacity, and so facili-
tate its expulsion.

Cough, very often indeed, arises from a morbid condition of throat;
and even when due solely to lung disease, the application of the mixture
just recommended, to the throat and parts about the glottis, is often
beneficial, in accordance with a general fact that remedies applied to the
orifices communicating with certain organs, as the nipple, rectum, and
throat, will by nervous communication act on the organs themselves. For
example, many coughs are allayed much more efficiently if the opium and
chloroform mixture is swallowed slowly, and so kept in contact with the
fauces as long as possible.

Being highly volatile, much chloroform passes off by the lungs, and
its odor can be detected in the breath; some, probably for the same reason,
escapes by the skin, and some probably by the urine. In its passage from
the lungs it is unlikely in any way to influence the mucous membrane of
the bronchial tubes, the quantity separated being very small; and even
during and after the inhalation of chloroform we do not observe that it
modifies in any way the secretion of this membrane. Its influence, if
any, on the kidneys and the urine is at present unknown.

Harley's observations on the action of chloroform on the respiratory
function of the blood tend to show that it lessens the oxidation of the
blood, and diminishes the evolution of carbonic acid; but to establish this
point we think further experiments are needed.

We will now give a succinct and practical account of the administration
of chloroform as an anjesthetic. It is needless to dwell upon the signal
and beneficent service this agent has in this respect rendered to mankind.

Chloroform at first very often causes a sensation of tingling and heat
in the lips and nose, and these parts, if accidentally moistened with it, may
become inflamed, even to blistering, an accident which can always be pre-
vented with care, particularly if the nose and lips are first smeared with
glycerine or cold cream, or some protecting substance.

The early sensations experienced vary much in different persons, being
sometimes so agreeable as to tempt to the inhalation of this substance
merely for the sake of inducing them; but in the majority the sensations
are more or less disagreeable, often intensely so.

At first there is a sensation of warmth at the pit of the stomach,
spreading to the extremities, and accompanied by some excitement; then
some or all of the following symptoms soon set in. Xoises in the ears,
lights before the eyes, heavy weight and oppression of the chest, great
beating of the heart, throbbing of the large vessels, and a choking sensa-

272 CHLOROFORM.

tion. These symptoms betoken no danger, and need excite no apprehen-
sion. At the very commencement of the administration some cough is
not unfreqnently excited, or even a passing spasm of the glottis, sure
signs that tlie vapor is administered in too concentrated a form, and tliat
more air must be mixed with it, by opening the valve in Clover's apparatus,
or by removing the lint farther from the nose and mouth.

At this early stage, women, by becoming hysterical, may give some
trouble and alarm. They laugh, sob, or cry; their breathing is often ex-
tremely irregular and hurried — a condition which frightens the friends,
and inexperienced chloroformers; but this state is to be accepted as an
indication to continue, not to withhold it; for this condition soon subsides
as the patient passes more deeply under the power of the anesthetic.

The pulse, at first cpiick, and it may be weak, if not due to the
patient's illness, is the effect of nervousness and anxiety; and as soon,
therefore, as unconsciousness sets in, the pulse falls in frequency, and
gains in force.

A few seconds from the commencement of the administration all dis-
comfort ceases, the patient becomes quiet, breathes calmly, and feels
brave. The consciousness is now more or less affected; questions are still
heard, but are slowdy answered, and not to the purpose. The induction
of this medium stage is adequate for confinement, and for the relief of
renal colic.

All knowledge of the external world soon becomes lost, and is fol-
lowed by a period of excitement. Various incoherent ideas occupy the
mind; some persons struggle, attempt to get up, and, when restramed,
often show much irritation. The stage of complete unconsciousness re-
quired for capital operations is now fast approaching. Violent tonic con-
traction of the muscles of the body often occurs before complete uncon-
sciousness and perfect muscular relaxation set in. The extremities
become rigid, the muscles of the chest are firmly fixed, and the respira-
tion thus becoming impeded, causes, in combination with the general vio-
lent muscular contraction, duskiness or lividity of the face. The e3'es
are injected or prominent, the lips blue, the jugulars stand out like large
black cords, the mouth is clenched, and a profuse perspiration Ijreaks out on
the body, especially about the face. In a few seconds all these symptoms
pass away. They may be accepted as a sure indication of the immediate
approach of utter insensibility, and complete flaccidity of the muscles,
and as a warning that the administration must be conducted with in-
creased caution, or the patient Avill suddenly pass into a state of danger,
Tvith noisy, stertorous, quick, shallow breathing, and quick, weak piilse.
These violent muscular contractions, which greatly distort the face, and
frighten the patient's friends, rarely occur in women or children, or in
men Aveakened by exhausting illness; and it is a condition more fre-
quently seen when the chloroform is administered too abundantly, and
the patient brought too quickly under its influence.

As these movements cease, the mustdes become flaccid, and the stage
of perfect insensibility is reached. Reflex action is lost, for while pre-
viously the brain is chiefly affected, now the spinal cord becomes par-
alyzed ; the conjunctiva can be touched without producing winking. The
limbs when raised and let go fall heavily. The breathing is calm, but a
little superficial; the pulse is not much altered, but it may be a little
more compressible. The face is moist with perspiration. The pupil is
much contracted. This condition may be nuiintained Avith due precau-
tion for a considerable time; but if now the chloroform is continued in

CHLOROFORM. 273

undiminished quantity, the breathing becomes noisy and stertorous ; the
pupil greatly dilates; the pulse loses its strength; the breathing becomes
more and more shallow, and less and less frequent, till both pulse and
respiration stop, for the respiratory centre has become paralyzed. Even
now artificial respiration will often restore the breathing, bring back the
pulse beats at the wrist, and restore the patient from the jaws of death.
On several occasions, while administering chloroform, I have witnessed
recovery from this critical condition.

On the other hand, it appears that sometimes, without warning, while
the pulse is beating well and the breathing is deep and quiet, the heart
suddenly stops, and respiration immediately ceases. This form of death
arises probably from cardiac syncope, while the other form of death is
l^robaljly due to paralysis of the respiratory muscles from the effect of the
chloroform on the respiratory centres. (See Belladonna.)

Chloroform insensibility may with care be maintained for hours, and
even days.

In administering chloroform, the attention should be directed to the
state of the pulse, the breathing, the conjunctiva, and the pupil.

The pulse usually retains throughout its frequency and force. Should
it become quick and weak, or irregular, then the inhalation must be
withheld, unless the frequency of the beats can be accounted for by the
patient's struggles. The breathing often affords an earlier sign of dan-
ger than the state of the pulse. If the respiration becomes very shallow,
and gradually less frequent, the chloroform should be suspended for a
time.

The surest signs of safety, and the earliest of danger, are afforded by
the state of the conjunctiva and pupil. While irritation of the conjunc-
tiva causes reflex action, and is followed by blinking, there is usually no
danger. The pupil is much contracted in the stages of insensibility when
no danger is to be apprehended; but on the approach of peril from over-
dose of the anaesthetic, the pupil dilates.

It is concluded that chloroform affects the pupil by first stimulating, and then para-
Ij'zing the motor oculi nerve centres, for during the contraction of the pupil, stimu-
lation of the cervical sj'mpathetic is without effect, but when the pupil begins to dilate,
this stimulation increases the dilatation. '

When, on touching the conjunctiva, reflex action is annulled, and the
limbs, when raised, fall heavily, the j)atient is fit to undergo any opera-
tion.
, One or two circumstances require a passing notice. Vomiting is liable

^ Dr. Buxton has kindly given me the following: — "There is a caution neces.sary
with regard to permitting operations to be commenced before the patient is completely
under the influence of the anaesthetic. AVithout attempting to theorize as to the cause,
it is undeniably a dangerous practice, and many deaths have occurred when it has been
followed. It should in every case be made a rule that no operative measures of any
kind be allowed until the patient is in the stage of relaxation. It is important to be
al)le to obtain early warning that vomiting during chloroform narcosis is about to
supervene. The pupil will, as was pointed out by M. Budin, afford a clue. He found,
and my experience confirms his statement, that when the patient is about to vomit the
pupils commence gradually to dilate. I have often observed efforts at swallowing air
are initiated at this time, and the pulse flags slightly. If now the chloroformization is
discontinued, the pupils widely dilate, vomiting occurs, and the patient regains con-
sciousness rapidly. But, on the other hand, if the chloroformist, aware of the import
of the.se signs, piialiex the chloroform, the pupils regain the contraction which is normal
to the state of relaxation, and vomiting is obviated, while the pidse recovers its force.
The gradual dilatatif)n spoken of above must not l)e confounded with tlie sudden
mydriasis which betokens grave danger. In this last case, stertor, shallow breathing,
and marked lessening of the pulse-force also occur, together with cyanosis."
18

274 CHLOROFORM.

to happen if food has been taken a short time before tlie chloroform,
occurring either as the patient is passing under its influence, or more
commonly on the recovery from it, ceasing always when under the full
effect of chloroform. Vomiting, happening after complete chloroformi-
zation, may he taken as a sign of returning consciousness; and, if the
operation is uncompleted, the inhalation should at once be continued, when
the vomiting will speedily cease. But, to avoid vomiting, it is advisable
that the patient should take no food for three or four hours before choro-
formization. At the same time too long a fast should be avoided, or its
very purpose may be defeated by inducing the tendency to vomit; and
fainting and much exhaustion may occur from a small loss of blood dur-
ing the operation. The head should be turned aside to assist the escape
of the vomited food, and to prevent choking.

It should be borne in mmd that operations on the rectum and vagina,
even when the patient is quite insensible, often, nay generally, cause
noisy catchy breathing, very much resembling stertorous breathing,
often mistaken for it, and sometimes thought to indicate that too much
chloroform has been administered; but this is not the case. The true
state of things can generally be discriminated by a little attention to the
circumstances. Thus, the noisy breathing does not occur until the rectum
and vagina are manipulated, and is especially loud and noisy "when the
finger or an instrument is passed with any force into either orifice.

On discontinuing the administration, consciousness usually returns in
a fcAV minutes, but is sometimes delayed for a longer period. If perfect
quiet is observed, its effects are often followed by sleep, which refreshes
the patient, gives time for many of the disagreeable consequences of the
inhalation to pass off, and allows the pain of the operation to subside.

Experiment, practice, and common sense show that the danger of
chloroform is in proportion to the percentage of vapor inhaled in the air.
The importance of ascertaining the minimum quantity sufficient to bring
the patient speedily and safely to a state of insensibility is apparent. Mr.
Clover had shown this to be in the proportion of -i to 5 per cent, of chlo-
roform vapor. With this percentage, insensibility can be produced in
about five minutes, with the minimum of danger. In animals killed by
the inhalation of this proportion of chloroform, the -heart will continue
to beat long after respiration has stoj)ped. At the beginning, Mr. Clover
administers about 2 per cent, vapor, and as the patient becomes accus-
tomed to its action the quantity is increased till 5 per cent, is reached.

AVhen any serious symptoms arise, and danger is apprehended, the
chloroform administration should, of course, be discontinued, and artifi-
cial respiration, after Sylvester's method, practised instantly and assidu-
ously, whether the breathing has ceased or is growing slower and shal-
lower. AYhere the breathing has been extinguished in a gradual manner,
the patient, provided artificial respiration is instantly adopted, in a few
seconds in most instances, fetches a deep gasp, which is soon repeated,
and presently the breathing grows more frequent, till it becomes natural,
and he is saved. When the chest has ceased to move, the pulse to beat,
and when the patient presents all the appearances of death, even at tliis
crisis life may generally be restored. Little is to be hoped, hoAvever,
from artificial respiration in those cases where the breathing and pulse
both cease immediately without any warning. Besides the use of artifi-
cial respiration, cold water should be dashed over the face and chest, air
should be freely admitted and all hinderance to breathing removed; indeed.

CHLOROFORM. 275

everything hampering to the breathing, as stays, or a tight dress, should
he removed before the administration of chloroform. The most serious
impediment to the breathing, sufficient to endanger life, may be caused
by the patient lying prone for the convenience of the operator. Several
times I have witnessed cases of imminent danger from this cause. When
this position must be assumed, the most anxious care must be paid to the
state of the breathing; for this prone posture is itself quite adequate to
arrest feeble breathing, which without this impediment would go on
safely.

It is a question of importance, whether galvanism should be used in
danger from chloroform. The Committee appointed by the Medical and
Chirurgical Society, are of opinion that this agent is useful, but that it is
far inferior to artificial respiration; but some authorities are wholly
opposed to its use, on the score of its influence to arrest a very feebly
acting heart, and so diminishing any slight remaining hope of recovery.
It is advised to apply it to the phrenic nerve to stimulate the diaphragm
to action, and thus maintain breathing till the chloroform shall have had
time to evaporate from the blood, and the system become free from the
drug. But artificial respiration is a more potent agent to excite the res-
piratory functions.

It has been ])roved that a certain percentage of chloroform, amply
sufficient to produce, speedily, complete unconsciousness, can be inhaled
with safety for an almost indefinite time. It is, therefore, obvious, that
the method required should enable us to give this percentage with cer-
tainty throughout the most protracted operation, so that the proportion
compatible with safety shall never be exceeded. The contrivance which
best fulfils this condition is the ingenious apparatus of j\Ir. Clover. Its •
advantages are so great as to out-balance fully the slight inconvenience
connected with its use. If this apparatus is not at hand, we may adopt
the use of a simple piece of lint and a towel, or Dr. Simpson's method, or
Skinner's cone.

Are there any conditions of age or health which forbid the use of
chloroform as an anaesthetic ? Provided due care is observed, I think it
may be given to all persons irrespective of their condition, having myself
given it without any threatening symptoms, in serious heart disease, in
every stage of phthisis, in Bright's disease, cancer, chronic bronchitis, to
patients almost dead of exhaustion from loss of blood, to children of a
few weeks, and to persons close upon a hundred years old. No doubt a
dilated or a fatty heart adds to a patient's risk, and enforces on the opera-
tor more care and anxiety, and the two extremes of age are conditions
which exact close watching whilst giving chloroform.

Inhalation of chloroform is borne better by the weak, those depressed
by illness, by women and children, than by healthy, robust men.

As might be expected from the similarity between alcohol and chloro-
form, we find that persons who take alcohol to excess require more chlo-
roform to induce unconsciousness.

Chloroform inhalation is now frequently used with much advantage
during delivery; it eases the uterine pains without increasing the danger
to mother or child. It is not necessary to obtain complete unconscious-
ness, but to give only sufficient chloroform to dull the pains. If this
recommendation is disregarded, and the antestlietic is pushed to the stage
of complete unconsciousness, it weakens the contraction of the womb,
and retards delivery. It is true that even if only slight unconsciousness

276 CHLOROFORM.

is produced, the uterine contractions are probably somewkit weakened,
but accoucheurs maintain that this disadvantage is more tlian compensated
by the relaxation of the parts, aiul the abatement of spasms. ])r. Play-
fair, who thinks chloroform inhalation is too indiscriminately used, says
he has often observed the pains alter, and become less effectual after
chlorof ormization, and when it is prolonged he thinks it favors post-partiun
haemorrhage. (See Chloral.)

In dental operations the patient incurs some additional risk of syn-
cope, owing to his sitting posture. Chloroform should be avoided in
dentistry; indeed, it is now superseded by nitrous oxide.

Chloroform inhalation may be used with signal benefit in renal and
biliary colic. In my experience it is inferior only to morphia injection,
and is very far superior to opium, warm baths, and the ordinary treat-
ment in vogue. It removes the severe pain before unconsciousness is
reached; indeed, it is never necessary to carry the admiiiistratipn of chlo-
roform very far. The pain often speedily returns, but may be quelled
again; and after two, or at most three, administrations, it is often per-
manently removed.

Chloroform inhalation in the treatment of chorea is sometimes very
valuable. It is applicable especially to those serious cases in which vio-
lent and constant movements prevent sleep, and even the swallowing of
food, so that speedy exhaustion and death are to be apprehended. Chlo-
roform in such cases often induces refreshing sleep; indeed, the sufferer
passes from the insensibility of chloroform into that of natural sleep, and
after perhaps some hours, wakes up soothed, refreshed, and with a
marked abatement in the movements. So great sometimes is this im-
provement, that patients, who before the chloroform could scarcely be
restrained in bed, after waking, sit up troubled with only slight involun-
tary movemeiit, and eat and swallow with ease. Soon, however, the
movements return, when the inhalation must be repeated. At first it
should be administered three times a day, then, proportioned to the im
provement, twice, and after a time once a day. This treatment, it is
stated, will cure the disease, on an average, in twenty-eight days. (See
Chloral.) In delirium tremens, when the usual means fail to induce
sleep, it has been advised to produce unconsciousness by chloroform in-
halation.

Chloroform inhalation will arrest convulsive fits, especially in children,
sometimes permanently. Chloroform inhalation is of great service in
puerperal convulsions. It is necessary in some cases to maintain uncon-
sciousness for hours, or even days, allowing the patient to wake every
three or four hours to take food.

In the reduction of hernia its use is obvious. It may be used to assist
the diagnosis of abdominal tumors, when deep-seated, and when the
walls of the belly are hard and rigid. It is useful also in determining
the nature of phantom tumors, which disappear entirely when the patient
is made insensible by chloroform.

Chloroform inhalation gives relief in neuralgia, sciatica, colic of the
intestines, if the pain is very severe, in distressing dyspnoea, whether this
is due to asthma, aneurism, etc. Mr. Gascoin reports a case of bronchitic
asthma much benefited by rubbing the chest for an hour daily with lini-
ment of chloroform. He attributes the success to the friction, and refers
to a WidoAV Pau, who has obtained a reputation in Paris by using fric-
tion in cases of asthma. The inhalation of a few whiffs in asthma, with-

CHLOROFORM. 277

out producing unconsciousness, sometimes affords relief, and should the
paroxysm return, on the effect of the chloroform passing away, the inha-
lation may be repeated. A small quantity of chloroform given in this
way often suffices to avert an attack, though in most cases the effects are
only transient, the paroxysm returning as the influence of the drug wears
off. Eight or ten drops on a lump of sugar is also useful in a paroxysm
of asthma, and, indeed, in other spasmodic diseases.

Dr. Bartholow finds injection of five to fifteen minims of chloroform
into the neighborhood of a neuralgic nerve very useful, and has some-
times a permanently good effect. He finds spirits of chloroform, ether,
or alcohol, likewise beneficial. It must not be forgotten that the injec-
tion of chloroform is sometimes followed by troublesome ulceration.

Dr. Buckler recommends 5 to 60 drops of chloroform by the stomach
in biliary colic, repeated every four to six hours. It is said to dissolve
the calculus, but it takes several hours' immersion in chloroform to dis-
solve even a small calculus. The treatment, however, is undoubtedly
useful. I have frequently administered five, ten, to twenty drops on a
piece of sugar every quarter of an hour with great relief to the joain.
The same treatment, or half a drachm to a drachm of ether every half
hour, is very useful in persistent hiccup, a paroxysm of asthma, and
other spasmodic diseases.

It has been highly recommended in drachm doses for tape-worm,
taken in the morning fasting, after a light supper the previous evening.
I presume few will treat tape-worm in this way, and the recommendation
is chiefly interesting as indicating that such large doses may be taken
without risk, at least by many persons. Dr. Davidson Hcott says he has
given a drachm dose in " more than 500 cases." He uses it as a hypnotic,
this dose inducing about two hours' sleep. He has " frequently " given
undiluted chloroform in teaspoonful doses to children two and three
years of age, and in one instance, a case of puerperal convulsions, he gave
undiluted a tablespoonful of chloroform, which arrested the convulsions
and induced quiet sleep.

Insomnia, tremulousness, and inability to fix the attention, are, it is
said, apt to follow the repeated use of chloroform inhalation.

In some experiments with Roy's tonometer, in which I used the en-
tire ventricle, and the lower two-thirds of the ventricle, I find that chlo-
roform, ethidene dichloride, and bromide of ethyl, will paralyze the ven-
tricle by their action on its muscular substance.

I find that chloroform and ethidene dichloride are about equally
poisonous to the heart's substance. These experiments show, too, that
chloroform and ethidene dichloride are far more poisonous than ether; in-
deed it requires about 80 to 100 minims of ether to arrest the ventricle,
while one or two minims of cliloroform is sufficient. I also find that
ammonia and chloroform, ammonia and ether, ammonia and bromide
ethyl, and ammonia and iodoform are mutually antagonistic. After the
ventricle is arrested, or almost arrested, by chloroform, ethidene dichlo-
ride, ether, or iodoform, the pulsations are restored and strengthened by
the addition of a small quantity of a solution of caustic ammonia.

278 ETHER.

ETHER.

The physiological action and therapeutic use of ether and chloroform
are, for the most part, identical.

As a local anaesthetic in neuralgia, toothache, etc., ether is less fre-
quently used than chloroform.

In the form of spray, after the method introduced by Dr. Eiehard-
son, ether is employed temporarily to abolish sensation of the skin ; the
rapid evaporation of the ether, and consequent abstraction of heat, freeze
the tissues and annul sensation. Ether spray isfrequenth^used in minor
operations, as the opening of abscesses, the removal of small tumors, etc.
It has been successfully employed in amputation of the leg, and in ova-
riotomy, but it is not generally available in operations so serious and
prolonged. The skin or mucous membrane, when sufficiently frozen to
permit of a painless operation, becomes pale, shrunken, tallowy -looking,
and feels as if oppressed with a great weight, "While recovering the nat-
ural condition the frozen tissues tingle and smart, sometimes so intensely
as to exceed the pain of operation. The obvious advantage of ether spray
over chloroform inhalation is its perfect safety.

Freezing the skin with ether spray sometimes removes sciatica or
neuralgia permanently, but the relief general^ is but temjaorary.^

Ether spray applied to the spine, at first every two hours, and then
less frequently, is said to be useful in tetanus, and ai^plied night and
morning, it is highly commended in chorea.

Ether has a sweetish, hot, pungent taste, and induces a sensation of
warmth in the stomach. Like chloroform it may be taken in full doses
to relieve biliary or intestinal colic. It increases the secretion from the
stomach, intestines and pancreas, and stimulating the muscular coat it
expels wind.

After its absorption it stimulates the heart, and is hence employed in
syncope and in prostration in fevers, but as it is rapidly eliminated chiefly
by the lungs, its effects are transient, not exceeding generally an hour.

Full doses of ether often act as soporifics, and are very useful in angina
pectoris, sometimes giving even more prompt and permanent relief than
nitrite of amyl. It is useful, too, in asthma.

It is sometimes employed hypodermically in heart failure from haem-
orrhage or from general diseases and adynamic pneumonia, etc. Fifteen
to thirty minims are injected three or four times a day. The injection
excites burning pain with some swelling, which subsides generally in an
hour or two, but sometimes it excites suppuration. It is also employed
in sciatica, being injected in the neighborhood of the painful nerve. I
have employed it in many cases of heart failure from various causes, with
very little, and often without any, benefit.

Ether is largely used as an inhalation to induce angesthesia, and is

' Dr. Debove employs methj'l chloride condensed by pressure, to congeal the
skin in neuralgia, especially in sciatica, and claims to generally cure tlie patient
after one or two applicatio^is. He congeals the skin over tlie area of pain, in
some instances from the trochanter to the malleolus. Tliis application freezes
the sivin much more readily than ether, but requires a special apparatus. He
saj's it causes but little pain and no inflammation or risk of sloughing. I have
employed this appHcation in a few cases and with some success, but certainly
with less than Dr. Debove's account led me to expect Moreover, tlie application
in ail my cases induced considerable and somewhat enduring pain.

IODOFORM. 279

generally preferred in most cases to chloroform, for ether has much less
effect in depressing the heart and paralyzing the vaso-motor centre than
chloroform. Like chloroform and alcohol it affects first the cerebral
hemispheres, causing delirium and unconsciousness, and next paralyzes
the spinal cord, affecting last the cardiac and vaso-motor centres.

It must, however, be given in larger doses than chloroform. It excites
the resj)iratory mucous membrane and may induce catarrh. It also
greatly increases the secretion of saliva and mucus.

Dr. H. A. Hare has recently shown that prolonged etherization con-
siderably lessens the body temperature. He has reduced the temperature
from 8° to 10° Fah., and in operations he has seen a fall of 4.4° Fah, in
man. Probably other anesthetics produce the same effect. ISome sur-
geons wrap children in cotton wool, covering not only the body, but also
the extremities, before giving the anaesthetic.

lODOFOEM.

Iodoform is used as a disinfectant, an antiseptic, an anassthetic, and
internally, probably by virtue of the iodine it contains. It contains 97
per cent, of iodine.

Iodoform is a healing and soothing application to spreading and
sloughing sores, as bed-sores, rodent ulcers, and especially to soft chan-
cres, and is said to prevent buboes. It is also very useful in syphilitic
and scrofulous ulceration. The sore dusted over with iodoform is cov-
ered with some bland application, as glycerine spread on lint. Its action
in chancrous and syphilitic ulceration is often prompt. In syphilitic
sores the following formula is very useful: Iodoform, 1 part, oil of eu-
calyptus, 15 parts. It has been successfully employed in ulceration of
the nose and thro it and in chronic ozaena. It relieves the pain of cancer-
ous sores. Dr. Moleschott uses it as an ointment, 1 part in 15, for en-
larged scrofulous or simply inflamed glands in orchitis. An ointment
composed of iodoform, gr. 4; oil of eucalyptus, 3 j; vaseline, 1 j, is highly
recommended in eczema. When employed in uterine cancer, a bolus
containing from eight to sixteen grains made up with cocoa-nut fat is
inserted into an excavation produced by sloughing or ulceration. It is
useful in lupus, and should be dusted several times a day on the ulcerated
surface. An iodoform suppository is also useful in painful diseases of
the rectum and bladder.

Dr. Munday highly recommends iodoform as an antiseptic dressing
on the battle-field.

Dr. Tanturri recommends an iodoform ointment of 3 j to 3 j for
prurigo.

Iodoform is said to relieve the pain of neuralgia and gout. A satu-
rated solution of iodoform in chloroform is advised in neuralgia.

One would expect that iodoform, either given internally or inhaled,
would act like alcohol, chloral, and chloroform, and this is true in some
measure, for it produces sleep and some anassthesia. From the large
quantity of iodine it contains it also acts when applied topically and when
given internally, in virtue of its iodine.

Though containing a large quantity of iodine, iodoform is not very

280 IODOFORM.

irritating to the stomach. In large doses it produces a kind of intoxica-
tion followed by convulsions with tetanic spasms, high fever, mental de-
pression, dilatation of the pupil, involuntar}'- evacuations, hallucinations,
sometimes sudden collapse and death. It is often employed internally
in secondary and tertiary syphilis.

When topically applied it produces in some 2:)ersons by absorption
serious symptoms. These may be of three kinds :

1. Coated tongue, loss of appetite, sickness, even diarrhoea.

2. Rapid feeble pulse, 140 per minute, perhaps irregular, with other
evidences of heart failure.

3. Delirium, active and furious, with hallucinations or melancholia,
loss of memory, coma, and not uncommonly convulsions and paralysis.

These symptoms may be transient, or they may persist for weeks, or
they may destroy life.

In children these symptoms rarely occur; and the aged are much
more liable; debility favors their occurrence.

It has a depressing action on the heart, and when given to frogs it
arrests the heart in diastole, probably by its action on the nervous gan-
glia.

In fatal doses it produces fatty degeneration of the liver, kidneys,
heart, and voluntary muscles; acting thus like chloroform and ether.

Ten-grain doses of potassium bicarbonate, given hourly, is said to re-
move these poisonous effects.

Rummo and others highly recommend a four per cent, solution of
iodoform in spirits of turpentine, as an inhalation or spray in phthisis
and chronic bronchial catarrh. It lessens cough, expectoration, and
fever. According to some observers it is also useful in phthisis when
given internally, six or eight grains with extract of gentian daily. Dr.
Dreschfeld confirms this statement, and finds that iodoform increases
appetite and weight, diminishes cough, expectoration, and night sweats,
and sometimes even lowers the febrile temperature.

It is employed internally in doses of one to four grains, and is gener-
ally given when iodides are useful. Dr. Bartholow strongly recom-
mends it in catarrhal jaundice, and in cirrhosis; especially the hyper-
trophic variety, if the disease has not too far advanced. He believes
cirrhosis may be cured by the persistent use of iodoform in moderate
doses. It appears to be useful, too, in phthisis, when administered by
spray, as an inhalation.

It is eliminated by the breath as iodoform, and by the urine as iodide
and a little iodate. Large doses may cause hematuria and albumin-
uria, and after death we find glomerular nephritis. It is said that it
also excites acute polio-myelitis.

Its local application having caused several deaths, it is now less ex-
tensively used than formerly, but if used moderately, there appears
to be little or no risk.

HYDRATE OF CIILOKAL. 281

lODOL.

Tetraiodopyeol contains eighty per cent, of iodine, and is em-
ployed in place of iodoform, having the great advantage of being free
from smell. It is insoluble in water, is slightly soluble in cold alcohol,
but freely in warm alcohol, ether and oil. Like iodoform it is anti-
septic and angesthetic, and appears, when a2)plied locally, to be much less
lioisonous than iodoform, one case only of poisoning having been at
present published. Dusted on sores, it prevents suppuration, and cleans
gangrenous wounds, and so promotes healing. It can be employed as
an alcoholic or ethereal solution, 1 in 16, or as an ointment, five per
cent., or as gauze. It is highly useful to syphilitic and chancrous sores.
Internally administered in two to four grain doses, several times a day,
it is useful in secondary syphilis. The pure powder applied by insuffla-
tion is useful in tubercular ulceration of the larynx.

It is readily absorbed by the stomach, and iodine speedily appears in
the saliva and urine. It is eliminated as an iodide.

Given in large doses to animals they emaciate and die, and fatty de-
generation of the organs is found, especially of the liver and kidney.

In one case of poisoning from its local application it acted like iodo-
form, inducing fever, a rapid, small, irregular pulse, and vomiting. Al-
though all the application was removed, iodine was detected in the
urine for two weeks. Like iodoform it is more slowly absorbed and
eliminated than iodides.

HYDRATE OF CHLOEAL.

This valuable soporific, introduced into medicine by Liebreich, when
added to an alkali, decomposes into chloroform and formic acid. This
led to the employment of chloral, with the expectation that the alkali
of the blood would slowly set free the chloroform. It appears, however,
highly probable that although a small quantity may be decomposed in
the blood, that it remains unchanged, and that its effects are due to the
unchanged chloral hydrate. In support of the view that chloral is de-
composed in the blood and acts as chloroform, several observers have
obtained chloroform by distillation of the blood of animals poisoned by
chloral; but probably the chloroform is given off by the heat necessary
for the distillation, for Hammarsten found that on adding chloral to
blood, and passing carbonic acid through the mixture, he failed to obtain
chloroform, but on subjecting the mixture to distillation, chloroform
was readily given off.

Further, the effects of chloral differ from those of chloroform and
arc more prolonged; no chloroform . is exhaled with the breath; and
chloral hydrate is excreted with the urine.

282 HYDRATE OF CHLORAL.

Chloral is antiseptic. It reddens and even blisters the skin wiien
applied in concentrated solutions. It has a hot, pungent, disagreeable
taste, which may, however, be considerably covered by syrup of orange-
peel or syrup of ginger. It quickly enters the blood. Its most marked
effect is sleep, and after larger doses there is lessened sensibility to j^ain-
ful impressions. It lowers blood pressure by dilating the blood-vessels
through both its action on the vaso-motor centre and by weakening the
heart. It at first accelerates and then slows the pulse, and a large dose
through its effect on the cardiac ganglia arrests the heart. As on the
brain, so on the spinal cord, it first produces slight increased activity,
followed soon by depression, and even complete paralysis. It contracts
the pupil; in larger doses, it first contracts and then dilates the pupil and
greatly reduces body temperature, as first shown by Dr. Brunton, mainly
by increased loss through dilatation of the cutaneous vessels, and in a
lesser degree, probably, by diminishing heat formation. Large doses
induce great muscular relaxation, abolish reflex action and sensibility,
and the animal dies, sometimes through the loss of heat or by j)aralysis
of respiration or paralysis of the heart.

The most characteristic effect of chloral is sleep, in part due probably
to its direct action on the nervous structure of the brain, but in part
also to the ana3mia it produces in this organ. Thus, Dr. W. H. Ham-
mond finds that at first chloral congests the retina, but in five or ten
minutes the opposite condition commences, and continues till the retina
assumes a pale pink color. As the retinal circulation corresponds with
the cerebral, he concludes that chloral affects the brain in the same way
as the retina, and has proved the correctness of this inference by means
of an instrument called the cephalohasmometer, invented independently
by himself and by Dr. Weir Mitchel. Dr. Hammond says that, while
tiie brain is congested, there is some mental excitement; but as the
vessels contract, drowsiness supervenes; and on this wearing off', the
retinal and cerebral vessels enlarge till they assume their accustomed size.

Dr. J. H. Arbuckle ( West Riding Lunatic Asylum Reports, vol. v.) finds that the
following;- substances, Nicotia, Atropia, H^'oscyamia, Aconitia, Hydrate of Chloral,
Nitrite of Amyl, Prussic Acid, Strychnia, Morphia, Picrotoxine, pushed even to a
fatal dose, do not in any degree affect the circulation at the fundus of the e\-e.
His observations were made on rabbits, and the results they obtained were, with
respect to some of these agents, confirmed by experiments on man ; hence the
statement, hitherto generally received, that the retinal circulation corresponds
with the cerebral circulation, changes in the one always implying changes in the
other, must be accepted with caution, unless, indeed, some of these drugs act on
the brain in a manner opposed to the accepted theory, and do not influence it by
affecting its blood supply.

Hydrate of chloral is chiefly employed to produce sleep. Chloral
sleep is generally calm, refreshing, and dreamless, not too profound
to prevent waking to cough, take food, etc. As a general rule, chloral
causes no giddine'ss, headache, nervous depression, constipation, sickness,
or loss of appetite. A patient roused from chloral sleep will eat a hearty
meal, then lie down and immediately fall asleep.

Chloral at first sometimes causes a good deal of heaviness and sleepi-
ness on the following day, but this effect soon wears off. It occasionally
produces frightful dreams, and sometimes much excitement, intoxication,
and even delirium without sleej).

HYDRATE OF CHLORAL. 28.^

Sleep comes on sometimes in a few minutes, but more commonly in
half an hour, after a dose of chloral. Like other soporifics, it should be
given shortly before bedtime, and the patient should avoid excitement,
and keep quite quiet, else it will produce restlessness instead of sleep.
It has been given for many months apparently without any bad results.
Its eifects sometimes wear off, but in a far less degree than is the case
with opium. Sometimes instead of sleej) it induces headache, excite-
ment, even delirium.

Chloral as a hypnotic has been found useful in a variety of circum-
stances. It subdues the sleeplessness of old people, and the wakefulness
induced by excessive mental fatigue, succeeding sometimes where opium,
bromide of potassium, and other remedies fail. In delirium tremens it
produces sleep, and calms delirium; but is especially^ successful when
administered at the onset of the symptoms, often averting a serious ill-
ness. Large doses have been given, even sixty grains or more, repeated
several times. Dr. Da Costa cautions against its administration to
patients with a weak heart. Large doses have caused serious and even
fatal results, and a much smaller dose should at first be tried to ascertain
how far the patient tolerates this drug. . He advises its combination with
opium. In paralysis of the insane, full doses induce sleep at night, and
a moderate dose calms excitement by day. Dr. Macleod has given it
daily to the same patient, without bad effects, more tlian three months.
It is used in acute mania.

It is employed in puerperal mania, and in puerperal convulsions. It
is conveniently administered to the insane in porter.

It is often employed in fevers, especially typhoid and typhus fever.
In fevers it often happens that the sleep is broken or the patient cannot
sleep at all. This sleeplessness rapidly exhausts the nervous system,
hence delirium ensues, followed by twitching of muscles and picking of
the bed-clothes. The want of sleep, especially with delirium, raj^idly
wears out the strength of the patient and soon the heart shows signs of
weakness, the pulse increasing in frequency and losing in volume and
firmness. Tlie cardiac failure is of course very dangerous, and unless
obviated, may end in death. In such cases so]3orifics are eminently
serviceable, for by inducing sleep we prevent or remove delirium, pro-
mote the appetite and assimilation, and sustain the strength. Soporifics,
judiciously employed, often save life. They should be given early, before
delirium sets in, and certainly before the heart becomes weakened
through want of sleep and delirium. For this purpose chloral is very
valuable, often inducing calm refreshing slumber from which the patient
can be awakened to take food, and yet fall asleep again. But whilst
fully recognizing the great value of chloral hydrate, I am convinced that
opium is in most cases still more valuable. I have often seen moderate
doses of laudanum induce sleep where chloral has failed, or has induced
disagreeable and dangerous excitement. Moreover, laudanum generally
induces a gentle perspiration, most comforting and favorable to fever
patients; moreover, opium strengthens the heart, not merely by induc-
ing sleep, but by its direct action on that organ. Further, in typhoid
fever laudanum checks diarrhroa. The combination of laudanum (fifteen
to twenty minims) with chloral hydrate (grains ten) is still more certain
in its action.

In the sleeplessness, or the dreamy, unrefreshing, broken sleep due
to worry, overwork, uterine derangement or the menopause, chloral

284 HYDRATE OF CHLORAL.

hydrate is often very useful. In such cases, however, I am convinced
that bromides are more etHcacious.

Chloral sometimes restrains the voluntary movements of chorea, but
in many cases it is powerless. It is most useful in those cases where the
violent movements render sleep impracticable, the want of sleep'in its
turn aggravating the choreic movements, till even deglutition may become
almost impossible. In these urgent cases ordinary remedies like arsenic
are useless, and recourse must be had to narcotics. Large doses of
chloral, frequently repeated, will often produce jjrof ound refreshing sleep
from which the patient wakes calmed and less convulsed. ( Vide Chloro-
form.)

E. Lambert recommends chloral in parturition in fifteen-grain doses
every quarter of ^an hour till the patient falls asleep; stating that this
treatment does not weaken the uterine contractions, while it prevents
pain, and ensures calm repose after delivery. Dr. Playfair thinks that
chloral acts far better than chloroform inhalation, as chloral does not
lessen the strength of the contraction, whilst it greatly lessens the suffer-
ing. Moreover, it is chiefly apjilicable at a period when chloroform
" cannot be used, that is towards the termination of the first stage, be-
fore the complete dilatation of the os." The patient falls into a drowsy
state — a sort of semi-sleep. Dr. Pla3"fair gives fifteen grains, and repeats
the dose in about twenty minutes, leaving its subsequent administration
to circumstances.

Chloral is often useful in tlie convulsions of children. Given in a
dose sufficient to induce sound sleep of some hours, the convulsions
cease, and often do not recur when the child wakes. If the child can-
not swallow, five grains given by the rectum soon induces a deep sleep,
and the convulsions then cease, at least temporarily. The liquid injec-
tion is often expelled during the convulsions, so that it is better to
administer the chloral as a suppository, pushed as far as the finger can
carry it. It is also very useful in ura^mic convulsions. Indeed, if given
in a sutficient dose, it will suspend or arrest any kind of convulsions.

Bouchut employs chloral hydrate to ^jroduce general ana?sthesia in
children. To children about seven he gives forty-five grains; and to
children from two to five he gives thirty grains. Anaesthesia is complete
an hour after the administration. The drug may be given by the
rectum. Children bear chloral well.

Five grains of chloral given twice or thrice daily will often remove a
common condition characterized by restlessness, irritability, and nervous-
ness — a condition of ceaseless misery.

Dr. Bradbury and Dr. Thompson speak very highly of the efficacy of
chloral in nocturnal incontinence of children.

Liebreich recommends chloral in sea-sickness; fifteen to thirty grains
should be taken every four hours. It is sometimes useful in the vomit-
ing of joregnancy.

xVccording to some writers a hypodermic injection of chloral (five to
ten grains) is very serviceable in cholera. It is said to remove the cramps
and coldness of the breath, and to save life. Bartholow speaks most
highly of this treatment, and says it acts still more effectively when
combined with morphia.

The shortness of breath affecting the emphysematous on catching
cold often yields to chloral. When the dyspnoea occurs at night, a full
dose (twenty-five to thirty grains) at bedtime calms the breathing, and

HYDRATE OF CHLORAL. 285

gives sound refreshing sleep. When the difficulty of breathing is con-
tinuous, small doses (two to six grains) should be given several times
daily.

It is necessary to give chloral with caution to patients with emphy-
sema and bronchitis accompanied with obstructed circulation, causing
lividity and dropsy; for, besides drowsiness, an ordinary dose may pro-
duce muttering delirium and a notable increase in the lividity; these
effects, often lasting several days, and attributable possibly to the slow
destruction of the drug in the blood, seem not due to any peculiarity on
the part of the patient, as I have seen chloral produce these symptoms
in a patient who had previously taken it with benefit.

A full dose of chloral is often useful in a paroxysm of asthma.

Some cases of tetanus have apj^arently yielded to chloral in large doses ;
and in some instances this drug has prolonged life and 'eased pain.

The statements concerning the influence of chloral on pain are con-
flicting, some asserting that it produces ansesthesia, while Demarquay
states that in many instances it excites hypera?sthesia. Chloral, it is
said, simply makes a patient oblivious of pain; but if the pain is too
urgent to permit of sleep, chloral fails to give relief. This metaphysical
explanation is certainly incorrect; the truth being that, for some unex-
plained reason, chloral in certain cases subdues pain, while in other
apparently similar instances it fails. Chloral sometimes relieves the pain
of neuralgia, chronic rheumatism, gall stones, colic, and gastralgia. In
doses of ten grains, three times a day, it has relieved most severe pain
of cancer, without inducing drowsiness. Injected hypodermically, it is
liable, like chloroform, to excite inflammation, and to produce an abscess
followed by a scar.

Chloral is very inferior to opium as a narcotic for the relief of pain ;
in painful affections opium or morphia must be used, as chloral will
often fail.

Chloral if too long continued may induce disagreeable symptoms,
capricious appetite, impaired digestion, deficient secretion of bile, de-
pression, nervousness, irritability, sleeplessness, and even slight paralysis,
symptoms which soon disappear on leaving off the drug. Eedness, in-
jection and ecchymoses of the skin have been observed in some cases.

When equal parts of chloral and powdered camphor are rubbed
together, they form a syrupy liquid, which, painted on the painful part,
or gently rubbed in, often affords relief in neuralgia. My friend, Dr.
George Bird, has used this compound in several cases of neuralgia and
pleurodynia, with great success. I have known it cure promptly neuralgia
of the inferior dental branch of the fifth and neuralgia in the temporal
region. It is said often to relieve toothache, even Avhen applied exter-
nally, and I have known it succeed when put into the cavity of the
carious aching tooth; but, like other applications, it often fails in
neuralgia without apparent cause, in cases very similar to others it has
benefited. When it does answer, this liniment generally affords almost
instantaneous relief. I have known it give relief in severe pleurodynia.

Chloral hydrate is antiseptic and is recommended highly as a topical
application in diphtheria. Some use a saturated solution in glycerine.

As we occasionally meet with persons who display an idiosyncrasy
regarding chloral hydrate, it is wise, therefore, at first to give only a
moderate dose of ten to fifteen grains. Large doses we have seen M^eaken
the heart. We are, therefore, often cautioned against giving chloral

286 HYDRATE OF CHLORAL.

where the heart is weak, and other hypnotics, like paraldehyde, are
recommended in its jjlace, but in moderate doses of fifteen to twenty-five
grains I have never seen it produce any depressing elfect on the heart.
The large doses recommended by some writei's in delirium tremens must,
of course, be given with caution — indeed I believe had better not be
given at all. Other soporifics should be tried instead.

Chloral is the antidote of strychnia, physostigma, and picrotoxine;
that is to say, if the known minimum fatal dose, or, rather, more than
fatal dose, of one of these substances is given, chloral will either prevent
death or greatly modify the symptoms induced by any of these poisons.
(See Strychnia and Calabar-beau.)

Liebreich asserts that strychnia is an antidote to chloral. The urine
of chloralized animals contains no sugar. Eckhard finds that chloral pre-
vents the appearance of sugar in the urine after the diabetic puncture
of the floor of the fourth ventricle. Even after severe injury to the
vermiform process diabetes was absent. Chloral hydrate also prevents
the diabetes inducible in animals by reflex action, as irritation of the
central end of a cut vagus.

Dr. Levenstein reports the extraordinary case of a man, aged 35, who
was poisoned by six drachms of hydrate of chloral. AVhen first seen, he
lay in a profound sleep, with congested face, heavy breathing, and pulse
of 100. An hotir after the j^oisoning he became livid, the veins were
distended, the respirations were intermittent, and his temperature was
103° Fah. An hour and a half after the dose he became pale, pulseless,
with contracted pupils, and his temperature had sunk to 91.2°. Xitrate
of strychnia, enough to produce twitching, was then injected hypodermi-
cally, and the heart at once began again to beat, and the thermometer
marked 91.9° Fah.; collapse, however, returned in a few minutes, the
circulation appearing to stop. Artificial respiration was performed and
nitrate of strychnia again injected, again with the same result. In ten
hours, the pupils responded to light; in twelve, the temperature was
100.4°; in twenty-four hours, he could be roused, and after thirty-two
hours, he awoke " quite refreshed," and did not complain of any gastric
disturbance.

PARALDEHYDE. 287

PARALDEHYDE.

This substance, a polymeric modification of aldehyde, has recently
been introduced into medicine as a hypnotic by Cervello of Palermo;
and Moseli, Popoff, Desnos, and Leech in this country have contributed
valuable papers on the subject.

It is a drug still on its trial, but the accounts given of it show that
it is a valuable narcotic with a role of its own, but in its action much
like chloral; but, unlike that drug, paraldehyde does not, except in toxic
doses, depress the heart. Its very disagreeable and nauseous taste, which
may persist long after it is taken, difficult to cover with flavoring agents
like syrup of orange-peel, will probably prevent its extensive employment.
However, it can be well administered by the rectum.

Its effects are usually rapid. After fifty minims quiet, refreshing,
dreamless sleep supervenes in from five to fifty minutes, and if the
patient is roused there is no confusion of ideas. The sleep lasts from
two to six hours. Sometimes, before inducing sleep, it causes slight
excitement, and the heart's action is often at first somewhat accelerated
as if with alcohol. It produces as a rule no bad after effects like head-
ache, sickness, or depression, and it may be continued for months. It is
said to be slightly auEesthetic, but if the jDatient suffers from pain or
annoyance from cough paraldehyde is not of much avail. It rarely
causes nausea or vomiting, but if the stomach is irritable it may do so,
and even cause cramp in the abdomen. It sometimes produces a roseo-
lous rash. In toxic doses it at first weakens and at last destroys sensi-
bility, reflex action, and voluntary power.

Small doses first increase excitability of the cortex of the brain ; large
doses from the first greatly depress this excitability. It affects sensi-
bility and reflex action by its influence on the spinal cord. It leaves the
sensory and motor nerves and the muscles unaffected. A large thera-
peutic dose does not affect the heart nor the arterial tension, but a toxic
dose first retards and then accelerates and weakens the heart's action
and lowers arterial tension, ultimately arresting the heart in diastole.
It is said to increase the urinary secretion, but other observers have failed
to detect any action on the kidneys. Toxic doses kill by paralyzing the
respiratory centre, the heart continuing to beat for some time after.

Paraldehyde, having so little action on the heart, is indicated in cases
of cardiac weakness which forbid the use of chloral.

It is highly recommended as a hypnotic in mania; in chronic forms
of mental weakness accompanied by agitation ; and in hysterical excite-
ment. It has relieved the severe pain of cerebral tumor.

It has been recommended in epilepsy in place of bromides.

It is excreted in part by the breath, which may smell of the drug for
one or two days after its administration.

Patients rapidly grow accustomed to it.

It IS antiseptic.

The narcotic dose for an adult is from 30 to 50 minims.

The taste can be partially covered by giving it in sugar-and-water,
and adding fifteen drops of tincture of orange-peel.

I have only compared the eft'ects of paraldehyde with those of chloral
hydrate in moderate doses. For instance, I very rarely exceed from twenty

288 HYDRATE OF CROTON-CHLORAL.

to twenty-five grains. In these quantities I have not yet met a case of
fever or of lioart disease at all depressed by chloral hydrate, hence I have
not been able to observe any superiority on the part of paraldehyde over
chloral. A few cases I have heard of where, from some individual jjecul-
iarity, even small doses of chloral excited disagreeable symptoms, and in
these instances paraldehyde acted excellently without any discomforting
effects. On the other hand, the taste of paraldehyde is far more offensive
than the taste of chloral hydrate, so that many persons are made sick
by paraldehyde, and many positively refuse to take a second dose. AVe
are particularly cautioned not to give chloral where heart-weakness of
any extent exists, and paraldehyde in such cases is highly spoken of.
Cardiac weakness is mostly met with in lack of compensation, as in aortic
regurgitation, or mitral disease, and in fevers. In the cardiac weakness
of deficient compensation, often displaying itself in cardiac dyspnoea,
by which the rest is broken, I find laudanum by the mouth or morphia
hypodermically is by far the best narcotic. It strengthens the heart,
obviates the dyspnoea, and permits refreshing sleep. The addition of
ten to fifteen grains of chloral no doubt increases the action of lau-
danum, and is a dose that, certainly never in ray experience, depresses the
heart.

UKETHAN.

A NEW hypnotic, introduced by Schmiedeberg, but already falling
into disuse, is a tasteless powder, insoluble in water, but readily dissolved
and absorbed by the stomach. Schmiedeberg considered that the
alcohol radical would affect the cerebrum whilst the amidogen would
stimulate the medulla and cord, and thus it would be free from danger
to respiration and the heart. It does not disorder the stomach. At first
it induces some excitement, soon followed by sleep, Avith some slowing
of the pulse and resjiiration. It does not reduce blood pressure. Large
doses depress the temperature and weaken, and even destroy the re-
flexes. The sleep is like that of chloral or paraldehyde, and ensues in
from fifteen minutes to an hour. It does not relieve pain. It must be
given in full doses of twenty or thirty grains, which may be repeated iu
an hour or two if sleep does not follow the first dose.

HYDRATE OF CEOTON-CHLORAL.

We are indebted to Dr. Oscar Liebreich for introducing this valu-
able agent into the service of medicine. This distinguished experi-
menter finds that in animals it produces ana?sthesia of the head without
loss of sensibility of the rest of the body; and in man, anaesthesia of the
fifth nerve only. In large doses it produces sleep, and in fatal doses it
destroys by paralyzing the medulla oblongata. He recommends it in
trigeminal neuralgia, but speaks of it as affording only temporary relief;
he, however, greatiy underrates its efficacy.

HYDRATE OF CROTON-CHLORAL. 289

Croton-cliloral is, perhaps, the most efficacious remedy in facial
neuralgia. In neuralgia due to carious teeth; in facial neuralgia in old
people, in whom the disease is generally most obstinate and severe, it is
alike beneficial. In the few cases of that severe form called epileptiform
tic that I have had the opportunity of using it, it has proved useless,
even in large doses. I have found it very serviceable in neuralgia of the
back of the head, and also of that of the neck with pain radiating to the
shoulders. There is but little evidence at present of its effects on
neuralgia of the other parts of the body; though it is reported to have
cured several severe cases of dysmenhorroeal neuralgia. I have not found
it successful in neuralgia of the trunk and extremities. In facial neuralgia
I have long employed with great benefit three grains of croton chloral
hydrate with 1.200 of a grain of gelsemia, administered every quarter of
an hour for six or eight doses, and then hourly.

I have found hydrate of croton-chloral very useful in migraine, com-
monly called sick headache, bilious headache, nervous sick headache, and
hemicrania. The most characteristic and commonest symptoms of
megrim are headache and sickness; but, in a typical case, these symp-
toms are preceded by other significant and interesting phenomena. At
the onset of an attack, a peculiar affection of the sight first occurs, soon
to be followed by perversion of the sense of touch and of the muscular
sense in the arms and legs, by disordered speech and defective ideation;
the headache then comes on, and, as it becomes intensified, nausea
gradually sets in.

The affections of the sight may coAsist of mere absence of vision,
beginning at the centre or circumference of the visual field. When at
the circumference, the defect is generally situated to the right or left of
the axis of vision. From the centre of the visual field, the blind spot
gradually expands, and as it enlarges it then clears up in the centre, and
so gradually disappears to the circumference. As the blind spot ex-
pands, its margin is often lighted up with spectra variously described as
glimmering, dazzling, bright zigzag lines, coruscations, etc.

In ten minutes to half an hour, numbness and loss of sensibility
occur on one or both sides of the body, followed by tingling formication,
"pins and needles," felt most distinctly in the hands, tongue, and lips.
Speech is commonly disordered, the aberration in some cases being
simply memorial, in others simply motorial; in others, again, these two
derangements of speech are more or less combined. In other words,
, one patient forgets his words, another forgets how to utter them, whilst
a third manifests a combination of these two defects. There is, too, loss
of memory, confusion of ideas, and a bewildered feeling, as if the patient
was going out of liis mind. In half an hour or a little longer, these
phenomena are followed by headache, which is generally felt on waking
in the morning; is at first slight, but intensifies till it may become most
severe — indeed almost unbearable. It affects one or both brows, and,
beginning at one sj^ot gradually extends, till it may involv^e the greater
part of the head. The throbljing, stal^bing, cutting, boring pain is in-
creased by movement, noise, light, smells, or food. AVlien the area of
pain is limited, the complaint is termed clavus. As the pain subsides,
or even during the whole attack, the patient may suffer dull or shooting
pains in the eye of the affected side. There is much tenderness of the
scalp during and after the attack.

Throughout the attack the patient complains of nausea, which may
19

290 HYDRATE OF CKOTON-CHLORAL.

be slight, but usually increases, and, when the pain is at its worst, ends
in vomiting, which may be severe and prolonged, causing much prostra-
tion ; yet occasionally vomiting affords relief.

Lasting a few hours, the whole day, or even two or three days, the
attack generally ends in calm refreshing sleep, but sometimes it gradu-
ally subsides or ends abruptly in vomiting, perspiration, or, more
rarely, a copious flow of tears. The attack may be preceded and followed
by very obstinate constipation or by diarrhrea, the liquid motions being
in some instances pale, in others of a deeji-brown mahogany color. Be-
fore and after the attack, there is often much dusky discoloration around
the eyes.

Dr. Liveing, to whose exhaustive work I am considerably indebted,
considers that, in a typical case, the disturbance takes place first in the
optic thalamus, and passes backward and downward, reaching to the
nucleus of the vagus below; for, as he observes, in a model seizure the
visual disorder is always the initial, the headache the middle, and the
vomiting symptom the final. Where morbid intellectual phenomena
and disorder of speech occur, the affection radiates from the thalamus
to the hemispheric ganglia, and where emotional j^henomena occur, to
the mesocephale.

Other observers regard the affection as seated in the cilio-spinal axis,
and to be of two forms, one depending on stimulation, the other on
paralysis of this j)art. When due to stimulation the temj^oral artery is
small and hard, the eye prominent, the paljDcbral fissure more widely
open, the pupil dilated and the* skin of the face pale; where the attack
is paralytic the 023posite of these symptoms occur.

Though the affection is seated in the nervous centres, yet it must
be recollected that both the frequency and the severity of the attacks
depend on peripheral exciting causes, due to the stomach, intestines,
liver, womb, etc. Even when the affection is strongly developed and the
periodic attack occurs apparently spontaneously, remote exciting causes
may render the seizures more frequent and severe ; nay, in many cases,
the affection may be so slight that it lies dormant till roused into
activity by some near or distant irritation, which, being removed, the
seizures cease.

The successful treatment of megrim depends less on change to be
effected in disordered nervous centres than on the removal of the excit-
ing cause.

The treatment of megrim, therefore, falls under three heads:

1. The treatment of the central nervous affection.

2. The removal or prevention of exciting causes.

3. The treatment of the paroxysm.

Many remedies act in a twofold or even a threefold way. Thus
bromide of jiotassium is often extremely serviceable in two ways. It is
very useful in cases where the seizure is due to uterine disturbance,
as in menorrhagia and dysmenorrhcea. Sometimes the attacks are more
severe and frequent, arising from the exhausted state of the nervous
system. Perhaps from over-long town residence, or from mental troubles,
the patient becomes irritable, depressed, nervous, excitable, with broken
sleep, harassed by dreams. The ensuing general depression increases
the headache. Now, bromide of potassium soothes the jiatient by pro-
moting a refreshing sleep, and thus lessens the frequency and severity of
the headaches. Bromide of potassium, moreover, is serviceable in the

HYDRATE OF CROTON-CIILORAL. 291

paroxysm itself, for it may produce several hours' sleep, from which the
patient awakes free from headache.

The pain of megrim is situated in the fifth nerve; and remembering
how closely megrim is allied to neuralgia, and how useful hydrate of
croton-chloral is in facial neuralgia, I have been induced to try this
remedy for megrim, and have found it useful in cases of which the fol-
lowing may be taken us a type :

A woman has been subject for years to nervous sick headache; then,
owing to some great trouble, or to excitement, fatigue, or flooding, or
prolonged suckling, or more often at the change of life, the headache
becomes much more severe, becomes continuous for weeks, perhaps
months, and is intensified greatly by fatigue, excitement, or at the cata-
menial period. If not actually continuous, the headache comes on daily,
lasting perhaps many hours, or several attacks may each day occur.
The pain is often intense; and whereas previous to the oncoming of this
intensified form of headache, the pain was probably limited to one brow,
it now affects both, perhaps the greater part of the head. The skin is
generally very tender. There is also a sensation of bewilderment, or, as
some term it, a stupid headache, and the patient says she feels as if she
should "go out of her mind." The sight may be dim, especially during
the exacerbations of pain. Some patients of this class are very excitable
and irritable, and are upset with the slightest noise. Nausea and even
severe vomiting may occur ■with each exacerbation of the pain. Five
grains of croton chloral every three hours, or even oftener, will give in
most cases considerable relief. I need hardly say that the drug does
not entirely free the patient from her attacks; but, in one or two dnys,
the j)ain ceases to be continuous, then the attacks recur, though only
once or twice a week, the interval gradually extending till an onset
occurs only every week, then about every fortnight, or even longer, till
the illness assumes its old tj^pe and ji^i'iodicity. In some cases, a week's
treatment suffices to bring back the headache to its original type of an
attack once in three or four weeks. Then the croton-chloral appears to
be far less serviceable, manifesting but slight effect on the periodical
attacks. In many cases of ordinary periodical headache, the patients
say that in the milder forms the drug distinctly lessens the severity
and duration, but in the severer forms it is without effect, even when
sickness is absent. In cases accomjianied by severe vomiting and retch-
ing, croton-chloral is useless, being speedily rejected.

Croton-chloral, I have found, will relieve the lighter attacks some
delicate and nervous women experience after any slight fatigue or ex-
citement.

In the continuous sick headache just desci'ibed, as the pain grows
better so the cutaneous tenderness disappears. It seems to me that, in
many instances, two kinds of headache co-exist, sometimes one predomi-
nating, sometimes the other. One appears due to affection of the cutane-
ous nerves, and is generally accompanied by tenderness. Patients de-
scribe the other as a " stupid headache," " a feeling of bewilderment,"
" a bewildering headache." After the dispersion of the first form by
croton-chloral this stupid headache often continues, but is ordinarily
relievable by bromide of potassium. Indeed, in many cases, I have
found it useful to combine these remedies. Bromide of potassium itself
is often sufficient in certain sick headaches; for instance, if the other
symptoms point to the use of this drug, as when, in addition to the be-

292 NITRITE OF A3IYL.

wildering or stupid headache, the j)atient complains of broken sleep, is
harassed witli disagreeable or frightful dreams, is jDrone to be very irri-
table and excitable, and feels as if she should "go out of her mind."'
Bromide of potassium, too, is often useful Avhere the continuous or
almost continuous form of sick headache is associated with, and is prob-
abl}^ due to, uterine derangement, as menorrhagia. The drug's efhcacy
is not due to simply checking the loss of blood, and ao indirectly im-
proving the health, for it manifests its efficacy before the occurrence of
the next flooding. In cases like this, it may be usefully combined with-
cannabis indica.

In the treatment of the paroxysm, salicylate of soda, or antipyrin, has
now quite superseded croton-chloral.

I have already referred to the effect of croton-chloral on the shooting
pains in the occijiital and auricular nerves, but I wish again to revert to
them, because they appear in many cases to be closely allied to migraine,
being often induced by the same circumstances. Thus, they are most
common in women, especially when in depressed health or subject to
worry. Sometimes the attacks are associated with nausea, and even
sickness. The pains occur in short stabs running in the course of the
nerve, and not in enduring jjaroxysms. Croton-chloral in such cases is
often very useful, although it may fail where the health is greatly de-
j^ressed, and where there is much anaemia. Sometimes the symptoms
indicate the employment of bromide of potassium.

Liebreich, who recommended croton-chloral as a soporific, and gives
as much as sixty grains for a dose, thinks it superior to hydrate of
chloral, since whilst it produces sleep it does not affect muscular tone,
nor interfere with the circulation or resjiiration. He thinks it applicable
in cases of heart disease. Much smaller doses are said to prodiice sleejj;
thus. Dr. Yeo states that sometimes two grains will suffice. I have
given five- and ten-grain doses in a considerable number of cases, but
never knew either dose to produce sleep, or even drowsiness.

It is best administered in a ijill. Three grains every quarter of an
hour, for an hour or an hour and a half, and then hourly, will generally
relieve neuralgia without causing any toxic symptom. Much larger
doses may be given, as ten grains several times a day. It is of little
use in toothache, unless this induces neuralgia, when it cures the
neuralgia, but leaves the toothache unaffected.

XITRITE OF AMYL.

To Dr. Brunton belongs the distinction of first using this remedy,
and the I'are merit of correctly inferring its therapeutic effect from its
jDhysiological action. It must give him the highest satisfactioji to know
how great a boon his scientific insight has provided for the hitherto
almost helpless patients under the anguish of angina pectoris.

In thirty or forty seconds, whether inhaled, subcutaneously injected,
or swallowed, it flushes the face and increases the heat and perspiration
of the head, face, and neck. Sometimes the increased warmth and per-

NITRITE OF A3rYL. 293

spiration affect the whole surface; or, while the rest of the surface glows,
the hands and feet may become very cold; and this condition of the
extremities may last many hours. It accelerates the pulse in a very
variable degree, sometimes doubling its pace, and this augmented pulse-
beat precedes the flushing by a few seconds. It causes the heart and
carotids to beat strongly, and the head to feel full and distended, " as
if it would burst," or " as if the whole blood were rushing to the head,"
and sometimes produces slight breathlessness and cough. It often
causes slight giddiness, mental confusion, and a dream-like state. When
given to animals in a deadly dose, the breathing becomes quick; there is
great weakness; loss of reflex irritability, and death ensues from arrest
of respiratio7i, but sensation and consciousness remain unaffected.

The acceleration of the heart is probably due in part to the lowered
arterial tension, and in part to depression of the vagus.

The most characteristic effect of this drug is its influence on the
vascular system. It relaxes the whole arterial system, greatly reducing
arterial pressure. The reduction of arterial pressure is due mainly to
the great dilatation of the arterioles, and, after large doses, to depression
of the heart. How does it dilate the arterioles ? It will dilate the
arterioles even after section of the cord just below the medulla oblongata;
hence it has been concluded that it does not act by paralyzing the vaso-
motor centre, which formerly was supposed to be situated between the
calamus scriptorius and the corpora quadrigemina. It must, therefore,
act either on the vaso-motor nerve trunks, or on the muscular coat of
the arteries. Some have concluded that it affects the arteries. Brunton
believes it partially paralyzes the sympathetic ganglia and their motor
nerves.

The i^aralyzing effect on the arterial system is well shown by the
sphygmograpliic tracings, the flushing of the face, and the increase in
the size of visible arteries like the temporal, which often becomes notably
large — sometimes, indeed, doubled in size, and branches previously in-
visible become j^lainly apparent; and by the interesting fact observed
by Talfourd Jones, who while cupping a patient over the loins, and find-
ing that blood would not flow, administered nitrite of amyl by inhala-
tion, when the cuts immediately began to bleed freely. xVfter an inhala-
tion, the larger arteries are slower in recovering their normal size than
the capillaries, a phenomenon I have often observed in the temjjonil
artery, which remains enlarged half a minute or longer after the blush
has left the face.

Dr. Horatio Wood has shown that the loss of reflex action and of
voluntary power occurring after large doses, is due to the depressing
action of the drug on the motor tracts of the cord, and, to a slight ex-
tent, on the motor nerves and on the muscles. It appears to have no
effect on the sensory tracts of the cord, nor on its co-ordinating centres.
It abolishes reflex action, but whether it represses the reflex function
of the cord is uncertain, as it may act simply on the motor part of the
cord.

The inhalation or subcutaneous injection of nitrite of am}^ produces
in rabbits sugar in the urine, with a considerable increase in the quantity
of urine. It has been experimentally shown that diabetes is produced by
dividing the sympathetic nerve of the liver, and thereby causing dilatation
of the hepatic vessels, so increasing the quantity of blood passing
through the liver. Probably nitrite of amyl acts by its influence over

294 NITRITE OF AMYL.

the vaso-motor nerves, increasing the quantity of hlood passing through
the liver.

Dr. Horatio Wood finds tliat nitrite of amyl lowers the temperature
by checking oxidation. He finds, too, tliat the inhalation of nitrite of
amyl changes both arterial and venous blood to a chocolate color, due, as
Dr. Arthur Gamgee shows, to the formation of metha?moglobin, and
that by this means the ozonizing property of the blood and hence oxida-
tion of the tissues are lessened.

R. Pick, from observations on himself and others, finds that after in-
haling amyl, if the eye is fixed on a spot on a blank wall, the spot itself,
with the surrounding surface, appears of a yellowish hue, the yellow circle
being encircled by a violet blue halo, with undulating lines at the edge.

Dr. Brunton first employed nitrite of amyl with signal success in
angina pectoris, and found it more effective than any other remedy he had
tried in this painful and dangerous disease. During an attack, his patient
suffered from throbbing of the heart and carotids as high as the ears, with
severe precordial pain extending to the right arm, though the usual char-
acteristic " sense of impending death " was absent. The pulse was slightly
quickened, and the sphygmographic tracing became modified, for, as Dr.
Brunton states, " as the pain increased, the curve became lower, both the
ascent and descent more gradual, and dicrotism disappeared. This form
of curve clearly indicates that the arterial tension is much increased, and
can, I think, be due only to contraction of the small systemic vessels."
The increased tension first led Dr. Brunton to employ nitrite of am^d.
In the case in question he attributed the attack to spasmodic contraction
of some, if not all, the small systemic and pulmonary vessels, a state of
arterial tension which gave way to the jiitrite, when the pain disappeared.
In recurring attacks, the patient inhaled the nitrite of amyl, and always
obtained instantaneous relief.

It is now very largely used in angina with considerable success; indeed,
in the majority of cases, no other remedy, except nitro-glycerine and ni-
trite of sodium, affords so much relief. As might be expected, it is not
uniformly successful. I have never known it fail to give some relief,
though sometimes this is very transient, the pain returning as soon as the
physiological effect of the drug passes away. Thus, in one case, due, as
we discovered after death to aneurism of the heart immediately below the
aortic valve, an inhalation always arrested the pain, but after a few seconds
or minutes it returned, even if the administration were several times re-
peated, as severely and persistently as though no amyl was used. In
another case, whilst it always arrested the paroxysm, it took ten minutes
to give relief, and seemed in no way superior to a full dose of ether, which
the patient preferred, as the amyl produced so much giddiness and sensa-
tion of fulness in the head. In other cases, however, it has proved
strikingly successful. In one desperate case, the slightest exertion brought
on intense pain, but armed with amyl, the patient coald always at once
cut short the attack, so that now he can walk several miles, though dur-
ing his Journey he is obliged to employ the amyl several times. It has
appeared to me, that by summarily checking the paroxysm, the attacks
come on less frequently and severely, and after a time, require a much
smaller quantity to control the pain ; so that amyl really contributes to
the prolonged relief of these unhappy patients. In some cases, the nitrite
of amyl either loses its effects or the severity of the attack increases, so
that the drug must be taken in increasing quantities and at shorter inter-

NITRITE OF AMYL. 295

vals. Two of my patients kept the bottle nearly always in their hands,
sniffing the drug every few minntes, and one used an ounce every week
for over a year.

Dr. Talfourd Jones found it remarkably successful in very severe at-
tacks of asthma, removing the dyspnoea immediately and averting its re-
turn ; others too have found it very useful. In my hands it has not
proved successful, for although it always arrests the paroxysm, yet on
cessation of the physiological effect, the dyspnoea has returned. Jones
found it beneficial also in a case of cardiac dyspnoea, accompanied by
extreme anasarca due to a dilated and hypertrophied heart.

Dr. Talfourd Jones advises inhalation of the nitrite in syncope, and
thinks it should be of service in the paroxysms of whooping cough. It is
useful in neuralgia, at least in neuralgia affecting the fifth nerve, often
easing the pain at once, and a single administration will sometimes avert
further attacks; but so signal a result as this is probably very exceptional.
Dr. Eichardson finds that nitrite of amyl arrests in frogs the convulsions
due to strychnia. In this way he has saved their lives: hence in strychnia
poisoning and tetanus, he advises a trial of the nitrite, either by inhal-
ation or subcutaneous injection.

It is better to administer the amyl by inhalation, for, according to
Brunton, it will not answer with anything like the same certainty, when
given by the stomach; for, in the striking case of angina pectoris just
cited, he gave ten minims in brandy by the stomach, with the effect of
staying the pain for only a short time, but a single inhalation afforded
perfect and permanent relief. It should be borne in mind that it affects
some persons much more than others; one individual being able to inhale
five or ten drops from a handkerchief, or to breathe the fumes from
the bottle held close to the nose, while a whiff from the bottle held at
a distance, will affect another with great giddiness, much mental confusion,
and general weakness. Patients become habituated to it, so that after a
while it must be inhaled several times before it affords relief. This habit-
uation is well exemplified in the internal administration of the remedy.
By exposure, it gets " flat," and loses its efficacy.

Nitrite of amyl is generally considered a powerful and even dangerous
remedy, requiring to be watched with great care, and given in a definite
quantity. I am sure it is not nearly so dangerous as is generally imagined,
though it is true that nervous sensitive women are far more powerfully
affected by it than men. No doubt its administration at first should be
conducted by a doctor, in order to ascertain how far the patient is suscep-
tible to its influence, and that the patient may learn when he ought to
discontinue the inhalation, but after one or two trials, patients soon learn
how to administer it to themselves. I have now five patients with angina
pectoris, each of whom carries a small bottle of this medicine, and on the
first warning of an attack, whether Avalking or standing, each at once be-
gins to sniff at the bottle. My patients have done this for months, and
one for just a year, using the inhalation many times daily, so that he con-
sumes two drachms a fortnight with still unfailing relief. Except in
relieving the angina, the amyl seems to produce no other effect on the
system.

Dr. Jones recommended a trial of it in epilepsy. To an epileptic patient,
who, in addition to severe and repeated attacks, suffered from much
mental confusion, and Avas haunted many times a day with an indescrib-
able dread and sensation as of an oncoming fit, although it came on only

296 NITRITE OF AMYL.

once or twice a week, I gave three drops thrice daily, and an additional
dose on the earliest warnings of a fit, with the effect of diminishing con-
siderably the frequency of the attacks, and entirely removing the
harassing sensations.

Sir Crichton Browne has lately jjublished some observations on the
inhalation of nitrite of amyl in this disease. In two rabbits made arti-
ficially epileptic, he prevented the oncoming of the convulsions which
otherwise follow the application of the electrodes to the brain, by mak-
ing them inhale nitrite of amyl. He likewise arrested epileptic attacks
on the occurrence of the aura before the onset of the fit, and has even
cut short the fit after its commencement. By the same means he has
rescued several patients out of that desperate jolight called status epilep-
ticus — a condition consisting essentially of a succession of fits, linked
together by intervening unconsciousness, the fits recurring with increas-
ing frequency, till at last, no sooner is one fit ended, nay, before it has
finished, another fit begins.

Amongst other successful cases, Dr. Weir Mitchell reports one where
the inhalation was used immediately the aura was i^erceived, and other
instances where the spasms lasted for hours, one fit following another. I
have given this remedy with considerable success to epile])tic out-patients,
in whom the attacks were very frequent. In some it has appeared to be
more useful than full doses (20 to 30 gr.) of bromide of potassium thrice
daily; in another case, whilst it decidedly lessened the frequency of the
attacks, it was less serviceable than bromide of potassium. I have given
it in two- to five-minim doses suspended in mucilage, every three hours,
or three times a day, without inducing any unpleasant effects, not even
in some cases causing flushing, whilst other patients have flushed with
each dose, but only whilst swallowing it.

Dr. Maraghano uses it successfully in epilepsy. He raises the dose
to even forty drops, and says the inhalation may be prolonged forty
minutes, and be repeated four or six times a day. He gives it at fixed
times of the day, and not just before or at the onset of an attack. In
twenty-four hours 1 to 3.5 grammes of sugar appear in the urine.

The patient should take the medicine whilst lying down, and as some
patients, especially women, are very readily affected by the drug, it is
well in the first instance to give it in smaller doses ; but until the remedy
is pushed to two and in some cases to five minims every three hours, I
have failed to obtain conspicuous results.

Sir Crichton Browne maintains that epileptics are more sensitive
than others to inhalation of amyl. I imagine that this medicine will be
found useful only in frequent attacks, and that it is not available when
the fits come at comparatively long intervals, as three weeks or a month.

Inhalation of nitrite of amyl has been recommended in sick head-
ache.

Nitrite of amyl is useful in sea-sickness. Nitrite of amyl was very
useful in the following singular case, no doubt allied to sea-sickness.
A young woman could not travel either by coach or train without suffer-
ing great sickness and headache leading to considerable exhaustion, these
symptoms persisting many hours after the journey. Half a minim of
nitrite of amyl dissolved in twenty minims of spirit and a drachm of
water, taken hourly, almost entirely prevented these symptoms.

I have used this remedy extensively with considerable success in cases
of tlic following kind : A woman, perhaps from the sudden arrest of men-

NITRITE OF AMYL, 297

struation, or tlirough depraved health, or nervous depression, or more fre-
quently at the change of life, suffers from frequent attacks of flushings
or " heats " starting from various parts, as the face, epigastrium, etc.,
thence spreading over the greater part of the body. The face, and even
the back of the hands, are often deeply reddened, the veins of tlie hands
in some cases dilating to double the previous size. Although the patient
feels deeply flushed sometimes the skin remains natural. The sensation
of heat may Ije so urgent that the patient opens her clothes, or removes
the greater part of the bed covering, and even throws open the windoAV in
the coldest weather. These heats may last a few minutes only, or an hour
or more, and may be repeated many times a day. The}' are generally fol-
io ved by perspiration, often very profuse, at other times the skin remains
dry; the attacks are then commonly termed "dry heats," The "heats"
are often accompanied by great throbbing throughout the whole body,
followed by mucli prostration, the patient seeming scarcely able to rouse
herself. After the heats pass away the skin sometimes becomes cold and
clammy, and may turn very pale. The least exertion or excitement may
hring on these heats, and such a patient generally complains of cold feet,
and sometimes of cold hands. The flushings are occasionally peculiarly
and abruptly limited, reaching to the thighs, knees, or elbows, and while
all the parts above these feel burning hot, the parts below feel icy cold.
Sleep, too, is often much broken, the patient waking with frequent starts,
and in the morning feeling unrefreshed. Sometimes they occur chiefly
at night. In many cases palpitation or " flutterings at the heart" occur
on the slightest excitement, or even without apparent cause.

Nitrite of amyl will prevent or greatly lessen these flushings or "heats,"
and avert the profuse perspiration, throbljiug of vessels, and great pros-
tration. Sometimes it Avarms the feet and hands and controls the flutter-
ing of the heart, but in most cases it fails to abate these symptoms, and
for their cure other remedies, as iron, are required, Amyl will also re-
move the giddiness, confusion of mind, heaviness in the head, and even
headache. It generally produces calm refreshing sleep.

When the flushings and perspiration are slight, this remedy is scarcely
needed ; moreover, the perspirations are generally considered vicarious and
beneficial at the change of life. These symptoms in many cases form
only a minor part of the troubles of the patient, who may complain of
great sinking at the epigastrium, or severe pains in different parts of the
body, and other suffering incident to this period, over which nitrite of
amyl has little if any influence; but when flushings constitute the chief
part of the patient's troubles, this medicine is most serviceable.

The nitrite of amyl in ten days completely cured a woman who for
three years had been horribly tormented with singular attacks repeated
several times daily, of severe burni]ig sensation over the loins, whence a
glow of heat spread over tlie whole body, followed by perspiration, the
burning sensation being so unendurable that she Avas constrained to open
the wind OAV at night cA'en in the Avinter, and sometimes to rush out of
doors.

For the symptoms just described I have generally administered this
drug by the stomach, though inhalation ansAvers as Avell, In respect of
dose it must be borne in mind that, like glonoine (nitro-glycerine), its
effects vary greatly Avith different persoiis, one, tAvo, or even three minims
]n-oducing in some only flushings of the face and slight giddiness, Avliile
Avith others eA'en a dropAvill induce A'arious disagreeable SA^mptoms. Thus

298 NITRO-fiLYCKRINE.

one woman immediately after a drop dose turned deadly pale, felt giddy,
and then became partially unconscious, remaining so for ten minutes.
In another patient the same dose ])roduced a sensation as if "a vapor
spread from the throat through her head," and rendered her quite power-
less for one or two seconds. A third of a minim dose sometimes excites
great nausea, or a tickling in the throat; and one delicate woman, after
one-thirtieth of a drop, passed for a few minutes after each dose into a
trance-like state, everything to her seeming unreal, and the breathing 1je-
coming rather panting. I began with a minim dose, but was obliged to
reduce this quantity, and ultimately found that, for the most part, these
patients can bear one-third of a minim without any disagreeable symp-
toms, but that a tenth, nay, even a thirtieth, of a minim will in some
patients counteract the flushing. It may be dissolved in rectified spirit,
two minims to the drachm, and of this the dose is three to five drops on
sugar every three hours, with an additional dose as soon as the flush be-
gins. Relief generally ensues immediately, but sometimes not till the
medicine has been taken for a week. As the patient grows accustomed
to the remedy the dose must be increased. Dr. Mary Jacobi finds inhala-
tion of amyl nitrite useful in dysmenorrhoea. In a case where two ounces
of laudanum had produced small and feeble pulse, infrequent respirations,
cyanosis, nitrite of amyl proved very useful. Inhalation of nitrite of amyl
immediately improved the symptoms, and the patient ultimately recov-
ered. Dr. Burroughs reports a case of opium poisoning, where nitro-
glycerine proved very useful.

Dr. P. A. Walters shows that nitrite of amy! inhalation influences in
no way the urea, uric acid, water, nor acidity of the urine.

NITRO-GLYCERINE.

NiTRO-GLYCERiNE is a trinitrite of glycerine. Dr. M. Hay holds that
it is decomposed in the body, other alkaline fluids and nascent nitrous acid
being liberated.

Dr. Murrell, whilst working with nitro-glycerine, was struck by the
similarity of its action to that of nitrite of amyl, and he was thus led to
anticipate that nitro-glycerine would prove iiseful in angina pectoris.

Twenty years ago, Mr. Field, of Brighton, took himself two minims of
a one-per-cent. solution. In three minutes he experienced a sensation of
fulness on each side of his neck, with nausea, and for a moment or two
some mental confusion. He heard loud rushing noises in his head, and
felt constriction round the lower part of his neck; his forehead became
bedewed with persj)iration, and he yawned frequently. These symptoms
passed away in aljout half an hour, but were followed by slight headache,
dull heavy pain in the stomach, with a sensation of sickness without vom-
iting, lie felt for some hours languid and disinclined for mental or phy-
sical exertion, and the headache lasted till next morning.

Mr. F. A. James, of University College Hos]Mtal, also tested the drug
on himself, and for a few minutes felt as if intoxicated.

Dr. Murrell made a large number of observations on himself and on
others confirmatory of the foregoing statements. After taking one or two
minims of a one-per-cent. solution he feels painful pulstition over the
whole head, the pulsation soon affects the entire body, and is so severe that
it seems to shake his entire frame, and is so marked that it visibly jerks a pen

NITRO-GLYCERINE. 299

held in his hand. The pulsation he feels to his fingers' tips. He expe-
riences a sensation of fulness over his whole body. Whilst he keeps quiet
these symptoms are sliglit, but they greatly increase on movement, and the
headache is intensified on stooping. These symptoms last about five
minutes, to be followed by a dull aching frontal headache, with languor,
depression, and inability for work. He never feels sick, has no mental
confusion nor giddiness. His sight and hearing are not affected till about
half an hour after taking the drug, but he feels drowsy. The headache
lasts till next day. For many years I have employed this substance, and
from my own experience can confirm all the foregoing statements.

In numerous observations Dr. Murrell finds that the symptoms begin
in about two to three minutes after swallowing the medicine, the acute
symptoms lasting about ten minutes, whilst headache and languor persist
about four to five hours.

Though the drug causes a glow on the face, accompanied by perspira-
tion, still it only very slightly flushes the face, in this respect differing
from nitrite of amyl. Sometimes nitro-glycerine causes very free perspi-
ration.

The headache is at first throbbing, and felt over the forehead, some-
times on the top of the head, sometimes at the back. The continuous
pain is dull and achiug. Xausea is an uncommon symptom.

It increases the pulse about twenty beats per minute. The acceleration
begins in about five minutes and continu.es half an hour. The pulse be-
comes full, bounding, large, and rather soft, but never intermittent nor
irregular. The pulse, indeed, manifests the characters due to extreme
arterial relaxation.

Dr. Murrell has made one hundred and fifty sphygmographic tracings,
and has compared the action of this drug on the same person many times
with nitrite of amyl, and finds that nitro-glycerine gives a similar tracing
to nitrite of amyl. The amplitude of the trace is much increased, the rise
and fall is abrupt. The trace displaj^s marked dicrotism. Dr. Murrell
therefore concludes that nitro-glycerine causes great arterial relaxation.

The effects of nitrite of amyl come on sooner, and last a shorter time,
than those of nitro-glycerine. Thus, the effects of amyl begin in fifteen
seconds, whilst those of nitro-glycerine are delayed for five minutes. This
difference is probably due to the great volatility of nitrite of amyl.

Nitro-glycerine, in medicinal doses, does not affect the temperature.

Chemists employed in preparing nitro-glycerine pills on a large scale
complain that it causes sleeplessness.

The susceptibility to this drug varies. One or two minims of the one-
per-cent. solution affects most persons, but I have seen even half a minim
greatly affect certain patients, and to such an extent that they could not
continue the medicine.

Dr. ]\Iurrell recommends nitro-glycerine in angina pectoris. It is cer-
tainly equal, if not superior, to nitrite of amyl. In many cases it is cer-
tainly superior. I have seen cases where the relief from amyl was very
transient, but much more persistent from nitro-glycerine. In some case
ayml succeeds best, in others nitro-glycerine. Nitro-glycerine is slower
in relieving pain, but its effects are often more prolonged. They should
be administered differently. Amyl is only useful when given during a
paroxysm. ISTitro-glycerine may be given at stated intervals, say every
two or three hours, and an additiojial dose on the onset of a paroxysm.
The regular administration greatly lessens the frequency of the attacks.

300 NITKITK OF SODIUM.

Occasionally, however, it jn-oduces so much headache that patients are
obliged to desist from its use. In one case it at first afforded much
relief, but afterwards each dose induced a slight paroyxsm. It should
be given in jj^-g-min. dose, either dissolved in water, or made into tablets,
as sold by Martindale. One of my patients took a hundred of these
tablets a day, with great benefit.

Nitro-glycerine is recommended in sea-sickness.

Dr. Neale has seen it of great service in the paroxysms of asthma,
and in migraine. Speaking of a case of asthma, he says, " the tongue of
the patient was touched with the stopper of a bottle contianiug a 5 per-
cent, solution, when the paroxysm was so severe as to cause const^nation
to all round, and in less than a minute there was a great calm."

It has been long used in migrainous headaches, and in many cases,
no doubt, it is very efficacious, though it fails not unfrequently.. I give
a tablet containing y^jj to -^1^- of a minim every hour or oftener immedi-
ately the headache begins. Dr. Hammond gives it in the aparoxysmal
period, and successfully, to avert the attacks. Dr. Hammond also gives
nitro-glycerine in epilepsy and the status epilepticus. It sometimes cures
hiccough, and, like nitrite of amyl, it averts the cold stage of ague.

Nitro-glycerine is employed in contracted kidney to lower arterial
tension, ancl often relieves the distressing headache of Bright's disease
better than other remedies. It is said to increase the quantity of urine
in chronic parenchymatous nephritis. Injected into the jugular vein
nitro-glycerine arrests the heart. It paralyzes the vagus (Brunton).
Like other nitrites, it affects the blood, which becomes chocolate colored.
It tetanizes, and then paralyzes frogs, but not through the spinal cord
(Brunton). It directly paralyzes muscle. It destroys the reflex func-
tion of the cord, and death takes jjlace from asphyxia.

NITRITE OF SODIUM.

We have just seen how similar is the action of nitro-glycerine to
that of nitrite of amyl, and it is probable that all nitrites act in the same
way; for instance, Dr. Reichert, Dr. Mitchell, and Dr. Matthew Hny,
find that nitrite of sodium and nitrite of potassium act just like nitro-
glycerine and nitrite of amyl. Moreover, in the preparation of nitrous
ether, the workmen suffer from symptoms just like those produced by
nitrite of amyl and nitrite of sodium.

Dr. Matthew Hay finds that nitrite of sodium in a dose of five, ten,
or twenty grains accelerates the pulse, causes throbbing, and a sensation
of fullness in the head and eyes, with slight flushing of the face. The
sensations of throbbing and fullness last an hoar or more; the larger the
dose the longer these sensations persist. Gamgee, too, has shown that
nitrite of soda affects the blood like nitrite of amyl.

Nitrite of sodium frequently acts purgatively on rabbits and dogs,
even when injected subcutaneously, and it reddens and inflames the
mucous membrane. It is useful in angina pectoris. I find it, however,
less useful than nitro-glycerine or nitrite of amyl. This may be due to
the rapidity with which it changes, so that but little or none of the
nitrite is administered. Its instability will probably prevent its coming
into use. One grain repeated several times a day is an efficient dose.

It has been recommended in eiailepsy, but further evidence is required

CAMPHOR. 301

to prove that it is useful for the graver forms of this obstinate disease,
though I have certainly lessened the frequency of attacks of petit mal
by a grain dose, given twice or thrice a day.

Lublinski finds it useful in nervous and bronchial asthma, but useless
in the asthma due to emphysema. He also finds it very useful in mi-
graine. It is useful in the asthma of Bright's disease. Like nitrite of
amyl, it will avert the cold stage of ague.

A large toxic dose causes giddiness, blueness of the face and hands,
fluttering at the heart, throbbing pains in the head, sometimes violent
perspiration, and these symptoms may continue for one or two hours.

CAMPHOR.

At the temperature of the body camphor is solid, but it slowly volat-
ilizes, even at a lower temperature. But little soluble in water, it freely
dissolves in oil and alcohol. Camphor destroys most plants, except those
of the lowest organizations, as the fungus — commonly called mould. It
is said to be poisonous to fleas, bugs, spiders, and other insects. Cam-
phor excites redness and heat, indeed slight inflammation, in the un-
broken skin, and. of coiirse, irritates more powerfully wounds and deli-
cate structures like mucous membranes, and may j^roduce not only active
inflammation, but even slough and ulcers. It has been api^lied to stimu-
late indolent sores. It is a useful addition to dusting powders to allay
the heat, tingling and itching of ezcema and intertrigo. Camphor is a
common ingredient of tooth-powder, and is a corrective of foul breath.
It is largely used as a liniment to relieve pain, neuralgic, myalgic and
•rheumatic; also to sprains and to joints afflicted with chronic rheumatism.

Camphorated alcohol has been recommeiided as a remedy for boils at
their earliest stages, applied three times a day for half a minute, after-
wards letting the skin dry, and then smearing it with camphorated oil. It
is said that a few applications will usually disperse the coming boil. In-
haled, or taken by the stomach, camphor exerts a decided influence on
" cold in the head." Employed at the beginning of an attack (it is useless
after the first stage), camphor sometimes arrests an ordinary cold, and,
failing this, it abates its violence, obviating or diminishing frontal head-
ache, and restraining the sneezing and running at the nose.

Camphor inhalations are sometimes useful in that troublesome and
chronic complaint characterized by seizures of incessant sneezing, and
profuse watery running at the eyes and nose, the patient remaining well
in the intervals. The attacks may occur daily, beginning early in the
morning, and may last for a few minutes only, or persist for several hours:
and they may occur at any hour of the day, recurring several times daily.
Sometimes several days intervene between the attacks, which may last
twenty-four hours, or even longer. They are generally accompanied by
severe frontal headache, and in some instances an itching of a point inside
the nose denotes the imminence of an attack. This affection lasts for
years.

In catarrh, and in this unnamed affection, the patient should either
sniff up finely-powdered camphor, or inhale by the nose some of the alco-
holic solution poured on a handkerchief, or into boiling water; but when
boiling water is used it is needful to protect the eyes from the camphor
vapor, to obviate smarting and inflammation. At the same time he should

302 CAMPHOR.

take four to six drops of the alcohol solution of camphor every fifteen
minutes for the first hour, and hourly afterwards.

For drowsiness or headache occurring at the change of life, or from
perverted action of the uterus, Dr. Tilt orders eau de Cologne saturated
with camphor to be rubbed into the head. A lotion of equal j)arts of
liquor of ammonia and spirits of camphor dabbed on the j^ainful sur-
face is n useful application for the heat and sensation of weight at the
top of the head, so frequent at the change of life or from menstrual dis-
turbance. The same lotion is useful in migraine.

Camphor excites in the mouth and stomach a sensation of coldness,
followed soon by a sensation of warmth. Large doses excite epigastric
pain, nausea, and vomiting. After death from poisonous doses the
stomach and intestines are found reddened, and sometimes even ulcerated,
the amount of mischief depending on the mode of taking the camphor,
which, if swallowed in solution, quickly passes into the blood, the stomach
being but little affected; but if swallowed in the solid form, owing to its
high melting point, it remains long enough in the stomach to excite
severe inflammation, and most of it escapes undissolved with the motions.

Dr. Bartholow recommends five to fifteen minims of sjiirits of cam-
phor for flatulence, especially hysterical flatulence, and for flatulent colic
occurring at the change of life.

Few, if any, remedies are comparable to camphor in summer diar-
rhoea and cholera. Its benign influence in cholera is most conspicuous,
for it generally checks the vomiting and diarrhoea immediately, prevents
cramp, and restores warmth to the extremities. It must be given at
the very commencement, and repeated frequently, otherwise it is useless.
Four to six drops of strong spirits of camphor must be given every ten
minutes till the symptoms abate, and hourly afterwards. It is a good
plan to mix it with a little brandy, but it acts admirably alone.

Dr. George Bird employs spirit of camphor with good results in the
acute dinrrhoea of infants, and where admissible gives it in milk. Cam-
phor generally restrains the diarrhoea excited by the effluvia of drains.
Some persons, especially women, on exposure to cold, suffer from diar-
rhoea, accompanied with severe cutting pains. Standing on cold objects
is especially liable to excite this diarrhoea. The pain may be very severe,
continuing till the bowels have acted three or four times. Camphor
generally relieves the pain, and restrains this diarrhoea.

Camphor readily passes into the blood, and manifests itself there,
and in most of the organs of the body, by its odor. Its influence on the
blood is unknown. Its influence on the heart appears to be capricious.
Large doses often slacken, sometimes quicken, and generally weaken,
the j)ulse. Moderate doses, it is said, quicken and strengthen the pulse.
Large doses sometimes disturb the brain, causing at first increased
activity, with a rapid flow of pleasant ideas; but subsequently, and in
some cases even at first, camphor produces great faintness, giddiness,
noises in the ears, much delirium, passing sometimes, like alcoholic in-
toxication, into drowsiness, and even convulsions, with coldness of the
surface, shrunk features, and clamminess of the skin. Large doses often
induce some smarting and pain of the urinary organs, with urgent desire
to pass water.

It is mainly given in adynamic fevers, and, according to Graves and
others, it is a very valuable remedy. It is said to strengthen, while re-
ducing the frequency of the pulse, to moisten the skin, and check the

TURPENTINE. 303

deliriiim, especially when of a low and muttering character. To control
delirium, it must be given to the extent of twenty grains, or more, every
two or tliree hours, and its eifects must be watched. Some practical
authorities, however, deny the efficacy of camphor in fever delirium.

It has also been recommended in melancholia, in spasmodic affections,
in nervous palpitation, and in hiccup.

It is rej^uted, on high authority, that considerable doses of camphor
will control inordinate sexual desire. It is said to relieve strangury.
Drachm doses of the sj)irit will relieve chordee.

Camphor is eliminated by the breath, probably with the perspiration,
and a small proportion with the urine. The irritation it produces in
the urinary mucous membrane, and the small amount of camphor sep-
arated by the urine, has led to the assumjjtion that some of the products
of its decomposition in the body escape with that secretion, ;ind, in
their passage, irritate the mucous membrane; but on this point nothing
definite is known, and at present there is no proof that camphor is con-
sumed in the body.

TUEPENTINE— OIL OF TURPENTINE.

TuKPENTiNE is antiseptic. Applied to the skin it excites a sensa-
tion of warmth, with some redness; and, if the application is sustained,
blistering takes place. It is in common use as a rubefacient and counter-
irritant. Over a flannel wrung out in hot water some turpentine or
turpentine liniment may be sprinkled, and applied till it produces red-
ness, tingling, and smarting. It is well to bear in mind that, as the
smarting arising from the application of a turj)entine stupe goes on
augmenting for some time after its removal, it should be kept on no
longer than just sufficient to excite a moderate degree of pain. Turpen-
tine stupes may be employed as a rubefacient for the same purposes as
a mustard poultice. It is often employed in the form of liniment, and
is useful in myalgia, superficial neuralgia and lumbago. Turpentine
liniment, or an ointment containing turpentine, is useful for unbroken
chilblains.

Dr. Faulis employs the following method in ringworm : — He cuts off
the hair and rubs the patch with turpentine till it smarts. He then
washes it well with carbolic soap (10 per cent.). The smarting soon
ceases. After well drying the skin, he paints on it two or three coats of
tincture of iodine. Lastly, he anoints the hair with carbolic oil (1 in 20).
He claims to cure the worst cases in a week.

Turpentine in the stomach excites a sensation of warmth, and large
doses sometimes produce nausea and vomiting. It generally, but not
invariably, acts as a purgative; and if, after large doses, purgation does
not take place, serious symptoms sometimes arise from the absorption
of the turpentine, and from its action on the organs at a distance from
the intestinal canal. Thus, when administered in considerable doses, it
is desirable to give, either simultaneously or soon afterwards, some more
active and certain purgative, as castor-oil. Even after large doses the
stomach and intestines of animals have been found sometimes free from
inflammation.

304 TUKPENTINE.

In staying hgemorrliage from the stomach, arising from chronic ulcer,
or other causes, from the intestines in typhoid, etc., few remedies are
more successful than turpentine given in small doses of five to ten drops,
very frequently rejieated. Later on v/e shall speak of the use of
turpentine in controlling hajmorrhages from other organs.

Turpentine proves useful in certain states of typhoid fever, probably
from its direct action on the intestinal mucous coat. Thus Dr. Wood
has drawn attention to its value in ten-minim doses, repeated every two
hours, when the tongue parts with its fur in flakes, and instead of be-
coming and remaining moist, looks dry and glazed, a condition usually
observed towards the end of the disease, and accompanied always by an
increase of the tympanites, and an aggravation of the other symptoms.
In " the course of twenty-four, or at most forty-eight hours, some ameli-
oration of the symptoms may be observed. The tongue becomes gradu-
ally moister, and covers itself with a whitish fur; the tympanitic dis-
tension ceases to augment, and after a time diminishes; the pulse be-
comes less frequent and the skin less dry and harsh, and the patient
enters slowly but regularly into convalescence, often without any other
remedy. As the case improves, the quantity of the oil should be dimin-
ished, but care should be taken not to omit it too hastily." Dr. Wood
further says, " I will repeat that oil of turpentine may be used with
great hope of benefit, in any case of enteric fever in the advanced stage,
with a dry tongue."

Dr. Graves employed it in the same disease, in drachm doses every
six hours in extreme tympanites, and he pointed out that the remedy is
of no use* if, before and during the j^roduction of flatulent distension
there is diarrhoea, when acetate of lead is invaluable. With the tympa-
nites there is very often much prostration, with muscular trembling, and
picking of the bed-clothes, and low, muttering delirium — symj^toms all,
according to Graves, benefited in many cases by the use of turpentine.

This drug is successful as a tape-worm poison, though it has now
given place to milder and more efficient remedies. Large doses of half
an ounce to an ounce must be given, and should be combined Avith a
purgative, for if absorbed, this quantity may produce disagreeable symjD-
toms. A smaller dose of a drachm may be given three times a day.

Turpentine injected into the rectum will destroy thread-worms, but
many other substances are just as effective vermicides.

Turpentine enemata are useful in flatulent distension of the bowels.

Turpentine may be inhaled with benefit in chronic bronchitis, but
terebine is pleasanter and preferable.

Turpentine passes readily into the blood, and may be detected in the
breath and sweat, and in altered st:ite in the urine, giving to this ex-
cretion an odor of violets, or of mignonette.

In large quantities, and especially if it fail to purge, and thus escape
promptly by the rectum, turpentine produces in most persons some ex-
citement, with giddiness, confusion of siglit, quickened pulse, and, in
extreme cases, insensibility, with dilated pupils. In many instances it
produces bloody and scanty urine; or indeed it may suppress this secre-
tion; occasionally it excites pain along the urinary tract with frequent
and painful micturition.

Dr. H. A. Ilare shoAvs that moderate doses increase the frequency
of the heart's beats from direct stimulation. But larger doses reduce
the frequency by stimulation of the vagus centre, lie finds, too, that

TURPENTIlSrE. 305

neither large nor small doses have much effect on the vaso-motor system.
In small closes it stimulates the whole of the nervous system, the brain
first and most, bat large doses depress this system, and lessen reflex action.

As we have said, it is very etficacious in bleeding from the various
organs of the body, as the lungs, nose, uterus, kidneys, and bladder. A
drachm should be given every three hours, a dose which sometimes
causes sickness, diarrhoea, and even blood in the urine; but on discon-
tinuing the drug the blood soon disappears. Given to check bleeding
from the kidneys, as in Bright's disease, it must be administered in very
small quantities. It is also reputed to possess the power of checking
bleeding in the hgemorrhagic diathesis, and to be useful in purpura. ,

Large doses of this medicine are given in puerjoeral fever, but author-
ities are divided as to its usefulness.

According to some authorities it has been employed with great suc-
cess in sciatica, in half-ounce doses, given for four or eight successive
nights, when, if it fail to give relief, it may be pronounced useless in
that particular case.

Dr. George Bird finds that in 20-drop doses, thrice daily, it is
markedly serviceable in lumbago. Sjiirits of turpentine, in half-drachm
doses, several times daily, is very useful in non-specific choroiditis.

Turpentine is an antidote to phosiahorus, and Dr. Letheby says that
at a lucifer-match factory at Stafford the workmen prevent necrosis of
the jaw by w^earing near their breast a small oi^en vessel containing
turpentine.

The experiments of Personne on fifteen dogs support this view. To
five dogs he gave phosphorus alone, and they all died. To five others,
an hour or two after the phosi^horus, he gave turpentine, and one only
died. To five others he gave tur^oentine immediately after the phos-
phorus, and only one dog died. These experiments, however, are not so
satisfactory as they easily might have been, as he does not ajipear to have
given an identical dose of phosphorus in all his experiments. Personne
thinks that phosphorus produces asphyxia by becoming oxidized, and
abstracting oxygen from the blood. Pyrogallic acid absorbs oxygen from
the blood, and Personne asserts that it produces the same symptoms
and post-mortem appearances in dogs as phosphorus. He thinks that
turpentine prevents the oxidation of ^ihosphorus, so that it is eliminated
unchanged without inflicting injury on the body.

Kohler confirms Personne's statement of the antidotal power of
turpentine, but controverts his explanation of its action. He gave
twenty-five animals from 0.006 to 0.09 grm. of phosphorus, and 4,5
grms. of turpentine, and on killing the animals the tissues showed no
fatty degeneration, or other signs of phosphorus poisoning. Kohler says
that a compound of phosphorus and turpentine is formed, which is
eliminated through the kidneys, giving to the urine a smell like opodel-
doc, and not of violets.

Some experimenters deny the antidotal virtue of turpentine. These
contradictory statements are now recoiiciled by the observations of
Jonas, who finds that pure turpentine has no effect on phosphoi'us,
whilst French turpentine forms a spermaceti crystalline mass — turpen-
tine-phosphoric acid, which is said to be harmless and to be eliminated
by the kidneys unchanged. Experiments with the different kinds of
turpentine as antidotes to phosphorus confirm these conclusions. The
French turpentine must be old when it contains ozone.
30

306

VOLATILE OILS.

Turpentine is reputed to be diuretic, and is sometimes administered

in small doses with this intent in Bright's disease.

It has been used in chronic cystitis, in gonorrhoea, and in gleet.

It has been given with apparent advantage in Ijiliary colic.

It is excreted by the lungs and skin, but chiefly by the urine, giving
it the odor of violets.

Group containing: —
NUTMEGS.
CLOVES.

CANELLA BARK.
CINNAMON BARK.
CAJEPUT OIL.
OIL OE ANISE.
FENNEL FRUIT.
CARAWAY FRUIT.
CORIANDER FRUIT.
DILL FRUIT.
ELDER FLOWERS.
LAVENDER OIL.
OIL OF ROSEMARY.
OIL OF SANDAL WOOD.
MENTHOL.

OIL OF PEPPERMINT.

OIL OF SPEARMINT.

OIL OF RUE.

OIL OF LEMONS.

CUBEBS.

BUCHU LEAVES.

BALSAM OF TOLU.

BALSAM OF PERU.

COPAIBA.

MEZEREON.

SASSAFRAS.

STORAX.

JUNIPER.

BENZOIN,

Etc.

This group consists of volatile oils, or substances containing volatile
oils. Some of the members containing a bitter constituent are tonics.

The ethereal oils penetrate the cuticle, and excite slight inflamma-
tion. Some are employed as rubefacients to rheumatic and gouty joints,
to the face in toothache, etc. Dr. Alfred Wright, of Finchle}', says that
in China he learned from the natives the practice of painting oil of
pepi^ermint on the face in facial neuralgia. He uses it also for gout,
the relief it gives in both instances being almost instantaneous.

There is a German quack anti- neuralgic liniment Avliich consists
chiefly of oil of peppermint. Balsam of Peru is a useful adjunct to
ointment for broken chilblains. Dr. Robertson, of Cheltenham, strongly
recommends the local application of cajejaut oil for chilblains, stating
that sometimes one application will effect a cure (vide Iodine). Dr.
Copland, in his Dictionary, states that in the form of ointment, for
which he gives a formula, it stimulates the growth of the hair.

All essential oils destroy lice, whether situated on the head, trunk,
or pubis; but in '' louse disease " oil of rosemary and powdered pyrethrum
are generally preferred.

Many excellent auihorities extol storax and Peruvian balsam in itch.
The following prei^arations are very useful: — Storax, an ounce; olive
oil, two drachms. Or, rectified spirit, two drachms: storax, an ounce;
olive oil, a drachm; mix the first two ingredients, and add the olive oil
to them. The whole body, except the head, is carefully rubbed with
either compound. One application, it is said, kills the insects; but, to
avoid the risk of failure, it is better to repeat the application in twelve
or twenty-four hours. These applications cause no irritation of the skin,
and they possess the additional advantage of an agreeable odor. Al-

VOLATILE OILS. 307

though not necessary to the success of this treatment, yet for the sake
of cleanliness, a warm bath should be given before and after the inunc-
tions.

Dr. McCall Anderson recommends storax highly, asserting that it is
as efficacious as sulphur, while, unlike sulphur, instead of irritating it
soothes the skin.

Compound tincture of benzoin painted on the skin, or mixed with
water, Avill sometimes allay itching from urticaria, eczema, etc. Five to
:^fteen grains of menthol to an ounce of simple ointment is very useful
in ]»ruritus ani, and to a less extent in the itching of eczema.

The stronger prejiaration may produce much smarting, therefore the
weaker preparation should -be first tried. This ointment is often suc-
cessful where calomel ointment fails. Dr. Selwyn Kussell finds that
cutaneous inflammations, like boils, carbuncles, excessive inflammation
following vaccination, are speedily relieved by painting the inflamed
tissue several times a day with a ten to fifty per cent, solution of menthol
in ether or alcohol.

A piece of cotton wool saturated with a ten per cent, solution of
menthol inserted into each nostril at the beginning of an attack of coryza
directly itching and sneezing begin, and allowed to remain for four or
five hours, is said to cure a cold in the head.

Benzoic acid dissolved in spirits or eau de Cologne is also very useful
in urticaria; a drachm added to boiling water, and used as an inhalation
night and morning, is often used in bronchitis, and even in chronic
phthisis — easing cough and lessening expectoration.

Terebine is a useful inhalent; for chronic bronchitis ten minims
should be used in boiling water, or dropped on a handkerchief and
placed near or over the mouth.

The members of this group have a warm, and many of them an
agreeable taste. Oil of peppermint, orange-flower water, oil of cinna-
mon, oil of lemons, conceal the flavor of disagreeable medicines.

These oils excite a sensation of warmth in the stomach; some of
them being used to increase appetite and digestion. In large doses they
excite slight inflammation of the stomach and intestines. Many of
them, as oil of cloves, oil of cinnamon, oil of anise, oil of fennel, oil of
coriander, oil of caraway, oil of pei^permint, are employed to prevent the
griping pains of purgative medicines.

Some, as cloves and cinnamon, are useful in diarrhoea as adjuncts to
astringents. Their stimulant action on the muscular coat of the stomach
and intestines removes colic and expels wind; oil of cajeput especially,
and oil of cloves, are generally preferred in flatulence. Spirits of horse-
radish, in half-drachm to drachm doses, is highly approved in flatulence.
Cajeput oil is said to relieve the pain of dysmenorrhsea.

These oils probably pass readily into the blood, and for the most part
act like turpentine. Many of them are employed as antispasmodics,
but they are inferior in this respect to chloroform and ether. Whether
they undergo any changes in the blood is at present unknown.

Balsam of Tolu and balsam of Peru, and copaiba, are given in chronic
bronchitis with a copious secretion of pus.

Mezereon and sassafras are reputed to be useful in syphilis and chronic
rheumatism.

Lavender, rosemary, rue, cinnamon, and some other members of this
group are given as stimulants to nervous and hysterical persons affected

oQg VOLATILE OILS.

with depression of spirits and other symptoms; but they soon lose their
effect, unless given in increased doses. Drachm doses of oil of cinna-
mon, given several times daily, is strongly recommended in menorrhagia
and flooding.

Senator finds benzoic acid, 150 to 180 grains daily, useful in acute
rheumatism, though inferior to salicylic acid.

These oils, and the resins derived from them, escape from the body
in jjart with the breath and perspiration, but chiefly with the urine, and
in their passage along the urinary tract they stimluate or irritate i^
mucous membrane. Copaiba sometimes causes bloody urine with
strangury and pain in the bladder.

I know of no remedy so useful in chronic cystitis as pereira. Two
to three drachms of the liquid extract every three or four hours speedily
reduces the amount of blood in the urine, and more slowly reduces the
pus and mucus. At the same time it often promotes appetite.

Copaiba, cubebs, and especially buchu, are commonly used in chronic
inflammation of the bladder and urethia.

Half drachm or drachm doses of tincture of cubebs in half a tumbler
of linseed tea thrice daily are very useful in coughs due to chronic
catarrh, or those following influenza, or a simple acute catarrh, or in
the cough of emphysematous patients. It often cures the cough "like
a charm."

Copaiba and cubebs are used in gonorrhoea and gleet, and cubebs
often succeeds when copaiba fails. Copaiba beneflts, it is said, the
chronic, but aggravates the acute, stages of gonorrhoea; while cubebs,
which must be give in large doses, is considered only useful at the com-
mencement of attack. Copaiba, however, often promptly relieves an
acute attack. Emulsified copaiba has been used, especially for women,
as an injection for gonorrhoea.

Balsam of copaiba, in ten to fifteen minim doses, sometimes acts as
a powerful diuretic, and Dr. Wilks, wdio used it with much success, finds
that the diuretic properties reside in the resin. Copaiba has been found
very useful in some cases of ascites, entirely removing the abdominal
dropsy, and in Bright's disease. I have in many cases used the resin in
ten to fifteen grain doses, often with great effect; I have seen it answer
in cardiac dropsy and in ascites, where the kidneys were healthy ; also
in ascites where there was fatty degeneration of the kidneys ; and in
Bright's disease, where the kidneys seemed the seat of fibroid change
and fatty degeneration, being much contracted, granular, red, firm, the
cortex much contracted, with numerous small, opaque, buff-colored spots.
I have also seen it remove, speedily and entirely, extensive dropsy, due
probably to pale fatty kidney. I have also known the resin benefit the
chronic diseases loft by an attack of acute liright's disease, and prevail
over a case of cardiac dropsy, with a small amount of albumen in the
urine, and wntli signs of general decay. Yet in cases which appear ex-
actly similar I have known it to fail entirely, leading me to think that
success or failure depends less on the nature of the disease than on some
individual peculiarity. In some cases copaiba causes bloody urine, in
others I have seen a large amount of blood in the urine quickly disap-
pear under the influence of copaiba resin.

Copaiba occasioiially produces a rash, sometimes like urticaria, some-
times very closely simulating the papules of measles, but there is no fever
with copaiba rash. If the medicine is continued, the papules last many

EUCALYPTUS. 309

days. The rash does not begin on the face, then spreading downwards
over the body, but is patchy, and shows a preference for the neighbor-
hood of joints. In doubtful cases, where j^atients deny that they have
taken copaiba, it may be detected in the urine by the smell, and with
still greater certainty by chemical reagents; for, if copaiba is present,
nitric acid makes the urine turbid, which heat dispels. Copaiba may
also be extracted from the urine by shaking it up with ether.

Oil of sandal-wood, in doses of fifteen minims three times a day, is
useful in acute and chronic gonorrhoea.

Probably most of these ethereal oils escape from the body with the
urine; but, from Weikart's experiments, quoted by Parkes, this does not
appear to be the case with copaiba, the volatile oil being destroyed in
the body, and only its resinous acid appearing in the urine.

Many persons highly esteem juniper as a diuretic in scarlatinal
dropsy.

Many of these oils may be prescribed in capsules.

EUCALYPTUS.

EucALTPTOL destroys the lower forms of life and is a powerful an-
tiseiDtic and disinfectant. It is more antiseptic than quinine; and this
jDroperty increases with its age, when it contains more oxygen. It arrests
the amoeboid movements of white corpuscles. When applied to the
skin and its evaporation is prevented, it excites redness, and even vesi-
cation.

Mixed with iodoform it is a useful application in chancrous sores and
hard chancres ; and with iodoform and vaseline is sometimes very useful
in the dry stage of eczema.

Eucalyptus and its oil have a warm camphoraceous taste, and increase
the salivary and intestinal secretions, producing copious and soft motions,
whilst large doses excite diarrhoea, and the stools smell of eucalyptol.
The active principles are readily dissolved. It is often employed topically
in diphtheria, the oil being applied to the throat and also used as an in-
halation.

Twenty drops inhaled several times a day with an oronasal inhaler
often relieve cough in chronic bronchitis and chronic phthisis. In most
cases it is decidedly inferior to creasote, but it sometimes succeeds where
creasote fails, and may be employed where the taste of creasote cannot
be tolerated.

It excites perspiration.

Preparations of eucalyptus are given in atonic dyspepsia, chronic
gastric and intestinal catarrh, and in vomiting from sarcins. Eucalyp-
tol is used as an injection for thread-worms. It is given in the various
symptoms connected with the change of life, as flatulence, palpitation,
flushings. It is used in the form of cigarette in asthma, and is highly
commended in chronic bronchial catarrh and bronchorrhoea, and in
chronic catarrh of the genito-urinary tract. It contracts the spleen. _

In large doses eucalyptol acts on the kidneys like turpentine, copaiba,
and cubebs, and, like these drugs, it is useful in small doses _ in acute
and chronic nephritis. Eucalyptol is highly praised in chronic inflam-
mation of the bladder.

310 ASSAFCETIDA AM.A[ONIACUM GALBANU.M.

lu toxic doses it probably depresses the spinal cord, the brain, medulla
oblongata, and heart, and so induces drowsiness, shallow breathing and
lowered arterial tension. It kills by arresting respiration.

It is used in intermittent fever, but in most cases it is undoubtedly
much inferior to quinine.

The active principles are eliminated by the skin, the bronchial mucous
membrane and the kidneys.

VALERIAS". VALERIANATE OF ZINC. VALERIAXATE OF
QUINIA. VALERIAXATE OF AMMONIA.

Like turpentine and the volatile oils, valerian produces a sensation
of warmth in the stomach, a quickened pulse, some mental excitement,
and, in a large dose, even delirum.

Neligan considers valerian a powerful anthelmintic, and especially
recommends it when the worms excite convulsions.

Valerianate of zinc is very useful for those numerous, distressing
and changeable symptoms included under hysteria, generally occurring
in women at the menopause. Thus it will ordinarily remove "flush-
ings of the face," " hot and cold perspirations," restlessness, nervousness,
depression of sj^irits, sensation of suffocation in the throat, throbbing of
the temples, fluttering at the heart, heat and Aveight on the top of the
head. In many instances these symptoms depend on uterine derange-
ments, piles, dyspepsia, or constipation; but, after the removal of all
discoverable diseases, or in cases where no cause for the symptoms can
be detected, valerianate of zinc is often very beneficial. Oxide of zinc
does good, but is certainly inferior to the valerianate. In many instances,
however, valerianate of zinc fails in the very cases we should exj)ect it
to be useful, our knowledge of the conditions indicating the employ-
ment of these medicines being at present not sufficiently precise to
enable us to predict the cases in which they will be likely to succeed. It
should be given in three- to five-grain doses in a silvered or coated pill.

Some prefer valerian or its tincture, and ascribe most of its efficacy
to the volatile oil, others prefer the salts of valerianic acid.

Valerian has been used with occasional advantage in epilepsy, but
whether in true epileps}-, or in the merely hysterical form of the disease,
does not appear.

Valerianate of zinc, or valerianate of ammonia, in twenty-grain doses,
sometimes relieves neuralgia of the face or head. It is recommended
in megrim in doses of from two to five grains thrice daily. It is said
that valerian preparations will control the paroxysms of whooping-
cough, and the involuntary movements of chorea. Large and increas-
ing doses of valerian are stated to be useful in diabetes insij^idus.

ASSAFCETIDA. AM^^EONIACUM. • GALBANUM.

These medicines act very similarly on the body; but assafoetida,
prob:iblv because it contains most volatile oil, is the most 2')owerful.

Assafcetida has a warm and disagreeable characteristic taste; it
stimulates the stomach and intestines, expels wind, and in large doses it

CANTIIAKIDES. 311

often excites nausea and vomiting. It increases the secretion from the
mucous membrane of the intestines, and hence acts as a mild purgative.
Probibly the active principles of these drugs do not pass quickly into
the blood; for they make the eructations offensive for twenty-four hours,
or longer.

They generally quicken, but sometimes slacken, the pulse.

A full dose of assafoetida induces general exhilaration, and sometimes
" various nervous or hysterical phenomena, and a general sense of
vudaise " (Jorg). It often produces headache and giddiness.

It is said to increase the bronchial secretions and perspiration. It
does not similarly affect all persons, since Pidoux took enormous doses
without experiencing any inconvenience, except from the offensive smell
of his ftBces.

Assafffitida is very useful in hysteria, in many cases removing hysteri-
cal headache and peculiar sensations in the head. It is also useful in
hysterical flatulence.

Assafoetida is useful in the flatulence of young children, unconnected
with constipation or diarrhoea. A teaspoonful every hour of a mixture
containing a drachm of the tincture to half a piut of water is readily
taken by children, and is strong enough to speedily relieve distension.
When the flatulence is due to constipation or diarrhoea, assafoetida does
very little good.

Assafcfitida has been recommended in asthma. All members of this
group are useful in chronic bronchitis, with much wheezing and abun-
dant discharge, symptoms commonly met with in elderly people, but in
cases like these, ammoniacum is generally preferred to assafoetida.

CANTHARIDES. {See Counter-irritation.)

Preparations of cantharides, taken internally, produce an un-
pleasant burning taste, and, if in a large quantity, inflammation and
vesication of the mouth.

The effect of cantharides in the stomach is in all respects similar to
that in the mouth. Even small doses cause smarting in the oesophagus,
pharynx, and stomach; but a larger quantity produces inflammation of
these parts, and of the intestines, with vomiting, and diarrhoea of bloody
and slimy stools, much pain and difficulty in swallowing, and often
general peritonitis, with which the system sympathizes, as indicated by
high temperature and quick pulse.

The active principle of cantharides passes from the stomach and in-
testines into the blood. Its passage, it is true, has not been chemically
demonstrated, but the symptoms following the administration of this
drug renders this conclusion certain; for, after a large dose, all the in-
dications of acute inflammation of the kidneys set in, with much irrita-
tion or even inflammation of the urinary and generative organs, and, after
a poisonous dose, headache, loss of sensibility, convulsions, and death.

The changes cantharidine in'oduces in the blood are at present un-
known.

The tincture or powder used to be given in cholera and epilepsy, but
this treatment has now fallen into complete disuse.

Little is known of the separation of the cantharidine from the body.

312 CANTHARIDES.

It is conjectured that, being volatile, some may pass off by the lung?;
but, if so, it produces, apparently, in its transit through the lungs, no
changes in the mucous membrane of the air-passages. Owing to the
same property, some of the cantharidine probably passes off by the skin;
and the internal use of preparations of Spanish-fly are recommended by
several eminent French dermatologists in psoriasis, eczema, lichen, and
prurigo. The chief portion of the active j^rinciples of cantharides escape
by the kidneys, and, as we have said, acts as a strong irritant to the
urinary and sexual organs. It may, like oil of mustard, turj)entine, or
copaiba, produce hyperaemia of the kidneys, with bloody urine, which
may partially set into a jelly from the fibrine it contains. This coagula-
tion is said to be characteristic of congestion produced by these and
allied substances. Camphor, in two to five grains, is said to remove
jjromptly this hyperaemia.

The preparations of cantharides have been recommended on high
authority in certain forms of Bright's disease, but this drug has for years
past been regarded as a most dangerous dug in this disease.

The discrepancy respecting the effects of cantharides arises, perhaps,
from the difference in the dose administered by various observers. I am
convinced of its usefulness in acute Bright's disease, when the active
inflammation and fever have subsided, as they invariably do about the
fifth to the eighth day. A chronic state often follows the subsidence of
the more acute stage, and the urine continues small in quantity, contains
albumen, and perhaps blood. If, just at this time, that is, on the im-
mediate subsidence of the acute inflammation, a one- to three-minim dose
of tincture of cantharides is given every three hours, the blood will
almost always quickly disappear, wdiile the albumen decreases more
gradually, and the urine becomes more abundant. At a crisis like this,
it is true that a like amendment not unfreqaently takes place without
any treatment; but the influence of the cantharides can often be put to
a conclusive test. To a patient in the condition described above, pass-
ing urine containing albumen and much blood, give the drug in the way
l^ointed out, and he wull begin to improve; now withhold the medicine,
and both blood and albumen return in their original quantity, and both
may be augmented and lessened again and again by intermitting and
reverting to the cantharides; but its restraining influence over the blood
is speedier and more decisive than over the albumen of the urine. Some-
times it checks the greater part of the blood, but a small quantity re-
mains for some weeks. This is especially the case when the patient gets
up, for even a small amount of exercise often exerts remarkable influence
on the renal bleeding. Merely sitting up in bed in some cases notably
increases the bleeding.

Cantharides, in a similar dose, has been recommended even in the
acute stage of Bright's disease; and when the kidney, having undergone
fatty degeneration, secretes very little urine.

After its separation by the kidneys cantharides acts as an irritant to
the urinary tract, and may be employed in cystitis, gonorrhcea, and gleet.
A drop of the tincture, although five are sometimes required, given three
or four times a day, is j)articularly useful in cases where there is frequent
desire to make water, accompanied by great pain in the region of the
jDrostate gland, and along the urethra, while at other times severe twinges
of pain are felt in the same part, the urine being healthy, or otherwise
containing an excess of mucus, or even a small amount of pus.

3IUSTARD. 313

Women, especially middle-aged women, often suffer from frequent
desire to pass water, or inability to hold it long, sometimes only in the
day on moving about. Micturition causes no pain, neither is there any
straining, and the urine is natural. Other women cannot help passing a
little urine on straining, or sneezing, or coughing. Sometimes women
are troubled with both sets of symptoms, which appear due to weakness
of the sphincter of the bladder. One or two drojis of tincture of can-
tharides, three or four times a day, will in many cases afford great relief,
and sometimes cure with astonishing rapidity, even when the symptoms
have lasted months or years.

Tincture of cantharides is useful in the incontinence of urine of the
aged, even when due to paralysis, and sometimes in that of children.
"With children, however, it is inferior to belladonna. Unfortunately,
each remedy fails in a not inconsiderable number of cases.

A drojD of the tincture, three times a day, in the majority of cases,
will abate or remove chordee.

Cantharides affects the generative organs. Large quantities of the
drug congest and inflame these parts, and often produce erection of the
jienis, effects generally attributed to the sympathy existing between the
genitary and urinary tracts. It certainly excites the sexual appetite,
and has been often given criminally for this purpose. Full doses of
cantharides, twenty to thirty drops of the tincture, or half a grain of
the powder with full doses of scsquichloride of iron and phosphoric acid,
or nux vomica, three times daily, is a combination effective in some
cases of impotence; in the impotence of old age, and in that resulting
from self-abuse, or sexual excess, it has proved successful, and the patient
has begotten children. Cantharides and iron combined are useful in
some cases of seminal emissions.

Cantharides has been sometimes successfully employed to produce
abortion ; but the danger is so great as to deter an}' medical man from
using this drug. Lahousse finds that cantharides affects simultaneously
the malpighian bodies, the renal tubules and matrix. The malpighian
vessels are greatly congested; albumen, leucocytes, and a few red cor-
puscles escape; the ei^ithelium covering the vessels and lining the
capsule swells and desquamates; the endothelium of the vessels swells
and may choke the vessels; the tubule cells swell, become granular and
die. The tubules contain haemoglobin in form of brilliant red homo-
geneous cylinders. Leucocytes escape into the matrix. Other observers
hold that the malpighian bodies are alone, or chiefly, affected.

MUSTARD.

A MUSTARD poultice is in common household use as a counter-irritant,
and an excitant. Much that has been said of blisters applies to mustard
poultices. (See Counter-Irritation.) As has been eleswhere stated, can-
tharides need seldom be applied to produce much vesication; and with
regard to mustard, vesication should be carefully avoided, as the sore so
produced is intractable, heals slowly, and pains greatly. Although mus-
tard may be used in all cases where we should employ cantharides, short
cf vesication, still there are differences in their action. A mustard poultice

314 MUSTARD.

is more painful than a blister, producing a severe burning, soon becom-
ing unendurable, and if not speedily removed creating troublesome vesi-
cation. A mustard poultice can rarely be borne longer than twenty
minutes or half an hour; if the skin is delicate, as in children and many
women, it cannot be endured for so long. Owing to the pain produced
and to its prompter action, a mustard poultice is more effective than a
blister when applied to rouse a drowsy and comatose patient from poison-
ing by opium or alcohol, or in certain conditions occurring in the course
of fevers. (See Counter-Irritation.)

Mustard leaves may be used in place of a mustard poultice. As they
often produce rather severe pain, one, two, or three, layers of damped
muslin should be placed between the leaf and the skin.

When a mustard poultice is employed to affect deep-seated diseased
organs, as in bronchitis, pleurisy, or pneiimonia, its action should be sus-
tained for a long time, over a considerable extent; the larger the tract of
skin attacked, the greater is its influence on the organs beneath. Small
mustard poultices are less useful, except to remove a localized pain. The
poultice, diluted with bread or oatmeal, should be of a size sufficient to
cover the front or back of the chest, or both, and should be continued for
five, six, or more hours. There is a prevalent idea, perhaps a true one,
that the action of cantharides is more searching, and affects the deeper
parts more thoroughly.

In bronchitis the whole chest of a child should be enveloped in a
jacket-poultice, which may be retained in its place by the following con-
trivance: — The poultice is spread on a piece of linen, sufficiently large for
the purpose, to which tapes are tacked ; the tapes may be tied over each
shoulder, and at three places in front of the chest. The poultice must
be made with tepid water; boiling water evaporates the active principle,
vinegar destroys it, and alcohol prevents its formation. On removing the
poultice the skill should be sponged with warm water, or, if the smarting
is severe, with ether, and then the application of a layer of cotton- wool,
although for the first few minutes it aggravates the pain, soon subdues
it altogether.

A general mustard-bath, when appropriately used, often does great
good. Although almost exclusively used for children, it is just as service-
able for adults. It may be employed on the recession of the rash of any
of the eruptive fevers, to bring it back to the skin. Again, in severe
general bronchitis of children, this form of bath is of great service as a
counter-irritant. A tablespoonful of mustard should be added to a bath
sufficiently large for the child, who should be held in it by the nurse till
her arms tingle and smart.

In case of arrested catamenia a mustard sitz-bath may be used to redden
and irritate the skin of the buttocks and thighs, a few days before, and
during the time the missing discharge is due. A course of mustard-baths
assists considerably the restoration of the uterine functions.

Added to a hot foot-bath, mustard is used to relieve headaches, con-
gestion of the head, and inflammations of the internal organs. A mus-
tard poultice, or the more convenient mustard leaf, covered with one,
two, or three folds of muslin, according to the susce^jtibility of the patient
to the action of the poultice, applied to the nape of the neck, is often
serviceable in various forms of headache.

It excites in the stomach a sensation of warmth, and slight pain,
which may be mistaken for hunger, giving rise to the notion that mustard

CAPSICUM. 315

sharpens the appetite, and promotes digestion; but it lias been proved
that mustard does not increase tlie secretion of gastric juice.

It is strange that a substance which acts so powerfully on the skin
should affect so slightly the mucous membrane of the stomach; consider-
able quantities may be swallowed without other effect than the production
of nausea and sickness. The mild action of mustard on the mucous
membrane cannot be explained by its expulsion by vomiting; for, even
when retained, it excites only a little catarrh of the stomach. Mustard is
used as an emetic when no other is at hand, and when no time is to be
lost. Cases of obstinate and even dangerous hiccup are reported which
have been immediately cured by drinking an infusion made with a tea-
spoonful of mustard steeped in four ounces of boiling water for twenty
minutes, and then strained.

Mustard appears to have very little action on the intestines, beyond
making the motions moister.

With many persons even a very small quantity of mustard, or pepper,
or capsicum, greatly increases their piles, and excites severe itching of
the anus. Piles are, indeed, a delicate barometer, as it were, and patients
find that they immediately tell them when they have transgressed, even
in a slight degree, their restrictive rules. Thus a little excess of food,
too rich in fat, a glass of champagne, etc., will, inevitably, increase their
piles next moring, which become swollen, painful, and protrude.

Some of the active principle passes into the blood, but the action of
sinapine on the organs is unknown. It is reputed to be diuretic, but this
is doubtful; moreover, its advocates fail to discriminate the cases in which
it is supposed to be beneficial.

It is said to be useful in whooping-cough.

CAPSICUM.

• Capsicfm irritates and inflames the skin, producing redness, a sensa-
tion of Avarmth or burning, and even vesication, but its preparations are
rarely employed as rubefacients. The tincture is sometimes lightly
painted over unbroken chilblains, but it is inferior to the ointments of
iodine. The following capsicum preparation of Dr. Rheims is highly
lauded for chilblains: —

" Make a strong tincture of capsicum pods by steeping them for
several days in a warm place, in twice their weight of rectified spirits of
wine. Dissolve gum arable in water to about the consistency of treacle.
Add to this an equal quantity of the tincture, stirring it together with a
small brush, or a large camel's hair pencil, until they are well incorporated.
The mixture will be cloudy and opaque. Take sheets of silk or tissue-
paper, give them with the brush a coat of the mixture; let them dry, and
then give another. Let that dry, and if the surface is shining, there is
enough of the peppered gum; if not, give a third coat. This paper,
applied in the same way as court-plaster to chilblains that are not broken,
and burns that are not blistered, speedily relieves the itching and the pain.
It acts like a charm, and effects a rapid cure. The same with discolored
bruises. It likewise allays rheumatic pains in the joints." (Vide Iodine.)
My friend, Mr. Henry Buck, employs capsicum in recent lumbago.

316 IPECACUANHA.

neuralgia, toothache, rheumatic pains, and acute torticollis. He in-
fuses a large handful of crushed capsicum pods in a pint of hot or cold
water for thirty-six hours; he applies a piece of lint soaked in this liquid
to the affected part, covering it with thin gutta-percha. It never vesi-
cates, and, indeed, a stronger preparation may be used. The effects, he
says, are often very striking; for instance, he cures acute torticollis in ten
minutes. A quack doctor in the West of England, who told his secret
to Mr. Buck, had long and successfully employed this preparation.
Powdered capsicum thickly sprinkled on a moist handkerchief, or on a
piece of moist brown paper, applied to the skin is a jjleasant, soothing
counter-irritant, which seldom produces redness.

Preparations of capsicum have a burning, tingling taste, and act on the
mucous membrane as on the skin. The tincture, as a gargle, in the pro-
portion of a drachm to half a pint of water, is useful in some sore-throats,
and may be applied under the same conditions which indicate the use of
nitrate of silver. Thus, in the very early stage of tonsillitis or pharyngi-
tis, either of these substances, which, acts as an irritant, will check the
inflannnation ; but when the deep parts become involved, and the tissues
much swollen, irritants of any kind do great harm. In malignant sore-
throat, capsicum gargle may be used with advantage to stimulate the
tissues into a healther condition, and here, again, its action is similar to
that of nitrate of silver. In relaxed throat, when the mucous membrane
is bathed with a gray mucus, or with pus, the same gargle may be em-
ployed, although it is probably not superior to the glycerine of tannic acid.

It acts as an irritant in the stomach, and, in large quantities, will
produce gastro-enteritis. It is often used as a condiment to spur diges-
tion, but whether it is effective in this respect is undetermined. The
stomach becomes accustomed to capsicum, and at last large quantities
must be eaten to produce any effect.

I can indorse Dr. Lyon's strong recommendation of capsicum in dip-
somania. Ten-minim doses of the tincture obviate the morning vomiting,
remove the sinking at the pit of the stomach, the intense craving for
stimulants, and promote appetite and digestion. It should be taken
shortly before meals, or whenever there is depression and craving for alco-
hol. Capsicum also induces sleep, especially in the early stages of delirium
tremens. Dr. Lyon sometimes gives twenty or even thirty grains made into
a bolus with honey, and repeats the dose in three hours if the first fails to
induce sleep. He says this quantity does not disturb the stomach.

Capsicum is often useful to dipsomaniacs, to enable them to overcome
their pernicious habit. By removing the sinking at the pit of the stomach
it often enables the drunkard to resist the drink-crave. A draught com-
posed of ten minims of tincture of capsicum, ten grains of bromide of
potassium, a drachm of spirits of ammonia, taken several times daily, is
very serviceable; or the bromide of potassium may be omitted, and re-
placed with two minims of liquor arsenicalis, or by a few drops of tincture
of nux vomica or tincture of orange-peel.

Capsicum is very useful in summer diarrhoeas, and in diarrhoias per-
sisting after the expulsion of the exciting irritant. It is used in flatulence.

IPECACUANHA AND ITS PREPARATIONS.

When' applied to the skin, ipecacuanha after some time produces a
sensation of warmth, attended with redness, and the formation of papules;

IPECACUANHA. 317

sometimes it even produces pustules, which on healing are not followed
by pitting or scarring.

It has a disagreeable bitter taste, and excites the flow of saliva.

In some persons the minutest quantity produces peculiar effects on the
membrane covering the eyes and lining the nose and respiratory tract.
On smelling the drug, or even entering a room where it is kept, they are
affected with swelling of the loose tissues around the eyes, with injection
of the conjunctiva, rejieated sneezing, abundant discharge from the nose,
severe tensive frontal pain of the head, much oppression at the chest, with
frequent cough, and the signs and symptoms of bronchitis. Ipecacuanha
thus excites symptoms and appearances similar to those occurring in hay
fever; that is, it excites a certain catarrhal inflammation in the mucons
membranes. It is highly probable that ipecacnanha produces similar re-
sults in all persons, and that its action on individuals differs only in de-
gree. Indeed, it is probable, as we shall see, that ipecacuanha affects all
the mncous membranes.

Small doses produce in the stomach a slight sensation of nneasiness,
with increase of mucus, whilst larger doses excite nausea and a still greater
secretion of mncns from the stomach and from the bronchial tubes. In-
crease of mncns, indeed, occurs with all nauseating medicines, bnt prob-
ably ipecacnanha excites the secretion of nmcus independently of its action
as a nauseant and emetic. In animals large doses are stated to produce in-
flammation of the mucous membranes of the stomach, intestines, and bron-
chial tubes.

Ipecacuanha is frequently used in catarrh of either the stomach or
lungs. It is especially useful when the secretion from the lungs is abun-
dant and tenacious.

In larger doses it produces both nausea and vomiting, and, like all
other emetics, some general weakness, with sweating; and if there is any
spasm, relaxation of it. Thus, in nauseating doses, the drug is both dia-
phoretic and antispasmodic.

It is a mild, tardj^ but certain emetic. It produces repeated vomiting,
unaccompanied by much nausea or prostration; in these respects, and
also in its slighter action on the bowels, it differs from tartar-emetic. Its
tardy action renders it an unfit emetic in cases of poisoning, when the sul-
phates of zinc or copper are to be preferred.

M. Cliouppe, who has investigated the action of emetics, finds that
after section of the pneumogastric nerve, the injection of apomorphia or
tartar-emetic into a vein, excites vomiting as quickly and abundantly as
when the nerve is uncut, whilst emetin does not excite vomiting. As
regards emetin. Dr. Dyce Duckworth's experiments with emetin lead
him to a similar conclusion. M. Chouppe concludes that apomorphia and
tartar-emetic act directly on the vomiting centre, and that emetin acts
through the termination of the pneumogastric nerve.

On account of its slight irritant action on the mucoiis membrane
of the stomach, and perhaps by virtue of the strong movements it pro-
duces in that organ when it excites vomiting, ipecacuanha is found useful
in irritative dyspepsia, both of the acute and chronic kind, With some
practical authorities it is a favorite plan to give occasionally in such case
ipecacuanha in emetic dose. It is sometimes given to produce vomiting
in the bronchitis of children, where the patient breathes with difficulty
from the presence of mucus in the bronchial tubes. The movements of
vomiting expel nmch mucus mechanically, and temporarily improve the

318 IPECACUANHA.

breathing. From its mildness ipecacuanhu is fitted for sucli cases, and
as an emetic for delicate persons.

The quantity required to excite vomiting varies greatly, the smallest
quantity being sufficient for some, whilst others find large doses inopera-
tive. As a rule, children require large doses, and babies only a few
months old may need ten or twenty grains of the powder.

Few remedies are so efficacious as ipecacuanha in checking ' certain
kinds of vomiting. In numerous instances I have witnessed the efficacy
of drop doses of the wine administered every hour, or three times a day,
according to the urgency of the case, in checking the following kinds of
sickness: —

]. It will check the vomiting of pregnane}^ This vomiting is not
always of the same kind. In some cases it occurs only in the morning,
and is excited by the first waking movements. This form Avill in most
instances yield to ipecacuanha, taken in the way described; but should it
fail, the administration of the medicine to the patient on waking, and
sometimes before any movement is allowed, will generally give relief. In
other instances, the vomiting occurs not only in the morning, but fre-
quently during the day, recurring whenever food is taken, and may be so
severe that the stomach rejects all nourishment, while during the intervals
of meals there may be constant nausea and great loathing of all kinds of
food. Vomiting and nausea of this kind will, in most instances, be im-
mediately arrested by ipecacuanha, when the appetite will return, and the
stomach will bear almost any kind of food. Ipecacuanha may check the
nausea and vomiting, with the exception of the early morning attack, but
on taking a dose immediately on waking this early sickness too will gen-
erally cease, thougli in some cases it defies treatment.

In other instances the early morning vomiting may be absent, and the
attack may occur only on taking food, increasing in severity as the day
advances, and becoming most severe in the evening. Should ipecacuanha,
as is sometimes the case, fail to check this form of sickness, nux vomica
will generally give relief.

In some pregnaiicies, besides the sickness and nausea, there is much
heartburn, and perhaps great flatulence, symptoms which in many cases
j'ield quickly to ipecacuanha; but here agahi, should this remedy fail,
nux vomica Avill generally afford relief, though the symptoms yield more
surely to both remedies. It is singular that while ipecacuanha will remove,
in pregnant patients, excessive flatulence, co-existing Avitli sickness, yet if
the flatulence occurs without sickness this medicine is generally unavail-
ing, and recourse must be had to nux vomica, charcoal, sulphurous acid,
or sulpho-carbolate of soda; and of all these drugs most reliance is to be
placed on the suli)ho-carbolate, in doses of five to fifteen grains dissolved
in water, and administered immediately after a meal.

It has been stated that, in some instances, nux vomica succeeds when
ipecacuanha fails; and this is nottibly the case when the tongue is coated
with a creamy fur, Avhen the stomach is out of order, and when there is
much acidity and heartljurn. In such cases botli nux vomica and ipeca-
cuanha may be given simultaneously.

It nnist be confessed, however, that in certain instances, at present
unexplained, ipecacuanha fails to afford the expected relief. In such
cases vomiting is possibly kept up by a displacement of the uterus, or by
a chronic inflammation of this organ, or of its cervix, or os. as was long
since pointed out by Dr. Henry liennctt, wh'ni of course the treatment
should be directed to the removal of these conditions.

IPECACUANHA. 319

2. Some women, who during pregnancy are nntroubled with nansea
and vomiting, yet suffer with both tliese symptoms during the whole or
part of the time of suckling. These symptoms usually begin after the
first few weeks of suckling, and continue till the child is weaned, and
may be so severe, and produce so much exhaustion, as to compel the
mother to wean her child prematurely. Great flatulence may accompany
the nausea and vomiting. Drop doses of ipecacuanha wine, administered
three times a day, will commonly soon cure these symptoms.

3. Similar troubles to those just pointed out afflict some women at
each menstrual epoch, occurring immediately before, during, or directly
after the period. These cases, too, will generally yield to ipecacuanha.

4. The morning vomiting of drunkards; but this morbid state is more
effectively controlled by arsenic.

5. The morning vomiting which sometimes accompanies general Aveak-
ness, and is met with in convalescents from acute diseases.

G. Ipecacuanha will at once control the vomiting in children, with
acute catarrh of the stomach. Indeed, this remedy appears to exercise
greater influence over the vomiting of children than over that of adults.
Arsenic succeeds admirably, likewise, in removing the vomiting of acute
stomach catarrh; and either remedy may advantageously be given with
aconite, to subdue the inflammation, and reduce the fever.

7. In whooping-cough ipecacuanha often removes or lessens the vomit-
ing, when this is occasioned by the violence of the cough, although its
severity may in no degree be lessened. Cases of vomiting from this cause
occur, which are unaffected by ipecacuanha, but which yield immediately
to alum. (See Alum.)

8. A species of vomiting occurs after meals, without nausea or pain,
or even discomfort, the food being merely rejected partially, or often very
little digested. This condition may persist a considerable time, but ipe-
cacuanha wine, in many instances, quickly cures it. x\rsenic, however, is
a still better remedy.

Ipecacuanha, in my experience, proves of little use in the following
forms of vomiting: —

(a.) In children, where the vomited matters are composed of large hard
lumps of curdled milk. In sucli a case, Avhen diarrhoea is present, lime-
water mixed with the milk is the best remedy, but if the child is consti-
pated, bicarbonate of soda should be substituted for the lime-water; and,
should these remedies both fail, milk must be altogether excluded from the
diet.

(b.) Ipecacuanha is not generally useful in that form of vomiting
met with in young children a few weeks or months old, who almost im-
mediately after the ingestion of milk, reject it with considerable force,
either curdled or not, perhaps through both nose and mouth. At the
post-mortem examination nothing may be discovered to explain this fatal
form of vomiting; but sometimes the mucous membrane of the stomach
is extremely soft, and looks as if made of Avater arrowroot. This form of
vomiting is best treated by hourly small doses (one-third of a grain) of
gray powder, or by calomel (one-tenth of a grain).

(c. ) In hysterical vomiting.

Ipecacuanha is sometimes effective in checking the vomiting from
cancer of the stomach, and has succeeded sometimes after the more com-
monly used remedies have entirely failed.

1 have several times met with cases where the symptoms may be com-

320 IPECACUAlSrHA.

])ared to rumination. The food, quite tasteless, has simply regurgitated
into the mouth, without any effort at vomiting. These patients often
chew the food a second time and swallow it without distaste. There may
be no other symptoms, though, so far as I have seen, this regurgitation
occurs generally when the health is disordered. I have seen ipecacuanha
or arsenic promptly remove this regurgitation, though it may have con-
tinued, with intermissions, for months or years. Emetine excites in dogs
diarrhoea, and even dysenteric stools.

Ipecacuanha excites an increased production of mucus m the mucous
coat of the intestines, and becomes in this way slightly purgative, and is
reputed to assist the action of other purgative medicines, as jalap. It is
also stated that a grain of powdered ipecacuanha each morning, while fast-
ing, will relieve constipation depending on great torpor of the intestines.
The same treatment, it is said, will remove the dyspepsia frequently asso-
ciated with constipation, and characterized by depression of s])irits, some
flatulence, coldness of the extremities, and by the food lying on the stom-
ach "like a heavy Aveight."

Rutherford, in his experiments on fasting dogs, finds ipecacuanha.
Avhen mixed with bile and introduced into the duodenum, a powerful
hepatic stimulant. He employed sixty grains, Avhich did not jiurge, but
increased the mucus of the intestinal canal.

It is well known that this drug is largely and beneficially employed
in dysentery. In some epidemics it answers admirably, while in others it
appears to fail. Large doses are required, and will often succeed where
small ones fail. Sixty to ninety grains of the powder are given at a dose,
and repeated if required, oftentimes without the production of either nau-
sea or sickness; but these symptoms, should they arise, may generally be
obviated, if the patient, after taking the drug, will remain quietly on his
back. In chronic cases not requiring prompt treatment, it is a good prac-
tice to administer the first dose at night when the patient has gone to bed.
Should the first few doses excite sickness, it soon passes away on persever-
ing with the medicine.

E. 8. Docker, who has had a very large experience of this treatment,
extols ipecacuanha. He states that its effects in suitable cases are almost
instantaneous, the motions in the very worst cases becoming natural in
frequency and character. Ninety grains of the powder cuts short at once
very severe attacks of dysentery, not only restraining the discharge off-
hand, but freeing the patient from pain immediately, while inducing nat-
ural stools without straining or griping. The disposition to relapse, so
common in acute dysentery, is not observed after the ipecacuanh'\ treat-
ment; and there is no need for after-treatment: nor for any great precau-
tions concerning the quality of the food. After a large dose, as sixty or
ninety grains, Docker recommends an interval of ten or twelve hours' l)e-
fore repeating it, and should the bowels meanwhile remain quiet, to forego
the medicine altogether. It is recommended to inject ipecacuanha, espe-
ially when it is rejected by the stomach.

An injection three or four times a day, of half a drachm or a drachm
of powdered ipecacuanha suspended in a small quantity of fluid into the
rectum, is very useful in acute and chronic dysentery.

The dysenteric diarrhoea of children, whether acute or chronic, will
generally yield speedily to hourly drop doses of ipecacuanha wine. The
especial indication for this treatment are slimy stools, green or not, witli
or without blood. Vomiting, if present, as is commonly the case, affords

IPECACUANHA . 321

an additional reason for the adoption of this treatment. After the first
or second dose of tlie medicine, and generally before the diarrhoea is
checked, the sickness will often cease. Sometimes it happens that although
the ipecacuanha abates the number and the dysenteric character of the
evacuations, yet supplementary treatment may be required.

The active principle of ipecacuanha, without doubt, enters the blood,
and Ave have next to consider its action on the distant organs of the body.

It produces an increased secretion from the bronchial mucous mem-
brane. Some maintain that this occurs only Avhen ipecacuanha excites
nausea, and that the action of the drug is solely due to the production
of this physiological state; for it is well known that during nausea an in-
creased secretion takes place from most of the surfaces of the body, includ-
ing the respiratory mucous tract. Others consider that it can affect this
mucous membrane irrespective of the production of any sensation of sick-
ness, and that this is the correct view is borne out by the powerful effect
of even a minute quantity of this medicine on the bronchial tract of some
persons, though the same dose may fail to produce sickness, or even nau-
sea.

Eossbach, in his experiments on animals with the trachea exposed,
finds that emetin, apomorphia, and pilocarpine administered through the
blood increase the tracheal secretion, whilst atropin and its allies act in
the reverse way.

Ipecacuanha in the form of wine is of almost constant use in bron-
chitis, when the expectoration is profuse, and diflficult to expel.

The successful use of a secret remedy by a well-known practitioner in-
duced me, in conjunction with Dr. William Murrell, to try the effect of
inhalations of ipecacuanha spray in those obstinate complaints, winter
cough and bronchial asthma. Our observations were made during Janu-
ary and February, and whilst undergoing this treatment the patients took
only colored water, and continued their usual mode of living in all re-
spects. First, regarding winter cough, we made observations on twenty-
five patients, whose ages varied between 45 and 72, with one exception,
that of a woman of 32 years, and we purposely selected severe cases. The
following general description of a typical case will serve in most points
to illustrate the condition of them all: — The patient had been troubled
with winter cough, perhaps for many years. During the summer he is
pretty well, but during the cold months, from October to May, he suffers
sometimes without any intermission, occasionally getting a little better,
and then catching cold; or perhaps he may lose his cough for a few weeks,
but again takes cold on the slightest exposure. So short is the breathing
that he can walk only a few yards, especially in the cold air, and finds it
very hard work to get upstairs, and is often quite unfitted for active life.
The breathing grows worse at night, so that he cannot sleep unless with
the head propped up with several pillows. He is troubled, too, with a
paroxysmal dyspnoea, usually at night, which may last several hours and
constrains him to sit up. Sometimes the breathing is difficult only on
exertion, and in most cases fogs, east winds, or damp, make it much worse.
The expectoration, generally difficult to expel, varies greatly. In a few
cases there is very little; usually, however, it is rather abundant, often
with little or no rhonchus. The cough is very violent, frequent, hacking,
and paroxysmal, and the fits may last ten to twenty minutes, and even ex-
cite vomiting. They are generally brought on by exertion; nay, in bad
cases, so easily are they provoked, that the patient is afraid to move, or
'21

322 IPECACUANHA.

even to speak. The con2;li and expectoration are much worse in the
morning on waking. Sometimes tlie cougli is slight, and the expectora-
tion is generally scanty, the distressed breathing l^eing the chief symptom.
The patient generally wheezes londly, especially at night. In a Ijad case
the legs swell, the patient is emphysematous; there is often no rhonchus,
or only sonorous and sibilant, or a little bubbling rhonchus at both bases.

In this common but obstinate complaint our results liave been very
striking, although so bad was the breathing in many of our patients that,
on being shown into the out-patients' room, they dro]>ped into a chair,
and for a minute or so were unable to speak, except in monosyllables,
having no breath for a sentence. We used the ordinary spray producer
with ipecacuanha wine, pure or variously diluted. At first it sometimes
excites a paroxysm of coughing, which generally soon subsides, but should
it continue a weaker solution should be used. The patient soon becomes
accustomed to it, and inhales the spray freely into the lungs. At first a
patient often inhales less adroitly than he learns to do afterwards, as he is
apt to arch his tongue so that it touches the soft palate, and consequently
less spray enters the chest than when the tongue is depressed. The spray
may produce dryness or roughness of the throat, with a raw, sore sensation
beneath the sternum; and sometimes it causes hoarseness, whilst, on the
contrary, some hoarse patients recover their voice witli the first inhalation.
As they go on with the inhalation they feel it getting lower and lower into
the chest, till many say they can feel it as low as the ensiform cartilage.

The dyspncea is the first symptom relieved. The first night after the
spraying the paroxysmal dyspncea often improved, and the patient had a
fair night's rest, although for months before shortness of breath and
coughing had much broken the sleep. The difficulty of T)reathing on ex-
ertion also quickly abates, for often after oven the first administration the
patient walked home from the hospital much easier than he came to it;
and this improvement is continuous, so that in one or two days, or a week,
the patient can walk with very little distress, a marked improvement
takes place immediately after each inhalation, and although after some
hours the breathing may again grow a little worse, some permanent im-
provement is gained, unless the patient catches a fresh cold. I have heard
patients say that in a week's time they could walk two miles with less
respiratory distress than they could walk a hundred yards before the use
of the spray. In some instances two or three days' daily spraying elapses
before any noticeable improvement takes ])lace, this comparatively slow
effect being sometimes due to awkward inhalation, so that buj^ little ipe-
cacuanha ])asses into their bronchial tubes. The effect on the cougli and
expectoration is also very marked, these both greatly decreasing in a few
days, though the im2')rovement in these respects is rather slower than in
the case of the breathing; sometimes for the first few days the expecto-
ration is even rather increased; it speedily alters in character, so that it
is expelled much more readily, and thus the cough becomes easier, even
before the expectoration diminishes. The patient is soon enabled to lie
down at night with his head lower, and in a week or ten days, and some-
times earlier, can do with only one pillow, an improvement which occurs
in spite of fogs, damp, or east winds, nay, even whilst the weather gets
daily worse, and when the patient is exposed to it the chief part of the
day. These patients all came daily to the hospital. Of course it would
be much better to keep a patient iu a warm room.

Of the twenty- five cases all were benefited except one. In one case

IPECACUANHA. 323

the improvement was very gradual, but each inhalation produced evident
temporary improvement. In twenty-one cases the average number of
inhalations required was 9.4, and the average number of days was twelve
before the patients were discharged cured. The greatest number of inhal-
ations in one case was eighteen and the smallest three. The case longest
under treatment required twenty-four days, the shortest four.

In order to ensure, as far as possible, only the topical effects of the
ipecacuanha spray, we were careful to direct the patient to spit out, and
even to rinse out the mouth at each pause in the administration, for far
more wine collects in the mouth than passes into the lungs. If this pre-
caution is not adopted, sometimes enough is swalloAved to excite nausea,
and even vomiting, by which means the bronchial mucus is mechanically
expelled, and of course in this way effects temporary improvement. Even
when this precaution is observed a protracted inhalation will excite nausea,
and sometimes vomiting, by the absorption of the wine by the bronchial
mucous membrane; though, strange to say, vomiting, when thus induced,
was long delayed, even for several hours, nay, sometimes till the evening,
though the inhalation was used in the morning. In our cases, however,
the improvement was not due to the nauseating effect of the spray, for we
took care to avoid this contingency by administering a quantity inadequate
to produce this result. The duration of each inhalation will depend on the
amount of spray produced by each compression of the elastic ball, or on
the susceptibility of the patient to the action of ipecacuanha. As a rule,
the patient at first will bear about twenty squeezes of the S'pray without
nausea, and will soon bear much more. After two or three squeezes,
especially on commencing the treatment, we must pause a^sdiile. It is
necessary to look at the patient's tongue, and tell him to learn to depress
it; for if the tongue is much arched it will hinder the passage of the spray
to the lungs. It is a good plan to tell the patient to close his nose with
his fingers, and to breathe deeply. The inhalation should be used at first
daily, and in bad cases twice or thrice in the day, afterwards every other
day suffices, and the interval may be gradually extended. If the ipecacu-
anha wine is diluted, then the spray must be used a longer time. In
cold weather the wine should be warmed.

We have tried the spray with very satisfactory results in a few cases of
more severe, though closely allied, disease, which may be thus summarized:
— A patient has suffered for several 3^ears from severe " winter cough,"
with much dyspnoea, cough, and expectoration, and on several occasions
lias spat up a considerable quantity of blood. The physical signs denote
slight fibroid consolidation, with excavation of both apices with much
emphysema, perhaps atrophous in kind. There is little or no rhonchus,
and no fever. The expectoration may be slight, or very abundant, muco-
purulent, or purulent. The dyspnoea is perhaps so very severe and is so
paroxysmal as to justify calling the case bronchial asthma' with emphysema
and fibroid phthisis.

In this class of cases the ipecacuanha spray is almost as beneficial as in
that just previously described. The spray soon controls the dyspnoea,
thus enabling the patient to sleep, greatly lessens expectoration and cough,
and by these means really improves the general health. As in the previous
cases, the first inhalation may considerably improve the breathing, though
the effects are not permanent, the dyspnoea returning in the evening, so
that spraying is needed night and morning, and may be required for Aveeks
or months, the ipecacuanha appearing rather to mitigate than to perma-
nently cure the dyspnea.

324 IPECACUANHA.

We have used this spray in cases of true and severe bronchial asthma,
with very opposite results. In one severe case, accompanied by a great
deal of bronchitis, it gave very great relief. The other patient, not so ill,
had been all his life asthmatic, and on catcliing even a slight cold his
breathing became greatly oppressed. In this instance each application
of the spray considerably aggravated the dyspnoea, even when the wine
was diluted with an equal quantity of water. Possibly a still weaker solu-
tion might have been borne, but we are inclined to think that in this case
any quantity of ipecacuanha would have disagreed, as the tightness of
breathing increased almost immediately on commencing the inhalation.
The successful case was a very severe one. For years this woman had
suffered from bronchitic asthma, and when she applied to the hospital
was unable to lie down, owing to violent paroxysmal dyspnoea. The
worst attack began about 3 a.m., compelling her to start out of bed and
struggle for breath. She was very emphysematous, the expiration enor-
mously prolonged. She was very hoarse. The first inhalation removed
the hoarseness in a few minutes, and much improved her breathing,
which continued freer until midnight, when the dyspnoea returned. The
cough became easier, and she expectorated more freely. Each inhalation
always gave her very great and marked relief. She walked to the hospital
with great difficulty, being constrained to stop frequently. On entering
the room she could not speak, but labored violently, and with loud
wheezing, to get her breath. A few inhalations would gradually set the
breathing free, so that air entered more and more freely, with gradual dimi-
nution of the wheezing, till, by the completion of the inhalation, she could
breathe without difficulty. As the breathing improved she could feel the
spray descending lower and lower in her chest. At first it would seem to
reach only the back of the tongue, then the top of the sternum, then
descend to mid-sternum, and at last she felt as if it reached as low as the
pit of the stomach. This improvement was maintained through the day,
but at evening, a relapse would occur; yet her nights, though at first bad,
were still decidedly better than before the treatment. Soon, however,
the effects became more lasting, and she slept well. On discontinuing
the spray, however, the breathing again grew worse, and she was obliged
to revert to the treatment; but unfortunately she so easily caught cold,
and so bad was the weather, that she was obliged to stay away for days
together. Whilst her breathing improved, the cough and expectoration
mended, but these two symptoms continued rather troublesome. So
marked was the benefit from the spray that the patient and her friends
expressed their astonishment, especially at the prompt relief it gave.

We have tried it in several additional cases of genuine asthma, but with
unsatisfactory results; for in most cases it has considerably tightened the
breathing to such an extent that patients have refused to give it a second
or third trial.

AVe have continued to carry on our observations with ipecacuanha
wine spray, and with results confirmatory of the statements made in the
Brit. Meil. Journal. We find, however, that some patients are very in-
tolerant of ipecacuanha spray; it causes a good deal of irritation, and even
tightness of breathing. It is advisable, therefore, at first to dilute the
wine with one or two parts of water, a precaution especially needful for
patients affected M'itli much dyspncea, with lividity; for the spray may for
some hours much intensify the difficulty of breathing and lividity, so as
to alarm the patient and. friends.

IPECACUANHA. 325

It ma}^ not be much out of place to mention here that, in several
instances, we have found the spray very serviceable in non-febrile inflam-
matory sore throats, the mucous membrane being swollen and very red.
We have found it useful, too, in hoarseness from congestion of the vocal
cords. Where the hoarseness has lasted a few days only, or one or two
weeks, the spray often speedily cures; but where the hoarseness has per-
sisted three montbs, or longer, the spray improves the voice considerably,
but leaves some hoarseness.

The late Dr. Hyde Salter strongly recommended ipecacuanha in hay-
asthma, and in other forms of asthma, employing it to cut short a parox-
ysm of dyspnoea. He thought that, in common Avith tobacco and anti-
mony, it contiwls by virtue of its action as a depressant. He preferred it
to the other two remedies just named, and gave it in doses large enough
to cause depression, but too small to excite vomiting. Like other de-
pressants, it must be given at the very beginning of the attack of dvspnoea,
for the influence of the remedy is considerably less over a fully-developed
attack. He preferred the powder to the wine, and seldom gave less
than twenty grains. This treatment, directed only against each attack of
dyspnani, leaves the complaint in other respects untouched, and more
permanent relief must be sought in an appropriate diet and a suitable
climate.

Dr. Hyde Salter enforced particular attention to the influence of diet on pure
asthma. As persons j^rone to asthma suffer from tightness of the breath for some
hours after a meal, and the smallest quantity of food greatly aggravates an attack of
asthma, therefore the meals must be small, and digestible. Asthmatic attacks occur
commonly at night, seeming to be favored by sleep: keeping awake often wards off
an attack. The attacks are especially liable "to occur after a late meal, therefore an
asthmatic should take a light tea, and go without supper; in fact, should take no full
meal after two o'clock. Breakfast should be the chief meal. Asthmatics must rise
early, to avoid a too prolonged fast. Their food must be plain, well-cooked, and nu-
tritious. Milk and eggs form a good diet. Cocoa is better than tea, but milk is better
than either. Mutton is preferable to beef or lamb, while pork and veal must be pro-
hibited; new boiled potatoes, or succulent vegetables may be permitted. Fish is suit-
able. Cheese, dessert, preserved meats or fruits, inust not be eaten, and stimulants
of any kind are generally bad. Heavy malt liquors, especially those containing much
carbonic acid, are the worst beverages. The quantity of food should not be large,
although food does not produce the paroxysm by its bulk, as the attack generally
occurs some hours after a meal, when tlie stomach is becoming empty. Most asthmat-
ics may eat what thej' like at breakfast. Dr. Pridham, who has had great success in
the treatment of asthma, and who long ago pointed out the impoi'tance of a regulated
diet, orders the following regimen: — Breakfast, at eight, half a pint of tea or coffee,
Avith a little cream, and two ounces of dry, stale bread. Dinner at one, two ounces of
fresh beef or mutton, without fat or .skin, two ounces of stale, dry bread, or well-boiled
rice. Three hours after dinner, half a pint of weak brandy-and-water, or toast-and-
Avater ad libiium. Supper, at seven, two ounces of meat, and two ounces of dry bread.
He prohibits drinking for an hour before dinner or supper, and till three hours after
meals. When digestion has improved, he allows three ounces of meat twice a day.
Dr. Salter gives the following excellent remarks on the climates suitable for asthmat-
ics: —

(«.) Kesidence in one locality will radically and permanently cure asthma resisting
all treatment in another locality.

{b.) The localities most beneficial to the largest number of cases are large, populous
and smoky cities.

(c.) That this effect of locality depends probably on the air.

(d.) That the air which would lie imagined to be the worst for the general health
is, as a rule, the best for asthma; thus the worst parts of cities are the best, and con-
versely.

(e.) This is not always the case, the very reverse being sometimes so.

(/".) That there is no end to tlie apparent caprice of asthma in this respect.

326 IPECACUANHA.

(l.) That possibly there is no case of asthma that might not be cured if the right «Ir
could be found.

(m.) That the disposition is not eradicated, l)ut merely suspended.

Bruntoii states that emetine hypodermically injected paralyzes the
vessels and greatly lowers arterial pressure even whilst the heart contracts
strongly, next it paralyzes the heart, arresting it in diastole. This state-
ment is in opposition to the result Dr. Duckworth obtained in his experi-
ments.

In many cases of whooping -cough ipecacuanha will often lessen the
severity and frequency of the paroxysms, and frecfuently arrest the at-
tendant vomiting. Dr. Philips, and some other observers, consider ipe-
cacuanha especially useful when the attacks of coughing are accompanied
by retching and vomiting. Like other whooping-cough remedies, ipe-
cacuanha often fails in cases apparently in all respects similar to those it
benefits, and in certain epidemics it appears to be all but useless.

It is also supposed to be a diaphoretic. Of course it excites sweating
when it excites nausea; but even irrespective of this condition it may
perhaps be a diaphoretic.

It has been highly praised for its efl&cacy in haemorrhages, as in epi-
staxis,' bleeding from the lungs or womb, and the flooding after delivery.
Some of its advocates give even drachm doses of the powder.

In flooding after delivery Higginbotham recommends ipecacuanha in
quantity sufficient to produce vomiting, and to this effect he ascribes its
great efficacy in arresting hemorrhage. In his hands this treatment suc-
ceeded in the most desperate flooding cases; but it may well be doubted
whether, beyond its emetic efl^cct, ipecacuanha exerts any influence over
uterine ha^moVrhage. Zinc would probably answer equally well. Dr.
George Bird tells me that he once Avitnessed, in the case of a Syrian
Jewess, the prompt suppression of flooding by the nurse, Avho crammed
down the patient's throat a handful of her hair. Probably the mechani-
cal excitation of vomiting would prove useful in flooding.

Ipecacuanha, acts more surely as an emetic when given in divided
doses, at short intervals; as five grains in a little warm water every five
or ten minutes.

^Dr. Martin, of Geneva, arrests epistaxis (the blood generally coming from one
nostril) by compressing the facial artery of tlie side upon the upper jaw, near the
nose, thus lessening the supply of blood to the nose.

VERATRUM VIRIDE. 327

APOMOEPHIA ,

was obtained by Matliieson and* Wright and first tested experimentally
by Dr. Gee, who discovered it to be a very prompt and certain emetic.

It first excites the cerebrum, producing delirum, and then paralyzes it.

Reichert finds that the sensory and motor nerves are first stimulated
and then paralyzed. According to Reichert and Harnsch apomorphia
is a muscle poison. It paralyzes the heart, and first stimulates and then
depresses the vaso-motor centre, and thus reduces arterial pressure
(Reichert). A large dose first accelerates and then slows the heart. It
increases the frequency of respiration, which afterwards grows very
shallow and unfrequent; this e:ffect is due to the action of the drug on
the respiratory centre.

It readily excites vomiting without nausea, a tenth of a grain given
hypodermically acting often in one or two minutes. It acts probably
on the centre for vomiting. It increases the bronchial secretion.

It is used hypodermically chiefly in cases of poisoning when it is
necessary to produce prompt and certain vomiting, as in cases of drunk-
enness, opium poisoning, etc. In such case one-fourth of a grain should
be employed. It sometimes dangerously depresses children.

It is useful in some hysterical affections.

It cured a case of persistent hiccup when hypodermic injection of
morphia and atropia had failed.

Weill confirms Gee that it is useful in chorea, Ludwig and Burg-
meister show that apomorphia is a topical anaesthetic, as far as the eye
is concerned, equal to cocaine, but it induces vomiting and salivation
by absorption. Six to twelve drops of two per cent, solution are need-
ful. The application is painful.

VERATRUM VIRIDE

contains several alkaloids, chiefly jervia and veratroidia (now shown
to be a mixture of alkaloids and resin), and these differ somewhat in
their physiological action. The action of these alkaloids has been elabo-
rately studied by Professor H. Wood.

In small dose the crude drug first reduces the force with much dim-
inution in the frequency of the pulse, which then grows unfrequent, and
may fall to half its natural number. At this time exertion induces very
great frequency, the pulse becoming feeble, thready, even imperceptible.
A poisonous dose induces a very rapid thready pulse, cold clammy skin,
nausea and vomiting, great muscular prostration and partial uncon-
sciousness.

Wood finds that jervia directly ^affects the heart, either through its
ganglia or by its action on the muscular substance. It powerfully de-
presses the vaso-motor centre, and the spinal cord. Veratroidia is more

328 VER ATRIA.

irritating than jcrvia, and induces vomiting and occasionally purging,
though the muscular twitchings and convulsions are less. It differs
from jervia in powerfully paralyzing the respiratory centre; hence after
poisoning, unless artificial respiration is maintained, arterial pressure
becomes greatly heightened ; but with artificial respiration, arterial press-
ure steadily falls as it does with Jervia. Wood, speaking of the crude
drug, says, " veratrum viride is a powerful spinal and arterial depressant,
exerting little or no influence upon the cerebral centre. In full thera-
peutic doses it lowers the pulse rate, both by a direct action on the
muscle (jervia), and by stimulating the inhibitory nerves (veratroidia);
it diminishes the force of the heart's beat by a direct influence on the
cardiac muscle (jervia), and produces a general vaso-motor paralysis
(jervia)."

\eratrum has been said to lower the temperature in health; but,
according to the late Dr. Squarey's observations, this is not the case.

Veratrum viride has been employed in the convulsions of children,
chorea, typhoid fever, scarlet fever, measles, pneumonia, and pleurisy.
In regard to pneumonia and pleurisy, some authorities consider that
veratrum is useful only in the asthenic forms, acting then like tartar-
emetic or aconite; others, however, as confidently recommend this
remedy in the asthenic forms. The tincture of veratrum viride should
be used, since veratria does not produce the same effects.

In the treatment of the foregoing diseases it is better to give small
doses, as one or two minims every hour, rather than larger ones at longer
intervals. It is requisite to augment the dose gradually in order to keep
the pulse down, otherwise it will sometimes suddenly rise to 1.20 or 140
beats, Avhich, liowever, may be reduced again in a few hours by a small
increase of the dose.

Veratrum is said to be efficacious in removing the pain of acute
rheumatism, and in controlling and shortening the fever. It is also said
to be of service in neuralgia, sciatica, and lumbago, and in the " con-
gestive headache " which occurs at the menstrual j)eriocl.

Veratrum album has been used with success in the vomiting and
purging of summer diarrhoea.

Veratrum viride is now very little used, hence it is probable that the
accounts of its usefulness were very much overdrawn.

VERATRIA.

This alkaloid is obtained from the seeds of veratrum sabadilla.

Veratria (from sabadilla seeds) is an irritant, and excites sneezing,
vomiting, purging, violent twitchings, and convulsions, and afterwards
great muscular Aveakness with loss of electric irritability. The pulse
at first is quickened and strengthened, then slowed, and afterwards be-
comes quick, weak, and irregular. The twitchings and convulsions are
probably in part due to the effect of the veratria on the muscles, and
partly on the cord.

The twitchings and convulsions are not jirodueed by the action of

VERATRIA. 329

veratria on the brain, as they occur after section of the spinal cord.
They are partly clue to the direct action on the muscles, for they take
place when the cord is destroyed, and in animals whose nerves are paral-
yzed by curare.

Veratria is a powerful muscle poison, and curiously affects the char-
acter of the contraction, acting in this respect much like calcium salts
and alkaline soda salts, as phosphate of soda and sodium bicarbonate; on
stimulation the muscle contracts anil relaxes, or partially relaxes, like a
normal muscle, but then rapidly contracts again and becomes very slowly
relaxed. On repeating the stimulation this effect of veratria speedily
ceases, and some time must be allowed before the muscle regains its
original condition. This affection of the muscle causes the movements
of the animal to be stiff and awkward. Sometimes the muscular con-
traction persists so long as to suggest tetanus of the cord, as after
strychnia, but that this effect of veratria on the muscle occurs when the
limb is separated from the trunk. In frogs under the influence of vera-
tria marked fibrillary contractions occur, looking much like the fibril-
lary contractions in progressive muscular atrojjhy. These fibrillary
contractions in the frog must be due to the action of the poison either
on the muscle or on the motor nerves, for they occur in an amputated
limb on stimulating the nerve. Since they almost disappear when
curare is administered, these twitchings are probably due to some altera-
tion in the motor nerves.

Veratria affects the cardiac muscle much as it does the skeletal
muscle, but is less poisonous to the heart than to voluntary muscle. In a
cardiac contraction it greatly delays diastolic dilatation, also resj^iration,
and induces irregular rhythm.

Veratria ointment excites a sensation of warmth and pricking, fol-
lowed by coldness. Unless applied for some time it does 2iot excite in-
flammation, but it then produces a red itching rash. It is a very
efficacious remedy in neuralgia, and, like aconite, has most influence
over neuralgia of the fifth nerve. An ointment of the Pharmacoijoeial
strength is generally strong enough when applied to the face, but in
other neuralgias a stronger ointment is required.

Dr. Turn bull, who largely employed veratria ointment, used a prep-
aration containing twenty and sometimes even forty grains to the ounce.
These strong ointments not uncommonly prove very useful in sciatica
when rubbed along the course of pain for twenty minutes to half an
hour, twice or three times a day. This strong ointment is sometimes
useful in the neuralgic pain consequent upon shingles. The suscejiti-
bility to its action varies; thus, in some persons, it readily produces
numbness and a sensation of coldness, which may last several days.

Like aconitia ointment, it is useful in sick headache, where the pain
is accompanied and followed by tenderness of the skin. It should be
well rubbed over the seat of pain on the very commencement of the
attack. It excites less irritation, and sometimes succeeds better than
the aconite, sometimes very quickly subduing the pain, preventing the
vomiting, and reducing the duration of an attack to one or two hours,
or even to a few minutes, wlyle previous to the veratria treatment it
used to last one, two, or three days.

Dr. Turnbull used a strong ointment to rheumatic joints, and no
doubt it relieves some cases, although, unfortunately, it more generally
fails.

330 coLCHicmr.

Turnbiill also applied the ointment to the chest of patients suffering
from heart disease, with ra})id, irregular pulse, hurried breathing, much
lividity and dropsy, palpitation and inability to lie down — to cases in-
deed usually benefited by digitalis. These symptoms the ointment not
uncommonly relieved, the patients passing a large quantity of urine,
even six pints a day. He likewise employed a strong ointment to the
j)ainful joints at the onset of an attack of gout. Care must be taken,
especially with the stronger ointments, not to apply them to the broken
skin, or they will excite much pain and inflammation.

When sniffed up the nose the smallest quantity excites violent sneez-
ing, sometimes lasting for hours.

The alkaloid passes readily into the blood, as is sufficiently proved by
the symptoms it occasions; dull, heavy, frontal headache, sometimes ac-
companied by shooting or stabbing pain over one or both brows, in the
pit of the stomach, and at the region of the heart. The heart is greatly
affected; for the pulse grows slow and weak, and may sink from 70 or 80
to 40 or 35 beats in the minute, becoming at the same so feeble as scarcely
to be felt at the wrist. Pushed to the full extent, this drug greatly
prostrates the muscular strength — to the extent, perhaps, of rendering
walking impossible, and the muscles may twitch and jerk spasmodically.
The surface is bedewed with a clammy sweat, the features are pinched,
and there may be complete blindness and deafness, but delirium is rare.
Dangerous as these symptoms appear, yet they speedily pass away if the
drug is discontinued. Some self-experimenters have experienced dull
aching pains, made worse by movements, and tonic and atonic contrac-
tions of the muscles, sometimes violent, especially of the face and ex-
tremities. This substance has the same prostrating effect on birds, and
in America is sometimes used to destroy these animals; it makes them
too weak to fly, and thus they are easily caught; but if left awhile, the
effects of the drug pass off, and they escape.

COLCHICUM.

"While the physiological effects of colchicum are very similar to those of
veratrum, yet one drug cannot be therapeutically substituted for the other.

Strong preparations of colehicuniy applied to the skin, irritate, excite
redness, prickhig and smarting, and the powder of colchicum sniffed up
the nose excites sneezing and watery discharge from the eyes and nose.

Colchicum is acrid to the taste, produces much irritation of the fauces,
with increase of saliva, sometimes in such quantity as might Avell be
termed salivation.

Colchicum is an irritant to the stomach and intestines, and produces
its effects, whether swallowed, or injected into the veins.

Small doses, continued for some time, produce a coated tongue and
disagreeable taste, impair the appetite, excite more or less thirst, with
pain at the epigastrium, rumblings of the stomach, and looseness of the
bowels.

Should vomiting occur, the ejected matters are bilious, or composed of
mucus, and after a large dose may contain blood. The stools are soft, or
even liquid, and of a high color; but after a large or poisonous quantity
they are at first of the character just mentioned, but afterwards become

coLciiicmr. 331

dysenteric, consisting of slime and blood, accompanied witli mucli strain-
ing and Cutting pains in the belly. Even when injected under the skin
colchicum alt'ects the intestinal canal in the same way.

Colchicum is rarely used in diseases of the alimentary canal. It has
been employed as a cholagogue. Rutherford, in his recent investigations,
finds that colchicum in large doses given to fasting dogs considerably
increases the biliary secretion, and at the same time purges powerfully.

Colchicum, it is supposed, is most serviceable in both gout and rheuma-
tism when it purges; but others hold purgation to be not only unneces-
sary but injurious; and there is no doubt that colchicum will as quickly
cure an attack of gout without purging.

Colchicum quickly enters the blood, and in full doses soon excites
warmth at the stomach, with a glow and outbreak of perspiration of the
whole surface of the body, throbbing of the vessels, and reduction of the
force and frequency of the pulse.

Poisoning by this plant, or its preparations, produces profound pros-
tration, sometimes pain in the head, pinched features, perspiration, clam-
my skin, small, weak, or intermittent quick pulse, and not unfrequently
strong muscular twitchings, accompanied by pain; indeed, pains have
been felt in all the extremities.

Colchicum is said to cause pain in the urinary tract, with smarting
on micturition.

A quantity sufficient to produce the symptoms just detailed congests
and inflames the stomach aud intestines.

It is reputed to be diuretic, and to stimulate, even in healthy persons,
the secretion of a large quantity of urinary water and uric acid; but
these statements have not been confirmed by the observations either of
Bocker or Garrod, which show that if it acts at all on the kidneys col-
chicum rather lessens the amount of excreted water, urea, and uric acid.

To Dr. Garrod the profession is indebted for much information on
the nature of gout. This philosophical observer has shown that in
gout there is retention, with possibly increased formation, of uric acid in
the system. From the urine of gouty patients very little, and, in some
cases, even no uric acid can be obtained, while plenty can be detected in
their blood. The urates, thus circulating through the tissues, are depos-
ited in various parts of the body, and excite active and painful inflam-
mation.

It is argued, liowever, that urates are not deposited in the cartilaginous and fibrous
tissues, for it is said if so they sliould be more abundant close to tlie vessels, whilst it
is well known that they are earliest seen, and exist most plentifully, in cartilages,
near their synovial surf ace, that is, at the greatest distance from the blood-vessels. Hence
it is maintained that the urates are not deposited, but are always associated in gout
with much mal-nutrition; thus an excess is formed of urates which remain unabsorbed.
in the slightly vascular and non-vascular tissues, and, of course, accumulate in those
structures at the greatest distance from the vessels. If tliis view is correct, the gouty
inflammation cannot be set up by the irritation excited during the deposition of the
urates, but is due to some hitherto undiscovered cause.

Colchicum, it is well known, gives prompt relief from the pain,
inflammation, and fever of gout. But how? Does colchicum cause the
elimination of uric acid from the system through the kidneys, and so re-
move the condition on which the gout immediately depends? Now Dr.
Garrod has experimentally shown that colchicum exerts no influence on
the elimination of uric acid in gouty people. Colchicum must, therefore,
control gouty inflammation without in any way affecting the condition on

332 COLCHICUM.

which the gouty inflammation in the first instance depends. Hence col-
chicum is merely palliative, removing for a time the patient's sufferings,
but, as experience abundantly proves, in no way protecting him from
their recurrence. For it is on all hands accejDted that colchicum is in-
operative to prevent a return of the attack; nay, many who suffer from
it are of opinion that, while the medicine removes altogether an existing
attack, it insures the speedy return of another. Hence gout-ridden
jDcople commonly advise their fellow-sufferers to abstain from colchicum.
But a gout sufferer is apt to continue gout-engendering habits, and to
forget that, as he grows older, his gouty tendency becomes stronger.

The effect of colchicum on the gouty inflammation is very rapid, for
a large dose of the medicine, say a drachm of the wine, often removes the
severest pain in the course of one or two hours, and soon afterwards the
swelling and heat subside. Some observations, conducted by Dr. Rick-
ards and myself, show that, while the pain is thus quickly subdued,
the temperature of the body falls very little during the day, but on the
following morning there is generally a considerable decline, and often a
return to the healthy temperature; but should the fall be postponed a
longer time, then on the second day after the use of the colchicum a
continuous decline of the temperature takes place, till all fever disap-
23ears.

There are two methods of employing colchicum. Some give small
doses, others give a drachm of the wine, others even two drachms at a
time. The larger dose sometimes produces sickness, diarrhoea, and great
temjiorary weakness, but it extinguishes the pain at once. Small doses
give like results only after some days.

Colchicum is sometimes of use in the treatment of various diseases
occurring in gouty joersons; for instance, bronchitis, asthma, chronic
urticaria and other eruptions, dyspepsia, etc. Colchicum is sometimes
used in chronic rheumatism and rheumatoid arthritis, but, I think, with-
out any very apparent benefit.

Some persons are very tolerant of colchicum. To a gouty patient I
gave at first two drachms and a half without any effect, and on a subse-
quent day four, and another day six drachms without any result. An
ounce slightly relaxed his bowels, and ten drachms relaxed his bowels
five times and caused a little sickness. IS'o symptoms set in till ten
hours after taking the medicine.

PODOPHYLLUM. 333

PODOPHYLLUM.

Podophyllum is a powerful purgative and cholagogue.

Dr. Anstie, wlio has studied the action of podophyllum on dogs and
cats, found that in from two to ten hours after the injection of an
alcoholic solution into the j^eritoneal cavity, and after the effects of the
alcohol had ceased, podophyllum excited vomiting, and almost incessant
diarrhoea. Dr. Anstie does not usually describe the character of the
stools, but in one experiment he states that they consisted of glairy
mucus, and in two other experiments the stools were highly colored
wath what looked like bile, Li many of the experiments the stools con-
tained blood. The animals suffered great pain, and soon became ex-
hausted. At the pos f -mortem examination the oesophagus was healthy,
but the stomach somewhat congested, induced. Dr. Anstie suggests, by
the violent efforts of vomiting. The small intestines, especially at the
lower part of the duodenum, were intensely congested, and in some in-
stances the lower ]3art of the duodenum was extensively ulcerated. The
large intestines were but slightly inflamed. Although the injections
were poured into the abdominal cavity, the peritoneum itself was not at
all inflamed, not even around some unabsorbed granules of podophyllin.
The contents of the intestines were liquid. In all the instances in which
the effect of the medicine on the heart and respiration is mentioned,
respiration ceased before the heart stopped.

From these experiments, it appears evident that podophyllin has an
especial affinity for the small intestines, and chiefly for the duodenum.

The Edinburgh Committee investigated the action of podOphyllin on
healthy non-fasting dogs, and their reporter, Dr, Hughes Bennett,
stated that doses of podophyllin varying from two to eight grains dimin-
ished the solid constituents of the bile, whether purgation took place or
not, and that doses which produced purgation lessened both the fluid
and solid constituents of the bile, (See Mercury.)

Lideed, these investigators found that in non-fasting animals all the
reputed cholagogues failed to increase the bile, and further, if they
purged they even diminished it. Some experiments by Rohrig on fast-
ing animals being opposed to these statements led Dr, Rutherford to
reinvestigate this question. He finds that podophyllin injected into the
duodenum of a fasting dog increases both the water and the solid con-
stituents of the bile ; and this increase is greater when the bile is allowed
to flow into the intestines than when it is drained off by a cannula.. The
augmentation of the secretion is greatest when the drug does not purge
severely; indeed, when it does purge violently it may lessen the biliary
secretion.

Drs, Rutherford and Vignal confirm Rohrig's statements concerning'
the influence of other drugs on the liver secretion in fasting animals.
They find that aloes, rhubarb, senna, colchicum, taraxacum and scam-
mony increase the biliary secretion ; that podophyllin, aloes, rhubarb, '
colchicum, and croton oil are the most powerful biliary excitants, senna
and scammony less so ; and that they all increase the water and the

334 PODOi'IIYLLUM.

solids of the bile. Taraxacum they find is only a feeble hepatic stimu-
lant. Eutherford thinks they act directly on the hepatic eells, and not
by increasing the blood supply Eohrig found that calomel given to
fasting dogs would not recall the secretion Avhen the flow had stopped,
though the drug would increase it when the bile had only diminished.
Drs. Ixutherford and Vignal find, however, that calomel generally lessens
both the water and the solids of the biliary secretion, thus affecting alike
fasting and non-fasting animals.

I)rs. liutherford and Vignal endeavor to reconcile the apparently
conflicting results of their experiments and those of the committee pre-
sided over by Dr. Bennett.

The absorption of food, they say, is undoubtedly followed by increased
biliary secretion. The purgative probably diminishes the amount of food
absorbed, seeing that it tarries a less time in the intestines, and this
Ijrobably overbalances in the course of the day the stimulation of the
liver. '' When such substances as podophyllin, rhubarb, aloes, and col-
chicum are administered (a) the liver is excited to excrete more bile.
{b) It purgation result, absorption of biliary matter and of food (if diges-
tion is taking place) from the intestines is probably diminished, and thus
by the twofold operation of increased hepatic action and diminished
absorption of biliary matter from the intestine the blood as it passes
through the portal system is probably rendered more pure."'

Podophvllin produces very marked effects on the motions of children,
with the following symjDtoms: — During the early months of life, esj^eci-
ally after a previous attack of diarrhoea, obstinate constipation may
occur, with very hard motions, crumbling when broken, and of a clay
color, often mottled with green. Sometimes, at each evacuation, the
passage of the hard stools through the sphincter of the rectum occasions
greatpain, causiijg the child to scream. At the same time there may
be much flatulent distension of the belly, which excites frequent colic,
this in its turn making the child cry, often without cessation. This
morbid condition of the motions is frequently observed in children one
or two months old, who are fed instead of suckled. I know nothing so
effectual in bringing back the projier consistence and yellow color to the
motions as podophjdlin. A grain of the resin should be dissolved in a
drachm of alcohol, and of this solution one or two drops given to the
child on a lump of sugar, tAvice or three times a day. The quantity
administered must be regulated by the obstinacy of the bowels, which
should be kept open once or twice a day. Under this treatment the
motions often immediately become natural, the flatulent distension of
the belly gives way, and the child quickly improves. The restoration of
the color of the motions is j^robably owing to the increased secretion of
bile induced by the podophyllin.

That disagreeable cankery taste, unconnected with excess in alcoholic
drinks, generally occurring only in the morning, but sometimes con-
tinuing in a less degree all day, gives Avay usually to podophyllin ; aiid,
if it fails, mercury generally answers. This symptom, it is true, wlien
due to constipation, is removable by many purgatives, but podophyllin
and mercury answer best.

In small doses, h or i of a grain, night and morning, podojdiylliu is
useful in cases like the following: — A busy, Avorried, over-worked man,
who takes perhaps too little exercise, feels all day, but especially in the

PODOPIIYLLU:\I. 660

morning, dull and depressed, his mind inactive and indolent, and he is
irritable. He has, perhaps, a stupid feeling. He is often bilious-look-
ing, and is dark around his eyes. JSTow these symptoms, no doubt, often
accompany sluggish bowels, and can be relieved by any purgative, but
they not uncommonly occur when the bowels are regular, and the
motions natural in color. In such a case, a small non-purgative dose of
podo2)h3dlin is most serviceable. The resin may be made into small
pills, or dissolved in rectified sjnrits in the proportion of one grain to
two drachms of spirits, and six minims of this mixture should be taken
night and morning in tea or coffee.

Small doses of podophyllin are highly useful in some forms of chronic
diarrhoea. Thus a diarrhoea with highly-colored motions with cutting
pains is generally relieved by small doses of podophyllin, the bowels be-
coming regular, and the pain speedily subsiding; and this medicine is
especially indicated if this form of diarrhoea occur in the early morning,
compelling the patient to leave his bed several times,, but improving
after breakfast, or by the middle of the day; or sometimes diarrhoea
does not occur after breakfast, but returns early next morning. Indeed,
jiodophyllin will generally cure this morniiig diarrhoea, even if the
motions are irale and watery. By means of podophyllin I have cured
chronic diarrhoea of watery, pale, frothy motions, with severe cutting
pain, even Avhen the diarrhoea has lasted for many years. Two or three
minims of the solution just mentioned should be given three or four
times a day.

Podophyllin is very useful in some forms of sick headache (migraine).
The nature and the order of the symptoms differ greatly in different cases
of sick headache. Some, for instance, are accompanied by constipation,
others by diarrhoea, and in each of these kinds the stools may be either
too light or too dark in color. But there are, besides, many other varie-
ties of sick headache. Where the headache is preceded, accompanied, or
followed by a dark-colored bilious diarrhoea, podophyllin generally does
good. Two or three minim doses of the foregoing solution, given three
times a day, will restrain the diarrhoea, lighten the color of the motions,
and if the medicine is persevered with, either prevent the attacks or
considerably prolong the intervals. When the diarrhoea is of a light
color, and the motions evidently contain too little bile, a hundredth part
of a grain of bichloride of mercury, given three times a day, is often very
useful. Again, when the headache is accompanied by constipation, and
the motions are of a dark, bilious character, a free podophyllin purge
every day, or every alternate day, is very beneficial. Even in those
nervous headaches occurring either Just before, at, or directly after the
menstrual period, if associated with constipation and dark-colored stools,
purgative doses of podophyllin often give relief.

It is now generally held that in sick headaches, or, as they are often
termed, nervous headaches, migraine, hemicrania, the origin of the mis-
chief is situated in some part of the central nervous system, and there-
fore it is asked — What is the use of giving medicine to act on the stomach,
liver, or intestines ?

Although the affection in migraine is situated in the central nervous
system, yet the affection appears to be dormant till roused into activity
by peripheral or other exciting causes — causes in many cases due to the
stomach, the liver, or the intestines. In such cases the sickness, the

336 GUAIACUM.

diarrhoea, or the constipation precedes the attack: Avhere these symptoms
accompany or follow the paroxysm, they may fairly be considered as part
of the attack, depending on changes occurring in the central nervous
system. The treatment of migraine, therefore, falls into three divisions :
1, removal of the exciting cause; 2, medicines directed to alter the con-
dition of the central nervous system producing the attack; 3, treatment
of the attack itself.

Where sickness, diarrhoea, or constipation precede the paroxysm they
act as exciting causes, and if we can remove these symj)toms by the aid
of mercury or podopbyllin, according to the foregoing directions, we
prevent the development of the attack, or at all events render it milder.
Even when these symptoms accompany the attack, and form, therefore,
very probably, an integral part of the paroxysms, these remedies, or
others like nux vomica, acting either on the stomach, or liver, may sup-
press the paroxysm.

The injection of podophyllin under the skin has been recommended.
It is readily soluble in equal parts of liquor potass^e and water; and, if
the drug is pure, the addition of water does not precipitate this solution.
The injection of this solution to the extent of one-third to one-tenth of
a grain quickly purges, sooner, it is said, than when given by the stomach,
and it causes no pain.

Podophyllin is a rather uncertain purgative; thus, a dose adequate
to purge one person violently will be inoperative on another. Indi-
viduardifferences occur, it is true, with other purgatives, but the action
of podophyllin appears more uncertain than other similarly acting drugs.
Again the"^time it takes to act varies, purging some in a few hours, whilst
with others it takes twenty-four hours. Sometimes instead of freely
relieving the bowels it frets them, by causing frequent attempts with
ineffectual results. The pure drug causes very little griping. In too
large doses it is very apt to produce slimy and bloody stools, particularly
in children.

GUAIACUM.

GuAiACUM has an acrid, pungent taste, and promotes salivary secre-
tion. It excites a sensation of warmth in the stomach, and increases the
gastro-intestinal secretions. Large doses excite vomiting and diarrhoea.
It is reputed to increase the secretion from the bronchial mucous mem-
brane and from the skin.

Its usefulness is most conspicuous in tonsillitis, and in this affection
it ranks with salicylate of soda and aconite; being, however, inferior to
salicylate of soda. " It is administered either in powder or as tincture, or
in lozenge form. Brunton prefers the guaiacum mixture to the am-
moniated tincture. The lozenges, taken several times a day for a long
period, appear to me to be useful in follicular pharyngitis.

It is recommended in rheumatic or neuralgic dysmenorrhoea. It is
employed, too, in chronic rheumatism, chronic gout, lumbago, sciatica,
and chronic bronchitis.

ACT^A (cimicifuga) racemosa. 337

ACT^A (CIMICIFUGA) RACEMOSA.

This medicine is used much more extensively in America than in
England. It has been emplo3'ed for centuries by the Indians and settlers
for chorea and many uterine diseases, and to assist the womb to expel
the child. Those with most experience of this drug sjieak loudly in its
praise.

It has been compared to aconite, by others to digitalis. It slows the
heart. Some observers maintaining that it weakens, others that it
strengthens each beat, and heightens arterial tension. In large doses it
causes giddiness, dilated pu2:>iis, sleepiness, and sometimes a good deal
of headache. It is recommended for the dyspepsia of drunkards, and
as an expectorant in bronchitis. It has been much commended in acute
and chronic rheumatism, lumbago, sciatica, and myalgia. In lumbago
and sciatica I have often tried it, but without success, though, from the
strong recommendations of others, it must be useful in some cases. I
have seen it very effective in some cases of rheumatoid arthritis.

According to American therapeutists, this plant operates powerfully
on the uterus; its action on this organ is stated to be very similar to
that of ergot, stimulating the contractions of the parturient uterus, and
hastening the expulsion of the child. Ergot produces a continuous con-
traction of the uterus, while actfea, it is said, merely strengthens, but
does not prolong the contractile movements, and therefore endangers
less the child's life and the soft structures of the mother.

Actrea is said to be useful in expelling the placenta and in prevent-
ing after-pains, but ergot is preferable, as it produces more persistent
contractions. Actfea has been recommended in amenorrhoea, dysmenor-
rhcea, and in menorrhagia. Though inferior to other remedies, it cer-
tainly controls menorrhagia.

Again, actsea racemosa, it is said, will restore the secretions, and re-
move the accompanying symptoms, when the menses are suddenly
checked from cold, shock, or mental emotion, or when, from similar
circumstances, the lochia are suppressed, distressing symptoms are apt
to occur, as more or less severe pain in the head, in the back, and down
the legs, stiff sore muscles, and bearing-down pains.

It has been given, too, to prevent miscarriages in irritable uterus and
prolapsus uteri.

Actgea is said to be serviceable in that common and distressing head-
ache occurring in nervous hysterical women, especially at the menstrual
period, or Avhen the flow is too frequent and too profuse, or at the
change of life. It is one of the most useful remedies for many of the
distressing symptoms occurring at the change of life. It is well to
combine it with small doses of tincture of gelsemium.
22

338 ACONITE.

Actaea is said to be effective in the pleurodynia dependent on uterine
derangements, one among the many troublesome complaints due to this
condition.

Sir J. Simpson stated that acttea is highly beneficial in the cages of
women who, during pregnancy and after confinement, occasionally suffer
from great mental disturbance, sometimes amounting to madness.

Aetata has been recommended in the headache arising from over-
study or excessive fatigue.

Some extol it as an expectorant, and it is also said to be useful in
phthisis.

ACONITE.

AcON"iTE is used externally in the form of liniment or ointment, to
relieve pain. In the neuralgias, especially of the brow or face, these
applications are often of the greatest use in relieving the distressing
pain, either permanently, or at all events temporarily. It is decidedly
more useful in facial than other forms of neuralgia, though in facial
neuralgia it not seldom fails, notably in those severe forms termed epi-
leptiform neuralgia.

We are unable as yet to predict, with any certainty, the cases wherein
aconite will succeed or fail ; this much, however, is clear, that neuralgias
depending on diseased bone, or on tumors pressing on nerves, are be-
yond the control of aconite ; but these are not the only forms of neuralgia
which will not yield to aconite. Facial neuralgia due to decayed teeth
is often obstinate, yet even these cases frequently yield to the external
application of strong aconite prejjarations. Sometimes a case Avill re-
quire the assidifous application of the aconite prej^taration during three
or four days. In neuralgia, however, due to this cause, aconite some-
times quickly loses its effect, and the pain returns with its former fre-
quency and severity.

As no harm can follow the employment of aconite externally, it should
always be tried; and if unsuccessful, then recourse can be had to other
modes of treatment. If aconite will succeed at all, it will generally suc-
ceed at once; hence, if relief does not come speedily it is useless to con-
tinue it. The preparation should be sufficiently strong to jDroduce
decided numbness and tingling in the skin.

A piece of the ointment, the size of a bean or nut, should be applied
with friction, which enhances its efficacy. This quantity should be
repeated until it induces a sensation of tingling. The liniment, applied
with a brush, may be mixed with one-half the quantity of chloroform
liniment to assist absorption.

In cases where many branches of the fifth are affected it is often
sufficient to apply the aconite over the seat of the most intense pain ;
and again, in cases where other nerves, like the great occipital and

ACONITE. 889

auriculur nerve, are likewise involved, the applicution of the aconite
over tlie branches only of the fifth most severely affected, will often give
complete relief.

Then we meet with cases of which the following may be taken as
a type : — A woman suffers from severe migraine, preceded by general
malaise, and a dark discoloration round the eyes; the pain affects, per-
\i\x])s,, only a small branch of the fifth, not uncommonly that twig situated
near the outer canthus of the eye, and when this happens, a neighboring
vein often becomes greatly swollen. The pain lasts with great severity a
variable time, extending even to one, two, or three days, accomj^anied with
more or less severe vomiting, the rejected matter being, perhaps, intensely
acid. As this pain declines, the patient feels severe shooting pains
passing up the back of the neck and head behind the ear, affording a
sure indication of the approaching decline of the attack; the secondary
pain lasts three or four hours, then ceases, leaving the patient limp and
weak.

The application of aconite ointment, or aconite liniment, at the very
beginning of the attack, over the affected branch of the fifth nerve, will
cut short the pain, prevent sickness, and the occurreuce of the secondary
pain in the back of the neck and head. In some cases veratria succeeds
better than aconitia ointment.

When the auriculo-temporal nerve is affected the salivary secretion
may be increased, diminished, or altered in character; and the secretion
of tears may be modified in the same manner when certain branches of
the supra-orbital nerve are affected. The aconite application, by remov-
ing pain, will restore these secretions to their natural state.

While using these powerful poisonous applications care should be
taken not to rl^b them in wounds or cracks of the skin, and to avoid
contact with absorbent tissues, as mucous membranes and the conjunc-
tiva. Spinal irritation, and intercostal neuralgia, and sciatica yield, in
some instances, to aconite ointment; but spinal irritation and intercos-
tal neuralgia give way more readily to belladonna ji reparations.

Given internally, aconite at first induces a sensation of warmth at the
pit of the stomach, and sometimes nausea and vomiting. The sensation
of warmth spreads over the body, and tingling of the lips, tongue, and
adjoining parts is soon perceived; the uvula and the tongue feel as if
swollen and too large, and deglutition is frequent. A large dose induces
tingling and numbness at the tips of the fingers, thence spreading over
the whole body, accompanied by diminished sensibility, and some mus-
cular weakness, which, with a very large dose, becomes extreme, and is
one of the most prominent and important symptoms of the drug.

The action of aconite on the circulation and respiration is most
noteworthy. Moderate doses greatly reduce the number of the heart's,
beats, even to 40 or 36 in the minute; but after a larger and dangerous
dose, the pulse beats faster, and may become irregular; sometimes even
a small quantity excites irregular heart action. Whether increased or
lessened in frequency, the pulse always loses strength, showing retarda-
tion of the circulation. Dr. Achscharumow has shown that aconite
paralyzes the heart of frogs, arresting the contraction in the diastole.
The effects on respiration are very similar; moderate doses render the
breathing slower, but a large and poisonous quantity often makes it short
and hurried.

340 ACONITE.

How does aconite affect the heart ? It certainly affects either the
muscular substance, or the contained ganglia of the heart. On this
point all observers are agreed, for aconitia affects the heart after section
of the pneumogastric, or the administration of atropia which paralyzes
this nerve; and it affects the extirpated heart in the same way as it
affects this organ in situ.

It is maintained, however, that it acts also through the pneumogas-
tric, Boehm and Wartmann believing that it paralyzes the terminations
of this nerve ; Achscharumow that it first stimulates the inhibitory centre
of the pneumogastric, and so slows the heart, and then the pneumogas-
tric becomes exhausted, and at last paralyzed, and then the heart beats
quickly and irregularly.

The heart muscle appears also to be affected, for after death it fails
to respond to galvanic stimulation.

From our experiments, Dr. Murrell and I are led to conclude that
aconitia paralyzes all tissues, and we suggest, therefore, that aconite
affects all the structures of the heart, first its ganglia, next its nerves,
and last its muscular substance.

So far as we may draw a conclusion from the scanty experimental evi-
dence on the subject, it appears that aconite does not affect the vaso-motor
centre or nerves, and therefore the lessened arterial pressure it induces is
due to its action on the heart.

It is generally held that aconite affects respiration by its influence on
the respiratory centres.

The views concerning its action on the nervous system are very diverse.
Achscharumow concludes that it paralyzes both the trunk and termina-
tions of the cerebro-spinal motor nerves, but leaves the muscles unaffected.

Boehm and Wartmann conclude, from their experiments, that aconi-
tia first paralyzes the sensory, and then the motor part of the cord.

Liegeois and Hottot believe that it first paralyzes the "perceptive
centres," above the spinal cord, and afterwards the terminations, and
lastly, the trunks of the sensory nerves.

From experiments detailed in the Journal of Plu/siology, 1878, I con-
clude that aconitia is a protoplasmic poison, and destroys the functions of
all nitrogenous tissues, first, of the central nervous system, next, of the
nerves, and last, of the muscles; but it has an especial affinity for the sen-
sory apparatus, paralyzing first the sensor-perceptive centre. Aconite,
like tartar-emetic and potash salts, is a powerful depressant, and we sug-
gest that these drugs do not merely depress through their paralyzing effect
on the heart, but that they depress also by their poisonous action on the
central nervous system, and on the motor nerves and muscles.

During the administration of aconite, cutting pains in the joints and
other parts of the body are often complained of, and sometimes an erup-
tion of itching vesicles breaks out on the skin. Delirium occurs in some
cases, but after fatal doses the mind often remains clear to the last. The
muscular weakness is extreme, and frequent faintings occur. Blindness,
deafness, and loss of speech occurred in some fatal cases.

As aconite diminishes sensibility, it has been used internally, in vari-
ous painful diseases; but for the relief of pain, other internal remedies
have for the most part superseded it.

The power of aconite to control inflammation and subdue the accom-
panying fever is remarkable. It will sometimes cut short an inflamma-
tion. Though it Avill not remove the products of inflammation, yet, by

ACONITE. 341

controlling inflammation, aconite will jDreveut their formation, so saving
the tissues from further injury.

It is therefore in the early stage of inflammation more conspic-
iiously serviceable: still, although the disease may have advanced to
some extent, and injured the implicated organs by the formation of new
and diseased products, yet while the inflammation is still going on,
aconite does good ; indeed, its beneficial effects are often visibly apjDarent
in pharyngitis, tonsillitis, etc.

The results of aconite are most apparent when the inflammation is not
extensive, or not very severe, as in the catarrh of children, in tonsillitis,
or in acute sore-throat. In these comparatively mild diseases, especially
if the aconite is given at the earliest stage, when the chill is still on the
patient, the dry, hot, and burning skin becomes in a few hours comforta-
bly moist, and then, in a little while, is bathed in profuse perspiration,
often to such an extent that drops of sweat run down the face and chest.
"With the sweating comes speedy relief from many of the distressing sensa-
tions, as restlessness, chilliness, heat, and dryness of the skin, aching
pains and stiffness; the quickened pulse simultaneously becomes far less
frequent, and in a period varying from twenty-four to forty-eight hours
both pulse and temperature reach their natural state. If caught at the
commencement, a quinzy or sore throat rarely fails to succumb in twenty-
four to forty-eight hours. After the decline of the fever, the sweating,
to the annoyance of the patient, may, on slight provocation, continue
for a few days. If administered early enough, the beneficial effects of the
drug soon become strikingly apparent. Thus, large, livid, red, glazed,
and dry tonsils will in twenty-four hours present the aspect indicative of
the subsidence of the acute stage of inflammation, the disappearance of
the swelling, with much redness, whilst the membrane becomes moist,
and bathed with mucus or pus. Just at this stage some strong astringent,
as glycerine of tannin, or nitrate of silver, will remove most of the remain-
ing diseased appearance, and the pain, if any should remain. To those
who may not have tried it, these visible effects of aconite on inflamed
tonsils, etc., may seem exaggerations, but any one who will employ the
aconite in the way we are about to jjoint out can verify my statement.

Its effects on catarrhal croup, or, as it is sometimes termed, spasmodic
laryngitis, an hereditary disease often traceable through several genera-
tions, and leaving the child when about eight years old, are just as con-
spicuous. It removes the urgent dyspnoea in a few hours, and shortly
afterwards subdues the fever, and almost extinguishes, in a few hours, an
attack lasting usually three or four days. When there is little or no
fever, it apparently checks spasms and croupous breathing, and in those
rarer cases where these symptoms continue after the subsidence of the
fever. Aconite is equally serviceable in severe colds, with much chilliness,
great aching of the limbs, a hot, dry skin, and quick pulse.

Aconite is often of great service in an attack of asthma, with the fol-
loAving symptoms: — The patient, generally a child, is first seized with
coryza, accompanied, perhaps, with repeated and severe sneezing, then
the inflammation passes down to the lungs, causing, perhaps, sore throat
before the broncliial tubes are reached. The coryza may precede the
bronchial symptoms by three or four days, ceasing wlien the chest symp-
toms begin, which, in the early attacks, may consist only of cough with
wheezing, and but little shortness of breath, with inability sometimes to

342 ACONITE.

lie low at night. As the disease advances the asthmatic cliaracter bn-
comes more developed, and tlie coryzul symptoms often simultaneously
decline, till at last well-marked bronchial asthma becomes established,
without any preliminary coryza, or the coryzal and asthmatic symptoms
begin simultaneously. 1 believe that with children asthma often begins
in this way, and throughout life it may retain more or less of its coryzal
character. Daring the coryzal stage there is decided fever, and then is
the time when aconite proves so serviceable, for given at the onset of the
fever aconite cuts it short, and arrests the inflammation before it reaches
the chest, and in this way averts the asthma.

In other cases of asthma, though there is no coryza, the attack is
ushered in by chilliness and fever, which for some days precedes the
tightness of breathing, and here aconite, given at the very commence-
ment of the fever, may avert the attack of asthma.

In a variety of the above-described diseases, of which the following
account may be taken as a type, aconite is likewise beneficial. A patient
is very prone to catch cold from the slightest exposure to a draft or to
damp cold. The symptoms always follow a definite order; the throat,
first attacked, becomes sore, swollen, red, and beefy-looking; the soft pal-
ate, its arches, and the uvula may be implicated. The inflammation in
a very variable time, sometimes almost at once, oftener after three, four,
or five days, spreads upwards to the nose, causing coryza, and downwards
to the chest, producing catarrh and cough. Sometimes the disease tends
to pass upwards, sometimes downwards to the chest. In bad cases, or cases
that have lasted some time — and the affection may harass a patient for years
— the aspect of the throat never becomes natural, the mucous membrane
always remaining swollen, red, and beefy-looking. Exposure to cold or
damp intensifies this condition, which then invades the nose and chest.
This condition, if left unchecked, will induce emphysema towards middle
age, through the repeated attacks of pulmonary catarrh. In the throat
stage there is often fever, and aconite with belladonna, given at the very
outset of the attack', will often summarily cut it short and prevent the
coryzal and lung symptoms. Applications to the throat are very useful
in this troublesome and pertinacious affection. It is a good plan to " hard-
en" the throat to diminish its tendency to catarrh, by the nightly use of
the cold wet compress, and daily swabbing with an astringent like glycer-
ine of tannin. 1 have found the Turkish bath and the inhalation of sul-
phurous acid and of carbolic acid useful in these cases.

In pneumonia, pleurisy, and the graver inflammations, the effects of
this valuable drug, though not so rapidly, are often manifest.

In pericarditis, accompanied with violent throbbing and extreme pain,
aconite will speedily quiet the undue action, and so relieve the pain.

Most observers ascribe its influence on inflammation to its action on
the heart, and point out, truly enough, that it is most useful in the sthenic
forms of disease; and, indeed, it may do harm unless care is taken where
there is great weakness, with feebly-beating heart.

It appears to me that in fevers we can considerably reduce the frequency of the
pulse without lessening tlie rapidity of the circulation. A moderate dose of aconite,
while it makes the pidse less freqiient, renders it fuller, stronger, and less compressi-
ble. This indeed, we should expect, for if the heart does the same amount of work,
after it beats slower, each individual beat nuisl do much more work, so that if we
reduce the pulse from 120 to CO the heart must do twice as much work afler it has been
slowed by aconite. It may be said that though each beat is stronger, yet the heart is
doing less work than when it was beating quicker. As tending to su'pport the view

ACONITE. 343

tliat aconite weakens the heart's contractions, it must be admitted that even
small doses, after a time, sometimes make tlie pulse unsteady and even irregular.
I would suggest whetlier the slowmg- efl'ect of aconite may be useful by in-
creasing- the heart's period of rest and nutrition. The diastole of the heart occu-
pies nineteen out of twenty-four hours, and is the period for rest and nutrition.
Thus when tiie heart is made to beat quicker the acceleration takes place at the
expense of the diastole, thus shortening the recuperative period. By slowing the
heart, aconite prolongs the diastole, and thus increases the time of the heart's
rest and nutrition.

The method of employing the drug has much to do with its efficacy.
It should be given, as already stated, without delay, at the very onset of
the disease, every hour being important. Half a drop or a drop of the
tincture in a teaspoonful of water should be given every ten minutes or
quarter of an hour for two hours and afterwards hourly; but if there is
much prostration, with feeble and weak piQse, a still smaller dose. Now
and then a patient experiences nausea and even sickness after each dose.

We feel constrained to point out here the signal service rendered by the
thermometer in enabling us to decide whether or not to give aconite. In-
deed, in the treatment of inflammations, the thermometer and aconite
should go hand-in-hand. If the symptoms and physical signs are not suffi-
ciently developed to enable us to decide whether or not an acute inflam-
mation of some deep-seated part has set in, the thermometer will often
clear up the doubt. No acute inflammation can exist without preternatu-
ral heat. Hence, in a doubtful case, if the temperature after careful in-
vestigation, is found natural, the case is not one for aconite; while, on
the other hand, if the other symptoms doubtfully indicate an inflamma-
tion, a rise in the thermometer will add considerably to the probability
that we have to deal with an inflammation, and will indicate the advisa-
bility of employing aconite. Sometimes the throat is swollen, very red,
and presents the appearance of an ordinary sore throat accompanied by
fever, but fever is absent. Without the thermometer, we are unable to
discriminate Avitli certainty these two kinds of inflamed throat, and the
inability to distinguish the one from the other has often led, no doubt,
to the mistaken use of aconite, so bringing discredit on this valuable drug.
The non-febrile form is affected very little, if at all, by aconite.

Again, the use of the thermometer after scarlet fever is very impor-
tant: for, as is well known, a patient is then liable to acute inflammation
of the kidneys, the flrst onset of which is at once indicated by a rise in
the body temperature. It is well, therefore, during the convalescent stage,
to direct the nurse to take the temperature night and morning; and if tliis
should rise beyond the healthy standard, she should at once give aconite,
so as not to allow some hours to elapse l3efore the patient can be visited
by the medical attendant. The fever, it is true, may depend on some
other cause than inflammation of the kidneys; but even then it will prob-
ably be inflammatory in character, arising from gastric catarrh, over-feed-
ing, and the like, and in any case aconite is indicated.

Aconite does not shorten the fever of acute specific diseases, as scarlet
fever, measles, etc. , but it has a beneficial influence in these diseases, sooth-
ing the nervous system and favoring sleep by inducing free perspiration.
Whether it can lessen the severity of the fever, or diminish the duration
of the acute specific diseases, is doubtful; but there is no doubt that it
can control the inflammatory affections which often accompany them, and
which by their severity may endanger life. Thus aconite will moderate,
but neither prevent nor shorten the course of the throat inflammation in

344 ACONITE.

scarlet fever and the catarrh and bronchitis in measles, and in this indi-
rect manner it may lessen the height of the fever.

Aconite proves useless in certain epidemics of febrile inflammatory
sore throat. These cases are met with chiefly during the prevalence of
scarlet fever. The throat is much swollen, of a very dusky red color, and
the pulse is very frequent and very weak. There is great jDrostration, and
the symptoms are of a marked typhoid character. Here stimulants, with
the application of a strong solution of nitrate of silver, do most good.

The thermometer, again, renders notable service whilst giving aconite
in the acute specific fevers and the sore throat Just described. Under the
influence of this drug, the skin becomes moist and the pulse falls perhaps
to its normal state, and we might conclude that the temperature likewise
had become natural, only the thermometer shows that it remains unaltered.

Aconite is sometimes of service in erysipelas. Administered at the
commencement, it often at once cuts short the attack ; and even when in
spite of it the disease continues, aconite will reduce the swelling and
hardnesSjlessen the redness,and prevent the inflammation from spreading.

In children after vaccination, perhaps when the spots have nearly
healed, an erysipelatous redness occasionally appears, spreading over the
arm and a great part of the trunk, usually ceasing in one part, then suc-
cessfully attacking contiguous parts, and leaving a yellow discoloration and
desquamation. The redness is often intense, the tissues being very hard,
painful, and shiny, and this inflammation may continue for weeks. It
may run down the arm, involve the hand, and implicate the greater part
of the chest; or it may appear in the leg and gradually spread to the foot;
or, again, it m.ay spread from the hand up the arm, and once more down
to the hand, and this may be repeated many times. Sometimes the in-
flammation terminates in small abscesses. In cases like these, aconite
generally at once arrests the inflammation; and even when it persists aco-
nite renders the redness less intense, and the swelling less hard and pain-
ful. The troublesome inflammation often arising after the vaccination of
adults ordinarily yields to aconite, especially if supplemented by the local
application of belladonna ointment twice daily.

In the treatment both of simple inflammations and acute specific
diseases aconite may be appropriately administered in conjunction with
any other remedy which may he indicated.

Aconite has been much praised by eminent authorities in the treat-
ment of acute rheumatism, but its good effects are not so apparent as in
acute inflammation. Acute rheumatism, having no regular course or
duration, may last untreated only a few days, or may endure for many
months. It is difficult, therefore, to decide Avhether, in certain cases,
the speedy decline of the fever is a natural decline, or due to the aconite.
It is certainly ineffectual in many cases, which appear to run their course
uninfluenced by this drug; so that it is still required to determine in what
class of cases it is useful, and in what class of cases it is useless. It often
appears to be of service, however, in subduing the pain from inflamed and
swollen Joints.

Gouty pains are said to yield to this remedy. It has been given in
neuralgia, apparently with good results. Gubler, indeed, maintains that
aconitia is highly useful in trifacial neuralgia, and that it cures the most
unpromising cases. He insists on its l)eing given in solution, and begins
with Y^ij-th grain of the nitrite, increasing the dose till yVth grain is
reached. This treatment must be avoided if the i>atient suffers from heart

DIGITALIS. 54 O

disease. Seguin confirms this statement, but points out that suscepti-
bility to the drug is greater in some persons than in others. He finds
tliat as a rule distinct physiological effects follow -i^yth grain thrice daily.

It has been elsewhere shown that aconite lessens the rapidity of the
circulation. It may, therefore, be used in all cases where it is needful
to subdue vascular excitement; in fact, it may be given in precisely
those cases which were formerly treated by bleeding.

In sudden check of the menses, as from cold, aconite will often restore
the flux, and thus obviate the distressing and peculiar train of symptoms
jiroduced by arrested menstruation.

It is recommended in otitis, and quickly relieves the pain.

Small doses of aconite, administered frequently, will often quickly
check the nose-bleeding of children and of plethoric people.

Aconite will usually subdue the " fluttering of the heart " of nervous
persons, and also nervous palpitations. More general treatment is often
required; but when the conditions causing the disturbance are unde-
tectable or irremovable, then aconite may be usefully employed.

In several cases I have seen aconite quiet the distressing restlessness
of " fidgets," which affects men as well as women, and have known a few
drops at bedtime calm the patient and give sound, refreshing sleep; if
one drop is insufficient, it may be repeated hourly for three or four
hours.

A drop of tincture of aconite each hour yields satisfactory results in
the acute stage of gonorrhoea; and it is even said to remove chordee.

DIGITALIS AND ITS PEEPARATIONS.

Large doses of digitalis excite nausea, vomiting, and diarrhoea; the
matters voided, either from the stomach or bowels, being of a grass-green
color, due to the action of the gastric juice on some constituent of the
digitalis. These results may follow even a medicinal dose.

The digitaline readily passes unchanged from the intestines into the
blood; for the same symptoms ensue whether the alkaloid is swallowed or
injected into the veins.

The action of digitalis on the heart is very noteworthy, and our knowl-
edge of its influence on this organ, whether healthy or diseased, is becom-
ing daily more exact.

A large class of poisons, namely, sodium hydrate, potassium hydrate,
ammonium hydrate, the carbonates and bicarbonates of these elements,
barium salts, strontium salts, digitalin, antiarin, helleborein, digitoxin,
strophanthin, apocyniin, scillain, adonidin, oleandrin, digitalein, apocy-
pein, convallamarin, tanghinia, upas, erythrophlein, phrynin, affect the
frog's heart much in the same way, and perhaps it is fair to conclude
that they act similarly on the mammalian heart.

When administered through the circulation, or especially applied to
the exposed heart, they all induce persistent contraction in the ventricle.
In consequence of this so-called persistent spasm, contracture or tonicity,
the ventricle expands less during dilatation and its capacity is reduced;
while the systole becomes more powerful and com])lcte. With this per-
sistent contraction the rhythmic contractions continue, but as owing to

346 DIGITALIS.

lessening of diastolic dilatation the capacity of the ventricle is dimin-
ished, less blood is propelled with each systole.

The amount of persistent contraction is in proportion to the dose of
the drug, and Avith large quantities the j)ersistent contraction is sufficient
to contract the ventricle completely ; and then in default of dilatation
of course rhythmic action ceases. But rhythmic action is not destroyed,
for if the ventricle is dilated by increasing the internal pressure rhyth-
mic action is restored.

All the substances enumerated affect the muscular substances of the
ventricle directly, for if topically applied to a portion only of the ven-
tricle they induce persistent contraction in that part, so that it dilates
in a less degree than the rest of the ventricle; and if the application is
strong enough, the part experimented on may remain persistently and
fully contracted, whilst the rest of the ventricle fully dilates.

Digitalis with several other, and perhaps all the other substances
named in the foregoing paragraph, sometimes induces irregular action
in the ventricle.

The irregularity of the frog's ventricle consists in one or more por-
tions of the ventricle becoming rigid, white, and contracted, while the
remainder of the organ continues to dilate regularly. When the yielding
portions are small, a peculiar appearance, as if the wall of the ventricle
formed crimson pouches or protrusions, is produced.

This irregular action is due to some parts of the ventricle being more
influenced by the digitalis than the rest, and these affected parts becom-
ing persistently contracted, consequently dilate in diastole less than the
neighboring portions affected in a lesser degree by the digitalis.

Digitalis increases the force of the heart's contraction, and at first
reduces the number of its beats; but later, after large doses, the beats
become frequent, feeble, and irregular.

The isolated heart of a frog was made to pump serum through a
glass tube; on applying digitalis the heart acted with greater force, but
larger doses diminished its power. Finally the heart stopped, with
every drop of serum squeezed out of the ventricles. Each individual
beat of the heart was greatly increased in strength, in some instances
nearly doubled. The loss of power after large doses appeared to be due
partly to the great slowing of the heart, partly to the incompleteness of
the diastole, and the consequent imperfect filling of the ventricles.
(Boehm.)

Messrs. Bouley and Reynal, in giving large doses of digitalis to horses,
found the circulation became more rapid, the heart beats more abrupt,
their energy much increased, and accompanied, after a certain time, with
vibratory thrill, with a decided metallic tinkling, and, as poisoning went
on, a distinct bellows murmur was heard, becoming more audible on
exertion; the heart beats then showed a decided intermittence, and the
pulse was small, thready, and intermittent.

In doses less rapidly fatal, there is, at first sight, excitement of the
heart, with a little quickening of its beats, then they soon grow less fre-
quent, and fall to 25 to 20 a minute. The cardiac sounds are more
clearly heard, more distinct from each other normally, and with a differ-
ent rhythm, there being occasionally intermissions occurring regularly
or irregularly, and after a time a vibratory thrill is detected, followed
by a bellows murmur. As death approaches, the beats become rapid,
90, 100, or 140. Dr. Brunton, who has heard the blowing murmur

DIGITALIS. mj

several times, says it occurs in horses, dogs, and in the human subject,
and that it is probably due to mitral or tricuspid regurgitation, from
irregular contraction of the columnar earner.

Digitalis also greatly heightens arterial tension. Digitalis slows the
jDulse by stimulating the vagus nucleus, and the ends of the nerve in
the heart, for Boehm finds that after giving digitalis a farad ic current
applied to the vagus induces greater effect than before the administra-
tion of it.

The rapid action of the heart after large doses of digitalis is due to
the drug paralyzing the ends of the vagus.

The greatly increased tension depends partly on the increased force
of the heart's contractions, but chiefly, as first pointed out by Brunton,
to contractions of the arterioles.

Traube and Boohm's experiments would seem to indicate that digi-
talis acts only through the vaso-motor centre,

I venture, however, to suggest that digitalis acts directly on the
arterial muscular tissue.

I. We have seen that digitalis (in common with the group of sub-
stances I have enumerated) undoubtedly affects directly the muscular
tissue of the heart, inducing persistent contraction, and not through the
agency of nervous tissue; and it is presumable that it will affect other
muscular tissue in the same way.

II. Drs. Donaldson and Stevens in America, and Dr. Sainsbury and
myself simultaneously experimented, employing the same method; and
we find that digitalis does undoubtedly cause strong- contraction of the
blood-vessels when these are quite cut off from the central nervous
system. Hence digitalis must either act directly on the muscular
tissue of the walls of the blood-vessels, or on some peripheral nervous
apparatus which governs the muscular tissue of the blood-vessels.

A poisonous dose of digitalis after a time paralyzes the arterioles,
which therefore dilate, and the arterial tension falls.

We can conceive that in a given disease digitalis may afford relief in
one of the five following ways —

I. By strengthening the action of a weak heart.

II. By reducing the strength of the beats of the heart acting too
powerfully.

III. By lessening the frequency of the heart's beats.

IV. By correcting irregular action of the heart.

V. By increasing tonicity and so lessening the size of the cavities of
the heart, thereby reducing the quantity of blood propelled by each
contraction.

Digitalis is of especial service in mitral disease.

It will often be found of eminent service to a patient presenting the
following symptoms and physical signs: — There is dropsy, which may
be extensive; the breathing in the earlier stages of this condition is
much distressed periodically, and especially at night ; but when the dis-
ease reaches its worst stage the breathing is continuously bad, although
it becomes paroxysmally worse. The patient cannot lie down in bed,
and is perhaps obliged to sit in a chair, with the head either thrown
back, or more rarely leaning forward on the bed, or some other support.
The jugular veins are distended, the face is dusky and livid, and the
pulse very frequent, feeble, fluttering, and irregular. The urine is very
scanty, high-colored, and deposits copiously on cooling. The heart is

348 DIGITALIS.

seen and felt to beat over a too extensive area; and the cliief impulse is
sometimes at one spot of the chest, and sometimes at another. The
impulse is undulating, and the breathing very irregular and intermittent.
A murmur is ordinarily heard, having the character of that produced
by mitral regurgitant disease.

Obstruction to the passage of the blood occurs from the disease of
the mitral valve; hence congestion of the lungs, distension of the right
ventricle, tricuspid regurgitation, with general venous distension. In
fact, there occurs heightened venous tension, with corresponding dimin-
ished arterial tension, the diminished arterial tension causing diminished
pressure in the renal glomeruli, and this, conjoined with the slow circu-
lation, leads to diminished excretion of urine, and so produces hydrgemia,
and this, helped by the heightened venous tension which from gravita-
tion is most marked in the most dependent parts of the body, induces
drojDsy.

A case presenting these symptoms and physical signs will generally
resjjond quickly and favorably to digitalis.

The effects on the pulse, the urine, and the dropsy, are to be care-
fully Avatched. When the drug is projoerly administered the pulse grows
considerably stronger, more regular, and much slower, till in very many
cases all irregularity ceases, and the beats become natural in frequency
and rhythm, with much increase of tension. At the same time the
urine, which previously may not have amounted to more than half a
pint in the twenty-four hours, increases to one, two, four, or even eight
pints a day, and in proportion to this increased flow the dropsy dimin-
ishes till it finally disappears.

Xow this obstruction to the circulation with the above symptoms
may be due either to mitral regurgitation or to mitral obstruction, or to
both combined. Some observers, however, consider digitalis is beneficial
in mitral obstruction, others more especially in mitral regurgitation. I
am satisfied I have seen it of eminent service in cases where, after death,
the symptoms vrere seen to be due to mitral regurgitation, and but little,
if at all, to mitral obstruction.

How, then, does digitalis lessen the back flow of blood from the ven-
tricle to the auricle in mitral regurgitation ? The mitral valves are in-
sufficient to close the mitral orifice unless the ventricle contracts strongly;
hence, if the ventricle from weakness or from containing more blood
than it can propel contracts imperfectly, mitral regurgitation will ensue
in proportion to the insufficiency of the contraction. Further, if the
left cavities dilat-e, the mitral orifice becomes enlarged, and the valves
become insufficient to close the orifice. Xow digitalis may act in two
ways. It increases the amount of contraction, and in this way lessens
the auriculo-ventricular orifice and therefore diminished the regurgita-
tion permitted by the retracted, and therefore incompetent, valves. It
also increases the tonicity of the heart muscle and lessens the size of
the ventricular cavities, and so constricts the mitral orifice and lessens
regurgitation. I suggest, however, that a third explanation is feasible.
In mitral disease inducing the symptoms previously described, the heart
generally acts irregularly. It may be assumed in these cases that the
columnse carnefe do not act harmoniously with the walls of the ventricle,
hence from this want of co-ordination the closure of the mitral valve is
incomplete, and regurgitation ensues, or in the case of organic insuffici-
ency of the valves is greatly increased. In such cases digitalis obviates

DIGITALIS. 349

the irregular action of the heart and co-ordinates its various parts, and
thus removes the dynamic regurgitation due to inco-ordination. In
favor of this view is the fact that digitalis is especially indicated where
the heart's action is irregular, and is, in my experience, much less service-
able in those cases of mitral disease with a regular acting heart. Further,
the benefit of digitalis is in projDortion to its influence in co-ordinating
the heart. By those who believe that digitalis is useful in mitral stenosis,
the following explanations are given. The auricle empties itself into
the ventricle chiefly during diastole, consequently the longer the diastolic
pause the greater the time for the blood to flow into the ventricle.
Digitalis slows the heart's action, and so prolongs each diastole, and in
this way jjermits the auricle to become more completely emptied, thus
partially obviating the effects of mitral obstruction, especially where the
heart is contracting too frequently, the increased frequency encroaching
on the diastolic period.

Digitalis, too, may act by increasing the force of the auricular con-
traction; also by increasing the tonicity of .the auricle, and thus lessen-
ing its capacity, and so reducing the quantity of blood the auricle has to
propel with each contraction. Further, over-distension weakens the
contractile force of an organ, and by increasing the tonicity and lessen-
ing the size of the auricle, this over-distension is remedied and its weak-
ening effects obviated.

As I have said, digitalis acts best when the heart beats irregularly;
and an irregular acting heart is generally an indication for digitalis, and
certainly when the irregularity is associated with mitral disease. Irregu-
larity, however, may be due to fatty degeneration, or it may occur in
aortic disease Avith deficient compensation; but in these cases I find
digitalis inefficient, either in removing the irregularity or in obviating
any other symptoms.

In treating mitral diseases we may use the infusion, the tincture, or
the powder of digitalis ; all are serviceable ; but I have seen cases where
the infusion has succeeded after the tincture has failed. In respect of
dose, it is best to begin with a moderate dose, say a drachm of the in-
fusion or three to five minims of tincture, three or four times a day, for
patients differ considerably in their susceptibility to digitalis; and too
large a dose causes much distress and aggravates the troubles of the
patient. The foregoing doses failing, the dose of course must be in-
creased; but in most cases large doses of fifteen to twenty minims of
the tincture, as is often given, will be found quite unnecessary. Some-
times a patient cannot exist Avithout digitalis, for, on discontinuing it,
the heart troubles return, and he may be constrained to continue taking
digitalis for months or years, with perhaps a short intermission from
time to time.

Most authorities are agreed that digitalis is harmful in aortic disease
with deficient compensation. So long as compensation is equal to the
valvular defect, of course digitalis and other drugs are needless. With
aortic regurgitation, without adequate compensation, digitalis, unless
given in small doses undoubtedly in some cases increases the distress of
the patient. This bad effect is explained in the following ways: — Digi-
talis, as we have seen, slows Hie heart, and thereby increases each dias-
tole, and so prolongs the period during which blood can fiow back from
the aorta into the ventricle; hence, with each diastole, the amount of
regurgitant blood is increased with an increase of cardiac distress.

350 DIGITALIS.

Further, digitalis mucli heightens arterial tension, which will also in-
crease the rate of flow of the blood l3Tick from the aorta into the ventricle.
Hence some writers advise that in cases of aortic regurgitation, where
some of the symptoms indicate digitalis, it must be given in doses in-
adequate to slow the heart's action. (Foster.)

On the other hand, Dr. Balfour, a great authority on such a point,
speaks very highly of the effect of large doses of digitalis in aortic
regurgitation with deficient compensation. He gives it in very large
doses, of course watching its action very carefully; and he says he has
seen very striking results. Digitalis he thinks, increases the tonicity of
the heart, and so lessens the size of the dilated left ventricle, and thus
obviates the bad effects of dilatation.

Many writers ascribe the good effects of digitalis in mitral disease to
its tonic action on the heart, meaning thereby that digitalis strengthens
the contractions and thus assists to obviate the effects of deficient com-
pensation and enables the heart to overcome the effects of the valvular
defect. This view has led to the employment of digitalis in aortic ob-
struction with deficient compensation, and in pulmonary obstruction
from emphysema, etc., inducing distension of the right cavities of the
heart. In such cases I have failed to obtain, I think, any good; cer-
tainly the results are far less satisfactory than when dealing with mitral
disease; and this is admitted even by those who are most confident of
the usefulness of digitalis in aortic obstruction or in emjjhysema with
bronchitis.

This comparative uselessness of digitalis would suggest that in mitral
disease its good effects depend on some other action on the heart than
its tonic influence. Nor should we expect, indeed, that digitalis could
act much through its influence in increasing the contractions of the
heart. With valvular defects with deficient compensation, when symp-
toms arise they indicate that the heart is overworked and becoming ex-
hausted. At such a juncture to merely increase the work of the heart
would increase its exhaustion, and though perhaps of slight temporary
benefit, such a result must soon lead to increased exhaustion and in-
creased distress. It is obvious, therefore, that digitalis must act mainly
in virtue of some other effect than a mere increase of the force of the
cardiac contraction. It must act mainly by its influence on tonicity, or
on the frequency of the heart's contraction, or by removing irregular
inco-ordinate action. I have already shown how by reducing the heart's
frequency w^e may obviate the effects of mitral obstruction, but this
sloAving of the heart, Avhen it is beating Avith great frequency, since con-
struction takes place during diastole, must increase repair and permit
of great nourishment of the cardiac structures, for with increased fre-
quency of the heart's contraction, the diastolic intervals are greatly
encroached upon; hence the period for restoration and repair being
shortened the structures must become weakened.

We meet with cases of the following kind where digitalis is often of
great service. A patient with valvular defect suffers but little so long
as he remains quiet; but from excitement, or more frequently from
some strong muscular exertion, the heart becomes greatly embarrassed.
Its contractions grow very frequent, 150 #0 160 jDer minute, very weak
and very irregular. There follows much dyspnoea, even orthopnoea, with
much livid ity and jugular distension.

In such a case mental excitement, or physical exertion has accelerated

DIGITALIS. 351

the circulation quicker than the blood can be propelled through the
constricted valvular orifice; blood accumulates in the cavity behind, and
by distension weakens the contractions of the part of the heart behind
the source of obstruction. In such a case, the prompt and liberal ad-
ministration of digitalis will often' save a patient from death ; ten drops
of tincture of digitalis every hour for a few hours, and then every two
hours, should be given, or a corresponding dose of infusion. In such a
case wc can conceive that the digitalis increases the cardiac contractions,
and so enables the blood to be propelled through the constricted orifice
in quantity sufficient to remove the distension and weakening of the
cavities behind; or it may be that digitalis, increasing the tonicity of
the heart, lessening the size of its cavities, and diminishing the amount
of blood they contain, so reduces the quantity that the cavity is com-
petent to propel all it contains through the constricted orifice, and hence
the removal of the symptoms of obsti'uction.

It is generally held that digitalis and its allies are useless in fatty
heart. This is in accordance with my own experience.

Again, in cases of the following kind, I find the digitalis group use-
less. A patient suffers from arterio-capillary fibrosis, inducing hyper-
trophy of the left ventricle. Subsequently the heart itself becomes the
seat of fibroid degeneration, so that the compensatory hyj^ertrophy is
lost. Then follow the train of symptoms occurring in a weak left ven-
tricle — symptoms much like those occurring in disease of the aortic
valves with deficient compensation, for the conditions are much the
same, the seat of obstruction being in the arteries and arterioles instead
of the aortic valves.

Such cases support the view that where digitalis is useful it does
not benefit by virtue of its power to increase the cardiac contraction, but
through some other effect.

Da Costa strongly recommends digitalis in the condition termed by
him, " irritable heart." This disease occurs frequently among soldiers,
and may come on suddenly or gradually, with j^roneness to fatigue,
palpitation, and dizziness. It is characterized by j^ain, generally persis-
tent, but also paroxysmally intensified, lacerated, or more rarely burn-
ing or tearing, increased by exertion, and situated most frequently over
the apex of the heart, sometimes radiating in all directions, and shoot-
ing down the left arm, and accomjDanied by hypersesthesia of the cardiac
region, increased by each attack of paljDitation. The patient comj)lains
also of palpitation, varying in frequency and severity, occurring at all
times of the day, and accompanied by much distress and pain. The
palpitation is generally brought oj by exertion, although it may occur
while in bed. These attacks are accompanied by dull headache, giddi-
ness, and dimness of sight. The violent seizures may even produce in-
sensibility. The sleep is much broken and troubled by disagreeable
dreams, and the patient cannot usually lie on the left side. The pulse
is rapid, varying from 100 to 140 per minute, small, compressible, and
sometimes jerking, often irregular in force and rhythm — always remark-
ably affected by posture, being very frequent tl'hile standing, much
slower while lying down, the difference amounting to from thirty to
forty beats per minute. Palpitation greatly increases the frequency, in
one instance to the extent of 192 beats per minute. The respirations
are but little hurried, varying from twenty-four to thirty-four, and the
patient complains of ojopressed breathing, rendered worse by an attack

352 DIGITALIS.

of palpitation. Tlie impulse of the heart is extended, but is " quick,
abrupt, or jerking," and the heart may beat irregularly. The first sound
is deficient in volume, "feeble, or short and valvular, like the second."
Murmurs, as a rule, are absent. This condition is produced by over-
work and fatigue, and is fostered by depressing influences. It commonly
leads to hypertrophy, when, of course, the physical signs are modified.
AVhen the heart is not hypertrophied, Da Costa found that tincture of
digitalis, in ten-minim doses thrice daily, quieted the excited organ,
reduced the frequency of, and often strengthened, the pulse, and rectified
irregular cardiac action. If much hypertrophy existed, then digitalis
proves less serviceable, and sometimes failed to give any relief; but here
aconite in three- to six-minim doses was very useful ; though in purely
nervous cases this remedy was not only useless, but often even increased
the frequency of the pulse. In much irritability, with slight hyper-
trophy, a combination of digitalis and aconite did good. Belladonna
was useful in cases accomi^anied by irregularity of the pulse, but proved
of little service in other cases, modifying but little the frequency of the
23ulse. It was of no service in cases complicated with hypertrophy. He
often continued the digitalis for months without producing any toxic
effects. In addition to the foregoing treatment, Da Costa employed rest
in the recumbent posture.

Digitalis is often very useful in quelling the attacks of palpitation in
pure hypertrophy of the heart, which may be due to valvular disease,
especially of the aortic valves, or to Bright's disease, or to excessive
muscular exertion. In aortic disease the hypertrophy is compensatory;
hence, in most cases, especially of aortic obstruction, no treatment is
needed for the hypertrophy itself.

Sir B. Foster recommends digitalis in aortic regurgitant disease when
there is more compensatory hypertrophy than the impediment to the
circulation requires, indicated by violent action of the heart, bounding
vibratory arteries visible all over the body, almost constant headache,
flushed face, and noises in the ears. Sir Balthazar Foster points out
that in these instances the action of the medicine must be watched, for
too large a dose may induce alarming prostration, with aggravation of
the palpitations, effects which he attributes to the slowing of the heart
by digitalis, and the increase of the regurgitation at each diastole; but,
although this explanation may be partially, it is not wholly true, for the
same consequences follow too large a dose of digitalis in other forms of
hypertrophy unassociated with valvular disease. In cases like these, two
to five minims of the tincture is as much as can be tolerated. For the
most part they are best trciited by one to three drops of tincture of
aconite, given thrice daily.

I find digitalis of conspicuous service in cases of prostration from
fever, as typhoid fever or pneumonia. In such diseases signs of failure
may show themselves first in the nervous system, or sometimes earliest
in the circulatory system, and even if first in the nervous system the
heart also soon grows weak. The signs of nervous depression are sleep-
lessness, inducing delirium with tremulousness of the hands, tongue,
etc.. and muscular twitchings. This condition is best treated by the
early employment of some narcotic, which, by inducing sleep, prevents
the other symptoms and sustains appetite, digestion, and assimilation,
and obviates the need of cardiiic tonics like alcohol, etc. If untreated,
this condition of the nervous system soon induces cardiac failure, unless

DIGITALIS. 353

as in some cases the failure begins in the heart. The pulse becomes very-
frequent and feeble, or even irregular; hypostatic congestion sets in, the
ears, tip of the nose, lips, and dependent parts of the body become dusky,
and signs of hypostatic congestion or hvpostatic pneumonia arise. If
this cojidition of the heart is early treated by liberal doses of tincture of
digitiilis the j^ulse becomes greatly reduced in frequency and may speedily
become normal, at the same time growing fuller and of higher tension,
and coincident with these improvements duskiness of the parts most
distant from the heart is prevented or removed, and the pain is carried
safely through a dangerous condition. I give ten minims of the tincture
of digitalis every two or three hours, according to the urgency of the
case. Digitalis I find in such cases of much greater benefit than alcohol.
I suggest that digitalis acts by slowing the heart and so prolonging the
diastolic period, and giving a longer time for the nutrition of the
weakened heart and thus sustaining it.

Digitalis is to a small extent a diuretic, acting directly on the kidneys,
and is therefore useful in some cases of Bright's disease. When it obvi-
ates the effects due to cardiac disease its diuretic effects are astonishing.
I find that the diuretic action of digitalis is limited by the dropsy, for
when dropsy disappears, the remedy no longer causes an increased secre-
tion of urine. Tliis also is the case with some other diuretics.

How does digitalis, in certain heart diseases, cause so great an in-
crease in the quantity of urine ? First, it removes those kidney condi-
tions secondary to the heart disease, which diminish the urinary function,
when the unburdened organ acts as in health, and secretes a natural
quantity. But in the cases now referred to we find the urine increased,
from perhaps half a pint to three, or four, or even eight pints daily. Is
this excess of urine due to the direct action of digitalis on the kidneys ?
Were this the true explanation, then this excessive secretion should con-
tinue as long as the digitalis is administered, but we find, as I have said,
that when the dropsy has disappeared the kidneys no longer secrete in
excess. The copious flow of the urine must be explained by the fact
that digitalis, by relieving the heart, checks the conditions that produce
dropsy, when the dropsical fluid returns quickly into the circulation,
and the kidneys eliminate the excessive quantity of water in the blood.

How does digitalis affect the kidneys in heart disease, thereby in-
creasing the secretion of the urine ? The separation of the water of the
urine is effected chiefly through the Malpighian bodies, probably by
simple filtration, and therefore, the amount of the secretion depends on
the lateral pressure in the blood-vessels of glomeruli.

Thus, section of the cord below the medulla, i.e., below the vaso-motor
centre, causes great dilatation of all the blood-vessels, and thus produces
general lowering of the blood-pressure. The diminution of blood-press-
ure in the kidneys is followed by diminution, and even arrest of the
excretion of urine. Section of the renal nerves causing wide dilatation
of the renal vessels, and thus, heightening their lateral pressure, causes
a great increase in the urinary secretion.

Now, in the forms of cardiac dropsy benefited by digitalis, there is
tricuspid regurgitation, causing great repletion of the venous system,
with corresponding emptiness of the arterial system, and thus arterial
tension is greatly lessened.

Some writers ascribe the diminished urinary secretion entirely to this
loss of tension. It is true that the venous engorgement causes disten-
23

/)54 DIGITALIS.

sion ©f some of tlic capillaries of the kidneys, and thus heightens their
tension, and it might be expected that tiiis increase of lateral pressure
would cause an increase in the secretion of the urine. It is urged that
the venous congestion only affects the capillaries of the tubules, and does
not reach the Malpighian bodies, the capillaries of the tubules prevent-
ing this; thus the blood-vessels of the Malpighian bodies, through which
the water of the urine filters, become partly empty, their pressure greatly
diminished, and hence the secretion of the urin-ary water is diminished.
But is this statement true ? Are the blood-vessels of the glomeruli
partially empty in cases of tricuspid regurgitation and venous engorge-
ment ? To this question I should answer, certainly not, for in the post-
mortems I have made these bodies have always been greatly enlarged
and engorged, and consequently the lateral pressure increased, and thus
the water of the urine should be increased. The diminution of the
secretion appears to me to be due to the venous congestion. In tricuspid
regurgitation the passage of blood from the arteries to the veins is very
slow ; it, in fact, partially stagnates. The blood, on reaching the glom-
eruli, loses much of its water by pressure, but, having reached a certain
degree of concentration, the further separation of water is much slower.
In order to get a rapid filtration of water through the Malpighian bodies,
it is necessary not only that there should be high arterial pressure, but
also a rapid flow of blood. It appears to me that in venous engorge-
ment, we have high lateral pressure, but a slow flow of blood, and that
digitalis acts by removing congestion, and allowing a free circulation
through the kidneys.

Brunton's experiments on himself show that large doses of digitalis
somewhat increase the urinary water, and to a less extent the urinary
solids, lie points out that in fatal doses at the end of life, the urinary
secretion may be greatly diminished, or even arrested, due, he suggests,
to a powerful contraction of the renal vessels. Mr. Rose Bradford, in
his careful experiments, confirms these statements. He grai)hically
recorded variations in the carotid pressure and the supply of blood to
the kidney, this supply being estimated by Roy's oncometer, which
records any variation in the size, i.e., the blood supply of the kidney.
Mr. Bradford finds "that digitalin administered to cats in doses of 4V of
a grain and upwards produces marked contraction of the kidne3% which
is very persistent, lasting frequently for half an hour, and if large and
repeated doses are injected the kidney does not recover its previous
volume, even after some hours. Simultaneously with this renal con-
striction there is, as is well krtown, considerable heightening of the blood-
pressure. It is interesting to observe, with regard to this drug, that
although it produces contraction of the renal vessels, like the initial
action of caffeine, unlike caffeine, it does not cause any diminution or
arrest of the urinary secretion during this period of contraction. In-
stead of any diminution in the rate of urinary flow, this is, on the con-
trary, slightly increased by digitalin. The probable explanation of these
differences lies in the fact that whereas caffeine and digitalin both pro-
duce contraction of the renal vessels, with caffeine the general blood-
pressure is lowered at first and with digitalin it is raised. Hence, during
the initial stage of the action of caffeine the rate of flow of blood through
the renal vessels is lessened; Avhereas with digitalin this rate of flow is
increased."

Digitalis hjis been employed in the treatment of acute inflammation.

DIGITALIS. 355

Mr. King, of Siixmundham, held that no good was to be effected in in-
flammation, unless with a large dose, and he gave from half an ounce to
an ounce of the tincture; with these formidable doses he declared he
could subdue most inflammations if attacked at their very commence-
ment, and before the organs involved became disorganized. He admin-
istered a dose and then waited twenty-four hours to watch its effects; at
the expiration of the time, if the pulse did not become much less fre-
quent or irregular, he repeated the dose. He gave as much as two
drachms of the tincture to a child of nine months old. Vomiting some-
times quickly follows these very large doses. ]S"o serious or dangerous
symptoms, says Mr. King, ever followed his extensive and startling use
of digitalis.

Dr. Koyston Fairbank flnds digitalis, employed both locally and in-
ternalh', useful in inflammations. He narrates cases of acute inflamma-
tion of joints, acute inflammation of the legs from varicose ulcers, severe
inflammation of the breast, and of erysipelas, yielding speedily to fomen-
tation, made by infusing a small tea spoonful of the dried leaves in half
a pnit of boiling water, and apj^lied by means of flannels wrung out in
this decoction. Sometimes, after simple hot fomentations, he advises the
rubbing in of some tincture

Digitalis will reduce the temperature of fever, though large doses are
often required.

In typhoid fever, Wunderlich recommends digitalis, asserting that in
two or three days it will reduce the temperature of the body by 2° or 3°
Fahr., and will slacken the pulse, sometimes, by thirty or forty beats in
the minute.

Digitalis controls epistaxis, haemoptysis, and menorrhagia. In cases
of menorrhagia, unconnected Avith organic disease, this medicine, inde-
pendently of the state of the circulation, is said to be more efficacious
than any other remedy; and, Avhen organic disease gives rise to this form
of bleeding, the effect of the medicine is scarcely less manifest, although
the advantage may be temporary.

The late Dr. Brinton highly esteemed it in bleeding from the lungs,
stating that when it reduced the frequency of pulse the bleeding ceased.
The infusion is to be preferred for haemorrhages, and large doses may be
required.

In rare instances, digitalis occasions great strangury, with a desire,
almost incessant, to pass water, accompanied by great and painful strain-
ing, and, in women, by strong " bearing-down " pains.

Few remedies are of more avail in arresting sj)ermatorrhoea than
digitalis in drachm or two-drachm doses of the infusion twice or thrice
daily. The free application of cold water to the testicles and perina?um
aids the effect of the medicine ; and it is a useful practice to let the tes-
ticles hang in cold Avater night and morning for five or ten minutes at
a time.

The late Mr. Jones, of Jersey, excited considerable astonishment by
the announcement of the good effects he obtained from very large doses
of tincture of digitalis in the treatment of delirium tremens. He gave
half an ounce of the tincture, and repeated it when necessary in four
hours; and again in six hours; and again when needful in two-drachm
doses. Mr. Jones says of this treatment, " The pulse, so far from being
lowered in force, becomes fuller, and stronger, and more regular soon
after the first dose. The cold clammy perspirations wear off and the skin

356 DIGITALIS.

becomes warmer. As soon as the remedy produces its full effect, sleep
for five or six hours commonly follows. Hleep is the guide to the repeti-
tion of the dose. No action on the kidneys is evinced by an unusual
secretion of urine. Sometimes the bowels are acted on slightly, but
not commonly." Mr. Jones never saw any alarming symptoms follow
these large doses, although he treated in this way about seventy cases of
delirium tremens. It would appear that he adopted this treatment only
in the severer asthenic forms of delirium tremens. With regard to this
treatment of delirium tremens, the following conclusions appear to be
established :

I. The medicine may be given in the manner directed, without danger.

II. That it very often does good, producing speedily, in most cases,
refreshing, quieting sleep ; and, even when it fails to induce sleep, it gen-
erally calms undue excitement.

III. That some cases appear to be uninfluenced by the drug.

It yet remains, however, to ascertain the forms of the disease amen-
able to digitalis.

Under this treatment some severe asthenic cases, when owing to great
jDrostration death seemed imminent, have rallied astonishingly and
ultimately recovered. The evidence of this is too strong to be disputed.
Under the influence of digitalis, the weak, rapid and fluttering pulse
grows strong and steady, tiie skin comfortably moist and warm, while,
with the improvement in the circulation and state of the skin, the gen-
eral condition of the patient improves. On the other hand, it appears
equally certain that asthenic forms of the disease are also amenable to
this drug; in several instances I have seen this form of the disease yield
speedily to huge doses of digitalis.

I give a short account of a case of delirium tremens recently treated
with large doses of tincture of digitalis. The man, aged about 50, had
been a very hard drinker for many years. He was well nourished, but
his urine contained a considerable amount of albumen. After trying
large doses, of chloral and bromide of potassium, we gave him a grain of
liyoscyamia, which quieted him for several hours, but did not produce
sleep, and as he was in no way benefited by our treatment, we resolved
to give him half-ounce doses of tincture of digitalis according to Jones's
directions. Before giving him this first dose his pulse was 90, regular,
and fairly good ; in half an hour the pulse rose to 108. In three hours^
time the digitalis was repeated; in an hour the pulse was 120; in three
hours 150, irregular; in four hours 200, very irregular, very feeble: — in
four hours and a half it had fallen to 124, and was much stronger and
more regular; during the height it varied between 130 and 140. Xext
day at noon it fell to 90, and was intermittent, but not irregular; in the
evening it was GO.

Digitalis is said to be cumulative. We meet with patients who, whilst
taking digitalis, remtiin for many days but little affected, and then sud-
denly the pulse falls to 40, 35, or even to 30 beats a minute. This abrupt
occurrence of toxic symptoms is ascribed to accumulation of the drug
in the system, absorption from the stomach being more active than
elimination through the kidneys, etc. ; hence the digitalis accumulates,
in the blood and induces this sudden onset of symptoms.

STROPHANTHUS. 357

CONVALLARIA MAJALIS.

We now know a considerable number of remedies which affect the
heart and blood-vessels in the same way as digitalis, drugs which
strengthen the rhythmic contraction and tonic contraction of the heart,
and raise arterial tension, probably by their direct action on the blood-
vessels and not through the vaso-motor nerves.

Convallamarin (Convallaria majalis), Adonidin (Adonis vernalis),
Stroplianthin (Strophanthiis hispidin), first investigated by Professor
Praser and recommended by him as a substitute for digitalis, Erythro-
phlffiin (Casca) recommended by Brunton, and Sparteine are the most
important. While, no doubt, each of these is useful, it remains to be
seen if they are equal or superior to digitalis. Convallaria majalis has
been the most studied and is still on its trial, and it has certainly not
yet established its claim to be considered equal to digitalis. Though
these substances in their physiological action are much akin to digitalis,
yet they differ from it in some respects — for instance, strophanthin is
a far more powerful muscle poison than digitalis. It is certain then
that, whilst having much in common, these drugs play each a thera-
peutical rule of its own.

Convallaria has long been used by the Russian peasantry for dropsy.
Waltz discovered two alkaloids, convallaria, a simple purgative, and
convallamarin, on which its cardiac and vasculnr action depends.

Toxic doses cause in frogs jirogressive paralysis, muscular tremblings,
and at last complete loss of reflex action and death. Modei'ate doses
slow and strengthen the heart's contractions, larger doses accelerate the
heart and cause irregularity. Doses that slow the heart heighten arterial
tension. It acts directly on the heart, arresting it in systole, probably,
like digitalin, affecting the muscular tissue. It probably, too, acts
directly on the blood-vessels, but does not seem to affect the other organs
in any notable degree.

As regards its therapeutic value, opinions differ greatly; See con-
sidering it superior, other observers for the most part ranking it much
inferior, to digitalis.

It is well to point out that there is no officinal preparation of conval-
laria, consequently the preparation of one pharmaceutist is often much
stronger than that prepared by another.

STROPHANTHUS (KOMBI ARROW POISON).

Professor Fraser first investigated this drug and introduced it
into medicine.

It has a bitter taste. At one time it was said not to derange the
gastro-intestinal canal, but subsequent observations show that it some-
times causes loathing of food, nausea, vomiting, and diarrhoia, which
may be violent. In large doses it may produce a sensation of burning
in the oesophagus and stomach. Where, however, digitalis upsets the

358 SPARTEINE.

stomach, strophanthus is often well borne; hence when digitalis dis-
agrees strophanthus may he usefully substituted.

Fraser shows that like digitalis it poisons striated muscle. In my
experiments I find it poisons skeletal more than cardiac muscle. Fraser
finds it increases the contractile power of all striped muscle. It aifects
the heart in all resjiects like digitalis, and also heightens arterial tension ;
but this is said to be due mainly to increased contraction of the heart,
and but slightly to a contraction of the arterioles; this statement, how-
ever, has been controverted, and it is said to cause marked arteriole-
contraction.

Mr. Bradford has tested the action of strophanthus in animals on
the general blood-pressure and especially on the renal circulation, test-
ing the kidney circulation by means of Roy's oncometer. He says, " It
is well known from the work qf Fraser that strophanthus heightens
arterial pressure by increasing the force of the heart's beats. Thus this
drug differs from digitalin and spartein where the increased cardiac
action is accomjDanied by a constriction of the muscular coat of the
peripheral vessels. On the kidney, as investigated by means of the
oncometer, strophanthus has scarcely any action. The injection of the
drug is followed by an exceedingly slight and transitory contraction,
lasting but a few seconds. Further, the drug does not increase the flow
of urine, even when its effects on the blood pressure are marked. Hence
these results confirm Fraser's view that the action of strophanthus on
the vascular system is almost limited to its action on the heart."

As Fraser has shown, it may be used as a substitute for digitalis; and
if it should prove that strophanthus does not contract the arterioles,
then theoretically we should expect it would answer better than digitalis,
as under the influence of strophanthus the heart would be spared the
obstruction caused by contraction of the peripheral vessels.

At present its relative value to digitalis cannot be decided, but I
believe that it is now generally held to be inferior to digitalis. It is
certain that it is not nearly so much employed as it was a little while
ago. It must, however, be admitted that cases occur in which it svic-
ceeds where digitalis has failed ; but the special indications for the use
of strophanthus are not yet ascertained.

Drasche found it greatly relieved palpitation and dyspnoea in failing
heart.

It is also recommended in secondary failure of the heart in renal
disease, a condition I do not find benefited by digitalis.

Sometimes, like digitalis, it causes violent headache. It is said not
to be cumulative. It is useless in renal dropsy. The dose recommended
is from three to ten minims, but I do not often obtain much benefit
with smaller doses than five minims four times a day.

SPARTEINE,

a liquid alkaloid derived from broom, is highly recommended by See
as superior to digitalis. The alkaloid is insoluble in water, whilst the
sulphate is freely soluble; it is used in doses gr. ^ to grs. ij. The
accounts of its physiological action are somewhat discrepant. Some

ADONiDiisr. 359

observers find tliat it first accelerates the heart, and this action is due to
paralysis of the vagi. Next it slows the heart, increasing the force and
duration of its contractions. With full doses there is no primary acceler-
ation, but the heart is at once slowed. After toxic doses the pulse is
much accelerated and becomes irregular, hence in these respects sparteine
acts like digitalis and its allies.

It heightens arterial tension. Mr. Bradford finds in animals, " The
kidney vessels are constricted by it to a marked extent, the flow of urine
being considerably diminished, this diminution continuing for some time
after the constriction of the renal vessels has ceased." It is therefore
not a direct diuretic.

It is used in place of digitalis, and therefore is found useful in mitral
disease, with irregularity of the heart's action. It regulates tlie pulse,
increases arterial tension, diminishes venous congestion, accelerates the
circulation, and then acts as a diuretic, removing dropsy, its diuretic
action being in proportion to its influence on the heart. See recom-
mends it in all cases of Aveak heart, or when compensation is deficient,
but it is especially indicated where the pulse is irregular. See finds it,
too, useful in typhoid states, presumably from its action on the heart.

See ranks its efficacy above that of digitalis or convallamarin, but
most observers find it decidedly inferior to digitalis.

It is not, as we have seen, a diuretic by its direct action on the kid-
neys, hence it is useless in renal dropsy. Indeed, in some experiments
on rabbits it diminished the urinary secretion.

Since its action is speedier and less persistent than that of digitalis,
sparteine is preferable where a prompt effect is urgently required.

It sometimes excites slight diarrhoea.

ADONIDIN.

A GLUCOSIDE of adonis vernalis, or adonis cupaniana, given in doses of
■jij to -J grain several times daily, is employed as a substitute for digitalis.

Dr. H. J. Hare has examined its action on healthy animals. It first
slows, then accelerates and arrests the heart of frogs in diastole, height-
ening tension as the mesenteric arteries enlarge. On warm-blooded
animals it acts similarly, increasing the force of the heart's contraction
and heightening arterial tension. At first it slows and then accelerates
the heart, arresting it in diastole. With small doses no primary slow-
ing occurs. The initial slowing is due to stimulation of the vagus, and
the subsequent acceleration follows paralysis of the vagus. It heightens
tension partly by increasing the heart's action, but chiefly by its stimu-
lating eifect on the vaso-motor centre. It is evident, therefore, that as
respects its influence on the vagus adonidin is like digitalis. Dr. Hare
does not mention its direct action on the heart muscle, which is so con-
spicuous with digitalis. Moreover, adonidin differs from digitalis by
heightening arterial tension through its effects on the vaso-motor centre.
In my experiments I find that adonidin affects the frog's heart in all
respects like digitalis.

Mr. Bradford, in his experiments on cats, dogs, and rabbits, on blood
pressure and supply of blood to the kidneys, finds adonidin acts very

360 TOBACCO.

similarly to digitalis; but it differs from digitalis in not increasing the
urine, and in this resj)ect acts like sparteine.

Notwithstanding these differences, adonidin seems clinically to act
just like digitalis, and to be indicated in identically the same diseases.
It is mainly useful in mitral disease, slowing and strengthening the heart,
heightening arterial tension, removing venous distension, and increasing
the secretion of urine, removing by this means dropsy.

It sometimes causes vomiting and diarrhoea, with intestinal spasm.

The plant is caustic and vesicating, and the crushed plant is some-
times used as a domestic remedy to blister.

TOBACCO.

A POTJLTICE of tobacco leaves is said to relieve pain, and an ointment,
made by boiling half an ounce of tobacco in eight ounces of lard, kept
constantly applied to the breasts, is also said to arrest the secretion of
milk. In this respect it is probably inferior to belladonna. ( Vide Bel-
ladonna,)

As several deaths have occurred through the application of tobacco
to the abraded skin, it must be used externally with caution.

Tobacco, when introduced into the eye, contracts the pupil, also when
taken by the stomach.

Tobacco produces nausea and sickness, accompanied by great weak-
ness and faintness. It confuses the ideas, dims the sight, enfeebles the
pulse, and makes the skin cold and clammy with profuse sweating. Owing
to its prostrating effects it removes spasm. Tobacco in the form of clyster,
or administered by the stomach, has been employed in colic of the intes-
tines, and in strangulated hernia; but in spasmodic diseases chloroform
has quite superseded it. Tobacco-smoking excites an abundant secretion
of saliva; hence some persons maintain that tobacco-smoking aids diges-
tion. Smoking acts on the intestines as a slight purgative, and no doubt
a pipe or cigar smoked after breakfast is often sufficient to insure an easy
and satisfactory relief of the bowels ; and is, perhaps, a practice not with-
out advantage in habitual constipation.

Smoking in excess is, no doubt, a very injurious habit, disordering
digestion, lessening the appetite, inducing restlessness at night, with dis-
agreeable dreams, and weakening both mind and body. Chronic pharyn-
gitis, the mucous membrane looking like dirty-red velvet, with constant
hawking, and also chronic dyspepsia may, in some instances, be clearly
traced to excessive smoking. Even amaurosis is said to be sometimes
produced by excessive smoking. The habitual smoker has generally a
thickly-coated tongue. The symptoms produced by excessive smoking
soon cease when the habit is discontinued. If the tobacco is of good
quality, and contains but little nicotine, the evil consequences are much
less marked. In the cultivation of the plant, it is a point of importance
to develop the aromatic principles, and to diminish nicotine.

Nicotine causes in frogs tetanus and general paralysis. In warm-
blooded animals there occur twitchings and startings, and tetanoid con-
vulsions, excited by the slightest stimulus; the breathing is greatly
hurried, and the animal becomes very weak, or, if the dose is large, com-

CONIUM. 361

pletely paralyzed. It excites perspiration, and in cats free salivation.
It contracts the pupil, whether administered internally or applied topic-
ally. We have here an instance of a solanaceous plant contracting
the pupil and increasing most of the secretions, in these respects acting
in exactly the op})osite way to most other solanaceous plants, with the
exception of pituri, to which tobacco is very closely allied.

Nicotine tetanizes by its action on the cord. It paralyzes the cord,
motor nerves (Vulpian, Rosenthal, Krocker), the peripheral nerve end-
ings being first affected; it also paralyzes the muscles (Rene). The
brain is unaffected.

Nicotia appears to tetanize the heart, for when this organ, from a
mechanical cause, has ceased to contract after death, the direct applica-
tion of nicotia excites the pulsations, and the heart soon becomes rigidly
contracted — tetanized, in fact — and then, of course, the beats cease. In
birds and mammals killed by chloroform, when the ventricles are im-
mobile and dilated, and respond most imperfectly to stimuli, the appli-
cation of a drop of nicotine immediately occasions strong contractions
in the heart, and causes the organ to respond energetically to mechanical
and galvanic stimuli.

The experiments of Fraser and Brown show that nicotia, like other
tetanizing substances, as strychnia, brucia, thebaia, codeia, and morphia,
loses its tetanizing properties when converted into ethyl or methyl com-
pounds; but, unlike these, the methyl and ethyl compounds of nicotine
do not possess any paralyzing action on motor nerves. This difference
inclines these observers to believe tliat the convulsions of nicotia are not
produced in the same way as those arising from strychnia, brucia,
thebaia, etc.

Nicotia has been highly praised in tetanus, and many recorded cases
appear to show its usefulness in this fatal disease. It must be admin-
istered either by the rectum, or hypodermically; when put into the
mouth, it very generally excites a severe paroxysm, which may destroy
life, by firmly fixing the muscles of the chest till asphyxia is produced.

Tobacco-smoking commonly affords some relief in spasmodic asthma;
but, like all other asthmatic remedies, it succeeds much better in some
instances than in others.

Whether the active principle of tobacco is destroyed in the system,
or is eliminated with any secretion, is, at present, unknown.

Nicotine is supposed to be diuretic, but we are not told under what
circumstances.

CONIUM.

We are chiefly indebted to Christison, Schroff, Kolliker, and Gutt-
mann, for our knowledge of the action of this medicine. Paul Gutt-
mann, who made some excellent investigations on the action of this
alkaloid, says it is one of the most active and powerful poisons, being,
in this respect, scarcely second to prussic acid; yet some vegetable-
feeders, as goats, sheep, and horses, are said to eat hemlock with im-
punity.

Gonium contains two alkaloids, coniineand methyl coniine. Conium
exerts no influence on the unbroken skin, even when a^jplied in large

362 coNiuM.

quantity; but strong preparations applied to wounds excite inflamma-
tion, with its usual accompaniments of heat and pain.

The pounded leaves, or the expressed juice, or other preparation of
the drug, smeared over a poultice, will ease the pain of ulcers, both
simple and malignant, and, at the same time, improve the character of
the sore. The pain-easing property of hemlock rests on the evidence of
highly competent observers, and cannot be gainsaid ; yet it is now rarely
employed for this purpose, although formerly it was in constant use as
a soothing application to broken cancers and malignant sores.

The alkaloid, coniine, whether directly applied to the eye or swallowed,
eauses dilatation of the pupils, sometimes with subsequent contraction.
According to Harley, the dilatation is never very great.

The smell of conium has been compared to the urine of cats and
mice. It has a burning, acrid taste, provoking an increased secretion of
saliva. A drachm of inhalatio conise in boiling water, used twice or
thrice daily, is extremely useful in irritable cough of bronchitis and
fibroid phthisis.

Hemlock has scarcely any influence on the stomach and intestines.
It may produce nausea, vomiting, and diarrhoea; but such occurrences
are not common. Walshe has seen it relieve the pain of cancer of the
stomach.

That conia enters the blood is proved by the symptoms arising when
it is swallowed; but the physical or chemical changes, if any, it under-
goes in the blood are at present unknown. Added to blood after its
removal from the body, it produces in it no perceptible alteration.

The deficient coagulability and dark color of the blood, after death
from this drug, noticed by some, according to others are often absent;
and, when present, are due probably to the fatal asphyxia.

The effects of conium on man and animals is very similar. The best
account of the symptoms occurring in a human being, from a poisonous
quantity of the plant, is given by Dr. H. Bennett, who has recorded the
case of a man who ate hemlock in mistake for salad. Weakness of his
legs, so that his gait was faltering, was first noticed; as the weakness in-
creased he staggered as if drunk, and, at the same time, his arms began
to be similarly affected. Perfect loss of all voluntary movement followed,
and he was unable even to swallow. Lastly, the muscles of respiration
were slowly paralyzed, and he died of asphyxia. Up to his death his
intelligence was apparently unaft'ected, but his sight was destroyed.
Slight movements in the muscles of the left leg took place.

The same, or nearly the same, sequence of events happens in animals
poisoned by hemlock. With rabbits, early and severe convulsions occur,
but in frogs these are absent. In all the experiments and observations
of Guttmann, gradual paralysis of the voluntary muscles, and then of
the respiratory muscles, took place. The paralysis began first in the
hind extremities, next affected the anterior, soon afterwards the muscles
of the trunk, and lastly those of resjnration.

Coniiue affects chiefly the motor nerves, paralyzing first the end jilates.
It also paralyzes the terminations of the vagus. The spinal cord is but
little affected. Some experimenters assert that it affects the cord to a
slight extent, like strychnia, and depresses the reflex function. The
sensory nerves and muscles are unaffected.

Conia appears also to affect some parts of the vaso-motor nerves;
thus the arteries of the frog's foot fail to contract on irritation when

CONIUM. 363

the animal is poisoned by hemlock, but tlie motor nerves of some other
involuntary muscles are uninfluenced by conia, as the peristaltic contrac-
tion of the intestines of the rabbits killed by the alkaloid continued
active after death.

Its influence on the brain Avill next be considered. No doubt both
man and animals remain conscious of pain so long as they are capable of
giving any signs of it; that is before the muscles of expression become
IDaralyzed. But consciousness is possible, though at the same time the
brain may, in some way, be afl'ected. Schroff states that the poison, soon
after it is taken, is followed by a sensation of heaviness in the head, with
giddiness, inability to think, great impairment to common sensibility,
blunted taste, dimmed sight, dilated pupils, and a sensation as of insects
crawling on the skin.

The mind .is evidently in some degree weakened, and many of the
special senses suffer. In Dr. Bennett's case there was total blindness,
but the hearing was little, if at all, dulled. Some observers assert that
the mind remains quite uninfluenced by hemlock.

In poisoning by hemlock, as I have said, the pupils dilate; at the
same time there is drooj^ing of the upper eyelid, due, of course, to
jDaralysis of the third nerve, which leads JJr. II. Wood to conclude that
hemlock affects the pujDil by paralyzing the third nerve, not by stimu-
lating the sympathetic.

At an early part of this section it was stated that convulsions resulted
from poisoning by conium. Convulsions occur in some animals, not
in others. Kabbits appear to sulfer from convulsions, but frogs die
unconvulsed. These spasms, Kolliker has suggested, may be due to
asphyxia from paralysis of the muscles of respiration. This explanation,
however, appears to be insufficient, as convulsions are often among the
earliest symptoms, before any asphyxia has resulted; nay, if a tube is
introduced into the trachea and artificial respiration is performed, they
still occur. In man convulsions are certainly sometimes absent, ;fnd in
the case recorded by Bennett, only slight movements in the left leg
were witnessed.

Drs. Crum Brown and Fraser have shown that specimens of conia
are not of identical composition; for, while each specimen produced the
same symptoms, these they find were not always produced in the same
way. In other words, some specimens affect chiefly the motor nerves,
while others act on both motor nerves and cord. Their observations on
hydrochlorate of conium, methyl-conia, and iodide of dimethyl-conium
in a great measure explain these differences. They conclude that conia
"2)roduces paralysis solely by influencing the motor nerves." and that
hydrochlorate of methyl-conia acts " on the motor nerve and spinal cord.
With large doses the former action is completed before the latter." They
conclude that commercial specimens of conia consist of mixtures in vari-
able proportions of conia and methyl-couia. Sometimes meth3'l-conia is
present in small, at other times in large quantities ; and that this variety
of composition explains the varied physiological effects of different
specimens of conia.

Their observations on iodide of dimethyl-conium " show that the
paralysis produced by dimethyl-conium is dependent on an action on the
motor nerves primarily restricted to the iDcripheral terminations."

Concerning the action of this poison on the heart, very conflicting
statements have been made. Some authorities state that it reduces the

364 coNiUM.

frequency of the pulse, especially when the heart beats too quickly from
disease, as from fever, etc. Even a small dose iinder such conditions,
they say, suffices to produce a decided effect on the pulse, while in health
the same quantity exerts no influence. Such are the conclusions of
Wertheim.

Kolliker, Guttmann, and J. Harley conclude that conium does not
affect the heart. Harley, who gave the medicine in sufficient quantities
to produce partial paralysis, says, " excepting as a transient emotional
effect in nervous individuals upon the sudden accession of the symp-
toms after a first dose of hemlock the heart and blood-vessels are abso-
lutely unaffected by its operation. I have carefully determined this in
persons of all ages — in the weakly infant not three months old, in the
strong, in the debilitated, and in those who have intermittent action of
the heart."

In exj^eriments with warm-blooded animals poisoned by hemlock the
heart, it is true, soon ceases to beat; but this can be for a long time
retarded if artificial respiration is performed, and in the case of the frog
the poison appears to leave the heart unaffected.

In doses sufficient to produce physiological effects, conium, Harley
says, may be taken for months without affecting nutrition, and my ex-
jDerience quite confirms this statement.

It is supposed to be useful in whooping and other coughs. The suc-
cus conii in one- to fonr-drachm doses, or even more, has been recom-
mended lately by J. Harley in 'chorea; and these large doses certainly
control the movements temporarily, and impart steadiness to the patient;
but the improvement wears off if the medicine is not soon repeated.
Some cases, no doubt, are cured; but in my exjaerience this treatment
in most instances only palliates, and, on discontinuing the drug, the
symptoms return with customary severity. In order to maintain the
effects of conium on the choreic movements, the dose must be quickly
increased, for patients speedily become tolerant of the drug, and after a
short time will bear enormous doses without the induction of any ph3'si-
ological effect. Thus on one occasion I gradually increased the dose,
till the patient — a child — took, except when asleep, seven drachms of
succus conii hourly.

We have the high authority of Dr. Neligan in favor of hemlock in
various painful affections, as cancer, rheumatism, and neuralgia. It has
not yet been shown in any well-authenticated case that conium produces
either sleep, coma, or delirum.

Considering the physiological action of conia, it would appear that
it is not indicated in convulsive diseases dependent on affections of the
cord, as tetanus and strychnia poisoning; for the effects of this drug,
and the symptoms of these diseases are not antagonistic. Guttmann
j)ut to the test of direct experiment the power of conia to arrest or clieck
in any degree the tetanus from strychnia. He strychnized frogs, and
then gave them conia, but even when administered in doses sufficient
to completely paralyze the animals, this drug failed to check in any
degree the tetanic spasms produced by the strychnia.

Professor Christopher Johnson, of Maryland, however, reports cases
of recovery from severe traumatic tetanus under the use of conia. In
one case he injected hypodermically, every two hours, fifteen minims of
a solution composed of two minims of conia, one minim of dilute sul-
phuric acid to one drachm of water. In the second case he commenced

CALABAR BEAN. 305

with twenty minims of the same sohition every three hours; he then
increased the conia to one-third, then to two-thirds, of a drop, and
ultimately to rather more than a drop every hour, when the symptoms
abated. Afterwards he used two minims of conia hourly, but owing to
the weakness of the pulse, he returned to one minim every two hours,
but the spasms returning, he again used two minims every hour, and
immediately the spasms diminished. But these cases, unfortunately,
are much less satisfactory than they might have been. In the first case,
the cicatrices of the wound were removed by a hot iron, and in the
second bromide of potassium and morphia were administered. But Dr.
Johnson says that the spasms were considerably reduced after each conia
injection. •

It will be obvious how very similar the action of conia is to that of
curare. One difference there is between these substances which has not
been noted. Curare, when swallowed, is not poisonous, but is strongly
toxic when injected under the skin; conia, in either Avay, is equally
poisonous.

Claude Bernard believes that the innocuousness of curare admin-
istered by the stomach is due to its slow absorption, as contrasted with
its much more rapid elimination by the kidneys, so that a very minute
quantity is retained in the blood.

The most reliable preparation is the succus conii.

CALABAR BEAN.

Poisoning by calabar bean induces the following symptoms : — Weak-
ness progressing to complete paralysis; arrest of respiration; quivering
or fibrillary contraction of the muscles; increased secretion of saliva;
relaxed bowels with ' griping pains ; contracted pupils ; heightened
arterial tension; sometimes strychnia-like tetanus; whilst the mind
remains unaffected.

It apparently leaves the brain unaffected, but paralyzes the medulla
and spinal cord, the posterior columns before the anterior; thus it causes
weakness and paralysis and arrest of respiration. The motor nerves are
very little affected, and the sensory only when a strong solution is
applied topically to the nerve.

The fibrillary contractions are due to the action of the poison either
on the muscle or on the motor nerve, for they occur when the limb is
separated from the nervous centres; and since the contractions are con-
trollable by curare they probably depend on some change in the termi-
nations of the motor nerves.

Physostigma increases most secretions, as the salivary, lachrymal,
cutaneous, and the secretion from mucous membranes, affecting prob-
ably the glandular secreting cells. It also stimulates voluntary and in-
voluntary muscular fibres or their peripheral ganglia; hence it gives rise
to colicky pains and a relaxed condition of the bowels. It also contracts
the bladder, uterus, and spleen.

It contracts the pupil, heightens intra-ocular pressure, and produces
spasm of the muscle of accommodation, probably by stimulating the
terminations of the third nerve, and not by paralyzing the sympathetic.
It is largely used in eye diseases.

366

CALABAK BEAN.

Physostigma afEects the heart according to the dose; a small quantity
is said to strengthen and lessen the frequency of the contractions; a
large quantity kills by arresting the heart in diastole. It first accel-
erates and then retards respiration by stimulating the vagi termi-
nations.

The increased arterial tension is largely due tothe strengthening
influence of the drug on the heart, though probably in some measure to
vaso-motor stimulation, or direct action on the muscular coat.

The strychnia-like convulsions are probably due to calabarine, which
is reported"to act like strychnia, whilst all the other symptoms are due
to eserine.

We now come to the therapeutical application of this remedy. It
was some time ago suggested that the calabar bean might prove of much
service in tetanus and chorea, and Dr. Fraser has written an interesting
paper on this subject. Finding that the effect of strychnia on the frog
can be arrested, he believes that the bean may be used with the greatest
benefit in tetanus. Dr. Fraser very naturally insists on the importance
of employing the drug at the very beginning of the attack. It may be
administered by mouth, anus, or subcutaneously. When the convulsions
are severe, and when the slightest movement excites them, it is obvious
that, till the severity of the paroxysms is subdued, only the subcutaneous
method can be used. Yet, whilst the patient can still swallow, my ex-
perience leads me to prefer giving the drug by the mouth ; for the drug
to be of any use it must be giv^n in quantity sufficient to produce paral-
ysis, and must be pushed, indeed, to such an extent, that but a little
more would permanently arrest breathing. The drug, therefore, must
be given with great care and watchfulness, and to get the necessary
effects without inducing serious symptoms it is better to give small and
increasing quantities every hour, or'oftener, for then, should serious
l^aralytic symptoms arise, the drug can be stopped. Moreover, it is im-
possible to tell the dose adequate to subdue the paroxysms, and produce
paralysis, some persons requiring a much larger quantity than others.
Hence it is evident that it is more convenient to give the liquid extract
by the mouth than subcutaneously. I have already, in part, spoken of
the dose. It is generally, nay, probably always, necessary to produce a
certain degree of paralysis, amounting to heaviness of the limbs. Some-
times the dose of the spirituous extract must be very large; thus, Dr.
Eben Watson, who failed to obtain good effects from hypodermic injec-
tion, prefers to administer the drug by the mouth, or rectum, and insists
on the necessity of giving enough extract to produce relaxation of the
spasms. He has given it to the extent of seventy-two grains in twenty-
four hours.

In a successful case under my care, reported in the Pracfiiioner, the
patient, for a day and a half, took 2f grains of the watery extract hourly,
and for a short time 4 grains hourly. It is, of course, too much to ex-
pect that Calabar bean will cure every case of tetanus, but I feel con-
vinced that, were the treatment begun at the outset of the attack, and
were the drug pushed sufficiently, the results would be more successful
than those at present attained.

Dr. Fraser next makes a few remarks on the influence of this remedy
over chorea, but at present there appears to be little evidence on this
subject. " The treatment of this disease," he says, " will rarely require to
be so active or energetic as that recommended for tetanus. Physostigma

CALABAR BEAN. 367

should be administered either in the form of powder or of tincture. From
three to six grains of powder, three or four times daily, may be given to
children, and from ten to twenty grains, as frequently, to adults."

Dr. Crichton Browne finds Calabar bean markedly useful in general
paralysis of the insane; indeed, he states that he has even cured some of
his patients of this severe disease. I have known it arrest the progress
of general paralysis, and even slightly improve the mental and physical
condition. I have seen it not only arrest progressive muscular wasting,
.uncomplicated with much mental disorder, but also eifect considerable
improvement in the muscular power. Moreover, it has appeared to me to
be serviceable in some cases of long-standing hemiplegia. I have given
the extract of physostigma in one-thirtieth of a grain doses every two
hours.

In conjunction with Dr. Murrell, I have made observations on the in-
fluence of Calabar bean on certain nervous affections, giving one-tenth of
a grain of the extract every three hours, and in some instances we have
continued this treatment more than a year. We gave it in five cases of
paraplegia, due probably to myelitis. In one case no improvement ensued;
and but slight amendment in another; but even when the drug failed to
produce any improvement it yet seemed to us to arrest the disease. In
old-standing cases we could hardly hope for any amendment, where the
lower part of the cord had become disorganized; but we might fairly hope
to control the march of the disease in the less affected parts. In two
cases very marked improvement occurred, an improvement so decided as
fairly to astonish us, but in both relapse took place, and the patients
became as bad almost as before undergoing treatment.

In the fifth case the treatment effected a considerable and permanent
improvement, so that the patient, who was unable to move his legs even
in a slight degree, was enabled, before his discharge, to walk about the
ward without his stick. These cases, it will be said, do not tell conclu-
sively in favor of the efficacy of physostigma in paraplegia; we were both,
however, struck by the evident temporary improvement in some of the
cases, and the decided and permanent amendment of one patient, which
we could not help attributing to the drug, and we feel sure that this
subject is well worth further investigation. We gave the drug in the
same doses to two cases of locomotor ataxy, in one case for a year, in the
other for three months: both cases improved, and one, a very bad case,
considerably. We gave it also in ,a recent case of writer's cramp, and in
two months the patient recovered.

Dr. Bartholow recom. mends Calabar bean in the flatulence of the
climacteric period.

Between Clalabar bean on the one hand, and chloral, atropia, and
strychnia respectively, there is a well-marked antagonism. Here we shall
have occasion to speak only of the antagonism between physostigma and
chloral, referring the reader for an account of the other antagonisms to the
chapter on belladonna, and that on strychnia. The Committee of the
British Medical Association, in their recently published investigations con-
cerning the antagonism between drugs, concluded that the antagonism
between physostigma and chloral is greater than that between physostigma
and atropia. They point out that the antidotal properties of a drug are,
of course, modified by its more or less rapid action on the system. Serious
and even fatal symptoms ensue from Calabar bean much more speedily
than from chloral; therefore, to obtain the antagonistic effect of chloral.

368 MUSCAREN".

it must be given either "before, or immediately after the ingestion of Cala-
bar bean. The antagonism is not complete, for, in spite of an antidotal
dose of chloral, physostigma, although it averts convulsions, still produces
muscular twitchings, tremors, salivation, and contracted pupil; more-
over, a quantity of Calabar bean beyond a minimum fatal dose will kill,
notwithstanding chloral.

MUSCARIN.

MuscABiisr, the active principle of poisonous fungi, was first extracted
from the Amanita muscaria, and physiologically tested by Schmiedeberg.
He has since discovered a second alkaloid, identical with Jaborin, an
alkaloid of pilocarpine, and this alkaloid is antagonistic tomuscarin, as
jaborin is antagonistic to pilocarpine, llis conclusions regarding muscarin
have been confirmed and ou^- information extended by the researches of
Koppe, Prevost, Alizon, Lauder Brunton, and Schiff. Great interest
atbiches to muscarin on account of the close similarity of its action to
pilocarpine and its almost complete antagonism to atropia. It excites
copious perspiration and salivation, a flow of tears, and it increases the
intestinal mucus and the biliary and pancreatic secretions. Muscarin
affects especially the heart and intestinal canal. According to Lauder
Brunton it produces " uneasiness in the stomach, vomiting, purging, a
feeling of constriction in the neck, want of breath, giddiness, fainting,
prostration, and stupor." The stools sometimes contain mucus or even
blood. Topically applied, the merest trace at once arrests a frog's heart;
it slows the heart of mammals, reducing the beats from 120 to 60, 40, or
even 9 beats per minute, and sometimes it causes intermittency. ^I.
Alizon maintains that it first quickens the heart. It arrests the heart in
diastole; according to Prevost, by exciting the intracardiac nerve-centres.
It diminishes blood-pressure partly by its action on the heart, but partly
by dilating the blood-vessels. Respiration is depressed in proportion to the
depression of the pulse. It causes strong contraction of the intestines and
bladder; it lessens urinary secretion, even to the point of suppression;
it contracts the pupils.

In all these particulars atropia promptly antagonizes muscarin. When
a frog's heart is arrested by the topical action of a minute quantity of
muscarin, the .application of a little atropia will immediately restore the
pulsations.

Lauder Brunton has shown tliat muscarin has a singular effect on the
IHilmonary vessels. Schmiedeberg had noticed that muscarin produces
intense dyspnoea — a condition in which the arteries contain very little
blood, scarcely bleeding when cut across. Brunton's experiment on a
narcotized rabbit shows that this dyspucea is due to the muscarin causing
strong contraction of the pulmonary blood-vessels, so strong that the lungs
become blanched, and, owing to the contracted state of the pulmonary
blood-vessels, the right side of the heart becomes greatly distended. A
small quantity of atropia injected into the jugular vein at once removed
this spasm of the pulmonar\^ vessels, and unloaded the gorged right heart.
Muscarin, like pilocarpine (jaborandi), is supposed to arrest the heart
by stimulating the intracardiac inhibitory apparatus.

Stimulation of the vagus inhibits the heart's action. Thus the appli-

MUSCAKiisr. 369

cation of a weak electric current prolongs diastole and so slows tlic heart,
whilst a strong: current completely arrests the heart. After poisoning by
curare, stimulation of the vagus no longer affects the heart, but on apply-
ing the electrodes tq the sinus venosus the heart's action is immediately
inhibited. It is therefore concluded that curare paralyzes the vagus but
leaves the intracardiac inhibitory apparatus unaffected. After poisoning
by atropia neither stimulation of the vagus nor of the sinus affects the
heart, therefore it is concluded that atropia poisons both the vagus and
the intracardiac inhibitory apparatus. The local application of either
muscarin or pilocarpine quickly arrests the beat in diastole, " like a heart
inhibited by profound and lasting vagus stimulation. This effect is not
hindered by curare. The application of a small dose of atropia at once
restores the beat. These facts are interpreted as meaning that muscarin
(or jaborandi) stimulates or excites the intracardiac inhibitory apparatus
which atropia paralyzes." (Foster's Physiolofiy.)

Eecent investigations, made by Mr. Morshead and myself, show that
pilocarpine and muscarin paralyze the cardiac excito-motory apparatus and
the cardiac muscular substance. Atropia, therefore, antagonizes the
action of muscarin and pilocarpine on these structures. As atropia itself
paralyzes the excito-motory apparatus a^iid muscular substance we have an
instance of a substance which paralyzes a structure antagonizing the action
of another substance which paralyzes the same structure.

Pilocarpine and muscarin paralyze the excito-motory apparatus, and
yet pilocarpine removes the paralyzing action of muscarin on these struc-
tures, and in this respect is nearly as powerful as atropia. Here we have
another instance of a jmralyzer of the excito-motory apparatus and cardiac
muscle antagonizing the action of a substance which also paralyzes the
excito-motory apparatus and cardiac muscle. We have suggested
that this antagoiiism is due to chemical displacement; that atropia and
pilocarpine, whilst paralyzing the cardiac structures to a much less degree
than muscarin, have a stronger affinity for the cardiac nervous structure
and nmscular substance than muscarin; hence atropia and pilocarpine
displace muscarin and substitute their weaker action for the more power-
ful action of muscarin.

Schiff believes that poisonous mushrooms produce other symptoms
than can be accounted for by the action of muscarin, as restlessness, con-
vulsions, and dilatation and contraction of the pupils; and he is led to
believe that poisonous mushrooms contain two active ingredients — one
having an opposite, the other a similar, action to that of atropia.

In conjunction Avith Mr. E, A. Morshead I have made some investiga-
tions regarding the action of muscarin on the human body.

Our observations were undertaken to endeavor to ascertain whether the
action of muscarin on man is the same as on animals. The muscarin we
employed was synthetically prepared by Merck, of Darmstadt. In the
following experiments we administered the drug hypodermically. We
have made thirteen experiments on four men, seven, three, two, and one
respectively. These men, it is well to state, were not in good health;
three were in a delicate anasmic state, the other had slight fever from
some obscure cause, though his pulse was not quickened.

A large number of preliminary observations were made to ascertain
the minimum dose adequate to produce symptoms. This we found to be
a third of a grain given hypodermicall}^

We find that the action of muscarin on man is identical with that on
24

370 JIUSCARIN".

animals. It contracts tlio pupil, excites profuse perspiration, free saliva-
tion, running at the eyes and nose; it ^^^^I'gcs, sometimes excites nausea
and vomiting, and a strong desire to pass urine.

We shall now speak more in detail of these different effects.

Pers])inifion. — Sweating occurred in eleven of the thirteen experi-
ments. Half a grain always made it free, Avhilst larger doses, as three-
quarters of a grain or a grain, rendered it very abundant; quite as free,
indeed, as the perspiration excited by a third to half a grain of jDilocarpine.
After the larger doses the perspiration stood in large drops on the face,
the night-dress became soaked, and the skin felt sodden. In one man,
though we gave one-third of a grain and one grain respectively in two
experiments, we produced no sweating, but free salivation, amounting to
four ounces. Perspiration began in from three to fifteen minutes, oc-
curring earliest after the larger dores. It lasted from half an hour to an
hour and a half. On testing the reaction of the sweat in six experiments
we found it neutral in four and alkaline in two.

SaUvdtion was not so constant as perspiration; moreover, the saliva
varied in quantity more than the perspiration, corresponding in this
respect to ])ilocarpine. Salivation occurred in eleven experiments, and
was absent in four. In three it \Viis slight, in the rest free or profuse. It
began in from two to fifteen minutes, and lasted from twenty to eighty
minutes.

Laclirymation occurred in eight cases, amounting in some instances
only to suffusion of the eyes, but generally the tears trickled down the
face, so that the j^atient was obliged to wipe his eyes. It began in six
to ten minutes, and lasted generally about twenty to thirty minutes.

Purgation. — In the cases in Avhich it purged the injection took effect
in from ten to twenty minutes. In two experiments the drug excited an
inclination to pass a motion; in four experiments on the same man it ]iro-
duced a loose motion, one of a green color, though his bowels were opened
naturally a short time previously.

False. — In one of our four men the pulse was always ver}^ quick; in
the other three it was natural. The effect on the normal frequency was
nil, or almost ml, though in one man, on whom only one observation was
made, it reduced the frequency ten to sixteen beats. The medicine re-
duced the quick pulse from 120 to 80 and 60 beats per minute. Our
observations are too few to enable us to speak with certaint}^ of the influ-
ence of muscarin on the pulse, but it appears to us that the doses we
employed affected the frequency very little, but the larger doses made the
pulse softer and more compressible.

JiC'spiration. — The frequency of breathing was unaffected in every
experiment.

SifjliL- — AVe have notes of the states of the pupils in only ten experi-
ments. In each case the pupils became contracted, often considerably;
the contraction beginning in about fifteen minutes. The vision seemed
unaffected.

In three of our experiments made on one man with the larger doses,
the drug induced vomiting once, and once nausea.

In five experiments the patients were obliged to pass urine in from
nine to fifteen minutes after the injection, and two complained of supra-
pubic pain. In five the drug produced a frequent hacking cough. In
none did headache or other nervous symptoms arise. Like pilocarj)ine,
muscarin favors sleep.

MUSCARIN^. 371

To show how dose is the similarity in tne action of muscarin to that
of pilocarpine we give a short account of the effects of tlie latter drug.

Jaborandi (pilocarpine) flushes the face and produces copious perspira-
tion and salivation. It increases the bronchial secretion, exciting a slight
cough, and produces slight running at the eyes and nose. It causes nausea
and sickness, and, according to some authorities, diarrhoea, though this
never occurred in the numerous experiments made by me in conjunction
with Mr. Gould and ]\[r. Murrell. It considerably quickens the pulse.
It often produces headache, generally frontal, with heaviness over the
eyes, associated with giddiness and a stupid feeling. The sight is gener-
ally hazy, and in about two-thirds of our observations, when the drug was
applied to the eye, it contracted the pupil, often considerably; tliough,
Avhen administered by the stomach or hypodermicalh', it had but little in-
fluence on the pupil. It often produces suprapubic pain, and still oftener
a strong and irresistible impulse to pass urine.

The similarity between the action of muscarin and pilocarpine is evi-
dent. There are, however, slight dilferences. The perspiration and
salivation are generally greater after pilocarpine, and last a longer time,
though possibly larger doses of inuscarin might in this respect rival pilo-
cai-pine. We are led from our experiments to conclude that muscarin acts
rather more on the lachrymal glands than ]*)ilocarpine. Muscarin certainly
acts on the bowels far more powerfully than pilocarpine. Muscarin, in-
ternally administered, contracts the 2:)upils more strongly than pilocarpine.
On the other hand, Jaborandi ])roduces more suprapubic pain, and more
frequently and more strongly the impulse to pass water. Moreover, pilo-
carpine produces headache and giddiness, symptoms never yet noticed by
us after muscarin. In our experiments with muscarin none of our patients
complained of any disturbance of the sight, but on this point Ave have not
sufficiently examined them. Pilocarpine produced a little droAvsiness, but
Ave have not observed this after muscarin. In our experiments on man
pilocarpine in every case quickened the pulse, and as the fact has been
amply corroborated by other observers, we may conclude that it is estab-
lished, though Langley, in his experiments on animals, finds that it sIoavs
the heart, acting thus on animals like muscarin. In our experiments on
man muscarin produced very little effect on the pulse; if it altered fre-
quency at all, it reduced the number of beats.

Whilst muscarin thus so closely resembles pilocarpine in its action on
the body, in one respect it strangely differs. Administered internally,
either by the stomach or subcutaneously, pilocarpine slightly contracts
the ]nipil; topically applied to the eye it strongly contracts the pupil.
Muscarin, given hypodermically, contracts the pupil far more than pilo-
carpine; but, strange to say, when applied to the eye itself, it Avidely
dilates the pupil. Thus, Avhilst it is so generalh^ antagonistic to atropia,
in this one respect it is similar. In respect to its action on the pupil it
corresponds to gelsemium, which, administered by the stomach, contracts
the pupil, but applied locally, Avidely dilates it.

AVe tested the topical effect of muscarin in nine cases, using a solution
containing one part of the drug in ten of Avater. This solution produces
A'ery little or only transient smarting. In every case the pupil became
dilated, generally Avidely dilated, the dilatation beginning in from a quar-
ter to three-quarters of an hour, and continuing about tAventy-four hours
or a little longer.

So far as Ave can jiidge at present, from only a few careful observations,
the dilatation verv little interferes Avitli the sisrht.

372 JABORANDI.

In some of our experiments it seemed to us that the doctored pupil
contracted very slight!}' before it dilated, whilst in other cases both
pupils certainl}' at first contracted somewhat. To test the early effect
of the local application we dropped some of the solution into a cat's eye,
and watched the effect; but, although after a time the pupil widely
dilated, we could not detect any initial contraction.

De Haen, Andral, and Trousseau used agaracus with great success in
the sweating of phthisis. Recently, Dr. Peter has highly recommended
it in doses of 20 to 30 centigrammes shortly before bedtime. It is also
used to arrest the secretion of milk. Dr. Murrell finds it useful in the
sweating of disease. The white agaracus should be given in doses of 10
to 30 grains of the powder, 3 to 6 grains of the extract.

JABORANDI

contains four alkaloids: pilocarpine, on which its effects mostly de-
pend ; jaborine, which, strange to sa}^, has an action like atropia, and
therefore is antagonistic to the other alkaloid, pilocarpine: jaborine
present only in small quantities: also pilocariDiden and jaboriden — pilo-
carpiden acting like pilocariDin, and jaboriden like jaborin. Pilocarpine
can be easily transformed into j;iborine, and pilocarpidine into jaboridin.
This active and interesting drug, long in use in South America, was
lately brought from Pernambuco to Paris by Dr. Continho, who recom-
mended it as a powerful diaphoretic and sialagogue. Dr. Continho
advises the patient to drink the infusion with the susjiended leaves,
then to go to bed and cover himself with warm clothing. In about ten
minutes the face, ears, and neck become deeply flushed, and soon drops
of ]3erspiration break out over the body, whilst at the same time the
mouth waters. In a short space of time the perspiration rapidly in-
creases, the sweat running down the body and soaking the clothes, whilst
the salivation becomes profuse, oozing from the mouth, sometimes in an
almost continuous stream. The sweating and salivation persist from
two to four or five hours. Occasionally it happens that perspiration fails
to follow the medicine, and salivation is more frequently absent; but
when the drug fails to cause sweating it salivates, and vice versa. The
symptoms come on, as I have said, in aiiout ten minutes, but sometimes,
if the external conditions are not favorable, the symptoms may be much
delayed, even for an hour or longer, and often, perhaps, are brought on
only by brisk exercise. Hypodermically injected, the alkaloids act in
three to five minutes.

The amount of saliva secreted may amount to a pint, or a pint and a
half.

Pilocarpine promotes other secretions, as the tears, the bronchial and
intestinal secretions, though to a far less degree than the salivary and
cutaneous secretion. Thus the eyes water slightly, and sometimes there
is a little running at the nose, and a slight loose cough ; moreover, some
observers state that it relaxes the bowels, an effect I have never witnessed
in my numerous observations. In many cases these effects on the tears,
etc., are absent. It does not increase the biliary secretion.

JABORANDI. 373

Diirnig the sweating the body temperature falls from 0.4° to 1.4° Fall.,
the average in my observations conducted with Mr. Gould being 0.9°.
The depression lasts from one to four hours. This effect on the tempera-
ture is no doubt due to the perspiration, heat being lost by increased
evaporation and radiation, more blood being probably sent to the skin
during the sweating period.

In the human sul)ject jaborandi always quickens the pulse, my original
assertion on this point having been suljsequently abundantly confirmed.
Strange to say, ]\Ir. Langley finds tliat it slows the heart of warm-blooded
animals and frogs, and as regards frogs I have repeatedly verified this
statement. The pulse is increased in man from 40 to 50 beats, the ac-
celerated rate continuing for more than four hours; at the same time the
pulse is Aveaker. Jaborandi slows, and at last arrests, the heart of frogs,
whether injected under the skin or applied directly to the heart. The
heart stops in wide diastole. If, when the heart is greatly slowed, or
even stopped, a minute quantity of atropia is directly applied the heart
soon begins to beat again, and, ultimately, quite or almost recovers from
the effect of the pilocarpine. Mr. Langley's experiments lead him to
conclude that jaborandi slows and arrests the heart by stimulating the
same nervous apparatus that atropia paralyzes, and so quickens the heart,
namely, the intracardiac inhibitory apj)aratus.

It is curious that whilst jaborandi slows and arrests in diastole the heart of frogs,
and, according to Langley, of warm-blooded animals, it greatly quickens the heart of
man. We see the same contradiction in the action of atropia on man and the lower
auimals. Atropia quickens and strengthens the heart in man and horses, dogs, etc.,
whilst a full dose swallowed, or topically applied, arrests the frog's heart in diastole.

Jaborandi at first flushes and then pales the face. The pallor comes
on when the sweating is active, showing that the sweating is not due to
the excess of blood sent to the skin.

It often prodtices froiital headache, sometimes with giddiness and dul-
iiess. After the internal administration, the sight frequently becomes
hazy, without any alteration in the size of the pupils. But the topical
application to the eye, as I have shown, cattses decided contraction of the
pupil. ]\Ir. Tweedy concludes from his investigations that jaborandi,
locally applied, causes (1) contraction of the pupil; (2) tension of the ac-
commodative apparatus of the eye, with approximation of the nearest and
furthest points of distinct vision; (3) amblyopic impairment of vision
from diminished sensibility of tlie retina. These effects, however, do not
last long..

Jaborandi seems' to be slightly narcotic, for patients often fell asleep
during oitr experiments.

It not unfreqtiently excites sickness. 'Jhis can, in part, be accounted
for by the large quantity of saliva swallowed; often, indeed, the vomit
consists solely of saliva.

In many cases jaborandi j^i'oduces pain, often severe, over the pubes,
with a distressing irresistible desire to pass water, the pain at once sub-
siding on emptying the bladder. As the qtiantity of urine is not increased,
it is probable that jaborandi excites contraction of the bladder.

From a few experiments I have made I think it probable that jaborandi
promotes the secretion of milk.

Jaborandi affects children far less easily than adults. A small dose,
as one-sixtieth of a grain, induces local swelling without any aj^parent
general action.

374 JABORAXDI.

Pilocarpine induces increased glandular secretion by stimulating the
ends of secretory nerves.

Remedies excite sweating through their influence on the nervous system, some
acting on the sweat centres in the cord, others on the peripheral secreting ap-
paratus. Acetate of ammonia, plij^sostigma, nicotine and picrotoxine, acton tlie
cord; pliysostigma and picrotoxine on tlie sweat centres in the medulla. Pilo-
carpine acts on the peripheral nervous apparatus. (Marmie and Nawrocki.)

Ott concludes that muscarin acts on the gland cells, for on section of the sciatic
nerve, in a warm-blooded animal, aftei- an interval of nine days, stimulation of
the peri|)heral end excites no perspiration, showing that the sweating nervous
apparatus is paralyzed, but muscarin will still excite sweating in the foot of the
leg with the divided sciatic.

Pilocarpine first stimulates and then paralyzes the motor nerves of
involuntary muscular fibre. This action explains the infrapubic pain,
the contracted pupil, and the increased intestinal movements. It also
causes contractions of the uterus. It is evident, from the previous ac-
count, that there is a marked antagonism between atropia and pilocar-
jaine. But in three respects they correspond, for both produce frontal
headache and infrapubic pain, Avitli desire to pass water, and both affect
children less than adults. In order to test the antagonism between these
two drugs, I have, on many occasions, administered pilocarpine, and
when the sweating was profuse, I have injected hypodermically. grain
yi-fj- of atroj^ia, and in five to ten minutes the skin became quite dry,
and salivation ceased. Strange to say, not only did atropia remove the
antagonistic effects of pilocarpine, but likewise those symptoms common
to both drugs, namely headache and desire to pass water.

Jaborandi is useful in Bright's disease, especially on the occurrence
of urajmic symptoms. If ursemia is urgent pilocarpine may be injected
hypodermically, and I have seen marked improvement follow this treat-
ment. Drachm doses of the liquid extract should be given several times
a day. Large doses of the extract or full doses of pilocarpine produce
much depression and cannot be continued.

Dr. Berkart recommends the hypodermic use of pilocarpine in
asthma; and in bronchitis when the secretion is viscid and scanty jabo-
randi or its alkaloid have been used successfully.

Pilocarpine, in doses o^' -gV gi'ain,, given thrice daily, will check pro-
fitse perspiration, and I have often found it useful in the sweating of
jDhthisis, and other observers have verified my statement.

G. Guttmann and many other writers highly commend pilocarpine
in diphtheria. It manifests its action locally on the throat. It is stated
that the promotion of free secretion of these parts detaches the false
membrane. The experience of others, however, is not favorable to the
employment of pilocarpine in, this disease. Some employ pilocarpine in
mumps; and the accounts of some 'writers tend to show that this drug is
useful in removing the effusions in pleurisy, hydrothorax and ascites.

Bartholow finds a local application of jaborandi useful in baldness, and
recommends the following: — Extract of pilocarpine an ounce, tincture of
cantharides half an ounce, soap liniment an ounce and a half. To be
applied to the scalp daily. Possibly the action is due to the cantharides.

Xot only do arresters of secretion like atropia, etc., check excessive
pers})iration, but sweaters in small doses are equally effectital in check-
ing undue perspiration. Thus I have shown that pilocarpine, in -gV
grain doses thrice daily, is a most efficient remedy in excess perspiration,
as in phthisis. Agaracus (muscarin) and Dover's powder also check too
free sweating, and recently Dr. Murrell has shown that picrotoxine

GELSEMIUM SEMPERVIKENS. 375

effectually checks the night-sweats of phthisis in yf^ grain closes. It
may be administered in the form of infusion, made with sixty or ninety
grains of the powdered leaf, or as tincture, a drachm of which is equal
to thirty grains of the leaf, or as the alkaloid pilocarpine, of which half
a grain to three-quarters of a grain may be given by the stomach, or a
quarter to half a grain hypodermically, or as the liquid extract half a
drachm to a drachm three or four times a day.

GELSEMIUM SEMPERVIRENS.

This powerful drug has long been employed in America. Its physio-
logical action has been investigated by Dr. Koberts, Bartholow, Dr. Ott,
and Dr. Berger.

Gelsemium, lately introduced into this country as a remedy for neu-
ralgia, is especially useful in non-inflammatory toothache and in neuralgia
of the nerves supplying the teeth and the alveolar processes of the jaw.

Gelsemium is a powerful paralyzer and respiratory poison. Its paral-
yzing action is best studied in the frog. In these animals it often
produces tetanus as Avell as paralysis. Whether we produce paralysis
alone, or paralysis followed by tetanus, depends on the dose. Thus,
as a rule, with small doses of the alkaloid, we only get paralysis; with
rather larger, quiverings and tetanoid movements; and only after large
doses decided tetanus.

Is the paralysis due to the influence of the drug on the brain, the cord,
the motor nerves, or the muscles ?

It paralyzes the spinal cord, the motor nerves and the muscles being
unaffected.

The tetanus is due to the action of the poison on the cord, and I draw
special attention to the fact, that the paralysis of the cord always pre-
cedes the tetanus; that gelsemia has the property of first weakening and
then tetanizing the cord, thus corresponding to jaborandi, buxus seinper-
virens, and other drugs.

Gelsemium is a powerful respiratory poison; indeed, this drug gener-
ally, if not always, destroys warm-ljlooded animals by asphyxia, before it
produces complete paralysis. It produces no primary quickening of respi-
ration, and does not paralyze the phrenic nor the intercostal nerves, and
it acts after the division of both vagi. It asphyxiates, as Dr. Burdon
Sanderson has shown, by paralyzing the automatic respiratory centre. It
salivates cats.

Some individuals, however, as might be expected, are much more prone
to be affected than others. Thus a woman suffered from diplopia, head-
ache and liazy sight after a second dose of ten minims, one in four of
rectified spirits; and, in another case, two doses of twenty minims, at two
hours' interval, produced well-marked symptoms presently to be described.
On the other hand, I have given drachm doses hourly, for six hours, with
very slight effect; and in one instance I gave twenty minims to a delicate
young woman every three hours for several days, finally causing slight
heaviness in the eyelids

Unless given in dangerous doses gelsemium affects first and chiefl}' the
eyes and brows. The symptoms generally occur in a certain order; not
without exceptions, however, both in the order and number of the symp-
toms. The drug ordinarily first produces pain in the brows, followed
soon by giddiness, then by pain in the eyeballs, and soon after by dimness

376 GELSEMIUM SEMPERVIRENS.

of sight. A larger dose produces double vision without apparent squinting,
with sensation of great lieaviness in or under the upper eyelids, with
somewhat contracted pupils. A still larger dose causes drooping of the
upper lid, sometimes so marked that the edges become nearly closed, and
can be opened only by a strong and painful effort : and after straining to
open them, sometimes the upper eyelid is so tired that ptosis for a short
time becomes complete. The movements of the eyeballs are restricted,
and associated in one case with a strong double internal squint. The
patient next complains of weakness in his legs, and we have never pushed
the drug beyond the production of this symptom. AVhen decidedly under
the drug's influence, the patient is pale, with a heavy sleepy look. Some
say their eyes feel sleepy; others yawn frequently, and say they can hardly
keep awake, and when left to themselves fall asleep. Others complain of
dryness of the mouth, though the tongue looks moist, and to the finger
feels so. Some keep moistening the mouth with a little water, even hours
after the discontinuance of the medicine.

In most instances these symptoms occur, but in some even large doses
of the tincture induced only a few of the slighter symptoms. Thus, a
woman took a drachm dose hourly, for six hours, without exciting head-
ache, diplopia, or giddiness — only great heaviness of the eyes, and dimness,
amounting almost to temporary loss of sight; though on a former occasion,
in this very woman, we produced extreme diplopia with giddiness, with
four one-drachm doses of the tincture. Diplopia, as we have shown, is
generally preceded by headache, giddiness, and dimness of sight; but, in
one instance, diplopia occurred without these preliminary symptoms,
though, strange to say, on a subsequent occasion, in this same woman, with
a larger quantity — that is, six one-drachm doses hourly — we produced
much giddiness, and mistiness without diplopia.

The symptoms from gelseniium come on early, and soon subside. A
single drachm dose rarely produces any marked symptom, but in from ten
minutes to a quarter of an hour after the second hourly dose the symptoms
appear, and reach their highest point in about half an hour, and then
quickly subside, most of them ceasing in about an hour. With the repe-
tition of four or six hourly drachm doses the symptoms may persist six
or eight hours after the last dose; but the symptoms are most marked
half an hour after each dose, and then decline.

The patients described the pain in the head and eyes variously. It was
generally limited to the forehead, and most marked just over the eyes.
Some call it a dull sensation over the eyes; others, a heavy pain; others,
a giddy pain; and one patient experienced pahi over the occiput, with a
sensation as of lifting the crown of the liead off in two places. Some-
times this headache was absent, sometimes it follow^ed instead of preceding
the otiier symptoms. Dull aching pain in the eyeballs, now and then
shooting in character, oocasionally worse in one ball, sometimes followed
and sometimes preceded the headache. The headache and pain in the
eyeballs were often severe, and were intensified on moving the eyes.
AVhen ptosis was well-marked the effort to open the eyes widely caused
considera})le pain, and the patient seemed to get relief l)y closing his eyes.

Giddiness was another prominent and early symptom. Some felt it
over the whole head ; but by far the larger number said it was limited to
the Ijrows. Standing or walking made it much worse. "When well-marked,
the patients staggered, and were afraid even to stand, much less walk.
So giddy was one patient, that he nearly fell off the form. Some

GELSEMIUM SEMPERVIRENS, 377

described their heads as going round and round. They felt and seemed
drunk, though without any incoherence, or mental excitement.

In every case the sight was affected; indeed, dimness of sight and
giddiiiess appear to be the most constant symptoms, and may exist with-
out headache, pain in tlie eyeballs, or double vision. At first, the sight,
without being misty, is not so clear as usual; then slight mist comes before
the eyes, one patient comparing it to a "lot of smoke rising before his
eyes" and another to a "thick veil.'"' At last the sight becomes so af-
fected tliat it fails almost completely, first Avith distant objects; then with
further impairment of vision, nearer and near objects look liazy. Gelse-
mium alfects, too, the sight in animals. Thus we poisoned a dog, and,
after the production of slight muscular weakness, the sight became
almost lost, for the animal ran straight against objects without trying to
avoid them, evidently not seeing them.

The drug seems to produce two kinds of diplopia, one much more
persistent than the other. As to the transient kind, we find it, on
many occasions, a very passing phenomenon, lasting only a few seconds,
then disappearing, then, after a few minutes, reappearing. In this tran-
sient form images in the median vertical line appear double, distant objects
at first undergoing the duplication. Sometimes the patient was conscious
of the onset of the diplopia; thus one Avoman said, "I know it is now
coming on; I feel such a heavy weight under my upper eyelid.'' The
double vision then came on, and, with the heaviness, passed away in a
few seconds. One image was higher than the other; the images in this
respect varying much. Mr. T. Fox rapidly recorded, from the patient's
]ips, the phenomena occurring as fast as they could be written: "One
gas jet appears about six inches above the other, and there are six inches
between them horizontally; the upper one is to the left; now the right is
uppermost; now the left slightly again; going over to the right now again;
exactly over one another and quite close together; now again separated,
left the highest; now over one another." With other patients the two
images seem on a level. Sometimes the drug produces only this transient
kind of diplopia; at other times both kinds; and sometimes one kind pre-
ceded the other, the transient usually preceding tlie more constant form,
recurring from time to time, while the constant form persisted.

The phenomena of the constant form of diplopia follow a definite
order, and take place in the upper half only of the field of vision. They
occur first with objects held at the extreme right or left of the visual
field; and, as the patient passes more under the influence of the drug,
then with objects held nearer and nearer the middle line; and at last,
usually for a short time oidy, objects in the median vertical plane seem
double. As the effect of the drug wears off, the double vision disappears
in the inverse order. The outer lateral image is the higher, and the
further the object is carried to the right or left the greater is the horizon-
tal and vertical distance between the images. When a colored glass is
placed before either eye the outer and higher image is seen by the covered
eye. When the object is carried high above the head the two images
gradually coalesce, and the objects looks very much thinner, " like a
thread." AVith well- developed diplopia there is impaired movement of
tlie eyeball, chiefly alfecting, as far as can be ascertained, the external
and internal rectus, especially the external, for the outward and inward
movement of the eye-ball is less free than before the action of the medi-
cine. The ball appears to be moved by a greater effort, so that when

378 GELSEillUM SE3IPERVIRENS.

carried as far as the weakened muscles are capable it oscillates; as though
the patient, witli a great effort, moved it as far as he could, and then the
tired muscles gave way a little, but being roused to an effort, they carried
the eye back again, the frequent repetition of this effort giving rise to an
oscillation.

The external rectus is generally first affected, and not infrequently
one external rectus sooner than, and in excess of, the other. Even when
the diplopia is strongly marked the loss of power over the muscles is not
very great, and there is no obvious squinting. (We may remark here that
we could not detect aiiy squinting during the transient form of diploiiia.)
Then, as the patient becomes still more affected, ptosis supervenes, and a
great part, or the Avhole of the upper half, of the field of vision is cut off.
The loss of power in the eye muscles is then more marked, but without
the occurrence of obvious squinting. At this time symptoms no longer
follow the order previously described, but assume various forms, often
changing rapidly. Thus, whilst on one side the outer image is the higher,
if the object is carried to the other side of the field the inner image
becomes the higher; or, perhaps, for the first few seconds the outer and
then the imier is the higher.

In twenty-two out of thirty-three series of observations the pulse re-
mained unaffected in frequency, Avhilst in the remaining eleven it was
accelerated, the increase ranging from six to twelve beats in the minute.
Curiously enough, even in the same patients the effects were variable, for
although on some occasions the drug accelerated the pulse, on others it
failed to affect it. This was not a mere question of dose, for an increase
in the dose did not affect the result. With a patient fully under the in-
fluence of the drug we were inclined to think the pulse became a little
smaller and softer. These observations show that gelsemium produces
little if any effect upon the circulation, a conclusion confirmed by observa-
tions on the lower animals.

Dr. Burdon Sanderson concludes, from a kymographic experiment on
a rabbit, that gelsemium exerts no influence on the blood pressure.

Gelsemium acts less powerfully upon the respiratory centre in man
than in the lower animals, or, perhaps, to speak more accurately, we
should say that in the human subject other parts of the nervous system
are affected before the respiratory tract. Thus in man the drug produces
giddiness, pain in the head, loss of sight, diplopia, and ptosis before res-
piration is in any way affected. This ptosis may be so complete that the
eyes cannot be opened, and the sight may be temporarily almost destroyed,
yet the breathing will not be altered in character, or, at all events, will
become only slightly more superflcial. It may be said that the symptoms
we have enumerated may have been overlooked in the lower animals. I,
of course, cannot answer for the pain in the head and giddiness, but I am
enabled to speak positively as to the absence of ptosis. I frequently
noticed that Avhen an animal was so fully under the influence of the drug
as to be on its side in a condition of absolute helplessness it was still able
to open its eyes Avidely, apparently without the slightest effort.

In the lower animals gelsemium, as we have seen, acts first on the
respiratory centre, then on the spinal cord. In man, however, the muscles
of the upper eyelids, or more probably their motor nerves, are considera-
bly affected before either the cord or respiratory centre. Moreover, if the
cases of poisoning are correctly reported, Ave are justified in concluding
that in man the drug acts upon the spinal cord before it involves the

GELSE^IIU^r SEMPERVIRENS.

879

respiratory centre, for in several instances it is recorded that the patient
has recovered from a condition of complete paralysis. In my experi-
ments on cats, rabi)its, and dogs we found that the animal died from as-
phyxia before there was any great impairment of voluntary power.

Gelsemium, as I have already stated, has been highly praised in the
treatment of cough, especially in " convulsive or spasmodic cough."

For practical purposes we recognize three different kinds of cough: —

1. Where the expectoration is free, and the cough is not in excess of
the expectoration,

2. Where the expectorating power is diminished, as in emphysema and
fibroid degeneration of the lung. In fibroid degeneration, owing to the
great induration and thicke.iing of the pleura, there is little or no expan-
sion, and the air cannot be drawn into the small bronchial tubes behind
the mucus, Avhich is consequently not expelled. In these cases, although
the expectoration is slight, the cough is often troublesome, and not in-
frequently very violent.

3. Where there is excessive excitability of the respiratory centre, and
consequently a small secretion of mucus ■(suffices to set up violent and
freqent cough.

In every case the main object of our treatment is to diminish the
secretion of the mucus in the bronchial tulles. This method must be
chiefly relied on in the first and second varieties. In the third, we must
have recourse to the administration of sedatives, and ether, chloroform,
opium, and gelsemium will be found beneficial.

I have carefully watched for, but have been unable to detect in gelse-
mium, any influence on the mental faculties. It has been employed as
a mild narcotic. Patients, when under the influence of gelsemium, look
dull and heavy from the drooping eyelids, and often feel sleepy, but when
asked if they are conscious of any mental depression they always answer
decidedly in the negative. Xor is cutaneous sensibility affected. I have
tested sensibility roughly by pricking the skin and pinching, and also in
two cases by the use of the compasses, but Avas unable to detect any loss
of sensation, either in the face or forearm, although the patients to whom
I have more especially referred had taken for six consecutive hours drachm
doses of the tincture, and were fully under the influence of the drug. I
was led to pay particular attention to the action of gelsemium on the gums
from the success winch has attended its administration in neuralgia of
these parts. One patient, on both occasions on which I experimented on
him, complained spontaneously of a numb pain, and a little tenderness
along the teeth and the edges of the gums of the u]-»per jaw. I have
never, however, in any case been enabled to detect, either by pinching or
by the use of sharp instruments, any loss of sensation in the parts.

In addition to these observations on patients I made six temperature
experiments on rabbits, but the results obtained Avere simply }iiL I soon
found— a fact with which I was previously acquainted — that in these ani-
mals fright exerts a marked influence on the temperature. The mere
holding the animal's legs, or placing it on its side with a view of intro-
ducing the thermometer into the rectum, will rapidly reduce the tem-
perature by two degrees. My conclusions on the point in question have
consequently been drawn entirely from observations on patients.

Strange to say, the effect of an internal dose of gelsemium is opposite

380 GELSE3IIUM SEMPERVIRENS.

to that occasioned by its application to the eye itself. When given by
the mouth in doses sufficient to produce symptoms, the drug, in every
instance but one, caused contraction of the pupil; indeed, in the case in
which the drug i)roduced weakness of the legs, with a strong double
internal squint, the pupils were contracted to a pin's jjoint. In the ex-
ceptional patient just referred to, on Avhom I made two observations,
though on each occasion I jiroduced great giddiness, laziness, suscepti-
bility to light, and diplopia, the pupils did not contract, but manifested
a very unsteady condition, varying greatly in size, in rapid alternation,
■without any apparent cause. In another patient the pupils strongly
contracted when exposed to light, but they dilated freely in a darkened
room, and when they recontracted on exposure to light they seemed in
an unstable condition, oscillating a good deal. The eontraction of the
pupil does not cease on the disapiDcarance of diplopia or dimness; in-
deed, when the dimness passes away, the contraction of the pupil may
increase.

In cases of accidental poisoning it is reported that during complete
general paralysis the pupils are widely dilated, whence it might be in-
ferred that the condition of the pupil depends on the dose — a moderate
dose contracting, a very large one dilating, the j^upil. This inference is
possibly in part true, but the dilatation may be due likewise to the
asphyxia consequent 'on large doses. Dr. 0. Berger finds, and my obser-
vations confirm his statements, that dilatation of the pupils in poisoned
animals occurs only when asphyxia from paralysis of respiration has set
in, and that artificial respiration at once causes the pupils to contract.

On the other hand, the topical application to the eye dilates the
pupil. In the first instance I employed a tincture (1 in 10) of the
American liquid extract. These prej^arations dilate the pujiil slightly,
but they excite great irritation. Subsequently, I employed the alkaloid
prepared by Mr. Gerrard — one grain in twenty minims of water, a solu-
tion Avhich causes scarcely any smarting. Mr. T. Fox and Mr. Sydney
Pearse made for me nineteen observations. A few drops of the solution
were put into one eye, and in each case this trial pupil became Avidely
dilated, the dilatation usually beginning in about thirty minutes. Not
only does the pupil dilate, but the muscle of accommodation becomes
paralyzed and the sight affected; the vision again becomes nearly natural
in twenty-four hours, but the pupil remains dilated much longer, some-
times, indeed, for a week, or even a fortnight.

The fact that the internal administration contracts the pupil led me
to examine carefully whether the local application to the eye causes
any primary contraction; and in three instances I thought I detected
very slight contraction, lasting only a few minutes.

The local application also dilates the pupils of rabbits and cats.
The pupil of a cat being extremely sensitive, I thought that if the local
ai:)plication did cause primary contraction I should detect it best in this
animal.

In five observations the pupils in each instance became decidedly
contracted before dilating. In one instance the contraction began in
two minutes, in another it was delayed fifteen minutes, the average time
being ten minutes. Its average duration Avas twenty-four minutes, and
it was followed by wide dilatation.

I have said that the local application dilates the pupils, but I must
add that in rabbits absorption sometimes takes place so readily, and

GELSEMIUM SEMPERVIRElSrS. 381

these animals are so easily affected by the poison, that the}' become
asphyxiated, and die before the pupil has time to dilate. The con-
tracted pupils due to the internal administration of the drug, and the
dilated pupils due to its local aj)plication, are both associated with dim-
ness of sight.

I have said that the internal administration of gelsemium contracts the
pupil in man and the lower animals, and that dilatation occurs only on
the supervention of asphyxia, which at once disappears under the em-
ployment of artificial respiration, showing that this dilatation is due to
the asplwxia and not to the drug. It occurred to me that the internal
administration would probably dilate the pupil, but that a dose adequate
to produce this effect so quickly jmralyzes the respiratory centre that
before the drug has time to effect dilatation the animal dies asijliyxiated.
To ascertain the validity of our conjecture I made a rabbit insensible
with seven grains of chloral, then inserted a cannula into its trachea, and
injected into the subcutaneous tissues of the axilla thirty drops of the
liquid extract, and at once commenced artificial respiration, to prevent
the advent of any asph5'xia. In seventeen minutes I thought the pupils
were a little contracted; in twenty-six minutes well-marked signs of
paralysis set in, shown at first by a difhculty in keeping up the head; in
half an hour the animal could not raise its head off the table, whilst it
still retained considerable power over its trunk and extremities. At this
point the eyes became prominent and the pupils began to dilate, and in
thirty-four minutes the animal tumbled over on its side, and then I
noticed that the pupils were decidedly larger and the eyes more prom-
inent; but as at the expiration of an hour the pupil had not become
widely dilated, I repeated the thirty minims of liquid extract, injecting
it in two places into the subcutaneous tissue. Paralysis rapidh' increased,
till it became complete in the anterior part of the body, though still the
rabbit had considerable power over its hind legs; but at last these also
became almost completely paralyzed, and the animal lay on its side in a
helpless state. As the paralysis advanced the pupil dilated somewhat,
till at last it became above double its original size, though it never
reached the degree of dilatation observable in man and cats after the
local application of the alkaloid. I noticed that the animal retained the
power of closing its eyes quickly and strongly, even after almost com-
plete general paralysis, whence I conclude that the seventh or some of
its branches is one of the last nerves to undergo paralysis.

While performing this experiment I noticed that the anterior part of
the body was first and most severely paralyzed, for after the anterior
limbs were almost helpless the animal retained a good deal of power over
the posterior extremities, which likewise at last became helpless.

On another occasion I repeated this experiment, and continued arti-
ficial respiration for two hours and ten minutes. During this time I
injected under the skin a drachm of the liquid extract three times, com-
pletely paralyzing the rabbit. At first the pupils became slightly con-
tracted, but under the full effect of the drug they were slightly dilated.
This experiment shows clearly that the internal administration of a large
dose will dilate the pupil, though not considerably.

To sum up the effects of gelsemium, it has very little effect on the
brain beyond inducing some drowsiness. It tetanizes and paralyzes by
its action on the spinal cord. It paralyzes the respiratory centre; it

882 GRINDELIA ROBUSTA.

probably paralyzes the peripheral parts of some branches of the occulo-
motor nerve. It slightly dei)resse3 the heart by its direct action.

I have tried gelsemium with decided success in several cases of
neuralgia of the dental nerves, even when the teeth were carious. Un-
fortunately, in several cases, the necessary dose to relieve pain produced
much giddiness, haziness and sometimes sleepiness, a considerable draw-
back. In some instances ten minims three times a day produced these
toxic symptoms. To a girl of fourteen, suffering with neuralgia of the
supra-orbital branch of the fifth, I gave ten minims of the tincture three
times a day, and each dose produced complete ptosis of the neuralgic
eye, lasting an hour or longer.

I have found tincture of gelsemium in ten-minim doses thrice daily
useful in some cases of Meniere's disease. In five-drop doses repeated
every quarter of an hour the tincture is said to be useful in gall-stones,
and in one case in my experience it has repeatedly averted an attack. In
fact, the patient gets relief in five minutes after the first dose, and all
the sooner when he walks about.

A tumbler or two of hot water with a teaspoonful of carbonate of
soda is said to relieve the pain of gall-stones.

It has been employed in tetanus and in mania with sleeplessness.

It is highly spoken of in sleeplessness, especially of drunkards and
from over-excitement.

It sometimes benefits asthma, and is useful in ovarian neuralgia and
dysmenorrhoea, and in many of the distressing symptoms occurring at
the change of life.

GRINDELIA ROBUSTA.

This composite plant has acquired a considerable reputation in
America, where it is used as an antidote in poisoning by the rhus toxi-
codendron, and as a remedy in asthma, and in allied diseases. The prep-
aration of the liquid extract has proved, in many cases, so serviceable
that, although my own experience with respect to it has been slight, it
is so far favorable that, coupled with the strong testimony I hear from
jnedical friends, I am induced to give a brief account of this jjlant,
though I must own I have been greatly disappointed with it, and it has
failed to realize the expectations raised by the recommendations of
various writers. It slows the heart and respiration. Large doses dilate
the pupil and cause sleeji, when the cutaneous sensibility and reflex
movements are lessened. It kills by paralyzing the muscles of respira-
tion.

Grindelia is employed in two ways. Some give it in three-grain
doses of the extract thrice daily to prevent an asthmatic attack; others
give it to cut short the attack in twenty to thirty-minim doses of the
liquid extract every half hour, or hourly, beginning at the very onset of
the paroxysm.

It is also used in chronic pyelitis and chronic cystitis.

BELLADONNA. 383

BELLADONNA.

Certain animals, like pigeons and rabbits, appear to be almost in-
susceptible to tbe influence of belladonna.

Dr. Horatio Wood has shown that the local application of belladonna
does not dilate the pupil of pigeons, which supplements Wharton Jones's
observation that when administered internally the drug has no effect on
the eye. Stramonium and hyoscyamus, as well as belladonna, have very
little action on pigeons, and with these substances it is indeed almost
impossible to kill these birds. Two grains of atropia administered hypo-
dermically are required to kill a pigeon ; and Calmus found that fifteen
grains are required to kill a rabbit. It is said that vegetable feeders are
but little affected by belladonna, but that it is a powerful poison to
flesh-eaters; thus belladonna, it is asserted, has very little effect on
horses and donkeys.

The preparations of belladonna are in frequent use for external ap-
plications; no other applications are so effective for the relief of pleuro-
dynia and the hyper-sensitiveness of the skin and irritability of the
muscles of the chest in phthisis as the liniment or plaster of belladonna.
The liniment is preferable to the plaster, being stronger and cleaner,
and should be rubbed over the tender and painful part several times
daily, according to the severity of the pain. Although, as a rule, the
liniment is preferable, yet in certain cases of pleurodynia the constant
application of the plaster gives more relief.

The liniment of belladonna, or the ointment of its alkaloid, is some-
times used in facial neuralgia.

Myalgia often yields to belladonna, although opium preparations, as
the linimentum saponis cum opio, sometimes succeed better.

An attack of lumbago having perhaps affected the whole loins often
leaves behind it one painful spot, which may distress the patient only
when the body is moved in one direction.

This remnant of lumbago generally resists the usual methods of
treatment, and is perhaps driven from one spot only to reappear at
another; but a large belladonna plaster will generally relieve or altogether
remove this lingering pain.

Belladonna, employed either internally or externally, checks, and
even suppresses, the secretion of the glands. Tliis is true of the mam-
mary, sudoriparous, and salivary glands, and possibly of other glands.
Belladonna, it is well known, will arrest the secretion of milk, and is
employed with great advantage when, from any cause, a mother being
unable to suckle her child, the breasts become swollen, exquisitely pain-
ful, and threaten to inflame and suppurate, unless the tension of the

384 BELLADONNA.

ducts is relieved. If the milk cannot be drawn off artificially, the secre-
tion must be sup2)ressed by means of belladonna, which should be applied
early, before inflammation lias set in, and then, in a few hours, the
swollen, painful breast gradually diminishes and soon becomes soft,
comfortable, and painless. But if inflammation has set in, and tbe
breasts become tense, shiny, hard, knotty, red, and acutely jxiinful, the
continuous apj^lication of belladonna for twenty-four or forty-eight
hours will even then often remove the inflammation and tension, and
arrest impending abscess. The rapid relief it gives in these cases Avill
greatly astonish any one unaccustomed to its use. It should be em-
ployed in all cases, no matter how far the inflammation has advanced,
and it will often arrest the progress of an abscess, otherwise almost cer-
tain to maturate. Even when it fails to prevent suppuration, yet it will
reduce inflammation, subdue much of the pain, and greatly limit the in-
evitable abscess.

The liniment, the extract mixed with an equal quantity of glycerine,
the ointment, or a drachm of the tincture to an ounce of olive oil, or two
drachms of the liniment mixed with an ounce of lard, should be rubbed
especially over the areola around the nipple. The liniment is speedily
effectual.

Frequent fomentation with very hot water, unless cooler water should
be found more agreeable and soothing, is an excellent adjunct, but the
nurse must be cautioned to wipe the skin perfectly dry, or friction with
the liniment will perhaps produce a sore. Dr. Gabb, of Hastings, tells
me that he finds the combination of belladonna with the application of
an ice bag most useful in milk abscess. He smears the nipple and sur-
rounding parts with extract of belladonna and glycerine, and covers the
breast with an ice bag. The a2:)plication of ice must be strictly continu-
ous.

Belladonna will arrest not only the secretion of milk, but the secre-
tion of perspiration. A man forty-five years old had been troubled for
many months with profuse sweating of the right side of the face and
neck, which used to break out on the slightest exertion, or when near a
fire, or if excited, so that the perspiration ran down his face and neck in
streams, soaking his collar and the band of his shirt. His face was
neither red nor injected, but the sweat produced an abundant croj) of
miliary vesicles strictly limited to one-half the face.

The liniment of belladonna, applied two or three times a day, con-
siderably abated this excessive sweating, and reduced it to little more
than the natural amount.

The effect of belladonna in this instance led me to test its influence
over other kinds of sweating. If used twice or thrice a day the liniment
will completely check the sweating that soaks the pillows and bedews the
heads and faces of young children who have been sleeping. After a few
days the application may be discontinued, and there will be no return
of the perspiration. Again, many healthy adults are troubled all their
lives with profuse sweating of the hands or feet, sometimes so copious
as to run off in drops, and especially noticeable at the tips of the fingers,
and the ball of the thumb. Belladonna liniment rubbed into the hands
three or four times a day will often gradually diminish and sometimes
completely arrest this annoying affection, although, no doubt, there are
cases in which the treatment fails. The sweating may, at least, be

BELLADONNA. 385

arrested for a considerable time, and sometimes the good effects are
permanent.

Since the publication of the foregoing remarks I have made many
fresh observations, which confirm the efficacy of belladonna in checking
sweating. Thus, a j^atient, who all her life had suffered from profuse
sweating of the left side of the body, completely checked the sweating
by rubbing belladonna ointment into the face twice or three times a
day. Again, in cases of local sweating of the loins, over a surface a little
larger than the hand, the j)erspiration exciting a copious eruption of
eczema, belladonna checked the joerspiration, and likewise cured the
eczema.

Many experiments of the following kind were instituted. On several
occasions a patient, after undergoing a sweating in the hot-air bath, was
rubbed on one side of the face for a quarter of an hour three times a day
for two or three days with belladonna ointment. The bath of the same
temperature and duration was then repeated, when it was observed that
the sweating, both during the process and after, was very greatly lessened ;
also the effect was general, although the ointment was aj^plied only to
one side of the face.

In some cases the ointment was rubbed into the chest, but the effects
were much less marked than when applied to the face, possibly because
less ointment was absorbed.

As the local application checked sweating over the whole body it was
supposed that it acted by absorption, and this led to the internal admin-
istration of belladonna. The repressive effect, however, was apparently
decidedly less than when locally applied, possibly because the amount of
the drug swallowed was less than that absorbed by the skin. Still, no
doubt the internal administration of belladonna does effectually control
sweating, ^particularly in the case of weakly children perspiring pro-
fusely after exertion, and whilst sleeping.

In the curious case of a middle-aged man, who, after much mental
worry, suffered from excessive sweating of both cheeks while eating —
the tendency being promoted by hot meat, or vinegar — the sweating
ceasing immediately after the meal, ten drops of tincture of belladonna
thrice daily checked the sweating completely. This man passed, at
times, a profuse quantity of pale urine.

Employed hypodermically, atropia promptly checks sweating. After
repeated experiments I find that in profuse sweating produced by the
hot chamber of the Turkish bath one one-hundredth or one two-
hundredth of a grain of atropia will, in a few seconds, completely dry
the skin, and maintain it dry, notwithstanding the continuance of the
bath. These experiments led me to employ belladonna hypodermically
in the sweating of phthisis, and other exhausting diseases, and I found
that one one-hundredth, or even one two-hundredth of a grain would
generally arrest the sweating, sometimes for more than one night ; and
that in phthisis it made the patient sleeja better, and quieted the cough.
Dr. Murrell made, at my request, sixty experiments on phthisical
patients, and he finds that the drug, equally successful with men and
women in febrile and non-febrile cases, in the prostrate and compara-
tively strong fails in about from 8 to 10 per cent. Sometimes its effects
are delayed : thus, if administered at bedtime, it may not check sweating
till the following night j or its beneficial influence may extend over
25

386 BELLADONNA

several nights, then gnulually 'wear off, so that each night the perspira-
tion returns a little earlier. In a few cases it permanently checks the
sweating.

This treatment unfortunately produces disagreeable dryness of the
throat; but as many ]}hthisical patients suffer in this way, the slight
aggravation of the dryness is scarcely noticeable. It may be given as a
pill in one-fiftieth to one-seventieth of a grain.

Belladonna checks the secretion of the abundant foul-smelling sweat
from the feet. In making the liniment eau de Cologne may .be used
instead of simple spirit. We meet with cases where the soles of the feet
are very tender, and the skin jieels off in large flakes, leaving the dermis
very red. This condition is accompanied by much sweating of the feet,
and is probably produced by the sweating. It is apt to persist for years,
but may, in some cases, be cured in ten days or a fortnight by the local
application of belladonna night and morning.

In checking sweating aliout the head and face too much liniment
should not be applied at one time, or, becoming absorbed, it will dilate
the pupil and obscure the sight.

In the cases just described it was experimentally joroved that the
effects are due to the belladonna and not to the spirit.

Belladonna checks salivary secretion, and induces dryness of the
mouth and throat.

" The salivary glands are supplied by nerves derived from the
seventh. That part proceeding to the submaxillary gland runs incor-
porate with the chorda tympani nerve. Through tliis nerve the sub-
maxillary gland is stimulated to secretion. Thus, if an acid is placed
on the tongue, the secretion from this gland becomes abundant; but if
the chorda tympani nerve is divided, acids applied to the tongue or
mucous membrane of the mouth, fail to 2)roduce this secretion. If the
distal end is electrically stimulated, we produce the same effects as the
application of an acid to the mouth ; thus, the arteries leading to the
submaxillary gland enlarge, and the blood passes so quickly through the
gland that its veins pulsate and become filled with arterial blood, whilst
an abundant secretion pours forth from the gland. If atropia is given
to the animal, neither acids to the mouth nor stimulation of the chorda
tympani will excite submaxillary secretion. How is this arrest produced.
Does the belladonna prevent the flow of a sufficient supply of blood to
the gland and so arrest secretion ? This view, formerly accepted, is now
held to be erroneous, for though atropia will diminish the blood-supply,
still, if the chorda tympani nerve is stimulated, the vessels dilate, and
abundant blood is sent to the gland Avithout augmenting the secretion;
hence the action of atropia is not due to its paralyzing effect on the
vaso-dilator fibres of the chorda tympani ; and it is inferred that this
nerve also contains fibres distributed to tlie cells of the gland — in fact,
secretory fibres, and that belladonna paralyzes these fibres of the chorda
tympani.

" I would jioint out that atropia may possibly act directly on the
gland cell, this hypothesis explaining the foregoing facts as satisfactorily
as does the assumj^tion of the existence of secretory fibres.

" Experiments indicate the existence of sweat centres. Luchsinger
believes that these centres are situated in the lumbar and lower part of
the dorsal region of the spinal cord. Xawrocki believes that the medulla

EELLADONNA. 387

contains a sweat centre. It has been demonstrated by Lnchsinger and
Ostramoff that the sweat fibres run witli the vaso-motor fibres. Lnch-
singer and JSTawrocki sliow tliat pilocarpine and atropia affect the
sweat by tlieir action on the peripliery of the sweat apparatus, and
perhaj^s in tlie centre as well. Dr. Ott and Mr. W. Field also show that
niuscarin also excites sweating by its action on the peripheral sweat aji-
l^aratus.

" Belladonna, as we have seen, affects the salivary secretion by its
action on the peripheral part of the secretory nerves, and now it is
true that belladonna, i^ilocarpine, and muscarin act on the same part of
the sweat nerves."

Dr. Cook has recently reported cases of salivation from mercury and
scurvy, cured by the hypodermic injection of atropia.

Eecollecting that in acne there is over-abundant secretion from the
sebaceous follicle, I was induced to use belladonna with the hope of
checking it, and indeed this treatment seemed to be of some slight
service.

Whilst speaking of milk abscesses it was stated that, apart from its
milk-arresting power, belladonna will in some measure subdue inflam-
mation and its accompanying pain. Belladonna, too, is effectual in
other forms of inflammation which threaten to end in abscess. Mr.
Christopher Heath has shown that belladonna will prevent the forma-
tiqn of abscesses in the neck and elsewhere, and after the onset of sup-
jjuration wall check pain and inflammation.

The belladonna treatment of boils and carbuncles often succeeds.
(See Sulphides and Poultices.)

Belladonna preparations are of further use as local apj)lications.
Thus, the extract smeared over the painful cracks in the mucous mem-
brane is employed to relieve the pain of fissure of the anus.

The extract in conjunction with tannin, in the proportion of one or
two grains of extract to six or eight of tannin, is recommended by
Trousseau in leucorrhcea with ulceration of the os uteri, and in neuralgia
of the uterus. The belladonna arrests the too abundant secretion from
the mucous glands, while its action in this respect is assisted by the
tannin. In both affections belladonna is serviceable in relieving pain.
The mixture of belladonna and tannin may be wrapped in cotton-wool,
or made into a bolus with cocoar^nut fat, and placed in contact vsdth the
painful and over-secreting os. Some obstinate forms of leucorrhoea
yield completely to this treatment.

When the disease depends on too free a secretion of the mucous
glands about the os uteri, and when this condition is associated with
much pain, the following injection yields good results: — bicarbonate of
soda, a drachm; tincture of belladonna, two ounces; water, a pint. The
S3'ringe should be introduced as far as possible, while the j)atient lies
on her back, with her buttocks raised by a jiillow, while one or two
syringefuls, used cold, should be injected into the vagina, and made to
reach the mouth of the uterus. The position should be maintained for
a few minutes, so as to allow the wash to remain in contact with the os
uteri.

Dropped into the eye, applied to the surrounding skin, or introduced
into the stomach, preparations of belladonna very speedily produce ex-
treme dilatation of the pupil. This dilatation is one of the most character-

388 BELLADONNA.

istic symptoms of belladonna. In iritis, and some other e3'e diseases,
solutions of atropia are used to produce dilatation of the pupil, and to pre-
pare the eye for ophthalmoscopic examination. In conjunctivitis, and
other inflammations of the eye, belladonna is employed both locally and
internallv.

The local application of the liniment or ointment of belladonna will
often relieve, and sometimes even cure, neuralgia. Its efficacy is most
manifest on the fifth nerve, as in neuralgia of the brow, or under the
eye, accompanied by severe pains in the eyeball, and intolerance of light.
Even sciatica will sometimes succumb to it.

A full dose of belladonna produces great dryness of the tongue and
roof of the mouth, extending down the pharynx and larynx, inducing,
consequently, some difficulty ni swallowing, together Avith hoarseness, and
even drv cough; a large dose will sometimes induce dryness of the
Schneiderian membrane, and dryness and much injection of the conjunc-
tiva.

"After about two hours,"' says Dr. J. Ilarley, "the dryness of the
mouth gives way, to be replaced by a viscid, sticky, acid, and foul-smell-
ing secretion, and the mucous membrane becomes clammy, and the tongue
is covered with a Avhite fur." Ilarley produced ophthalmia in a dog by
belladonna. Several of these symptoms indicate the influence of bella-
donna in arresting secretion.

In several instances Ilarley has known belladonna to cleanse and moisten
the tongue of typhus-fever patients. Belladonna is employed in several
hiflamnuitory diseases of the throat, and its good effects are most apparent
when the throat and tonsils are acutely inflamed and swollen. It may
be given in combination with aconite, but the influence of aconite on this
form of inflamed throat, provided the pulse is full, and the skin hot and
dry, exceeds that of belladonna.

Tlie influence of belladonna on digestion is not known.

It is not j^et satisfactorily ascertained in what Avay belladonna affects
the intestines; but, bearing in mind its influence on the lining membrane
of the mouth, it may be conjectured that belladonna lessens the secretion
of the intestinal canal. It has been asserted that belladonna increases
the peristaltic movement of this canal, but others insist that whether given
in small or large doses, belladonna weakens the peristaltic actions.
Others assert that in small doses it increases peristaltis, but in large doses
paralyzes the muscular tissues of the intestine, and, indeed, maintain
that iDelladonna affects all unstriped muscular fibre in a twofold Avay. It
has been experimentally proved that it paralyzes the terminations of the
inhibitory fibres of the splanclmics distributed to the intestines; thus stimu-
lation of the splanchnics will stop intestinal movement, but small doses
of atropia will ])revent this arrest.

Trousseau recommended belladonna in obstinate constipation, and no
doubt, in many instances, it succeeds admirably. He advised doses of
from one-sixth to one-fourth of a grain of the extract to be taken once a
day, either night or morning, gradually increasing the dose and diminish-
ing or discontinuing the medicine when the constipation is removed. Dr.
Nunneley finds this treatment useful in all forms of constipation, espe-
cially when co-existing with dyspepsia, characterized by a tliinly-furred
tongue, with prominent red papilla? at the tip, epigastric tenderness, pain
after food, and often more or less headache. It ensures a natural evacu-
ation daily. It must be continued a fortnight or three weeks. The late

BELLADONNA. 389

Mr, Foster, of Tluntingdon, employed a small dose of belladonna to pre-
vent the constipating effects of iron. In some of the severest cases of
constipation where jwwerful purgatives have failed, a suppository of one
or two grains of the extract has opened the bowels.

Belladonna often relieves colic of the intestines, and is especially ser-
viceable in colic of children.

That the active principle of belladonna is readily absorbed into the
blood is proved by the symptoms. After a considerable dose of belladonna,
the face becomes much flushed; the eye bright, dry and injected; the
pupil dilated; the sight dim and hazy; while the power of accommodation
in the eye, for instance, is lost. The mind and senses are peculiarly
affected. The ideas, at first rapid and connected, become incoherent and
extravagant, and there is often decided delirium, with pleasing illusions.
Sometimes the patient is seized with restlessness, keeps continually mov-
ing, and cannot be quieted. A kind of somnambulism is occasionally
observed; cases are recorded where, under the influence of belladonna,
the patient for a long time performs the movements customary to his
occupation, and it is narrated of a tailor that he sat for hours moving his
hands and arms as if sewing, and his lips as if talking.

The delirium maybe furious and dangerous, requiring restraint; nay,
it is recorded of a man poisoned by this drug, tbat so violent did he become
that he was ordered to be confined in a mad-house. Sometimes a very
small dose will induce mental disturbance, and so great is the suscepti-
bility of some people that even when applied to the skin in the form of
plaster or ointment, belladonna induces marked cerebral disorder.

It is evident, then, that belladonna affects the cerebrum. Alberton
has experimentally proved, however, that it has no influence on the motor
centres.

Belladonna weakens the muscular power, renders the gait ixnsteady
and staggering, so that a patient, having lost control over his movements,
may run against objects he sees, yet desires to avoid.

This loss of power is due not to the action on the muscles, but to the
action of atropia on the motor nerves; for atropia paralyzes both the ter-
minations and the trunks of motor nerves.

Some experiments I made with the assistance of Dr. Murrell convince
us that some of this paralysis is due to the depressing effect of atropia on
the spinal cord.

Atropia affects the cord and excites tetanus, an effect long undetected,
till it was pointed out by Dr. Fraser.

Dr. Fraser has shown (1) that in frogs tetanic sj^mptoms follow the subcutaneous
injection of a dose of sulphate of atropia equivalent to about l.OOOth of the weight of
the animal; {2} that this tetanus sometimes sets in on the second day, but more fre-
quently on the third, fourth, or tifth; (8 ) that it varies in its duration from a few
hours to seventeen days; (4) that it is due to the action of the drug on the cord {medulla,
oblongata and medulla spinaUn).

In conjunction with Mr. JMurrell I have made some experiments on the subject.
Our observations were made during the months of May, June, and July. The frogs
used for the e.xperiments were, with a few exceptions, the ordinary liaua iemporaria.
We employed, except when the contrary is stated, a 1 in 20 solution of sulphate of
atropia in water, the requisite dose being injected either under the skin of the back,
or into the axilla. The first twelve cast's were observed thrice daily, l)etween seven
and eight in the morning, one and two in the afternoon, and live and six in the even-
ing. In the sul)se(pient experiments observations were made much more frequently,
with the view of determining how rapidly pai'alysis occurred, how soon it reached its
height, and how (luickly it declined. In .some cases the animal was under almost con-
tinuous observation for many hours, in others the notes were taken every eight or ten

390 BELLADONNA.

miinites for the first liour, and liourly for ever tliree hours subsequently. We may
take this opportunity of explainmg that whenever we employ the term " pithed and
pegged " we mean division of the eord 1)}' cut ting, and destruetion of the brain by the
introduction of a piece of wood into the cranial ca\ity. Like Dr. Fraser, we often oi)-
tained strong tetanus from the subcutaneous injection of atropia, but found that his
dose (from ^^^ to xsVtt oi the weight of the frog) usually killed our animals instead of
producing the desired result. With a smaller dose, however, namely, from yg^jj to
^TyW' ^^"^ were more successful. In our experiments the tetanus commenced earlier
than In Dr. Eraser's, our average period of onset being 20 hours; in one case it was
w-ell marked in 3 hours, whilst in the longest it was delayed 28 hours. With us, too, it
lasted for a shorter time, for in one animal it continued only eight hours, and never, in
any instance, exceeded live days. We imagine that these differences are due to the
time of the year at which the observations were made.

Why is the tetanus so long delayed after atropia poisoning ? One writer referring
to Dr. Fraser's paper says that the paralysis of the motor nerves prevents the tetanic
condition of the cord from displaying itself on the muscles, but Dr. Fraser himself
nowhere makes this assertion, and, indeed, his cases prove the contrary.

This proffered explanation we hold to be erroneous, for the following reasons: —

I. Bezold and Bla>baum have shown tliat even with very large doses it is ditlicult
to destroy completely the conducting power of the motor nerves, and it is obvious that
as long as their conductivity is, in the smallest degree, retained, the tetanic condition
of the cord must produce more or less tetanus of the nmscles.

IL The onset of tetanus is delayed even in cases in which the dose of atropia is so
small as to produce but slight paralj^sis, and it must be admitted that if the motor
nerves are capable of conveying voluntary and normal reflex impressions they can
conduct tetanic reflex stimuli. Thus, in many of Fraser's cases, there was never com-
plete loss of reflex and voluntary power during the period which elapsed between the
injection of the drug, and the onset of tetanus. It will be found that, of the cases in
wiiich he obtained tetanus, there were twelve in which the paralysis was incomplete;
that in seven of the thirteen in which it had been complete a partial recovery of reflex
and voluntary power had taken place for a day or more before the onset of tetanus.
In eleven of our own twenty-six cases there was incomplete paralysis of reflex action
and voluntary power, and in all these cases the onset of tetanus was delaj'ed. In two
cases, indeed, both voluntary and reflex power had been completely regained before
tetanus set in. In one case in which there had Iteen complete paralysis it began to
impi'ove five and a half hours before the commencement of tetanus.

III. If the poison be prevented from having access to certain limited regions by
ligature of the nutrient vessels the onset of tetanus is still delayed even in these pro-
tected parts. Fraser gives an account of four experiments, in which he adopted this
mode of procedure. In three, before poisoning the animal, he tied the femoral
vessels, and in one the abdominal aorta, and yet tetanus did not occur in the protected
limbs till twenty-two hours, fifty-one hours, three days, and twenty-t^vo hours respec-
tively.

We have tested the action of atro]3ia on ten pithed and pegged frogs, in which
before poisoning the abdominal aorta had Ijeen tied. The following was our mode of
procedure: — We first divided the medulla In^ cutting through the occipito-atlantal
membrane, and then passed a pointed wooden peg upwards through tlie foramen
magnum into the skull, so as to destroy the brain, and then tied the abdominal aorta
just above its bifurcation. In three cases in which we obtained tetanus it was delayed
for twenty-five, nine, and four and a half hours respectively.

We conclude then, for these reasons, that the late occurrence of tetanus in atropia
poisoning is not due to paralj'sis of the motor nerves, but that it is owing to the cord
being slowly affected. It appears that whilst the poison quickly paralyzes it takes
many hours, or even days, before it tetanizes.

It lias been suggested that this delayed tetanus, which often sets in
from the third to the fifth day, cannot be directly due to the atropia, but
must depend on some j)roducts slowly formed in the body by the atropia.

This explanation appears to me to be wrong, for the following reason: — Atropia
corresponds to other tetanizers, and conforms to Fraser's law tliat when alkaloids pro-
ducing tetanus are converted into ethyl or methyl compounds they lose tlieir jiower of
exciting tetanus, and paralyze the enils of tiie motor nerves. Ethyl-atropium does not
tetanize, but is a powerful paralyzer of the motor nerves, far more so than atropia itself.

The afferent nerves are unaffected, or but little affected by atropia.

BELLADONIS-A.

391

Most observers state that atropia produces severe pain in the head,
generally over the forehead, and in the eyes, and sometimes the top of the
head. Singing in the ears also occurs, with more or less giddiness. In
persons poisoned h}^ this plant spasmodic contraction of the sphincter of
the bladder has been not unfrequently observed, and a scarlet rash often
breaks out on the skin, a rash said to be like that of scarlet fever, and to
be most marked in the neighborhood of the Joints. jMr. J. G. Wilson re-
ports a case in Avhich the local application of belladonna produced a gen-
eral red rash, with redness of the throat and dilated pupils.

The first effect of belladonna on the pulse is to increase its frequency,
fullness, and force, to the extoit even of fifty to sixty beats in the minute,
moderate doses at the same time increasing the blood pressure. This
condition of the circulation continues till the tongue and mouth become
moist and -clammy, when the pulse diminishes in frequency, and loses
strength. (J. Harley.) In fatal cases the pulse grows rapid, intermittent
and weak. Dr. J. Harley considers belladonna a powerful lieart tonic,
and he points out how it serves to reduce the frequency and to strengthen
the beats of the heart when Aveakened by disease.

Atro])ia paralyzes the terminations of the vagi, for in animals
poisoned by atropia neither section nor galvanization of the vagi affects
the heart. When injected into the carotid, so as to reach the central ner-
vous system before the nerves, atropia first reduces the number of the
heart's beats, showing that it stimulates the nucleus, whilst it paralyzes
the termination of the vagi.

Atropia paralyzes an intracardiac inhibitoiy apparatus. Thus, after poisoning'
by curare, stimulation of the vagi has no effect on tlie heart, but, on the applica-
tion of the electrodes to the sinus the lieart is at once arrested. Curare paral3'zes
the terminations of the vagi, but leaves unaffected an inhibitory apparatus in the
heart itself. After poisoning by atropia, neither stimulation of the vagi nor of
the sinns affects the heart, whence it is concluded that atropia paralyzes the in-
tracardiac inhibitory apparatus.

Atropia is considered to stimulate the cardiac accelerator nerve.

Both reasoning and expermientation led Mr. Schiifer, Professor of
Physiology at University College, to recommend the use of atropia during
the"^ inhalation of chloroform. The chief source of danger during the
use of chloroform is its depressing action on the heart, the heart, in many
fatal cases, suddenly ceasing to beat. This action, Mr. Schiifer believes,
is due to the chloroform stimulating the inhibitory cardiac apparatus.
No doubt, too, some of the cases of sudden death are due to the effect of
the operation on the nervous system. Thus, it is well known, that when
the leg of a frog is crushed, the heart stops, but division of the vagi j3re-
vents this stoppage. Now Schiifer argues that a dose of atropia, sufficient
to quicken the pulse, i.e., to paralyze the inhibitory cardiac apparatus, will
prevent chloroform stopping the heart, and its arrest through shock.

Dr. Xtinneley asserts that in the frog belladonna neither increases
the frequency of the heart's beats nor dilates the pupil, and this state-
ment has been abundantly corroborated in respect to its action on the
heart, showing that belladonna must affect the frog otherwise than man
and some other animals, as the dog, the horse, etc.

Luchsinger finds atropia paralyzes smooth muscular fibre, but not
striped muscular fibre; hence it does not affect the striped muscular
fibres of the irides of birds and reptiles.

Atropia in moderate doses heightens arterial pressure, probably l)y

392 BELLADOISTNA.

its influence on the vaso-motor centre. Under large doses arterial pres-
sure falls, from direct paralysis of the muscular coat of the blood-vessels.

The action of belladonna on the pupil has been variously explained,
some believing that it depends on paralysis of the third nerve supplying
the iris; some teaching that it is due to excitation of the sympathetic;
others maintaining that belladonna produces the dilatation by preventing
turgescence of the vessels of the iris. From a survey of the numerous
observations of various experimenters. Dr. H. Wood, in his able and valu-
able work, concludes that atropia, applied locally, causes mydriasis by
paralvzing the peripheral ends of the oculo-motor nerve, probably by
stimulating the peripheral ends of the sympathetic. Given internally,
atropia almost certainly causes mydriasis, not indirectly by influencing
the nerve-centres, but by being carried in the blood to the eye itself, and
there acting precisely as if applied locally.

To briefly sum up the action of atropia, we find:

1. It tetanizes the cord and heightens its reflex function.

2. It stimulates the respiratory centre and the inhibitory centre of the
heart.

3. It stimulates the cardiac accelerator nerve or its centre.

4. It stimulates the vaso-motor centre and so heightens arterial pres-
sure.

5. It paralyzes the motor nerves, first affecting the trunk.

6. It paralyzes the termination of the vagi, both in the heart and
lungs.

7. It paralyzes the terminations of the secretory nerves of the salivary
glands, and those of the sweat glands.

8. It paralyzes the terminations of the inhibitory fibres of the splanch-
nics.

9. Large doses slightly depress the functions of the afferent nerves.

10. It paralyzes the termination of the oculo-motor nerves, and stimu-
lates the sympathetic, so far as the iris itself is concerned.

It appears, then, that whilst to a large part of the central nervous system
it acts as a " stimulant," to many of the nerves it operates as a paralyzer.

The influence of belladonna on the sympathetic led Dr. E. T. Smith
to employ it in two cases of exophthalmic goitre — a disease regarded by
some as due to paralysis of the sympathetic of the neck. The effects were
striking. Five minims of the tincture hourly afforded great relief in
four or five days, though the disease had lasted more than a year. In
tAvo months the exophthalmos had much lessened. Homoeopathic doctors
have long employed this treatment.

Belladonna is often used to relieve pain. Dr. Anstie considers it the
best remedy to mitigate every kind of pain in the pelvic viscera. Some
neuralgias, no doubt, yield to this medicine, and it appears to jjossess most
efficacy over neuralgia referable to the fifth nerve. Cases are recorded of
relief afforded by it in sciatica.

Trousseau recommended the following method of treating neuralgia: —
To administer one-fifth part of a grain every hour till giddiness is jiro-
duced, and then to lessen the dose; but to continue the medicine for
several days.

Trousseau also employed belladonna successfully in epilepsy, according
to the following method: — "During the first month of treatment the
patient takes a pill, composed of extract of belladonna and powdered leaves
of belladonna, each one-fifth part of a grain every day, if his attacks occur

BELLADONNA, 6\)A

chiefly in the daytime; or in the evening if tliey are cliiefly nocturnal.
One pill is added to the dose every month, and, whatever be the dose, it
is always taken at the same period of the day. By this means the patient
may reach the dose of from five to twenty pills, and even more." The
dose is to l)e regulated by circumstances. This treatment, it is said, even
when it fails to cure, yields much relief.

Belladonna often allays both the cough and oppressed breathing of
asthma. To ensure success it must be employed in considerable doses,
as Dr. H. Salter pointed out, and I have often verified his observation.
Ten minims 'of the tincture every two or three hours, a quantity gener-
ally well borne, is often sufficient; but, if any of the undesired symptoms
of belladonna set in, the dose must be reduced. If the patient is not very
susceptible to the action of the drug, far larger doses are sometimes
reqiiired. Thus, occasionally half a drachm of tlie tincture hourly is well
and advantageously borne. Such a dose need only to be taken at the
time of the paroxysm; but when this lasts several days, the medicine
should be given in the quantity recommended till an impression is made
on the disease. The effect is chiefly satisfactory in either averting the
attack or rendering it milder.

Belladonna is one of the best remedies for whooping cough; but as
in asthma, to obtain any good from it, it must be employed in coiisider-
able doses. To children two and three years old I often give as much as
ten minims of the tincture every hour, and this quantity usually produces
no efi'ect, except on the cough, neither dilating the pupil, nor, so far as
one can judge in children so young, making the throat dry; and it cer-
tainly does not in chikh-en a little older, who are able to express their
feelings.

Should drowsiness, delirium or dilatation of the pupil occur, of course the
dose must be diminished. The only symptoms I have witnessed from these
large doses is dilatation of the pupil. Children, it is well known, bear
belladonna much better than adults; hence the slight effect of so large a
dose, and the small influence which a less quantity exerts on whoopiug
cough — a disease of childhood. Some writers state that children become
rapidly accustomed to belladonna. These large doses, however, may be
given at first, and in the course of many cases 1 have never had to give
less on account of any toxic effects. These doses often much reduce the
severity and frequency of the cough, even during the period when it is
most violent ancl convulsive. But, like all other remedies in this disease,
belladonna is of little use if the child is exposed to cold afld cutting winds.
If the weather is cold the child should be confined to the house in a warm
room; if the weather is mild, out-door exercise is, of course, highly bene-
ficial ; but cold must be most carefully avoided.

AVhile there can be no reasonable doubt of the great efficacy of bella-
donna in many cases of whooping cough, it must be admitted that in
many instances, without apparent reason, it fails. Influences, at present
not understood, appear to modify its effects; for in some epidemics it is
very successful, while in others it appears to be inoperative. Belladonna
exerts but little effect on whooping cough when bronchitis or any irrita-
tion exists, as that from teetbiug, worms, etc. If the gums are red,
swollen, and painful, they must be freely lanced, and other sources of
irritation removed. Belladonna is considered of special use in the third
week of the attack — at a time, that is, Avhen the febrile stage has passed
away, and the violence of the convulsive attacks is declining.

394 BELLADONNA.

Belladonna is often useful in other coughs, although with our limited
knowledge on this subject it is impossible to lay down precise rules for its
employment.

It is often useful in certain forms of headache — for instance, when the
pain is situated over the brows and in the eye-balls, which seem as if too
large for the head, and as if they would be forced out of the skull. These
headaches are not due to stomach or uterine derangement, indeed, very
often their cause cannot be discovered. They are especially peculiar to
youns: women, and they seem due to weakness and over work. Three
minims of the tincture should be given everv three hours.

It is said that belladonna controls the delirium of fevers — as of typhus
fever.

Dr. John Harley finds belladonna useful in typhus fever. It slows and
strengthens the pulse, reduces temperature, moistens the tongue, and he
thinks shortens the course of the disease. Its prolonged use makes the
heart irritable.

Belladonna is both speedier and more certain than any other remedy in
removing that troublesome affection, incontinence of urine. It must be
given in doses of from ten, twenty, to thirty drops of the tincture three
times a day; small doses often fail when large ones at once succeed. It
may take a fortnight to succeed. Sometimes the incontinence is not
limited to the night, but may trouble children during the day. These
severe forms will often yield to belladonna; but while in some cases it is
thus effectual, still it often fails altogether, although no worms infest
the intestines, no irritation exists about the rectum, and no reason seems
to exist to account for its failure. Strychnia, cantharides, turpentine,
santonin, or galvanism, should then be tried. In nocturnal inconti-
nence the child should drink but little some hours before going to bed, and
he should be waked in the middle of the night to pass water.

It sometimes checks the incontinence of urine of the old or paralvtic.

Belladonna, used internally or externally, is certainly efficacious in
erysipelatous inflammation. It may be given in combination with aconite;
but when the skin is hot and pungent, and the pulse is firm and resistant,
aconite exeits over this inflammation an influence far more potent than
that of belladonna.

Belladonna has been recommended as a preventive of scarlet fever, but
so much prejudice has been introduced into the discussion of this question
that it is difficult to conclude Avhether it has any prophylactic virtue.

Belladonna has been found of service in the treatment of seminal
emissions; a grain aiid a half of sulphate of zinc with a quarter of a grain
of extract of belladonna, three or four times a day, is often a successful
remedy in cases of nocturnal emissions.

Atropia is antagonistic to opium. Calabar bean, muscarin, jaborandi,
bromal, aconite, and prussic acid.

As belladonna and opium are in some respects reciprocally opposed in
their action, as on the eye, etc., it has been assumed that they must Ije
opposed in every particular, and that one is as an antidote to the other.
Many cases are adduced of opium poisoning, where the symptoms, although
very serious, were apparently removed by belladonna, and vice versa. Dr.
Erlenmeyer is of o})inion that, in respect to their action on the brain,
these agents are antagonistic, and that nc 'joma will result when they are
administered conjointly; but they exercise no miitual counteractive influ-
ence on the sensory nerves, and hence he recommends them in combina-

BELLADONNA. 395

tion to relieve pain. On the other liaiul, some authorities, anionic whom
maybe named Brown-Sequard and J. Harley, dispute this antagonism, on
the ground that tlie cited cases are insufhcient to prove it; and it has not
been observed in experiments on the lower animals and on man. It must
be remembered, however, that these drugs do not similarly aft'ect animals
and man. The reported cases in favor of this antagonism have been se-
verely criticized by Harley, who points out that many Avere treated by other
remedies besides belladonna; in others a fatal dose is not proved to have
been taken; ajid the patient who recovered did not improve sooner than if
no belladonna had been administered. Harley concludes, and in most
respects he is directly opposed to Erlenmeyer: — " 1. That in medicinal
doses the essential effect of morphia (hypnosis) is both increased and pro-
longed by the action of atropia, whether introduced previously or at any
time during the operation of the former. 2. That atropia relieves, and
if given simultaneously or previously, prevents the nausea, vomiting, syn-
cope, and insomnia, which frequently result from the action of opium.
3. That if a sufficient proportion (for most individuals one forty-eighth
part of a grain of sulpli. atropia to a quarter of a grain of acetate of mor-
phia) atropia neutralizes the contractile effect of opium on the pupils;
but in larger doses dilatation takes place as if no morphia had been given.
It is also to be observed that if the qmmtivalent doses are successfuUij
introduced, the drug last administered exhibits for a short time a counter-
acting effect. 4. That all the other effects of atropia are inteiisified and
prolonged by the action of morphia induced previonsly or at any time
during the operation of the former. If, however, the dose of atropia be
small, and the morphia produce considerable deranging effects on the
vagus, the rapidity of the pulse is not greater than when the atropia is
administered alone." Had Earley given opium in a dose just sufficient to
destroy life, and had death ensued after the employment of belladonna,
he would have proved that belladonna Avould not arrest the fatal effects
of opium, and vice versa. In no reported instance did he use enough of
either substance to destroy life; hence his observations are not so convinc-
ing as they might have been; but as belladonna intensified the coma from
opium his observations are valuable.

On the other hand. Dr. Johnson, of Shanghai, who, during his resi-
dence in China, had striking experience of opium poisoning, having treated
in various ways upwards of 300 cases, speaks in the strongest terms of the
antagonism between opium and belladonna. It is, he says, in the worst
cases of poisoning that atropia displays its wonderful effects; for instance,
when the immovable pupils are contracted to a pin's point, the conjunc-
tiva insensible to touch, the face pale, the lips, eyelids, and nails livid,
the pulse weak and irregular, the breathing slow and stertorous, the
extremities cold, in ten or twenty minutes after the injection of half a
grain of atropia the pupils begin slowly to dilate, and in an hour or so the
face becomes flushed, the breathing soft without stertor, and the pulse
stronger. If witliin two hours the dose fails to produce these restoring
effects Dr. Johnson repeats the injection. In less profound coma he first
employs a quarter of a grain of atropia.

The Edinburgh Committee, presided over by Dr. Hughes Bennett,
conclude : —

1. That sulphate of atropia is within a limited range physiologically
antagonistic to meconate of morphia.

2. Meconate of morphia does not act antidotally after a large dose of

396 BELLADONNA.

atropia; thus, wliilst atropia is an antidote of morpliia, morphia is not an
antidote to atropia.

3. Mcconate of morphia does not antagonize the effect of atropia on the
branches of the vagi applying to the heart.

While there is doul^t concerning the antagonism between opium and
belladonna, the interesting ex])eriments of Eraser have demonstrated
beyond question tliat atropia is an antidote to physostigma; and, as the
action of these substances on man and animals is identical, he concludes
that atropia will neutralize the fatal effects of physostigma on human
beings. His experiments were conducted in three ways: — (1.) He admin-
istered the atropia before the physostigma; (2.) he administered them
together; (3.) he administered the physostigma, and, after the animal was
completely paralyzed, he injected atropia. In each series of experiments
atropia averted the fatal effects of physostigma, although physostigma was
employed in fatal quantities, as was afterwards proved by administering
to the animal the identical or even a smaller dose by itself, when in every
instance the animal speedily died. Fraser concludes that "the lethal
effects of doses of physostigma greatly in excess of the minimum fatal,
may be prevented by doses of atropia greatly below the minimum fatal."
He recommends, that "in treating cases of poisoning in a man the sul-
phate of atropia should be given by subcutaneous injection, in doses of
from one-fiftieth to one-thirtieth part of a grain. The exhibition of the
antidote should be persevered with, in repeated doses, until the pupils are
fully dilated and the pulse rate increased, and probably also until the
hypersecretion of bronchial mucus, which greatly impedes respiration, is
completely checked."

He thus summarizes the antagonism between these "two substances: —
" That physostigma increases the excitability of the vagi nerves, while
atropia diminishes and suspends this excitability; that physostigma di-
minishes the arterial blood-pressure, while atropia increases it; that phy-
sostigma greatly augments the secretion of the salivary, bronchial, intes-
tinal, and lachrymal glands, while atropia diminishes, and even completely
checks, the secretions; and that physostigma contracts the pupils, while
atropia, to a much greater relative extent, dilates tliem. Besides these
effects of the action through the blood, various opposed topical effects
have been observed, among which is the contraction of the veins by phy-
sostigma — the existence of which rests on the high authority of Mr. Whar-
ton Jones — and the contraction of the arteries by atropia."

Dr. Fraser has recently published some further experiments on the
antagonism between physostigma and atropia, being led to this investiga-
tion by reflecting that while, no doubt, the more active and poisonous
effects of physostigma are antidoted by atropia, still, it seemed possible
that physostigma might possess some properties — might aff'ect some part
of the body in a manner not opposed by atropia — and that both poisons
might possibly possess certain properties in common, so that while some
of the poisonous properties of each substance were antagonistic, other
poisonous properties might not be so o})posed, nay, might be similar in
kind and assist each other. His experiments confirm these conjectures.
He found that after a minimum fatal dose of physostigma death could be
averted by a dose of atropia, varying greatly in quantity; but as he in-
creased the dose of physostigma, so the range of antidotal doses of atropia
became diminished, and so far from requiring a larger maximum antidotal
dose, the greater the quantity of physostigma administered the smaller

BELLADONNA. 397

became the maximum antidotal close of atropia, till at last a point Avas
readied when atropia ceased to avert death. For instance, with a mini-
mum fatal dose of jihysostigma, a dose of atropia varying from nine-
thousandth to five grains prevented the rabbit's death; but on increasing
the dose of physostigma to one and a half times the minimum fatal dose
the antidotal dose of atropia ranged from one-fiftieth of a grain to four
grains; and on augmenting the dose of physostigma to two and a half
times the minimum fatal dose, the antidotal dose of atropia ranged from
one-fortieth to two grains and a half. With three and a half times the
minimum fatal dose of physostigma the range of atropia sufficient to avert
death was reduced from one-tenth of a grain, to one-fifth of a grain, and
with four times the minimum fatal dose of physostigma atropia failed to
avert death. Here, while atropia prevented the more powerfully fatal
effects of physostigma, yet, on increasing the dose of this drug, a point at
last is reached when its proj^erties, not antagonized by atropia, become
fatal. But the fatal issue is not solely due to increasing the non-
antagonized properties of physostigma, for the range of an antidotal dose
of atropia became lessened in proportion as the dose of physostigma was
increased, showing that the atropia assisted the physostigma. The fact is
also shown by the experiment of injecting simultaneously one-half the
minimum fatal dose of each substance with the result of killing the
animal.

The foregoing .experiments, moreover, make it apparent that atropia
is an antidote for only a given quantity of physostigma, and that if the
physostigma is increased a quantity at last is reached, the more active
properties of which, no doubt, are neutralized by atropia, but the other
properties, in conjunction with similar ones of atropia, are sufficient to
cause death.

It is a most singular fact, that while the minimum fatal dose of extract
of physostigma is 1.2, and that of atropia 2.3 grains, yet the nine-
thousandth of a grain of atropia injected five minutes before giving a
minimum fatal dose of physostigma prevents its fatal effects; in fact, a
quantity of atropia which produces no perceptible effects will avert many
of the serious effects of a fatal dose of physostigma.

Although it is experimentally proved that atropia can avert death from
physostigma the question yet remains unsettled whether physostigma can
prevent death from atropia.

Dr. Fraser conceives that " with regard to the counteracting actions
themselves, it is to be observed that various of the facts mentioned in
the record of experiments (of his paper) tend to make mutual antagonism,
probably not only of one, but of several, of the actions of physostigma
and atropia; and it is legitimate to suppose that, with a given dose of
physostigma, the counter-action produced by a certain amount of atropia
will be more ])erfect in the case of one or more of the antagonistic actions
than in that of others; and that with certain doses of the two substances
such incompleteness of counter-action may exist as would, even without
the occ^urrence of iioii-antiigomzed action, suffice for the production of
death."

The Edinburgh Committee confirm Eraser's statements, but find that
the range of antagonism is even more restricted than the limit fixed by
this investigator.

Dr. Brunton has drawn attention to the antagonism between atropia
and the poisonous principle of fungi — muscarin. Dr. Sclimiedeberg had

398 BELLAUOXNA.

previously pointed out an antagonism in respect to the action of these
drugs on the lieart; thus, whilst topically applied muscarin will arrest the
heart of a frog, a mere trace of atropia, applied to this organ, will some-
times restore the pulsations even after the heart had ceased beating for
four hours.

The poisons have likewise an antagonistic action on the pulmonary
blood-vessels. Muscarin produces intense dyspncjea and emptiness of the
arterial system, so that cut arteries scarcely bleed at all — effects which
Brunton has proved to depend on spasm of the pulmonary vessels. He
narcotized an animal with chloral, and, after the lungs were exposed, kept
it alive by means of artificial respiration, in which state a dose of musca-
rin caused blanching of the lungs, distention of the right side of the heart
and vena cava, and shrinking of the left ventricle. A little atropia now
injected into the jugular vein at once removed these phenomena; the
lungs became rosy, the distentions of the right side of the heart subsided,
and the left ventricle regained its natural size. Atropia removed the
dyspnoea as well as the other symptoms produced by muscarin.

Muscarin, moreover, stimulates the terminations of the chorda tym-
pani nerve, and increases salivary secretion, exhibiting in this respect also
an antagonism to atropia. Muscarin also excites copious perspiration.
(See Muscarin.)

There is a well-marked and interesting antagonism between atropia
and jaborandi. Jaborandi excites profuse perspiration and salivation, and
when applied to the eye it contracts the pupil, and, as Mr. John Tweedy
has shown, causes tension of the accommodative apparatus, in these
respects being obviously the antagonist of atropia. Jaborandi also pro-
duces a dull pain over the eyes, sometimes associated with giddiness; like-
wise over the pubes, Avith an urgent desire to pass water, in these results
as regards symptoms corresponding to the action of atropia; yet, even in
this respect, these drugs are opposed; for the injection of -y-i-^ gr. of
atropia not only speedily checks the sweating and salivation produced by
jaborandi, but checks also the headache and pain over the pubes, with
desire to pass water. Mr. Laiigle}^ has pointed out that these drugs are
antagonistic as regards their action on the lieart; thus, jaborandi at first
slows, and then arrests the heart in diastole, whilst atropia restores the
heart's action, even after its arrest for a considerable time. Atropia, as we
have seen, paralyzes the terminations of the pneumogastric nerves, and
Langley shows that jaborandi at first stimulates and then paralyzes
these nerves. Its antagonistic effects on the heart are not due to its in-
fluence on the pneumogastric, for it slows and stops the heart after the
complete paralyzation of the pneumogastrics by curare. The effect of
jaborandi on the human lieart ap})ears to be different, for in a large num-
ber of observations I found that jaborandi always considerably quickened
this organ. In two respects these drug agree; thus, each flushes the face,
and both affect children much less than adults. (See Jaborandi.)

Muscarin and pilocarpiu, it is tau.iiht, stinnilate the va^i, and so inliil)it the heart
and arrest it in diastole. Atropia paralyzes Ihe vaiii, and so prevents tiie "action of
muscarin and pilocarpiu. This view is no loni;er tenable. Muscarin and jaborandi
paralyze the e.xcito-niotory apparatus and the muscular .substance of the heart, and
atropia must antaii'onize these substances in these structures. Atropia itself weakens
the lieart, probably by its action on l)oth the excito-motor}' and nniscular substance.
So we have an instance of a poison which paralyzes the excito-motory, and muscular
substance of the heart antaironizins: a poison Avhich also jiaralyzes the excito-motory
and muscular substance. Pilocarpiu also antagonizes the action of muscarin on the

BELLADONNA. 399

heart, and in this respect it is almost as efficient as atropia. Tliiis we have another
instance of a paralyzer of the motory apparatus and muscular substance of the heart
antagonizing a poison which affects the heart in exactly the same way.

Atropia also antagonizes the action of aconitia on tlie heart.

Atropia, however, does not antagonize the action of digitalis nor of veratria on the
frog's heart. Digitaline antagonizes the action of muscarin, pilocarpin, aconitia, and
atropia.

I venture to suggest that these antagonisms may be due to chemical displacement.
That atropia, having a stronger affinity for the excito-niotory and muscular substance
of the heart than muscarin, pilocarpin, or aconitia, consequently replaces these sub-
stances, substituting its own action for that of muscarin, pilocarpin, or aconitia, and
atropia is a much less powerful paralyzer than muscarin, pilocarpin or aconitia. In-
deed, atropia only slows and weakens, but does not arrest the heart, whilst muscarin,
pilocarpin, and aconitia speedily arrest the heart in wide diastole. Hence, on the ad-
dition of a little atropia, we replace the action of muscarin, or of pilocarpin or of
aconitia, l)y the wealiening and slowing action of atropia.

Digitaline and veratria have a stronger affinity for the cardiac structures than even
atropia, and hence they antagonize the action of atropia and of all the substances that
atropia antagonizes. As, however, digitaline completely arrests the heart, on its addi-
tion to a heart arrested by muscarin or aconitia we do not restore the lost pulsations,
but change the character of the heart, converting the widely-dilated, flabby, distended
red heart of aconitia into the small, hard, pale, rigid heart of digitalis.

Atropia is antagonistic to bromal. Bromal ordinarily destroys life by
increasing the bronchial and salivary secretion to so great an extent that
tlie animal is choked by it. Now atropia checks these secretions, and
thus prevents the lethal effect of bromal. Bttt, on the otlier hand, it
need hardly be said that bromal will not prevent the fatal effect of atropia,
for this drng does not destroy life by its influence on the bronchial mucous
membrane or salivary glands.

Dr. John Harley points out an interesting antagonism between aconitia
and belladonna. He poisoned a dog with aconitia, and reduced the pulse
to G5 and 75 per minute, and then gave gr. l-9Gtli of atropia, with the
speedy effect of both quickening and strengthening the heart, and in
three-quarters of an hour the heart beat 300 per minute, being 230 beats
faster than before the administration of atro])ia. Harley adduces this
experiment to show that atropia affects the heart by its stimulating action
on the sympathetic, and thus atropia both strengthened and quickened
the heart's beats; but whilst atropia by paralyzing the vagi might quicken
the heart it could not increase its strength, this being probably due to
the action of the atropia on the excito-motory cardiac apparatus.

Preyer maintains that atropia, by paralyzing the peripheral branches
of the vagus nerve, will prevent the arrest of the heart's contractions, by
hydrocyanic acid, and is thus an antidote to it.

That atropia is separated from the body in part by the tirine may be
proved by putting into the eye some of this secretion voided by one under
the influence of belladonna. J. Harley states that atropia is eliminated
from the body within two hours, none after tliat time being found in the
urine.

Dr. Garrod has shown that caustic fixed alkalies destroy the active
principle of belladonna, hyoscyamus, and stramonium, but that carbonates
and bicarbonates of potash and soda do not destroy it. Lime-water, too,
is equally destructive; hence it has been recommended as an antidote in
belladonna poisoning. (J. Harley.)

400 ETHYL-ATROPIUM.

ETHYL-ATROPIUM. METHYL-ATROPIUM.

Tpie action of these substances, in which an atom of ethyl or methyl
IS substituted for a molecule of H in atropia has been studied by Fraser
with his accustomed tlioroughness and ability. Fraser experimented with
iodide of methyl-atropium, sulphate of methyl atropium, and iodide of
ethyl atropium. In conjunction with Dr. Murrell I have studied the
actions of ethyl-atropium. We experimented with uncombined crystalline
ethyl-atropium, prepared for us by Mr. Wright, under the direction of
Dr. Graham, Professor of Chemistry at University College.

From experiments on frogs, Fraser coneludes that these substances paralyze the
terminations of the motor nerves, leaving unaffected the sensor}^ nerves and spinal
cord. Our experiments led us to conclude that ethyl-atropium paralyzes the motor-
nerves and the spinal cord, but leaves the sensory nerves unaffected.

Like Fraser, we find that these compounds do not tetanize.

Fraser ascertained that whilst atropia produces in dogs both paralysis and convul-
sions, ethyl-atropium induces only paralysis.

His experiments on rabbits show that these substances powerfully paralyze the car-
diac inhibitory fibres of the vagi.

In fatal doses, Fraser finds that ethjd-atropium slightly dilates the pupil. We have
given it to men in doses suttlcient to produce decided symptoms, but without causing
any dilatation of the pupil. We all tind that its topical application to the eye widely
dilates the pupil; but our experiments on man show that in twelve, or twenty-four
hours, the dilatation nearly or quite passes off.

In our experiments on man this drug, given in doses sufficient to produce marked
symptoms, neither strengthened nor quickened the heart; hence we may infer that in
tiie doses we gave it does not in man ]3aralyze the ^'agi.

In man, a dose of one grain, given hypodermically, produces decided but transient
paralysis, the patient lieing unable to stand or walk, and the head dropping rather
towards the shoulder or chest, and the up])er eyelids drooping. Fraser finds that in
fatal doses it produces complete iwralysis in dogs and rabbits.

In man, ethyl-atropium excites pain over the eyes, but, unlike atropia, it does not
excite delirium nor produce coma, nor does it check the salivary or the cutaneous
secretion.

Fraser finds that these compounds act more powerfully on frogs and rabbits and
dogs than atropia. Oiu" observations confirm his statement as regards frogs, but we
find that the action of ethyl-atroiiium on man is far feebler tlian that of atropia. Thus
a grain given hypodermically excites merely sligiU but distinct symptoms, whilst a
grain of atropia produces great weakness and sleep, lasting some hours, ^\^th delirium.

It seems, therefore, that atropia conforms to Fraser's law, namely, that a tetanizing
alkaloid, when converted into an ethyl or methyl compound, loses its tetanizing action,
and produces paralysis of the motor nerves. But in the conversion of atropia into
ethyl-atropium and methyl-atropium, many of tlie other effects of atropia are lost; thus,
like atropia, these compounds dilate the pvu^il, ]iaralyze the terminations of the cardiac
inhibitory vagus fibres, and paralyze, in a far greater degree, the motor nerves,
whilst they lose the atropia properties of tetanizing, or diminishing the salivary and cuta-
neous secretion, of affecting the brain, and, according to Fraser, of paralyzing the cord.

In respect to the effect of these compounds on the cord, we suggest that there may
have been some slight difference in the preparation used by Fraser and that prepared
for us. Our observations were very carefully performed, and we believe they may be
relied upon, and we feel equally sure that Fraser's are likewise trustworthy; and only
by the foregoing assumption can we reconcile the discrepancy between us.

HYOSCYAMUS. 401

HYOSCYAMUS

contains two alkaloids, hyoscyamin and hyoscin. Hyoscin is by far the
more powerful.

The effects of this drug in many, if not in all respects, correspond to
the effects of belladonna and stramonium. Thus it flushes the face,
dries the mouth and throat, dilates the pujoil, j)roduces a subdued form
of delirium and hallucijiation, and in large doses comatose sleep. It
greatly quickens and strengthens the heart's contraction, and sometimes
produces a red rash, which, like that of belladonna, may be patchy. It
increases the quantity of urine. In some observations made by Mr.
Pearce and myself it failed to produce increased action of the kidneys
(Lawson); poisonous doses produce a drunken gait, from loss of volun-
tary power, the drug probably acting on the nervous system like bella-
donna. Mr. Clifford Gill tells me that hyoscyamia given in large doses
Avill induce nausea and vomiting, and patients in describing their sensa-
tions say that it produces a feeling of "sea-sickness," or "deadly sea-
sickness." In some valuable papers Dr. Robert Lawson has recom-
mended hyoscyamia in various forms of mania, with the view of producing
sleep, and substituting a mild for a more active and obstinate delirium.
He gives a grain to a grain and a half, which in fifteen minutes generally
induces sleep, lasting ten to twelve hours, when the patient wakes free
from delusions. These large doses cause sleep so deep, and a degree of
paralysis so marked, as to excite alarm in both the patient's friends and
to the doctor himself. It is better, therefore, to give a smaller dose, as
1 6tli to l-8th of a grain, which is generally sufficient to induce several
hours' sleep. Hyoscyamia is especially useful in the more violent forms of
intermittent mania, when it is difficult to restrain the patient. It quiets
a patient at once through its action on the nervous system. I have tried
this drug in a few cases, and my observations, in common with those of
other observers, entirely corroborate the statements of Dr. Lawson.

I have tried it in four cases of delirium tremens, but without any
very satisfactory results. Small doses failed to produce sleep, but simply
quieted the violent patient and substituted the muttering delirium of
hyoscyamia for the uncontrollable delirium of the disease. Larger
doses produced many hours' sleep, but, on waking, the delirium and
general condition were unamended. In one case we gave the alkaloid
several nights successively, but without any benefit; then a dose of
chloral made the patient sleep all night, followed next day with much
improvement. It will probably be useful in cases where the patient is
very violent, and irrestrainable, with delirium like that of acute inter-
mittent delirium. Hyoscyamus is generally used to produce sleep when
opium disagrees. It has been employed also in neuralgia.

Dr. Leguin finds hyoscyamin useful in paralysis agitans and chorea.
He gives l-50th grain daily, hypodermically, or l-50th grain by stomach
night and morning. It quiets the movements of paralysis agitans, but
on discontinuing the treatment the symptoms recur unmitigated.

The fixed caustic alkalies destroy hyoscyamin, like atropia, as Dr.
Garrod has proved. The effects of hyoscyamia are so similar to the
effects of atropia and.daturia that I determined to compare the operation
of these three alkaloids in a case of acute mania, and found that they
produced almost identical results.
26

402 HYOSCINE.

HYOSCINE

is one of the alkaloids of hyoscyamus Ladenburg first extracted from
the mother liquid after hyoscyamin was crystallized out. It is em-
ployed in the form of hydrobromate or hydriodate.

Dr. Horatio Wood, who has drawn prominent attention to the drug,
has made a physiological examination of it. He finds that it depresses
the spinal cord, in this respect corresponding with the secondary effect
of atropin. It leaves, however, the motor nerves unaffected, in this
differing from atrojiin, which somewhat dejjresses the motor nerves.
Like atropin, it kills by paralyzing the respiratory centre, and so arrest-
ing respiration; but unlike atropin, when the frog recovers from the
I^aralysis due to a full dose no tetanus arises.

Hyoscine affects the heart and circulation but slightly; hence the
blood pressure is but little affected. First there is a slight fall in the
pressure, probably due to the drug rather weakening the heart. Very
large doses, like atropia, lower blood j)ressure by depressing the heart and
paralyzing the vaso-motor centre. Unlike atropia, hyoscine slows the
heart, and in man the pulse sometimes falls to 48 or 50. It therefore
neither paralyzes the vagi nor the intra-cardiac inhibitory apparatus.
At first atropia often slows the heart, possibly through its primary effect
on the intra-cardiac apparatus. In this respect it corresponds to hyos-
cine, for this drug slows the heart by its effect on the intra-cardiac
structures, as the fall in the frequency of the pulsatio]is occur when the
vagi are cut. Like atropia, it antagonizes the effect of muscarin on the
heart, and as muscarin paralyzes the muscular structure of the heart,
hyoscine must exert an influence on the muscular tissue likewise.

Like atropin, it at first excites delirium, followed by deep sleep, and
sometimes as sleep passes off' delirium returns. Patients who have taken
an efficient dose feel stupid and giddy, their movements are inco-ordi-
nate, the face is often flushed, sometimes pale; they complain of frontal
headache. In all these resj)ects again corresponding with atropin.

It somewhat reduces the frequency of the respiration, and may induce
Cheyne-Stokes breathing.

Like atropin, it dries the mouth and dilates the pupil; but, unlike
atropin, it does not apparently check perspiration, and, in some cases,
where very marked symptoms occurred, the skin was moist with j^erspira-
tion. It is employed chiefly as a sojiorific, especially in maniacal patients.

In other cases it should not be given till the more usual hypnotics
are tried, for its action is somewhat uncertain, and the susceptibility to
the drug greatly varies in different peojile; hence, symptoms rather
alarming in appearance, though not dangerous, may arise. It is the
best remedy to calm the delirium of mental affections, and to induce
sleep. It is useful in puerperal mania. From y^ to y^t ^^ ^ S'^'^^'^> given
by the mouth, is the dose that usually succeeds, but ^ to -^ may be re-
quired. It can be conveniently administered, as it is tasteless. To
quell mania it may be given hypodermically in -y^ grain. Wood has
found it useful in the sleeplessness arising from worry or excessive
cerebral activity, or when the sleep is much harassed by dreams, and it
may succeed when other soporifics have failed. The sleep is refreshing.

It is highly recommended in paralysis agitans,. removing the tremor
and the contracture. On discontinuing the medicine, however, these
symptoms return. In this disease ^^„ gram is suflicient.

DUBOISIA MYOPOROIDES. 403

It will check salivation, and the sweating of phthisis. TojDically ap-
plied, it dilates the pupil, its effects passing off more quickly than those
of atropia, but sometimes it is absorbed in sufficient quantity to produce
general symptoms. Wood finds it useful in sj^ermatorrhroa.

It does not relieve pain. It sometimes excites nausea and vomiting.
It is excreted by the urine.

STRAMONIUM.

Stramonium produces symptoms very similar to those induced by
belladonna. A stramonium ointment, used at the Middlesex Hospital,
is made by mixing half a pound of fresh stramonium leaves with two
pounds of lard, and gently heating till the leaves become friable, then
straining through lint. This ointment spread on lint and applied thrice
daily relieves pain. Stramonium, smoked with or Avithout tobacco, is
mainly used to reduce spasm in asthma. It is especially valuable in
pure asthma, that is, when the lungs are structurally free from disease,
and is useless when the dyspnoea is due to heart disease. Twenty grains
of the dried leaves, or ten of the powdered dry root, may be smoked,
inhaling meanwhile into the lungs ; or an inverted tumbler, into which
fumes have been puffed until it is filled, may be placed over the mouth,
and the contents inhaled by a deep respiration. It excites a good deal
of cough. The inhalation may be repeated again and again. It is
better to smoke the plant unmixed, as few can draw the fumes of tobacco
into the lungs without great discomfort. There is no doubt that, in
many cases of asthma, stramonium is very successful; but in others,
without apparent reason, it fails, and, even when it succeeds, its influence
gradually diminishes by use. Sometimes datura tatula succeeds when
datura stramonium has failed. Dr. Salter believed that stramonium
often failed owing to the badness of the preparation, and he advised
asthmatics to grow and prepare their own stramonium. Its effect is
more manifest when employed at the very commencement of an attack,
affording but little relief when the paroxysm is fully developed. Cold
stramonium smoke can sometimes be inhaled when the hot is intolerable.
It has been used in neuralgia.

Like belladonna and hyoscyamus, its active principle, as Dr. Garrod
has shown, is destroyed by caustic potash and caustic soda.

DUBOISIA MYOPOROIDES.

Mr. John Tweedy has introduced into this country this solanaceous
plant, for some time used in Australia. It yields an alkaloid which
possesses the same proj^erties as atropia, but is far more powerful in its
action on man. It dilates the pupil and paralyzes the muscles of accom-
modation. It checks perspiration, and dries the mouth. It produces
delirium, headache, great weakness, and sometimes a rash similar to that
of belladonna. It accelerates the pulse and antagonizes the action of
musciiria on the frog's heart, and tetanizes and paralyzes. The alkaloid
1^ so powerful that a 1 in 120 solution applied to the eyes often excites
great giddiness, weakness, and a " drunken feel." Though duboisin
acts much stronger than atropia on man, atropia acts more powerfully
than duboisin on froafs. Duboisin is now considered as identical with.

404 HYDROCYANIC ACID.

hyoscin, but in some respects it differs from the accounts given of
hyoscin, for it certainly checks j^erspiration.

HYDROCYANIC ACID. CYANIDE OF POTASSIUM.

These poisonous substances are destructive alike of animal and vege-
table life.

AVhen applied to the skin for a long time, solutions of these sub-
stances, particularly of the cyanide, excite some inflammation on account
of their alkalinity.

Kept in contact with the skin for a while they diminish sensibility.
Formerly they were employed externally in painful diseases, such as neu-
ralgia and rheumatism; now, however, they are quite superseded by more
successful remedies. But in allaying the tormenting itching of urticaria,
lichen, eczema, and prurigo, they are undoubtedly very serviceable. The
itching skin should be bathed with a lotion made of a drachm of the
cyanide of potassium to a pint of water, or thirty drops of hydrocyanic
acid to the ounce of water or glycerine. In respect to the cyanide, the
action of the prussic acid is assisted by the potash combination with it.
It need hardly be observed that such a lotion must not be applied to broken
skin, for fear of poisoning by absorption.

Dr. Gee employs sulpho-C3'anide of potassium in tinea tonsurans. He
recommends the hair to be kept close cut, and to Avash the scalp twice a
day with warm water and soap, and after drying the head, to rub well the
patches with a lotion composed of half an ounce of sulpho-cyanide of
potassium, 1 ounce of glycerine, and T ounces of water. The scalp should
be covered night and day with lint soaked in this lotion, super-imposing
a piece of oiled silk; a stronger solution is apt to excite eczema.

The acid possesses a bitter characteristic taste, and excites a sensation
of itching in the mouth. It stimulates the flow of saliva, possibly by its
action on the mucous membrane of the mouth.

Taken in moderate doses, in a healthy stomach the acid appears neither
to produce nor to undergo change; it is, nevertheless, much used, fre-
quently with benefit, in painful diseases of this organ, as in chronic ulcer,
cancer, chronic gastritis, gastralgia, etc. Not only does it occasionally
mitigate the pain of these affections, but it may also check vomiting.

Hydrocyanic acid passes very speedily into the blood, and is as speedily
eliminated, probably with the breath; hence, if life can be supported for
half an liour after a poisonous dose, the patient is generally safe.

As Brunton points out, the symptoms induced by a fatal dose of prussic
acid are identical with the symptoms of rapid asphyxia, with the exception
that in hydrocyanic acid poisoning the blood is arterial in tint and artifi-
cial respiration will not avert death.

It is a general poison, affecting all parts of the nervous system and the
muscles, as one would expect in a remedy that induces asphyxia. It has
not been proved how it induces asphyxia, but it has been suggested that
its combination with ha?moglobin lessens oxidation. Cyan-hsmoglobin,
however, is often aljsent from the blood in prussic acid poisoning. I^ar^e
doses kill by arresting the heart, smaller doses kill by paralyzing respiration.
The arrest of the heart is partly due to irritation of the vagus roots,
and partly due to the action of the poison on its ganglia and muscular tis-
sue. It first raises arterial pressure, but soon lessens it.

OPIU3I. 405

From his experiments on frogs, Kolliker concludes that it paralyzes first
the brain, next the cord, and then the motor nerves, the paralysis extending
from the trunk to the periphery. It paralyzes the heart, its action ceas-
ing in diastole. The voluntary muscles soon lose their irritability, and
become stiff. Preyer maintains that a large dose of hydrocyanic acid par-
alyzes the heart at once; that moderately fatal doses deprive the blood of
oxygen ; and that, as belladonna paralyzes the peripheral branches of the
vagus, and at the same time stimulates the nervous centres of respiration,
atropia in these cases, h3q3odermically injected, will prevent death. Hy-
drocyanic acid is a useful addition to cough mixtures, to allay irritable
cough. Syrup of Virginian prune, which is often employed in cough
mixtures, probably owes its efficacy to the prussic acid it contains.

OPIUM.

Opium chiefly afPects the brain physiologically, and therefore thera-
peutically, and in the lower animals excites tetanus by its action on the
cord. It has very little action on either sensory or motor nerves, though
some observers maintain that it first stimulates and then depresses sen-
sory nerves. Large doses paralyze the vaso-motor centre. The muscles
are unaffected by it.

Small doses of opium excite tetanus in frogs; but birds, such as ducks,
chickens, and pigeons, cannot be poisoned by crude opium, by aqueous
extract, nor by black drop (acetum opii), given internally; and morphia
salts must be given in enormous doses. Morphia employed hypoder-
mically in very large doses never causes sleep nor stupor, but convulsions.
Thebaia is a tetanizing agent, inferior only to strychnia and brucia. Nar-
cotina, almost without effect on man, destroys birds in doses of two to
seven grains when used hypodermically. Codia is a fatal convulsive agent
to pigeons. Meconia given internally causes emesis. but is harmless when
injected under the skin. Narceia has no perceptible influence, except to
disturb the respiration slightly. Cryptopia in doses of one-fifth to one-
half a grain has no effect. None of these agents cause sleep in pigeons,
ducks, or chickens. (Dr. Weir Mitchell.)

Dogs, cats, and rabbits require larger doses of opium to produce stupor
or sleep, which is generally accompanied by convulsions. In the lower
animals, like frogs, opium only excites tetanus; but as we ascend in the
animal kingdom the soporific effects become apparent, and are most
marked in man. Race modifies the effects of opium, for it drives the
Japanese and ^Malays into temporary madness; and even among Europeans
its effects vary considerably in different individuals. In some persons,
especially women, it produces much excitement but no sleep, the excite-
ment being sometimes pleasant, at other times extremely disagreeable. In
some instances if it fails to induce sleep it soothes, and pleasant ideas
occup}' the mind; with other persons it induces restlessness, excitement,
and even delirium.

Preparations of opium, applied by means of poultices or friction, are
absorbed by the unbroken skin.

Poultices containing laudanum are used to allay the pain of superficial
and even of deep-seated infiammations, and enough may be absorbed in
this way to produce deep sleep. Friction considerably increases the ab-
sorption; thus linimoit of opium, well rvibbed in, relieves neuralgias.

406 OPIUM.

pleurodynia, and myalfj^ia. The al)raded skin absorbs still more freely,
and preparations of opium or morphia are applied to irritable, cancerous,
and simple sores. JMorphia, dissolved in glycerine and spread on lint, is
a useful application to a painful cancerous sore.

The hypodermic injection of morphia, originated by Dr. Alexander
Wood, is now extensively employed to relieve pain, produce sleep, prevent
spasm, and for other purposes, and is preferable to the administration of
the drug by the mouth. Its action is more rapid, its effects more per-
manent, and it neither destroys the appetite nor constipates the bowels.
At first not more than a sixth part of a grain should be injected; a larger
quantity sometimes produces serious symptoms.

An injection not unfrequently causes a good deal of excitement, giddi-
ness, even intoxication, great nausea, and repeated vomiting, followed by
considerable depression. Often, indeed, the patient is unfitted for work
during the rest of the day. These inconveniences, however, can mostly
be avoided by keeping the patient recumbent for some hours after the in-
jection. Belladonna seems to obviate these unpleasant symptoms, if
combined with morphia in the relative proportion of twenty parts of mor-
phia to one part of atropia.

An injection occasionally jiroduces redness of the face, contraction of
the jaw, dyspnoea, clonic spasms of the limbs, hammering frequent pulse,
symptoms which last about five minutes, followed on their decline by vio-
lent sweating. These symptoms are said to occur when the injection
directly enters a vein. By long persistence in hypodermic injections
the system becomes habituated to opium, so that not only must the
quantity be increased, but when discontinued a patient suffers the de-
pressing effects of an opium-eater deprived of his opium.

Sometimes so severe are these sufferings, that patients declare that
the distress occasioned by the intermission of the injection is worse than the
pain itself. The injection may be made in any part of the body; but, for the
sake of convenience, it is better to choose a place where the skin is loose. A
fold of skin should be pinched up firmly, and then the needle thrust quickly
through it into the subcutaneous tissue. If patients dread the slight pain
of the puncture, the sensibility of the skin, may be first deadened by the
ether spray, or by the application of a piece of ice dipped in salt. If
a patient administers a hypodermic injection to himself he can conveniently
nip up the skin with a wooden clip, this contrivance enabling him to in-
ject the solution in his arm, Avhen of course he can only use one hand.
It is hardly necessary to say that it is rarely advisable to allow a patient
to administer the injection himself. Immediately after the injection, a
sharp smarting pain is felt, and in many cases a large flat wheal, like that
of urticaria, soon arises. If care is taken to make the solution as nearly
neutral as possible, the pain is much reduced. It should be remembered
that these injections sometimes leave a hard horny cicatrix; hence it is im-
portant to inject some part of the skin covered by the clothes.

Eulenberg states that the sensibility round the punctured spot is
lessened if the injection is made over a superficial sensory nerve; and that
the sensibility of the Avhole skin territory of this nerve is somewhat
blunted.

A single injection sometimes cures recent and even long-standing
sciatica, facial and other neuralgias, biit it usually gives only temporary
relief, and the injection miist Ije repeated from time to time.

Injections continued for days, weeks, or perhaps months, sometimes cure

OPIUM. 407

obstinate cases of neuralgia and its allies. Sometimes ever}' second day, or
twice a week, is sufficient to mitigate the pain and after a time to cure.
A single injection frequently cures lumbago at once; but, as the mere
insertion of a needle is often equally efficacious, some of the speedy cures
attrilnited to the injection must be due to the effects of unintended acu-
pimcture. Hypodermic injection relieves the pain of severe pleurodynia,
but most cases of pleurodynia yield to milder treatment. It is particu-
larly efficacious in the pain of renal, biliary, and intestinal colic.
Although not often required, a mild morphia injection will allay severe
toothache. Morphia injections are sometimes needed to relieve the pain
of acute inflammations, like pleurisy and pneumonia, but are rarely re-
quired unless the suffering is severe or persistent.

Morphia injections are used to produce sleep. Morphia, subcutaneously
injected, acts more speedily and in smaller quantities than when swallowed.

Morphia is injected to produce sleep in acute mania, delirium tremens,
chorea, etc. In delirium tremens, even when bromide of potassium and
chloral have failed, an injection often speedily produces sleep. A mor-
phia injection is useful in chorea when the movements prevent sleep, and
when wakefulness, by weakening the patient, increases the movements.
Dr. Clifford Allbutt employs morphia injections in dyspepsia of an irrita-
ble kind, when the patient is spare, fretful, keen, hasty, or absent in
manner, with a tongue too clean, red at tip and edges, small pulse, and
broken sleep.

Dr. Allbutt strongly recommends a morphia injection in the dyspnoea
of heart disease, and in disease of tlie large vessels, in the pain of angina
pectoris, and of intra-thoracic tumors. By removing dyspnoea it permits
sleep, and recruits the worn-out patient. It strengthens the heart, and
so removes congestion of the lungs and face. Dr. Allbutt considers it
less useful in aortic than in mitral disease. I have long employed these
injections in heart disease, and can corroborate Dr. Allbutt's statements.
It is hardly possible to exaggerate the relief this treatment confers on a
patient suffering from cardiac dyspnoea. Almost directly on falling asleep,
a severe sensation of dyspnoea comj)els the patient to awake and sit upright
in bed; he often says that the distress from want of sleep is harder to bear
than other serious sufferings. The appetite, already bad, becomes worse,
lack of sleep and weakness rapidly set in. In such a case the comfort
afforded by a hyijodermic injection is almost incredible. It ensures several
hours' refreshing sleep, from which the patient awakes wonderfully re-
vived, and the dyspnceal attacks for the next twenty-four hours are
warded off. The heart, thus strengthened, and in the case of mitral
disease the pulse made more regular and slower, the patient's condition
is not only notably relieved, but his life is prolonged. J^ must be borne
in mind that, in heart disease, the cardiac dyspnoea is often associated
with another form of dyspncea arising from dropsy of the pleura, and of
the lung. The dyspnoea due to these two causes is permanent; whilst
the dyspnoea due to the heart is paroxysmal, and generally occurs only on
falling asleep. The hypodermic injection of morphia will not relievo per-
manent dyspnoea or orthopnoea — conditions best treated by incisions into
the dropsical legs, to drain away the dropsical fluid. In cardiac dypsnoea,
a sixth of a grain twice or three times a week often suffices, but the dose
and frequency in severe cases must be gradually increased to a quarter of
a grain each night. Doctors are often afraid to administer morphia in
the case of a patient propped up in bed, with livid ears, nose and nails.

408

OPIUM.

with distended jugulars and dropsical extremities, with weak, frequent,
and irregular pulse. They dread lest the morphia should weaken the
heart, make the patient Avorse, if not kill him outright. This fear is
quite groundless, and this treatment may be employed Avithout any ap •
prehension of injury to the patient, even if in a rare instance it should
fail to benefit.

Dr. Spender employs morphia injections to arrest the severe vomit-
ing of pregnancy and other obstinate and dangerous forms of vomiting.
An injection often arrests persistent hiccup, and sometimes puerperal
convulsions; it has likewise been successfully employed in tedious labor,
produced by a rigid os uteri.

Dr. T. J. Gallagher, of Pittsburg, and more recently Dr. John Patter-
son, of Constantinople, have witnessed great benefit from the hypoder-
mic injection of morphia in cholera, even in the stage of collapse. The
cramps and vomiting cease, the patient falls asleep, the skin gradually
becomes Avarm, and the pulse returns. They employ one-fourth to one-
eighth of a grain of morphia, and usually one or tAvo injections suffice.
In the early stages the patient falls asleep and AA^akes almost Avell. Dr.
Patterson has employed this treatment for children. Many subsequent
observers, however, deny the efficacy of hypodermic injection in Asiatic
cholera. A small hypodermic injection of J,t to ^ of a grain of morphia
is most useful in the choleraic diarrhrea of children. The sickness and
vomiting cease. The surface becomes Avarm, the child falls asleep, and
wakes well-nigh cured.

I have often seen hypodermic injections promptly cure sporadic Eng-
lish cholera, checking at once cramp and inducing sleep, the patient
waking free from sickness or diarrhoea.

Dr. BraithAvaite has successfully given small doses of morjohia hypo-
dermically in haemoptysis.

A hypodermic injection of morphia is sometimes, as Mr. Hunter has
pointed out, very useful in melancholia. I have seen a patient dread-
fully depressed, whose expression became completely altered, and Avho
at these times Avas weak and tottery, and Avithout appetite. Five minutes
after the injection this man became himself again. His depression and
weakness left him, his natural expression returned, and he could at once
take a walk of several miles, and return home and eat a good meal. It
is a most difficult question to decide Avhether in such a case the doctor
is Avarranted in permitting the injection, lest the patient become the
victim of the opium habit. But I must confess that, seeing the
wonderful transformation it has caused, how the patient has passed from
utter Avretchedness to happiness and serenity, I have not been able to
prohibit its usc-^

Dr. Buxton Sliillitoe strongly recommends for carbuncles and boils
the local application of an extract of opium, the consistence of treacle.
The extract must be thickly smeared three or four times a day over and
around the SAvelling. Applied early, it often causes the boil to abort;
or it limits its progress and eases pain. After the extract, Mr. Shillitoe
applies a plaster, composed of equal parts of soap, opium, and mercury,
spread on thick leather. Should suppuration set in, he lets out the
matter, and applies a poultice over a small hole cut in the plaster.

Dropped into the eye, laudanum and solutions of morphia cause
smarting, redness, and slight inflammation of the conjunctiva. They

opimr. 409

contract tlic pupil, but in a less degree than if administered in other
"ways. Opium, however, is never used specifically to contract the pupil,
Calabar bean effecting this more safely, easil}^ and thoroughly. Opium
wine, dropped into the eye, is used to relieve the pain of conjunctivitis,
and by slight stimulation to improve the condition of the membrane.
The wine of the present Pharmacopoeia, containing spices, must not be
so employed, as it would aggravate the mischief; but the wine of the
Pharmacopoiia of 1804 must be used. Mixed with either tannin or
creasote, opium is introduced into the hollow of a painfnl tooth, and if
the 23ain is produced by inflammation of the exposed pulp, this applica-
tion often gives relief.

A somewhat full dose of opium produces much disagreeable dryness
of the mouth and throat. The same annoying symptom follows likewise
on the hyijodermic injection of morphia.

The preparations of opium are rarely used for their topical effect
on the throat, but their good effects are often, I think, due to the local
action. For instance, many coughs, as in some cases of phthisis, are
really produced by the condition of the throat, — red, inflamed, and even
ulcerated — a condition which excites much irritation, and a frequent
hacking cough, especially troublesome at night. Tlie topical applica-
tion of morphia dissolved in glycerine, honey, treacle, syrup of Virginian
prune, mucilage, or some other viscid substance, which causes the mixture
to linger some time over the irritable membrane, often relieves this kind
of cough. It is well known that the cough of chronic phthisis is often
best treated by directing the patient to retain for some time in the
pharynx a weak solution of morphia in glycerine, honey, syrup, or
mucilage, so as to blunt the irritability of these parts. Heiice, too, the
excellent effects of morphia lozenges allowed to dissolve slowly in the
mouth. Even in coughs entirely dependent on lung disease, opium or
morphia administered so that the medicine clings for some time in
contact with the structures just outside the larynx, appear to have a
greater influence tlian when the mediciiie is conveyed tjuickly into the
stomach. This result is probably due to the fact, heretofore insisted
on, that drugs appear to possess remedial virtues over the organs of
the body, even when applied only to the orifice of the passages leading
to them.

The following is a good formula to allay coughs: Morphia, one-
fortieth part of a grain; spirits of choroform, three minims, in a drachm
of glycerine, syrup of lemons, diluted honey or treacle, repeated fre-
quently at times when the cough is troublesome, till the paroxysm is
subdued.

It is often taught that morphia should not be gi^en in catarrh or
bronchitis. When the expectoration is abundant, and there is duskiness
of the skin, showing deficient oxidation, opiates or other narcotics that
produce j^rofound sleep must of course be given very guardedly, other-
wise the expectoration during sleep may accumulate in the lungs, and
give rise to serious results. On the other hand, we meet with cases of
free expectoration, with very little rhonchus, and no signs of obstructed
oxidation, and very violent and frequent cough. In such cases opiates
relieve cough, and lessen expectoration; for the secretion of mucus in
the bronchial tubes is certainly stimulated by violent coughing, nnd when
this is allayed, the exjDectoration becomes much less abundant. That

410 OPIUM. ^

coughing m;iy excite secretion in the bronchial tubes is sliown by the
common fact, that if a patient can restrain his cough, the expectoration f
becomes less, without any signs of accumulation in the lungs. '

Taken into the stomach, opium lessens both its secretion and its
movements, and consequently checks digestion. Its retarding effect on
digestion is exemplified by the well-known fact, that when an opiate is
given too near a meal, the food vomited hours afterwards is only very
partially digested. Xay, according to Bernard, a hypodermic injection
may have this effect, for he found the crops of pigeons full after a hy-
podermic dose of morphia. Here we have a sufficient reason why opiates
should not be given shortly before or after a meal, unless, indeed, it is
intended to diminish appetite, or to hinder the natural movements of
the stomach.

Opiates not uncommonly excite nausea and vomiting, symptoms very
apt to occur in the morning after a night dose.

Opium, or its alkaloid, morijhia, is given to quell the pain of many
stomach affections, and to check the vomiting which may accompany
them. Thus it is useful in cancer and chronic ulcer of the stomach, and
in chronic gastritis from excessive indulgence in alcoholic drinks.
Morphia, in small doses, combined with tonics, taken a short time before
meals, is very efficacious in removing the pain, the nausea, and want of
appetite, so often connected with alcoholism. In the treatment of
gastrodynia with heartburn, it is usefully combined with bismuth.

The effects of opium on the intestines are identical with those on
the stomach; that is to say, it checks both secretion and movement, thus
constipating the bowels in health and restraining diarrhoea in disease.
Constipation, one of the disagreeable consequences following an opiate,
is much less marked when morphia is employed hypodermically.

Some persons can never take even a small dose of laudanum or
morphia, without producing for a day or two clay-colored motions and
high-colored urine.

Opium, or its alkaloid, morphia, is very frequently and very benefi-
cially given in both acute and chronic diarrhcea. It is useful in the
acute forms, after the expulsion of the disturbing irritant. It is, more-
over, of great use in the chronic diarrhoeas of tuberculosis, dysentery,
and other organic diseases.

In typhoid fever, opium in small doses, given at night, may serve a
double purpose. In wakefulness, with delirium, whether of boisterous
or muttering kind, opium will often produce sleep, and thus check the
delirium, while at the same time it will control or even subdue the
diarrhoea.

There is a form of dyspepsia and diarrhoea which yields to small
doses of opium. There is probably increased peristaltic action of the
stomach and intestines, so that the food, soon after it is swallowed, is
forced in a half-digested state through the pylorus into the intestines,
where, owing to its crude condition, it acts as an irritant, exciting the
vermicular action, already acting unduly, so that a diarrhcea of partially
digested food occurs soon after a meal. The patient suffers from a sen-
sation of emptiness and hunger, which is relieved for a short time by
food; but the meal being imperfectly digested, and exi^elled through
the anus long before it can be absorbed, the system is imperfectly
nourished, and these uncomfortable symptoms soon recur. The char-

OPIUM. 411

acteristic symj)toms are — sinking at the stomach, relieved for a short
time by taking food, and the occurrence of an evacuation of partially
digested food immediately after a meal, nay, sometimes even before it
is finished, and generally at no other time. This complaint, a common
form of chronic dyspepsia in children from six to twelve years of age,
is quickly arrested by administering from two to five drops of tincture
of opium a few minutes before each meal, a dose which seems to check
the excessive muscular action, and so enables the food to tarry a suffi-
cient time to undergo digestion. Still more effective in such cases is
arsenic.

Colic of the intestines is well combated by small doses of opium or
morj)hia frequently repeated. As this painful aifection is generally ac-
companied by, and is dependent on constijDation, a purgative should like-
wise be given. The opium assists the purgative by relaxing that con-
traction of the intestines which hinders the j)assage of the intestinal
contents.

Opium quiets the intestinal movements in inflammation of the peri-
toneum and of the intestines, or in wounds of the abdomen. Opium is
useful in peritonitis, not only by restraining the intestinal movements,
but by its direct beneficial influence on the inflammation; and the dose
must be rapidly increased up to the limit of toleration, to the extent of
very large doses of several grains every two or three hours.

Opiates are administered by the rectum for a variety of purposes.
Laudanum is usually injected mixed with an ounce of decoction of
starch, at a temperature of 100'' or thereabouts, and is very efiectual
in checking acute and chronic diarrhoea; and in those severe forms of
diarrhoea which sometimes carry off young children in a few hours, a
laudanum injection is often the speediest way of controlling the danger-
ous flux. When other methods fail, the same injection often checks
the purging of typhoid fever, or of ulceration of the intestines, or of
dysentery-. It is highly useful in pain of the bowels and of the organs
in the neighborhood of the rectum. Thus, an opiate injection will
generally subdue the pain and frequent micturition of cystitis, and the
pain arising from various uterine diseases. A suppository of opium or
morphia is sometimes introduced into the rectum as far as the finger
can conveniently carry it, but the injection of the laudanum and starch
is more effectual.

Opium mixed with gall ointment is an excellent application to pain-
ful bleeding piles, and to fissures of the anus, which cause excruciating
pain with much evacuation. Mild purgatives should be simultaneously
employed.

Ojnum injected into the rectum is absorbed, and affects the distant
organs of the body. A rectal injection will sometimes induce sleep
when the ordinary method of administering it by the mouth completely
fails. In obstinate forms of dyspejitic sleeplessness, or the wakefulness
of convalescents from acute disease, the injection of laudanum by the
rectum will often prove successful. Both Dupuytren and Graves state
that in delirium tremens and traumatic delirium, this mode of giving
opium is preferable to its administration by the mouth. The dose of
laudanum injected in the rectum must depend on the nature of the
case. If employed to relieve local pain, a small quantity will generally
suffice; but to produce sleep, a dose must be given about threefold or

412 OPIUM.

fourfold that administered by the stomach— at least, so it is generally
taught; but an ordinary medicinal dose, even when given by the rectum
— well cleared out previously by a simple enema or a purgative — is often
amply sufticient to ensure sleep.

The active principles of opium readily pass unaltered into the blood ;
for whether the opium is swallowed or injected under the skin, the
same symptoms are induced.

To one unaccustomed to opium a small dose produces a soothing and
luxurious mental calm, followed in the course of forty or fifty minutes
by a disposition to sleep; if this does not happen, the drug gives general
repose to both body and mind. The pulse at first quickens slightly, in
ten to twenty minutes, by eight or ten beats; but in half or three-quarters
of an hour, it again falls ; at first it is made stronger and more resistant.
The mouth and pharynx are dry, and perspiration often breaks out.
Larger doses, as from two to three grains, generally at first 2)roduce much
excitement, with noises in the ears, and closely contracted inipils. The
ideas are confused and extravagant, and decided delirium may occur;
the head feels heavy and full, the senses are blunted, and then follows
sleep, which is often heavy, even stertorous, and harassed by disagreeable
dreams, while the pulse, at first full and frequent, soon becomes slow.

The susceptibility to the action of opium, and the symptoms it pro-
duces, vary greatly in different persons. Some are so easily affected by
opium that even a small quantity endangers life; a susceptibility so ex-
treme is, however, not common. In some it produces only disagreeable
sensations and ideas, in others just the reverse; in some the stimulant
effects predominate, in others the narcotic. Some persons after a
moderate dose of opium never become heavy or drowsy, but feel the
drug diffuse a glow throughout the body, followed by a luxuriant calm
of mind and body. I have heard some i3eo2:)le who were not accustomed
to opium say they dare not take opium, for the sensations it produces are
so delicious that they feared the temptation to take opium might become
irresistible. There are others, again, who after even a minute dose
become excited, restless, sleepless, and even delirious.

After a poisonous dose the primary stage of excitement is very brief,
and narcotism rapidly supervenes. Great giddiness and a sensation of
oppression come on, with an irresistible craving for sleep. There may
be both nausea and sickness. The sleep soon passes into profound in-
sensibility, the breathing grows slower and slower and more and more
shallow, till it ceases. The face is pale, or livid and bloated, and the
veins swollen. The pulse, at first full and strong, becomes small, feeble,
and thready. The pupils are very greatly contracted. The power of
swallowing is gradually lost, the pupils become insensible to light, the
muscles relax, and the patient cannot be roused from this state of pro-
found insensibility. Mucus collects in the throat, and at last, the
breathing ceasing, death takes place. Patients may die in a state of
collapse, and not from asphyxia, though death usually happens from
l^aralysis of respiration.

Sometimes in the final stages of opium-poisoning breathing stops for
a time, and then recommences, and this alternation is repeated. While
breathing the pulse is frequent, often 120 to 140. When respirations
cease, the pulse progressively falls in frequency till it reaches 80 or 90,
and after a time suddenly drops perhaps t^^enty beats, this drop preced-

OPIUM. 4 i O

ing always the recommencement of breathing, and after two or three res-
pirations the pulse rapidly rises to its original frequency. Sometimes
the first sign of recommencing breutliing is a slight movement of the
larynx. Similar changes in the pulse are sometimes observed in Chcyne-
Stokes breathing.

In opium poisoning a variety of other symptoms occasionally occur,
as diarrhoea, diuresis, convulsions (most common in children), lockjaw,
even dilated pupils, sometimes one being dilated while the other is con-
tracted, and itching and dryness of the skin.

In some respects opium poisoning simulates apoplexy, drunkenness,
and uraemic coma.

Opium poisoning may be generally discriminated from apoplexy by
attention to the following points — history of the attack, odor of breath
and vomited matters, the patient's age, and the state of the pupils,
which in apoplexy are very generally dilated, and are very often unequal.

Only cases of profound intoxication put on a superhcial semblance
of opium 25oisoning. In each case there is great insensibility. If the
drunkard can be roused, he answers questions incoherently; but if
poisoned by opium, although he is slow to speak, yet his answers are
rational and to the point. The breath and vomited matters will very
often tell if alcoholic drinks have been taken ; but it must be recollected
that suicides by laudanum not uncommonly take the drug in beer or
other drinks; but even then the odor of the laudanum may generally
be detected. In opium poisoning the pupils are much contracted, but in
profound drunkenness the puj)ils are widely dilated. Moreover, the
early symptoms of the attack are sufficient to ensure discrimination
between opium and alcoholic poisoning.

Urgemic coma may occur very suddenly and without any, or scarcely
any dropsy. To distinguish such a case from opium poisoning the
history of the attack should be ascertained. A patient in ura^mic coma
can generally be roused partially, Avhen some information can be ex-
tracted from him. An analysis of the urine, moreover, may throw much
light on the case, while the state of the pupils precludes suspicion of
poisoning by opium. The presence of a hypertrophied heart, high
tension pulse, with a small quantity of albumen in the urine Avould
show that the patient suffered from contracted kidneys, — the form of
kidney disease usually producing uraemia, but which also favors cerebral
haemorrhage.

Effusion of blood into the pons varolii will produce symptoms almost
identical with those of opium poisoning; thus in both cases there is jaro-
found insensibility, with closely contracted pupils, and slow stertorous
breathing. It may be impossible to discriminate between these two
conditions till a posf-inorfeni examination reveals the real cause of death.

In poisoning by opium use the stomach pump, rouse the patient and
I'eep liim constanthj moving, to prevent sleep; give strong coffee, apply
cold affusion to tlie head, and, if necessary, adopt artificial respiration.

It is not an uncommon practice to give brandy or wine to a patient
recovering from the effects of a poisonous dose of opium, Avith the view
of overcoming drowsiness; but having watched the action of alcohol
under these circumstances I always found that it greatly increased the
sleepiness, and in fact did harm.

In this country the habit of opium eating is not so largely indulged

414 OPIUM.

in as among Asiatics, but it is practiced here in some localities to a
startling extent. It is taken for its primary stimulating effect, but
after a time increasing doses are needed to produce this result. Though
carried to a very great pitch, opium-eating in some individuals induces
neither physical nor mental weakness, whilst others waste, and grow
physically and mentally weak, irritable, fretful and desponding, especially
when the opium is withheld; the memory is much impaired; the skin
becomes shallow; but, strange to say, in many cases the bowels are not
constipated.

The horrors which opium-eaters suffer when the drug is withheld
are well known, and need not be dwelt on here; so great, indeed, is the
suffering, that few have sufficient resolution to relinquish the habit.
The amount of opium taken is often enormous. De Quincey took 3::i0
grains daily ! Moderate indulgence of the habit is perhaps not more
prejudicial to health than tobacco-smoking.

Barnard's experiments led him to conclude that opium depresses
the functional activity of the sympathetic system, and notably that part
supplying the submaxillary gland. Gscheidlen considers that opium
affects the terminations of "the motor nerves; small doses at first
heightening but afterwards depressing their function, whilst largedoses
depress it from the first. Opium is said to lessen the conductivity of
sensory nerves, though this blunted sensibility must be due in some
measure to the effect of opium on the gray matter of the brain, depress-
ing the power of perception.

In the course of fevers, specific or inflammatory, soporifics, and above
all others opium, are often of the greatest value. Some patients first
show signs of failing in the nervous system ; and this depression of the
nervous system is generally due to want of sleep. From sleeplessness
the nervous system becomes exhausted and the patient wanders. If sleep
does not occur spontaneously, or is not induced by drugs, the delirium
becomes more marked and may be violent, as is often the case with
typhus, or muttering, as in typhoid fever. With the still further ex-
haustion of the nervous system there arises the trembling movements of
the extremities or of the protruded tongue, and the muscles tAvitch.
The tongue becomes dry; appetite, digestion, and assimilation become
depressed. With this nervous exhaustion, even if the heart's action has
for some time remained good, cardiac exhaustion, shown by a frequent
and feeble pulse, soon sets in; and henceforth the patient is in a highly
critical condition. If laudanum is given early, and before much nervou-s
exhaustion occurs, refreshing sleep is induced and the nervous system is
sustained; hence the need of stimulants is avoided or much lessened.
Ten or fifteen drops of laudanum is generally sufficient, but its action
is made much more certain by the addition of ten or fifteen grains of
chloral.

It may, however, happen that the opportunity of warding off nervous
weakness is lost, and the patient has become very delirious. Where the
delirium is of the furious kind it is well to combine the opium with
tartar-emetic, as this combination calms the excitement and produces
sleep more speedily and effectually than opium given alone. Graves
gave three or four drops of laudanum, and one-sixth to one-eighth of a
grain of tartar -emetic every two hours till tranquillity and sleep were
ensured; in very boisterous delirium he increased the dose of tartar-
emetic. If the delirium is of the muttering kind, laudanum either

OPIUM. 415

alone or combined with chloral is preferable. The h5'podermic injection
of morphia often succeeds in such cases. The good effect, too, of opium
is well shown in cases of marked nervous exhaustion. A slee^^less patient
with twitching and tremor of the muscles, quivering, dry, brown tongue
and parched skin, with rapid and feeble pulse, after a dose of laudanum
falls into a sleep of several hours; the delirium abates or disappears, the
twitching and quivering of the muscles becomes much less, the tongue
becomes moist, the appetite improved, and the pulse stronger and less
frequent; and with a nightly use of laudanum this improvement is
sustained.

Laudanum, by inducing sleep, greatly lessens the amount of alcohol
Avhich otherwise would be required, and if the laudanum is given early,
alcohol is not often needed.

The cases I have here dejiicted, where the weakest resistance is in
the nervous system, contrast strikingly with another class of cases where
the resistance is least in the heart, and this organ, instead of the nervous
system, primarily yields. In such a case we get signs of danger in the
frequent and feeble pulse; and this may occur whilst general strength
appears good, the voice strong, aj^petite and digestion fair, and whilst
there is no delirium. Where the heart failure occurs early, opium is
of little use, and alcohol is required. In such a case digitalis is often
very serviceable, slowing the heart and sustaining its strength and so
obviating the need of much alcohol. Quinine with digitalis is also
useful in the case just described.

In deliriuiti tremens opium does good service by producing sleep,
and it answers best when employed hypodermically. If the patient- is
strong, the delirium boisterous, the pulse full, tartar-emetic or tincture
of aconite may be added to the opium. It is convenient to administer
the opiate with j^orter or spirits, this combination apj^arently heighten-
ing its action, while it is more readily taken by the delirious patient.
It has been already mentioned that opium in delirium tremens some-
times acts more efficiently when given by the rectum.

It is still better to employ it hypodermically. In delirium tremens
it is well known that the effects of opium vary greatly, a moderate dose
even sometimes producing a fatal sleep. This variable effect often
depends on the condition of the kidneys. These are often diseased in
drunkards and tipplers. In Bright's disease it is necessary to give opium
with caution, not that the disease contra-indicates it; on the contrary,
it is often useful; but in Bright's disease the opium acts often with
unusual power; thus, in this disease, it must at first be given in a small
dose to test its effect. Hence, in delirium tremens, before giving opium
or morphia, the urine should be tested for albumen.

Many cases of acute mania may likewise be treated satisfactorily by
opium and tartar-emetic. (See Ciiloral.)

Scanzoni finds the hypodermic injection very useful in nrtemic con-
vulsions.

Dr. Anstie strongly insisted that opium acts chiefly in virtue of its
stimulating action, and that as a stimulant it relieves neuralgia, and that
it is not necessary to give narcotic but only stimulant doses. This view
has lately been urged by Dr. Pope, of New Orleans, who attributes the
usefulness of opium in fevers with great prostration to the stimulating
action of opium, and not to its producing sleep. He recommends the
hypodermic use of morphia in the debility consequent on onanism. I

416 OPIUM.

have often seen morphia, given hypodermically, useful in cases of the
follo'ving kind: — An hysterical patient suffers acutely from flitting neu-
ralgia, attacking now one nerve, and speedily seizing on another, and so
forth. She is greatly depressed mentally and physically. The hypoder-
mic injection of morphia sends a glow throughout the body, reaching even
the fingers and toes, and the cold extremities at once become warm, the
neuralgic pains disappear, and the mind and body become invigorated,
and these effects last several hours. Again, I have seen the hypoder-
mic injection of great comfort in cases of this kind: — A man suffers from
melancliolia, is disinclined to exercise, and has loss of appetite. After
an injection the depression of sprits clears off like a thick cloud, the pati-
ent becomes cheerful and chatty, the appetite returns, and he is able to
take a long walk without fatigue. In such cases, no doubt, we see the
stimulating action of the opium; but this result always appears to me to
depend on an idiosyncrasy, and not on the nature of the disease; that
these effects occur in those who obtain only the soothing and delicious
effects of opium; for in other patients with the same symptoms the hypo-
dermic injection of morphia fails to relieve anything but the pain, or may
even produce great depression, and very uncomfortable symptoms It
appears to me, therefore, that the stimulating action depends chiefly on
an idiosyncrasy of the patient, and in cases of prostration in fever I attrib-
ute the good" effects of opium far more to the soothing, strengthening
effects of the sleep than to the stimulating action of the opium; a conclu-
sion confirmed by the fact that good results do not generally follow unless
the opium produces sleep.

Dr. Graves has well pointed out that when an opiate is given as an
hypnotic attention should be paid to the time of its administration. It
should be given at the usual time for sleep, or when the patient feels
inclined to doze, so that the medicine may come in aid of nature; smaller
doses are then more effectual than if given at a less seasonable time.
From example, in chronic wasting disease, accompanied with hectic, the
opiate should be given very late at night; for with hectic there is often
no inclination to sleep till the early morning hours. Opium ordinarily
requires about one or two hours to produce its narcotic effects. Chronic
sleeplessness, independent of any very notable disease, should not be
treated with opium if it is possible to avoid it. Dyspepsia and uterine
derangements are constant causes of sleeplessness, and chloral and bromide
of potassium are much better agents than opium.

Opium will, of course, relieve or abolish pain; yet in the treatment of
chronic cases it is right first to exhaust all other methods, for the opiate
soon loses its influence, and must be given in increasing quantities, i;ntil
the patient becomes accustomed to it, and is unable to discontinue it with-
out great discomfort, even after permanent removal of the pain.

Opium, especially when employed hypodermically, often relieves pain,
and ensures sleep in acute rheumatism.

Ojiium is often of signal use as an anti-spasmodic. Its action in this
respect, as well as its narcotic power, is much enhanced if given with a
stimulant, as alcohol, ether, or chloroform.

Laudanum or morphia is of marked service in the convulsive stage of
whooping-cough. A sufficient dose should be given to a child to produce
very slight heaviness, which state should be maintained by giving one-fif-
tieth of a grain of morphia every, three or four hours, or a proportionate
dose every hour. A quarter of a drop, or two drops of laudanum, accord-

OPIUM. 417

ing to tlie age of the child, must be given every hour. This treatment
often quickly removes the whoop, and reduces the severity and frequency
of the cough; but in the case of an irritation, as of teetliing, or of worms,
tuberculosis, or much bronchitis, this remedy, like most others, is of little
or no use.

Opium and its preparations are beneficial in renal and biliary colic.
Morphia answers best when employed hypodermically. If administered
by the mouth, small doses of the opiate, combined with spirits of chloro-
form, should be administered every five or ten minutes, till the pain gives
way.

Opiates are also beneficial in cases of asthma, yet with some asthmatics
morphia will induce a paroxysm of dyspnoea.

Opium is very useful in diabetes, to control inordinate appetite; the
diminution of quantity of ingested food reduces the kidney secretion, and
abates the troublesome thirst. It was at one time thought that this was
the only way opium proved useful in diabetes, but it has been lately shown
that large doses, frequently repeated, will greatly lessen, and, indeed,
remove the sugar from the urine, the diet and the appetite remaining
unchanged.

Opiates are also used in spasmodic stricture.

Opium and its preparations are reputed to check the excretion from
all the mucous membranes of the body, and on this account are given in
bronchitis to check excessive secretion of- mucus and pus.

Opiates are employed as diaphoretics.

Ten grains of Dover's powder at bedtime will generally check the
night sweats of phthisis, and other exhausting diseases, even when other
remedies, like zinc, have failed.

It is well known that opium, in a small dose taken at night, if resorted
to at the commencement of the attack, will cut short a cold in the head.
Some attribute its efficacy to its influence on the skin; and Dover's pow-
der is very generally employed. Two or three drops of laudanum, taken
at bedtime, is often sufficient at once to abolish a threatening attack of
cold in the head. A glass of hob grog assists the action of the opium.

Laudanum, especially when mixed with tincture of nux vomica, is
very serviceable in some of the distressing symptoms which afflict hysteri-
cal women, or nervous, overworked, anxious men. Both men and women,
but .chiefly women about forty or fifty years of age, are apt to complain of
a sensation of great weight and heat on the top of the head, with frequent
flushings of the face, suffusion of the eyes, hot and cold perspirations,
and sometimes shooting pains passing up the back of the head. The pain
occasionally centres in one brow, with much heaviness and torpor after
meals, and now and then the sensation as of a tight cap on the vertex, or
dull aching pain in the same part, with inability to fix the attention, and
much depression of spirits. These symptoms may generally be traced to
a variety of causes, as d;^'spepsia, especially the flatulent form, heartburn,
uterine derangements of various kinds, or unhygienic conditions. In any
case, however, a drop of laudanum, with two of the tincture of nux vom-
ica, repeated three or four times a day, will generally dissociate the fore-
going symptoms from the disease with which they are connected, to the
great relief of the patient.

Morphia occasionally produces an eruption, sometimes like that of
measles, at other times like that of nettlerash. It maybe accompanied by
distressing itching, sufficient often to counteract the anodyne properties of
the medicine. 27

418 opirM.

Tincture of 0]->ium in a large dose ( 3 j). mixed with brandy, is recom-
mended in ])rofuse flooding iifter parturition, accompanied with much
exhaustion of the uterus.

The influence of opiates on the urine of diabetes has already been
pointed out.

The i)reparations of opium diminish the water and urea of healthy
urine, probably by lessening the appetite and hindering digestion. Mor-
phia passes partly away by the urine.

Under the influence of opium the urine is sometimes retained for sev-
eral days in the bladder.

It is important to bear in mind that the active principles of opium
pass out with the milk, so that a child at the breast may be dangerously
affected by opium given to its mother.

Individual peculiarity, disease, age, custom, sex, modify the action of
opium.

We have already spoken of individual peculiarity. Mr. J. Brown has
shown that there is sometimes hereditary susceptibility to some drugs, as
opium and mercury.

As is well known, very large doses are tolerated in some diseases,
especially in the cases of severe pain.

Age influences the action of all medicines, but in an especial degree
that of opium. That a dose of a medicine should act far more powerfully
on the young than the old is only natural, for as it becomes mixed and
diluted with the blood the dilution is, of course, greater in adults than in
children. Other things being equal, the dose, as a general rule, mast be
proportioned to the weight of the individual, provided there is no undue
development of fat. Opium, however, is a notable exception, the relative
susceptibility of young children to its action being far greater than in
adults. So great is the power of opium over individuals of tender years
that great care must be taken in its administration.

The influence of custom on the action of opium has already been
mentioned.

Opium, it is said, affect women more readily than men, particularly as
regards its exciting effects.

Morphia is said to be less stimulating, less constipating, less diapho-
retic, and less liable than opium to produce headache and nausea.

Some writers extol the narcotic virtues of codeia, asserting that, unlike
opium, it produces calm sleep without disordering digestion, exciting
nausea, constipation, or producing headache; other observers, however,
consider it useless as a narcotic.

Karcein has been much recommended as a hypnotic and sedative. It
is said to be more efficacious than morjihia, and to produce no lieadache,
to induce less perspiration, not to constipate, nay, in largo doses to purge,
rarely exciting vomiting, but often nausea and loss of appetite. One
observer computes that narcein is four tnnos Aveaker than morphia. It is
stated that narcein is the only alkaloid of opium which does not produce
convulsive movements.

Dr. J. Harley considers narcein a pure hypnotic, much feebler than
mor]ihia, and of very little use in medicine, its insolubility rendering it
unfit for subcutaneous injection. On the other hand, having tested it by
mouth and hypodermically Dr. Fronmiiller asserts that narcein possesses
no narcotic properties, a dose of 20 grains by the stomach producing no
sleepiness or any effect on the respiration, pulse, heat of skin, urine,
or pu})ils.

NUX VOMICA. 419

Narcotine, in doses of one to three grains, is asserted to possess anti-
periodic properties, some considering it even superior to.qninia in ague.

Very conflicting statements are made regarding other properties of
narcotine. Eulenberg, Charvet, Fronmiiller, and others, assert that small
doses increase the frequency and the strength of the pulse, but after a
time make it irregular, and that it increases the frequency of the respira-
tions and exalts the temperature. Small doses they say are not narcotic.
Schrolf says doses of 0.06 to 0,12 grm. produce symptoms like the first
stage after a usual dose of opium, but without affecting the pupil or pro-
ducing nausea. Fronmiiller asserts that 15 to 30 grains produce sleep,
but Bailey gave 60 to 120 grains without inducing sleep.

Papaverine is said to possess strong narcotic properties without induc-
ing the ])revious stages of excitement, and is not folloAved by headache
and giddiness. It contracts the pupil, and, when it causes sleep, reduces
considerably the frequency of the pulse, to the extent even of twenty to
thirty beats. Fronmiiller also finds that it is a narcotic, and that it dila-
tes the pupil — the pulse, respiration, and temperature remaining unal-
tered. Hoffman, in some experiments on himself, could not obtain these
results.

The statements concerning the action of the opium alkaloids are most
contradictory, due probably in part to the use of impure preparations,
or to the employment of a mixture of the alkaloids, or in part to the fact
that the action of these substances on animals is different to their effect
on man. Thus, as regards man, morphia is the most powerful alkaloid;
but according to Bernard, as regards animals it ranks fourth. Thebaia
is to animals the most poisonous alkaloid, but its effect on man is much
less marked; again, it is said that with respect to animals narcein is the
most soporific of the alkaloids, but its action on man is far less than that
of morphia.

NUX VOMICA. STRYCHNIA. BRUCIA. THEBAIA.

The three alkaloids, strychnia, brucia, and thebaia, ajipear to exert
a similar action on the spinal cord, so that, for convenience sake, they
are grouped together; but it should be stated that strychnia is more
powerful than brucia, and brucia than thebaia. Our succeeding remarks
aj^ply mainly to nux vomica and its alkaloids, as thebaia has not yet been
put to any therapeutic application.

The late Dr. Anstie recommended the hypodermic injection of
strychnia, in one-hundred-and-twentieth of a grain doses, to relieve the
pain of cardialgia and gastrodynia. " There is," he says, " no such
remedy for gastralgia as this."

Mr. Charles Hunter advises the injection of strychnia hypodermically
in cerebral, spinal, and other forms of parah'sis. About one-eightieth
to one sixtieth of a grain, administered twice or three times a week,
will, he says, after three or four injections, almost always show if
strychnia manifests any effect on that jiarticular form of palsy. The
injection produces a general warmth or glow of the skin lasting a few
hours, felt most in the paralyzed limbs, and down the spine; it removes
the sensation of heaviness, or weight, and the muscular twitchings.

420 NUX VOMICA.

spasms, or cramps, and may induce sweating, especially of the i^alsied
parts. Most of these results I have myself witnessed.

Hypodermic injections progressively increased, till even one-twelfth
of a grain is injected at one dose daily, are useful in essential jjaralysis
of children and in diphtheritic paralysis.

Dr. Julian Chesolm employs h^-^^odermic injections of strychnia in
eye and ear diseases, beginning with one-fortieth of a grain daily, increas-
ing the quantity till, in fifteen to twenty days, one-sixth or one-fifth of a
grain is reached, and no benefit may take place till these larger doses are
administered. As we meet with idiosyncrasies in respect of strychnia, it
is well to begin with a small dose. He employs these injections in mus-
cular asthenopia, amblyoj^ia, tobacco amaurosis, and in progressive nerve
atrophy not dependent on intra-cranial disease. Dr. Werner finds strych-
nia by injection useful in traumatic amaurosis. Perhaps these large
doses given by the stomach might prove just as serviceable.

The preparations of nux vomica have an intensely bitter taste, and,
like other bitters, augment the flow of saliva.

They produce a sensation of hunger, but there is no evidence that, in
a healthy person, either strychnia or any other bitter substance increases
the digestive power. Like other bitters, and, perhaps, in a greater
de^'ee, these preparations, by their slight irritant action, check unhealthy
deviations of the gastric mucous membrane, and may in this way promote
digestion. The action of bitters, and especially of the tincture of nux
vomica, far the best and most agreeable agent for this purpose, is well
shown in certain perverted conditions of the digestive canal. For exam-
ple, in the course of chronic diseases, such as bronchitis, dilated heart, or
cirrhosis of the liver, the tongue not unfrequently becomes thickly coated
with a white fur, and the symptoms indicate chronic catarrh of the
stomach: one or two drops of the tincture of nux vomica in a teaspoonful
of water, every two hours, or of tener, for twenty-four to forty-eight hours,
will often clean the tongue, improve the digestion, and, at a critical time,
clear the way for the administration of nourishment. Again, during early
convalescence, Avhen the tongue still continues coated, and the digestion
weak, nux vomica will prepare the way for stronger tonics and more liberal
diet.

This treatment greatly mitigates the annoying flatulence and indiges-
tion occurring in cases of mechanical obstruction of the circulation in
the digestive organs, as from cirrhosis and dilated heart; indeed, nux
vomica is more or less serviceable in flatulency of any kind. Heartburn
also frequently yields to small quantities of the tincture, given three or
four times a day.

TTux vomica is of great service in a group of symptoms, including
weight at the pit of the stomach after food, acidity, and heartburn; flatu-
lence, accompanied by heat and weight at the top of the head, the last
symptom occurring usually in woman, especially about middle age. This
dyspeptic condition is often benefited by five drops of the tincture of nux
vomica taken about a quarter of an hour before food, three times a day.
The heat and sensation of weight on the top of the head, even when oc-
curring independently of any gastric disturbance, often yields to the same
treatment.

In acute gastric catarrh, accompanied by *'sick headache." the action
of tincture of nux vomica is sometimes very marked. This common and
troublesome complaint is sometimes traceable to error in diet, or consti-

NUX VOMICA. 421

pation, but it occurs often without any apparent cause. Headache is often
the most prominent symptom, the nausea being very slight, amounting
to mere qualmishness. A drop of the tincture in a teaspoonful of water,
taken every five or ten minutes, to the extent of eight to ten doses, and
then continued at longer intervals, often quickly mitigates, and in a few
hours removes, this kind of headache, which otherwise would continue
all the day.

The tincture or extract of nux vomica has long been employed to
correct constipation, habitual or temporary. The extract, mixed with
otlier remedies, such as rhubarb or colocynth pill, should be taken daily
shortly before dinner, to aid digestion, and the proper unloading of the
bowels. The same effect may often be obtained by giving one or two
drops of the tincture twice or three times a day. As our knowledge of
the action of nux vomica in its relation to constipation is at present im-
l)erfect, the results appear to be capricious. It is as well, therefor^?, not
to be too sanguine of success; for in some cases it answers beyond all ex-
pectation, while in other apparently similar cases it completely fails. If
the bowels are habitually sluggish, the patient should take occasionally,
early in the morning, half a tumblerful of some natural purgative water to
assist the nux vomica. Should the tardy action be due to insufficient
supply of bile, the motions being pale in color, nux vomica will fail, and
other medicines are required.

Strychnia, as Mr. Savoy has shown, is much more poisonous when in-
jected into the rectum than when swallowed, a curious difference, not due
to the digestion and destruction of the alkaloid by the gastric juice, since
Mr. Savoy has proved that this secretion exerts very little, and probably
no effect, upon strychnia.

Strychnia, another active principle of nux vomica, quickly enters the
blood, as is shown by the rapidity with which a poisonous dose is followed
by characteristic symptoms. Moreover, the alkaloid can be extracted from
the blood and urine, a conclusive proof of its absorption.

A large and poisonous dose produces symptoms very closely resembling
those of tetanus. Symptoms usually come on in twenty minutes to half
an hour, and are rarely delayed beyond an hour. The first symptoms are
general uneasiness, with restlessness and soreness of the limbs. Shooting
pains like electric shocks occur in various parts of the body, often first in
the back, and down the arms and legs. Tetanic and paroxysmal contrac-
tion of the muscles soon sets in, and these symptoms grow rapidly worse,
and make the body rigid while the paroxysm lasts. The first paroxysm,
may be very severe. The respiratory movements are completely arrested,
so that the face becomes bloated and livid, the jugular veins stand out in
the neck, the eyes are staring and prominent, the jaws firmly clenched,
and the pupils dilated. Each spasmodic attack lasts from a few seconds
to a minute or more, and then generally ceases altogether for a time.
Throughout the paroxysms, the mind is quite unaffected, and the, patient's
sufferings are agonizing. A breath of air, a slight noise, movement of
the bed-clothes, the most trivial cause, will excite tetanic spasms. In a
fatal case death is rapid; but if the patient should survive two or three
hours, sanguine hopes may be entertained of his recovery. A fatal ter-
mination may be due either to exhaustion from the repeated convulsions,
or to asphyxia from spasms of the muscles of the chest. The muscles of
the jaw are usually the last to be affected.

422 Nux VOMICA.

Brncia, tliebaia, and most of the opium alkaloids affect the body in
the same way.

The symptoms of strychnia poisoning differ from those of tetanus in
the following particulars: — From the first the poison symptoms are very
strongly marked and raj)idly reach their worst, perfect intermissions occur,
and death soon takes place; or the symptoms rapidly decline, and the
patient recovers. Fatal doses of strychnia raise the temperature of dogs
from 4° to 6° Fah.

Treatment of poisoning: — Stomach ptwip, if available in time, for after
tetanic symptoms have set in the introduction of the tube would excite a
paroxysm. Animal charcoal. Tannin solution of iodine. Chloroform
inlialation. Injection of curare, or of methyl and ethyl compounds of
strychnia, of brucia, or of thebaia. Artificial respiration. Fats.

Leube and Rosenthal find that pulmonary insufflation arrests strychnia
tetanus by increasing, as they supposed, the absorption of oxygen. Brown-
Sequard confirms tliese statements concerning insufflation, but contends
that the arrest of convulsions is due to the mechanical effect produced Ijy
the forcible impact of the air upon the ramifications of the vagus, of the
bronchi, and of the nerves of the diaphragm, exciting a reflex inhibitory
action; for section of the cord above or below the origin of the phrenic
nerves and section of the vagi prevent the action of insufflation.

Strvchnia excites tetanus, not through the brain; for in poisoning by
strychnia, the mind, to the last, remains unaffected, and between the
paroxysms animals can execute voluntary movements. Xor does it teta-
nize through the muscles or nerves; for after division of one sciatic nerve,
strychnia excites tetanus in every part of the body except in the limb sup-
plied by the divided nerve; yet as the vessels of this limb are undivided,
its convulsed muscles and nerves are as much poisoned by strychnia as
those parts which are convulsed. As strychnia tetanizes neither through
the brain, muscles nor nerves, it must act through the cord. This con-
clusion is confirmed by the following experiments: 1. If the cord and all
the vessels supplying its posterior part are cut and the animal is then
poisoned, convulsions occur in the anterior portion of the body, but simple
normal reflex acts follow stimulation of the posterior part of the body,
that part indeed under the control of the division of tbe cord protected
from the poison by secretion of its vessels. '2. If all the blood is allowed
to drain from the body of a frog by section of its heart, and a small quan-
tity of strychnia is then placed on the forward part of the cord, the anterior
parts of the body become speedily tetanized, and this condition slowly
extends to the posterior parts as the strychnia descends and affects the
rest of the cord.

Dr. G. Walton finds that strychnia, in a dose sufficient to produce
tetanus, so affects the cord that any stimulus capable of producing a
reflex contraction produces a maximal contraction, provided a certain time
has elapsed since the preceding stimulation. The necessary interval varies
with the degree of poisoning, being a few seconds only when the frog is
strongly poisoned. During this interval the degree of contraction depends
on the strength of the stimulus. All the contractions are tetanic. After
strvchnia there is no summation of stimuli, the behavior of the strvchnized
cord thus differing strikingly from the unpoisoned cord. The minimjil
stimulus, capable of producing a reflex movement, becomes less and less
as the poisoning effect increases. The motor and sensory nerves. Dr.
AValton finds, are unaffected by strychnia.

NUX VOMICA. 423

After traumatic and strychnia tetanus the functions of the motor
nerves and muscles are depressed, the motor nerves convey impressions
imperfectly, whilst the muscles contract imperfectly under, direct galvanic
stimulation and become stiff from rigor mortis. Kolliker has shown that
this is in part due to the excessive activity these parts have been made
to undergo through the strychnia. But strychnia apparently also directly
depresses the motor nerves, for large doses kill without exciting convul-
sions when the motor nerves are found to have lost their conductivity.
Moreover, if, before poisoning, the sciatic nerve is divided, thus protect-
ing the limb from convulsions, the divided sciatic loses its irritability,
though not so soon as the undivided nerve. Again, if all the tissues of a
frog's leg except the nerves are tied, and the portions beneath the ligature
thus defended from the poisoned blood, all parts become tetanized; but
the convulsions cease sooner in the poisoned than in the protected leg,
the motor nerves of the former having been paralyzed by the strychnia-
containing blood.

Ilarley's experiments show that the poison acts on all parts of the
spinal cord, its effects on this organ appearing to be twofold. It dilates
the vessels, thus increasing the supply of blood, and also augments the
activity of the functions of the cord.

It is stated that traumatic and strychnia tetanus produce minute ec-
chymoses in the cord. This is not the case with frogs tetanized by strych-
nia;, for these animals may be tetanized for weeks without the produc-
tion of ecchymoses — a fact which proves that ecchymoses are the result
and not the cause of tetanic spasms.

It seems worthy of remark that strychnia does not merely heighten
the reflex action of the cord, but so affects it that impressions are not
confined within their natural limits, but diffuse themselves throughout
the cord ; strychnia, in fact, lessens the resistance of the cord and increases
the diffusibility of impression. Strychnia heightens arterial pressure by
stimulating the vaso-motor centre.

Nux vomica or its alkaloid is commonly employed, often with great
benefit, in motor paralysis. Sometimes it is administered with the view
of exciting slight twitching in the paralyzed muscles, so as to keep up
in them a sort of artificial exercise calculated to maintain their nutrition
and prevent their wasting; but if strychnia benefited in this way, surely
galvanism would effect the object better. Dr. Brown-Sequard recom-
mends nux vomica or strychnia in those forms of paraplegia dependent
on softening and wasting of the cord, when, for example, the supply of
blood conveyed to it is diminished through degeneration and partial
blocking up of the vessels.

Strychnia is supjiosed to dilate the vessels and to increase the sup-
ply of blood in the degenerated tissues, and thus to avert their further
destruction.

Strychnia affects paralyzed sooner than unparalyzed muscles.

In medicinal doses strychnia is said to strengthen the heart beats. It
has been shown that the heart of an animal poisoned by strychnia ceases
to contract sooner after death than that of an animal destroyed by me-
chanical means ; and further, that if a frog's heart is placed in a solution
of strychnia it ceases to beat sooner than another placed in simple water.
It is not said whether this organ ceases to contract in the systole or dia-
stole. Harley states that when a solution of strychnia is dropped on a
heart its muscles become tetanic. The same authority says that both

424 NUX VOMICA.

strychnia and brucia lessen the absorption of oxygen and the production
of carbonic acid; in other words, they lessen the respiratory function of
the blood, and if either alkaloid is mixed with blood recently drawn, the
amount of oxygen it absorbs and of carbonic acid it gives otf, are less
than with simple blood. Is it not probable that any substance capable
of altering the physical or chemical condition of the blood will lessen its
respiratory functions ?

Strychnia stimulates the resjiiratory centre, and clinically, when
given in full doses, it is found of much service in chronic bronchitis
and emphysema.

Strychnia, given to a rabbit with young, causes abortion; it has
therefore been stated that this drug possesses a direct influence on the
uterus, but there is no evidence to confirm this conjecture.

Strychnia is useful in prolapsus ani, and if this condition is associated
with constipation; the nux may be added to a purgative, as tincture of
rhubarb. If diarrhoea occurs, it should be checked, and the prolapsus
will probably cease; if not, strychnia will generally succeed quickly in
ridding a child of this troublesome complaint. These preparations, es-
pecially the tincture, are often of much use in so-called hysteria of
middle-aged people. In many cases it appears to control the distressing
flatulence commonly connected with this state, and to relieve the sensa-
tion of heat and weight at the top of the head; and it often removes
effectually, although less surely, flushings of the face, and hot and cold
perspirations. It is still more effectual when combined with small
quantities of laudanum. Strychnia given hyj)odermically or by the
stomach is highly recommended in alcoholism and delirium tremens.
Persistently administered it prevents the recurrent crave for drink, often
met with in j)ersons who inherit the propensity direct from a drunken
parent, or as the result of an altered neurosis. It must be administered
in increasing doses. Some patients have reached the enormous dose of
one and two-third grains of the extract of nux daily with much benefit
and without the induction of any toxic effect. In delirium tremens
strychnia given hypodermically in ^'^ to ^ grain, or even larger doses,
calms excitement and induces sleep.

The late Dr. Anstie noticed that strychnia sometimes produces
symptoms closely resembling intoxication, unsteadiness of gait, perver-
sion of the intellect, and a meaningless smile. On one occasion I was
able to connect a peculiar wandering delirium at night with the employ-
ment of strychnia, though there were no tetanic twitchings.

According to Dr. Anstie, strychnia promotes capillary circulation,
and he recommends it in troublesome coldness of the hands and feet.

Sti-ychnia sometimes induces persistent erections, which phenomenon
has led some medical men to give it in impotency and spermatorrhoea.

Large doses of strychnia are sometimes useful in spermatorrhoea,
especially when associated with impotence.

Strychnia is sometimes employed Avith much benefit to old people
with paralysis of the bladder, when the water constantly dribbles away.
It may also be useful in the incontinence of urine of cliildren.

Strychnia is sei^arated in part, at least, by the kidneys. Its influence,
if any, on the urine, has not yet been ascertained.

In a remarkably able paper, Drs. Crum Brown and Fraser record some
experiments made with methyl and ethyl compounds of strychnia, brucia,
and thebaia, and have arrived at some astonishing results. While retain-

NUX VOMICA. 425

ing most of tlio chemical properties, giving the ordinary reactions of strych-
nia, brucia, and thebain, yet the physiological action of these substances
on the body is completely altered. These obscu'vers experimented with
iodide of methyl-strychnium, sulphate of methyl-strychnium, and with the
nitrate and hydrochlorate of the same base, and likewise with iodide and
sulphate of methyl-brucium, and with iodide and sulphate of methyl-
thebaium.

As we have already stated, strychnia, brucia, and thebaia affect the
cord, and produce, according to the dose, more or less severe tetanic con-
vulsion. But these substances, Avhen converted into the ethyl and methyl
compounds, cease to act in this manner, and produce general paralysis of
the bod}^ an effect shown by these experiments to depend on paralysis of
the ends of the motor nerves. In fact, these new compounds act on the
body in the same way as curare.

in their action on the heart and muscles these new substances were
likewise found to differ much from strychnia, brucia, etc.; for after
poisoning by the methyl or ethyl compounds the heart continued to
contract naturally for a long time, while the muscles for many hours con-
tinued flaccid, contractile, and alkaline.

Drs. Crum Brown and Fraser further experimented on codeia, mor-
phia, and nicotia. At the conclusion of their treatise they say: —

" The change in the character of the physiological action is remarkably illustrated
by strychnia, brucia, and thebaia, whose purely spinal tetanic action is converted
into a paralyzing action on the periphery (and organs) of motor nerves; it is apparent
in codeia and morphia, whose couvulsant action is also converted into a paralyzing
action on motor nerve-end organs, and whose hypnotic action is apparently altogether
destroyed in the case of codeia, and certainly greatly diminished in that of morphia;
and it is obvious, though less so than with the others, in the case of nicotia, whose
convulsant action is diminished, if not altogether removed. We may conclude from
these facts that when a nitrite base possesses a strychnia-like action, the salts of the
corresponding ammoniimi bases have an action identical with that of curare.

" It is well known that curare and strvchnia are derived from plants belonging to
the same genus, and it is therefore interesting to observe such a relationship. It may
not, however, be altogether superfluous to add that strychnia, brucia, and the other
s]iinal .stimulant alkaloids examined in this paper have not been converted by chemical
addition intd curarina — the active principle of curare. The action of the methyl de-
rivatives of these bases is of precisely the same character as that of curare, and they
possess the same peculiarity of slow absorption by the mucous membrane of the
dige.stive system, but the degrees of their activity are very different. If we confine
our attention to the salts of the methyl derivatives of strychnia, brucia, and thebaia,
where the action is uncomplicated, we observe they form a series in which the fatal
dose varies for each, while this dose, in the case of the most active oi the three, is con-
sitlcrably above that of curare, and greatly above that of curarina. Besides, curarina
has a characteristic color reaction that belongs to none of these bodies, and the latter
further proves this dissimilarity by each of them po.s.sessing special color reactions, by
which they may be distinguished from each other. "

There is a distinct antagonism between strychnia and calabar bean and
between strychnia and chloral. These antagonisms have lately been in-
vestigated by a committee presided over by Dr. Hughes Bennett. Pre-
vious experimenters have shown that calabar bean modifies strychnia
tetanus, but it is of no avail to save life, and Dr. Bennett's committee
confirm the conclusions, that whilst the symptoms induced by strychnia,
as tetanic convulsions, are modified by calabar bean, so far from saving
life it actually helps to destroy it, for, when both poisons are administered
together, but each in quantity less than the minimum fatal dose, their
combined action in this dose is fatal.

The antagonism between chloral and strychnia is far greater; chloral

426 LOBELIA INFLATA.

modifies the stryclmia symptoms to a great extent, and, as might be ex-
pected, the sooner chloral is given after strychnia the greater is the
antagonistic etfect. Very large doses of strychnia require very large and
even dangerous doses of chloral, enough to produce serious symptoms.
Whilst chloral antidotes strychnia, it is doubtful if strychnia will avert
death from chloral. Chloral produces profound coma, and destroys life
by its action on the cerebral hemispheres. JStrychnia does not affect
these parts.

LOBELIA IXFLATA.

This remedy has been highly extolled, and strongly condemned,
answering with some beyond expectation and to others yielding nothing
but failure and disappointment. This discrepancy may be reconciled
easily, for it will be found that lobelia has been given in very different
doses by two different sets of authorities. Unless given in large doses
— doses thought to be poisonous — this remedy is inoperative. It is er-
roneously imagined that lobelia is a highly poisonous and dangerous drug,
to be given only with much caution and close watching. It contains
lobelin. Lobelia first raises and then depresses blood pressure. Large
doses paralyze the vaso-motor centre and the peripheral ends of the vagi.
It kills by paralyzing the respiratory centre.

Lobelia is of great service in many cases of asthma, whether dependent
or not on visible structural changes in the lung. It is useful in the
peptic, and especially in the bronchitic form. These two forms are
generally more or less mixed, the tightness of breathing in bronchitic
asthma being increased by food, and the peptic asthma leading after a
time to emphysema and bronchitis. Lobelia, is, I think, less useful
when the attacks come on periodically, at intervals varying from about
three weeks to a month. It may, indeed, for several days, jiostpone or
partly suppress the paroxysm, but after a time the lobelia is apparently
unable to prevent the attack. My experience leads me to esteem lobelili
higher the more I try it, and I frequently hear it extolled by patients.
It must, however, be confessed that in some cases it fails entirely. In the
bronchitic form patients often say it " helps them to get up the phlegm."
It is hardly necessaiy to observe that lobelia is not useful in all forms of
dyspnoea; it is useless when this depends on heart disease, and when the
difficulty of breathing comes on only from exertion, or from a bad fit of
coughing. Lobelia being only palliative and not curative of the condi-
tions causing the dyspnoea, it should be given only during a paroxvsm.
On any signs of an oncoming fit the medicine must be taken immediately
in doses of a drachm of the simple tincture every hour, or even every half
hour, or ten drops may be taken every ten minutes or quarter of an hour
till the dyspnoea gives way. It is better to adopt the smaller and more
frequent dose, as the medicine can be discontinued, should sickness or
depression occur. The great drawback is its uncertain action, some
patients being made sick and faint by doses which others take without
any such penalty. The risk of depression is obviated by small frequent
doses, and a patient soon learns the suitable dose and periods. It is well
to inform patients of the possible occurrence of sickness and faintness,
Avhich may make them feel very ill; but these symptoms soon disappear,
and never, so far as I have seen, become serious or dangerous. I have
repeatedly given two-drachm doses without any dangerous consequences;
but this large dose generally excites a sensation of sinking at the stomach.

CANNABIS INDICA. 427

with nausea, and, not nnfreqnently, vomiting. When the patient com-
plains of more or less constant tightness of the chest, with frequent
exacerbations during the day, he should take ten minims of the tincture
thrice daily, with an additional dose on the occurrence o! the exacerba-
tion. In bronchitic asthma, where the breathing is a little tight all day,
but much worse at night, the patient should take ten minims three times
a day, with additional doses according to the state of the breathing at
night. It should be given cautiously to asthmatics with heart disease, or
it may render the pulse irregular, and very weak. Lobelia inflata allays
the dyspnoea which accompanies capillary bronchitis in emphysema.

In certain epidemics of whooping-cough lobelia is very serviceable,
whilst in other epidemics it seems useless. Lobelia is useful in the sjiasmodic
stage, and in two or three days generally reduces by one half the frequency
of the attacks, lessening their severity at the same time; the speedy subsid-
ence and disappearance of the whoop attest the influence of this drug. Like
all other Avhooping-cough remedies it acts best in uncomplicated cases,
and when the weather is warm and mild. If the weather is cold, and the
winds cutting and sharp, the child should be confined to a warm room,-
but under other circumstances the child should live as much as possible
in the open air. For a patient two years old, I order ten minims of the
tincture of lobelia every hour, and an additional dose each time the cough
is imminent, provided the | aroxysm gives sufficient warning. Children
bear large doses of the drug; for, in no instance have I witnessed nausea,
sickness, faintness, or any ill effects follow the doses Just recommended.
I find, indeed, that adults are much less tolerant of lobelia than chil-
dren. Sometimes lobelia produces a slight burning sensation in the
throat. Whooping-cough is well known to be a very obstinate and dan-
gerous affection in children only a few months old, and in such cases
lobelia often appears to do less good than to older children. Even to
very young children I give five minims of the tincture every hour.'

Lobelia has been recommended in broiichitis; and I have tried it in
several cases, but while it removed any paroxysmal dyspnoea, it appeared
to be powerless over the bronchitis itself. It has been employed in laryn-
gismus stridulus and in croup.

CANNABIS INDICA.

Indiaist hemp does not affect all persons similarly, and race and cli-
mate are supposed to modify its influence. Its effects are most marked
on the brain, whose functions it more or less perverts in various ways.
It generally produces a pleasurable intoxication, and the dosed person
becomes talkative, or sings, or perpetually giggles, and objects often as-
sumed to him very grotesque aspects, exciting him to much merrimeiffc.
He is possessed with a feeling of happiness and contentment, and ideas
of a pleasing kind pass rapidly through the mind, sometimes unconnected
and immediately forgotten; but in other instances recollected on the

' 'Sir. Foster, of Huntingdon, and Dr. Howard Sartjent, of Boston, America, re-
commended clover in whooping-conuii. Dr. Sarg'ent gives a wineglassf ul occasionally
through the day, of an infusion made with two ounces of carefully dried blossoms of
red clover, steeped in a pint of boiling water for four hours.

428 CANNABIS INDICA.

return to the normal state. The delirium is sometimes furious. After
a time sleep sets in, generally accompanied Avith delightful dreams. There
may be pain in the head, " a sensation as of the Ijrain boiling over and lift-
ing the cranial arch, like the lid of a tea kettle." Among the early symp-
toms is a sensation of heaviness of the arms and legs. The head feels hot
and heavy. The eyes are bright and shiny, with sometimes giddiness and
noises in the ears. General sensibility is also alfected, and pricking in
the feet, or over the whole bod}^ Avith num.bness, often of a pleasurable
kind, is an early symptom. Pressure on the skin may excite a sensation
of burning. After a time, complete anaesthesia sets in to sucli an extent
that while standing there may be no consciousness of touching the ground.
The muscular sense is even lost, and pain is lessened or removed. Some-
times it produces complete catalepsy. It often occasions a ravenous sen-
sation, not to be appeased by food. In some instances the pulse is said to
be at first rather increased in frequency and strength, Init neither pulse
nor breathing is much altered. It dilates the pupils, but they contract
to light. Sometimes' there is strong sexual desire.

Such is the group of symptoms induced by Indian hemp, though they
do not all occur in the same person, but are variously combined ; and some-
times it produces sensations anything but pleasant, as nausea, vomiting,
great thirst, frequent, weak, and intermittent pulse, Avith disagreeable
sensations and ideas.

If indulged in for a long time, as is common in the East, it produces
loss of appetite and strength, trembling, and much mental Aveakness.

It is used to produce sleep, and its effects have been coriipared to those
of opium; but it differs from this drug, it is said, in not producing nausea,
constipation or headache. Fronmiiller administered it in 1,000 cases, and
found that it succeeded in 530; partly succeeded in 215; and produced
little or no effect in 255 instances. A large dose is required to induce a
hypnotic effect, as eight grains of the spirituous extract, Avliich sometimes,
soon after its administration, excites headache, A'omiting, and giddiness;
and the headache may be severe, dull, and throbbing, and accompanied
by a coated tongue. The preparation used by Fronmiiller must be far
Aveaker than the extract employed in this country, for in some cases even
half a grain of native extract excites disagreeable symptoms.

Cannabis indica is one of the most valuable remedies for megrim or
sick headache. It appears to act on the nervous centre Avhence this head-
ache springs. It is found serviceable both in cases associated Avitli little
or no nausea, and in cases accompanied by severe vomiting. It is useful
in attacks accompanied Avith spectra. It is most useful, in my experience,
in preventing the attacks, not in arresting them Avhen once they luiA^e
begun. It is sometimes useful in those seA^ere, continuous forms of head-
ache lasting for Aveeks (see Croton Chloral) ; but it is especially effective
when from fatigue, anxiety, or change of life the attacks become much
more frequent; then the drug gradually, and indeed sometimes quickly,
lengthens the interA'al, and at last brings back the attacks to their old
periodicity, or eA'en extends the interA-als between the seizures. It need
hardly be said that cannabis Avill not cure these patients. I have given
this drug Aveeks or months continuously, in doses of one- third to one-
half a grain twice or thrice daily. As ana?mia or constipation, favoring and
even exciting attacks of migraine, often co-exist Avith it, cannabis indica
may be combined in pills Avith eitlier iron or aloes.

Subsequent exi^erience has fully confirmed the favorable ojiinion of it

ERGOT. 429

just expressed; no single drug have I found so useful in migraine.
Not only is cannabis indica useful in the inter-paroxysmal period to
prevent headaches, but a third to half a grain of the extract given at the
commencement of an attack will sometimes cut short the paroxysm. In
the inter-paroxysmal period I generally give half a grain of the extract
three times a day; but sometimes, especially in women, this dose induces
very disagreeable symptoms, which may not occur till after several days^
use of the drug.

Dr. Clousden recommends cannabis indica combined with bromide of
potassium in mania, giving a drachm of bromide of potassium with a
drachm of the tincture of cannabis indica.

It has been found useful in neuralgia, whooping-cough and asthma,
and it appears to be serviceable in some cases of hysteria. Some accord
it a high reputation as a diuretic in acute and chronic Bright's disease,
and consider bloody urine to be a special indication. It is said to
relieve dysuria and strangury, and to be useful in retention of urine,
dependent on paralysis from spinal disease. It is used occasionally in
gonorrhoea. It is very useful in menorrhagia, or dysmenorrhoea. Half
a grain to a grain thrice daily — though a grain every two hours, or hourly,
is sometimes required in those who can tolerate so large a dose — often
relieve the pain of dysmenorrhoea. It 'is said to increase the energy of
internal contractions. It is also recommended in impotency. Possibly
owing to differences in the quality of the drug, but generally on
account of some peculiarity on the part of the patient, we find that
even half a grain of the extract strongly affects some persons. No
doubt women are more powerfully affected by the drug than men. I
have known cases wdien half a grain, three times a day, was well borne,
and with benefit for many days, and then suddenly disagreeable and
pronounced symptoms rose, which could not be accounted for by the
time or circumstances under which the medicine was taken. It is
better to begin with a quarter of a grain of the extract at first, to test
the patient's tolerance, and if this is well borne then the dose should
be increased.

ERGOT.

Large doses, even an ounce of the liquid extract, are sometimes ad-
ministered immediately after delivery, and without producing toxic
effects. Further, ergot is sometimes administered in considerable doses
for a long period without in any way deranging the health, hence whilst
producing powerful therapeutic effects it has but little toxic action.

Ergot has a disagreeable, bitter taste, and occasions an abundant se-
cretion of saliva. In large doses it produces nausea, vomiting, colic,
diarrhoea, giddiness, dilatation of the papil, great retardation, and slight
weakness of the pulse, pain in the head, dimness of vision, giddiness
and stupor.

Whether administered by the stomach or hypodermically, ergot
contracts the arteries and greatly heightens arterial pressure. Injected
into the jugular vein it produces at first for a short time a slight fall

430 ERGOT.

of blood pressure, followed by a great rise in tension. "Wood and others
find that division of the spinal cord prevents the heightened tension,
showing that ergot stimulates the vaso-motor centre. Dr. 8ainsbury's
and my own ex])eriments show that a weak solution of ergotin in saline
solution circulating through the posterior part of the body of a tortoise,
Avhose spinal cord is completely destroyed, greatly retard's the flow of
the fluid through the vessels; showing that ergot, by its influence on
either the jjerijjheral nervous system or on the muscular tissue of the
blood-vessels, certainly induces strong contraction.

Ergot slows and weakens the heart, hence the rise of blood pressure in
no way depends on the influence of ergot on the heart. The slowing of
the heart is due to stimulation of the terminations of the vagi, for the
slowing does not occur if atropia is administered before ergot. Large
doses arrest the heart in diastole, and strong direct excitation does not
induce contraction, showing that the arrest is not due to inhibition
through the vagus, but depends on the direct action of the ergot on the
cardiac muscle.

Ergot stimulates involuntary muscular fibre and so increases ver-
micular action of the intestines, induces contraction of the bladder and
of the uterus, especially in its pregnant, and still more in its parturient
condition.

Large doses induce ansesthesia and paralysis, probably through the
spinal cord. The motor nerves and muscles are unaffected. It kills by
paralyzing the respiratory centre and arresting respiration.

Administered either by the stomach or hypodermically, it is most
valuable in haemorrhage; indeed in this respect few if any remedies
rival its efficacy. Dr. Currie Eitchie and Dr. Drasche were the first to
use it hypodermically, and they report successfully of cases of haemop-
tysis, epistaxis, haematemesis, and intestinal hsmorrage in typhoid
fever; and many other observers have since confirmed their statements.
In severe bleeding, when it is urgently necessary to check it at once,
the hypodermic application must be used, in from two- to five-grain doses
of ergotin. I have seen this injection in many instances produce a
good deal of swelling and pain, which, however, always subsided without
suppuration. It is well to warn the patient that this temporary unto-
ward accident may occur, ^o irritation arises if the injection is made
into> muscular tissue instead of connective tissue. In less urgent bleed-
ing, administration by the stomach is very successful. It is very useful
in haemoptysis, in doses of thirty or forty or even sixty minims of the
liquid extract every three or four hours, indeed hourly in severe cases.

Hildebrand advises hypodermic injections of ergot for fibrous tumor
of the womb; a curious measure, it would seem, but it is indorsed by
Drs. Keating aiid Ashurst, distinguished American physicians, Avho state
that the injections at intervals of five to six grains of ergotine Avill greatly
diminish the size of fibrous tumors. In a case reported by Dr. Keating
the pulse, respirations, and temperature fell for a time after each injec-
tion, the fall increasing with each injection; thus, after the fifteenth
injection, the pulse fell to fifty-six, the respirations to twelve, and the
temperature to ninety-six (?) The ergotin excited much nausea and
sickness; due probably to the effect of the ergot on the Avomb, for the
introduction of the finger into the os uteri increased the vomiting. The
occurrence of luiusea and sickness, however, is not usual.

Ergot is strongly recommended in purpura.

ERGOT. 431

If taken for a long time it is said sometimes to produce fatal conse-
quences, namely, spasmodic contractions of the muscles, and now and
then gangrene of the extremities, in character generally like senile gan-
grene. These statements, usually repeated in therapeutic works, must be
very greatly exaggerated, as we now administer considerable quantities of
ergot for weeks, or even months, without joroducing either gangrene or
spasm.

Its effects are most expressed on the womb, especially when pregnant,
exciting in the gravid uterus powerful and continuous contractions. It
is used in tedious labors, when the uterus is becoming exhausted, but
must not be employed when there is obstruction to the passage of the
child, otherwise it may occasion serious damage to the delicate structures
of the mother. Many suppose that it endangers the life of the child in
two ways, namely, by subjecting it to jjowerful and continuous uterine
pressure, and by weakening its heart. This injurious pressure may be
avoided, it is said, by administering the medicine in small doses, so as to
strengthen the natural intermittent contractions of the uterus, but not to
make them continuous. It is recommended to watch its action on the
foetal heart, and if the pulsations fall to 110, or the beats become irregu-
lar, either the drug should be discontinued or the delivery effected by
instruments.

It is 'extremely useful in post-partum hemorrhages, arresting the
bleeding by producing firm contraction of the uterus, and by its influence
on the blood-vessels. It is also of great use in the various forms of men-
orrhagia, even when it depends on uterine tumors. It is, perhaps, the
most valuable medicine known in uterine haemorrhage, cliecking the
bleeding when other remedies have failed, and when the patient is reduced
almost to a helpless state. In such critical circumstances it must be
given in full doses. Some doctors give half an ounce of the liquid ex-
tract, and repeat it in half an hour, or even in a shorter time, without any
toxic effects. It promptly checks, and in a few hours effectually stays
the bleeding. Dry cupping over the sacrum is useful. Perfect rest
should be enjoined.

It is said that ergot will arrest sweating.

Ergot is said to reduce the temperature of the body, but most ob-
servers doubt the truth of this assertion. The hypodermic injection is
said to reduce the temperature of cats and dogs.

It is stated to be useful in neuralgia and paraplegia, whooping-cough,
incontinence of urine, and even in some cases of leucorrhoea; but the
form of leucorrhoea is not mentioned. It is also recommended in amen-
orrhoea with ansemia, after the use of iron. Perroten strongly praises
ergotine injections in prolapsus of the rectum.

It is the most useful remedy in diabetes insipidus, and Da Costa first
employed it in this disease. The dose should be regulated by the effect,
but doses large and frequent are often required.

Dr. Davidson reports a singular case of poisoning by ergot. A preg-
nant woman for several months took large doses of liquid extract and
powdered ergot, till at last it caused death. When called to see the
patient she complained of lumbar and arthritic pains, and vomited a red-
dish brown pultaceous matter (blood). She passed urine looking like
blood. After his visit she vomited half a pint of blood. The upper part
of the body was intensely jaundiced. She had " genuine black eye."
Her lips and tongue were swollen and covered with dry black blood.

432 COFFEE.

Her heart beat 150 per minute. After death he found numerous ecchy-
moses in the subcutaneous fat in the peritoneum and in the lungs. Also
much blood in the peritoneal cavity and in the stomach and intestines.

COFFEE. CAFFEINE.

Caffeii^e is now largely used on account of its action on the heart;
and also mainly for its influence on the kidney, since it acts as a direct
diuretic. It is generally given in the form of citrate, in the dose of two
to five grains several times a day.

Dr. Pratt took twelve grains of caffeine, which induced restlessness,
mental depression, muscular tremulousness, frequent desire to pass water,
and great sleeplessness.

A man took a drachm of the citrate by mistake. There occurred
burning in the throat, giddiness, nausea, faintness, numbness, tremors,
free diuresis, great cardiac weakness, cold extremities, collapse. Intelli-
gence was not affected. The man recovered. (Routh.)

Poisonous doses given to mammals produce restlessness, hurried
breathing, muscular weakness, tetanic and clonic convulsions, and death
from respiratory paralysis.

It affects then both the brain and cord, the mental alterations being
due to its influence on the brain, and the tetanus to its action on the cord.

In frogs it induces rigidity by its direct action on the muscles. At
first it accelerates the heart's action, but soon the contractions grow in-
frequent and irregular, these effects being due to the direct action of
caffeine on the heart. It heightens arterial pressure.

Binz and Leven find that heightened arterial tension occurs after
section of the vagus.

The motor nerves are unaffected. Pratt finds that the sensory nerves
are depressed.

It strengthens the cardiac contractions and heightens arterial tension,
thus acting like digitalis, which in some measure it can therapeutically
take the place of. Some say it is more efficacious than digitalis, but
certainly this has not been my experience, and certainly it possesses less
power to regulate an irregularly-acting heart.

Subsequent experience has fully demonstrated the inferiority of
caffeine to digitalis. It is, however, a useful adjunct to digitalis in cases
of cardiac disease.

Coffee, to some persons, is slightly purgative.

The active principle of tea and coffee is absorbed, and acts as a stim-
ulant to the nervous system. These beverages are especially useful in a
fatigued state of the system, and under ordinary circumstances are pref-
erable in this respect to alcoholic drinks.

" Coffee," says Dr. Parkes, in his work on Hygiene, " is a most imj^or-
tant article of diet for soldiers, as not only is it invigorating, without
producing subsequent collapse, but the hot infusion is almost equally
serviceable against both cold and heat, in the one case the warmth of the
infusion, in the other the action of the skin, being useful, while in both

COFFEE. 433

cases tlie nervous stimulation is very desirable. Dr. Hooker tells us that
in the Antarctic Expedition the men all j^referred coffee to spirits, and
this was the case in the Schleswig-Holstein war, 1849. The experience of
Algeria and India, where coffee is coming more and more into use, proves
its use in hot climates." The same authority, speaking of tea, says,
" Tea seems to have a very decidedly stimulative and restorative action on
the nervous system, which is perhaps aided by the warmth of the infusion.
No depression follows this. The pulse is a little quickened ; the amount
of pulmonary carbonic acid is, according to E. Smith, increased. The
action of the skin is increased, that of the bowels lessened. The kidney
excretion is little affected; perha2)s the urea is a little lessened, but this
is uncertain."

"As an article of diet for soldiers tea is most useful. The hot infusion,
like that of coffee, is potent against both heat and cold, is most useful in
groat fatigue, especially in hot climates (Ranald Martin), and also has a
great purifying effect on water."

Tea and coffee are useful in the headache of nervousness and exhaus-
tion, and as an aid in rousing and keeping a patient awake in opium
poisoning.

A small cup of very strong coffee is often very useful in the paroxysm
of asthma; in fact it gives relief in most cases, but in very unequal de-
gree. Caffeine, as first recommended by Gubler and Leech, is largely
employed, in five-grain doses, as a diuretic in ascites and cardiac and
renal dropsy.

In cardiac drojjsy it is much inferior to digitalis and its allies. In
renal dropsy it is very uncertain, in some cases acting abundantly, but
in most cases producing little or no increase of urine. This difference
in its action is dil^ticult to explain. A similar difference occurs in healthy
persons; in some coffee stimulating the kidneys strongly; in other persons
producing no effect; and this individual difference may modify the action
of caffeine in disease. It is supposed to act on the kidneys in two ways
— to increase the amount of blood flowing through the kidneys, and to
stimulate the secretiiig structures of the kidneys.

The influence of caffeine on the general circulation, and on the circu-
lation through the kidney, has been ably investigated by Dr. Bradford
and Dr. Phillips. The following is an account Dr. Bradford has kindly
prepared for me :

" The method of experimentation was as follows: In chloroformed
and curarized animals (mainly dogs) the general blood pressure, the
volume of the kidney, and the rate of the flow of urine were simultane-
ously recorded on a moving surface. A solution of the particular drug
experimented with was then injected into the external jugular vein, and
the moment of injection was also recorded. The general blood pressure
was recorded by connecting the carotid artery with a mercurial mano-
meter, the volume of the kidney by means of Eoy's oncometer, and the
flow of urine by an apparatus so constructed that each drop of urine, as
it fell from a cannula placed in the ureter, made a mark on the blackened
surface of the drum.

"By means of this method it was possible not only to determine the
action of a drug on the circulation and secretion of the kidney, but also
to see whether those results are due to a direct action on the kidney, or
only to an indirect action resulting from the effects of the drug on the
heart and vascular system generally.
28

434 COFFEE.

""When a solution of citi'ate of cafFcinc is injected into tlie external
jugular vein in doses of half a grain to a grain of the salt, the following
changes are seen to occur: The general blood pressure is lowered at
first, and this fall is followed by a slighter rise; but witli such doses as
the above both effects are small and transitory. The fall of j^ressure is
due to a diminution in the force of the cardiac beats, and this is followed
by a period during which the heart beats are slowed and markedly
strengthened, to be in turn followed by a period of acceleration, of short
duration, however, during which the blood jjressure regains, or even
slightly exceeds, its former level.

" The effects on the kidney are, however, much more marked. Im-
mediately after the injection the kidney contracts, and this contraction
may last for as long as one or two minutes — that is to say, for a much
longer time than the effects produced on the general blood pressure,
whicli only persist for some twenty or thirty seconds. This contraction
or diminution in bulk of the kidney is very considerable, and is, no
doubt, due to constriction of the renal vessels. It is followed by a large
expansion — that is to say, the kidney not only returns to its previous
volume, but it expands considerably beyond it. This expansion of the
kidney is of much longer duration than the j)revious contraction, and its
course is also slower — that is to say, the dilatation of the renal vessels is
gradual, whereas their previous constriction w^as quite sudden. The
renal dilatation may persist for as long as twenty or even thirty minutes.

" Thus the action of caffeine on the kidney vessels is a double one, and
the observed effects on the volume of the kidney are directly due to this,
and not indirectly to any effect on the general blood pressure. That
this is the case is shown by the fact that smaller doses, i.e., ^ to ^ graii^j
will produce marked effects on the kidney without any very obvious
variations occurring in the general blood pressure.

"The action of the drug on the heart is probably also a mixed one;
not only does it cause a diminution in the force of the beats, but it
jjrobably at the same time causes a contraction, tonic in character, of the
ventricular muscle. As a result of this, the capacity of the heart is di-
minished, and hence a smaller quantity of blood will leave the organ at
each systole, thus leading to the fall of arterial pressure.

"The effects on the flow of urine are also very marked. During the
period of the contraction of the kidney the flow is either greatly dimin-
ished or even arrested. During the subsequent expansion the rate of
flow is greatly increased, and this increased rate persists for as long as
the renal dilatation. Many other drugs besides caffeine will produce con-
traction of the kidneys, but, apparently, this is the only drug that pro-
duces any actual arrest of the urinary secretion during this contraction.
Ulexin, a powerful alkaloid obtained from the seeds of gorse, has a very
similar action on the kidney to that of caffein, producing at first con-
traction, then dilatation accompanied by free diuresis. Its diuretic action,
however, is more transitory than that of caffeine, and, inasmuch as it
l^roduces violent vomiting in the human subject, it is not a drug at all
suitable for diuretic purposes. Tiiere is, however, one point of interest
with regard to these two drugs. If several doses of caffeine be injected
into the circulation at short intervals we soon arrive at a jioint when
each injection causes only contraction of the kidney, and diminished
secretion; no diuretic effect whatever being produced by the drug. With
ulexin it is different; repeated doses, or single large doses, onl}^ jaroduce

COCAINE. 435

a moderate degree of expansion instead of the double effect of contraction
followed by expansion. With regard to caffeine, this difference in the
action when the doses are repeated too rapidly may be a point of some
practical importance, since, under these circumstances, the drug ceases
to be a diuretic.

" Many other substances will produce expansion of the kidney, as, for
instance, urea, acetate and chloride of sodium, etc., but in no case are the
results so marked as with caffeine."

Although tea and coffee are very wholesome beverages, yet either one
or the other, or both, will in some persons occasion 23alpitation of the
heart, sleeplessness, and mental excitement.

Some maintain that caffeine is as useful as a local anaesthetic as
cocaine; thus two minims of 2.5 per cent, solution completely removed
sensibility (Terrier) ; and Dr. Faurel emi^loys a 2 per cent, solution of
caffeine almost to tlie exclusion of cocaine in affections of the pharynx
and larynx. This, however, does not agree with the experience of others.
Dr. Laborde could not obtain anaesthesia of the cornea with even con-
centrated solutions, nor with theine; but Laborde finds that a glucoside
obtained from Boldo produced anaesthesia quite equal to cocaine.

Caffeine, often in the form of effervescing citrate of caffeine, is useful
in sick headache (migraine). Salicylate of soda, or antijDyrine, or anti-
febrine, are, however, much more effectual.

The following solution is usefiil for hypodermic use : — Twenty grains
of caffeine, seventeen and a half grains of salicylate of soda, and a fluid
drachm of water. Three minims of this solution contain one grain of
caffeine.

COCAINE.

[% Dr. Dudley W. Buxton.'] '

Cocaine produces a localized anaesthesia when applied to the mucous
membrane or skin; its action is extended more deeply when a hypodermic
injection is made into the subcutaneous tissues. Paul Bert asserts that
the action of cocaine is purely local, only extending so far as the drug
actually comes in contact with the tissues. However, this does not corre-
spond with the experience of others. It has been thought, although as
yet no sufficient proof has been advanced, that cocaine acts by paralyzing
the terminal twigs of the sensory nerves, as well as sensory end organs.
On the other hand, many careful observers have come to the conclusion
that the anaesthesia caused by cocaine is due to vaso-motor action. The
cocainized area becomes pale, blanched, and finally almost bloodless, so
that the sensory nerves, being deprived of their due blood supply, cease
to communicate painful impressions received from without. It is found
that there is firstly a loss of sensibility to pain, next to variations in tem-
perature, and finally tactile sense is abolished.

' The additions to this article, between brackets, for the present edition are
made by me, S. R.

436 COCAINE.

And further, the nerves of special sense cease to convey their peculiar
impressions. The cocainized mucous membrane of the nose loses its ap- 7
preciation of smell, so that of the tongue is devoid of power of taste. In :
every case the effect produced is transitory, and j^asses off in from twenty
minutes to half an hour. _ _ ^

"When jiainted over the skin, a sensation of warmth is at first experi- ■
enced, to be succeeded in a few minutes by complete loss of sensation, *
the part becoming anaemic.

The depth to which the action of cocaine penetrates seems to differ
considerably, but in no case does the anaesthesia appear to extend beyond
the structures j^roper to the skin and mucous membrane.

Coca has long been known to exert very decided influence over the
central nervous system. Many South American tribes habituate them-
selves to feats of endurance by its use, needing, it is said, little food or
rest while under its influence. Aschenbrandt administered 4- gr. of
hydrochlorate of cocaine to Bavarian soldiers without their knowledge
and found it removed their sense of fatigue, while it enabled them to
undergo fresh hardships and to subsist on a minimal diet. He found no •
subsequent ill effects followed this treatment. However, Moreno and I
Maiz state that coca habitues suffer from impaired digestion, emacia- *
tion, muscular tremor and die of marasmus.

IJpon the centre nervous system cocaine acts as an excitant. Tumas,
of St. Petersburg, found that painting over the exposed motor areas of the
brain lessened their excitability, but without any initial increase, and he
also showed that epileptiform convulsions were provoked with difficulty,
and required a very strong Faradic current when the motor area had been
previously painted with cocaine. In the lower animals, the first effect
of cocaine is to produce a curious calm, to which succeeds a period of great
excitement. Weakness, marked by muscular tremors, then appears, and
the tremors later on pass into convulsive movements, while the wealvuess
gives place to paralysis. The head rolls from side to side like a pendulum,
a phenomenon which Von Anrep attributes to some alteration caused by
cocaine in the tension of the fluids of the semicircular canals. Epilepti-
form convulsions are developed subsequently, and finally tetanic (spinal)
rigidity supervenes, and the animal dies asphyxiated.

The reflexes were increased, and this took place both before and after
section of the spinal cord. In dogs large doses cause great excitement,
with, expression of joyousness and delight, but if the dose be pushed, the
animals became dejected and struck with terror, their limbs trembled,
and they were seized with convulsions. In some animals opisthotonic
convulsions occurred, and in some spastic rigidity. In man only the ex-
citement stage with exhilaration has been attained, as it is probable that
the toxic dose of cocaine is for man very large. [A large dose first stim-
ulates, and then paralyzes the sensory and motor nerves, the sensory be-
ing more affected than the motor. The spinal cord, Ott finds, is similarly
affected.] As much as twenty grains have been taken without any harm-
ful result. It kills by causing cessation of respiration.

Upon the circulation cocaine acts in two ways : it constricts the ves-
sels, and so increases arterial pressure, while it stimulates the heart. The
last-mentioned effect passes off before the contraction of the vessels dis-
appears.

[The contraction of the blood, induced by either topical or general
administration, is followed by dilatation, and if a large quantity is used.

COCAIJN^E. 437

dilatation at once ensues of the arteries, capillaries, and veins. This
primary dilatation lasts about six minutes, and is followed by contraction
for about the same space of time. Weak doses, liypodermfcally admin-
istered, contract the vessels for a short time, dilatation beginning in
about ten minutes, and continuing for three quarters of an hour (Kriiger).
The contraction of the vessels is ascribed to stimulation of the vaso-
motor centre, as section of the spinal cord prevents a rise of blood press-
ure. Small doses accelerate the pulse, large doses slow the pulse. A
full dose, as of half to three quarters of a grain, given hypodermically,
accelerates the pulse to 120, or 130, or l-iO beats per minute, and makes
it irregular.]

Cocaine exerts a modifying effect upon the secretions. It lessens the
production of saliva, gastric juice, tears, and, it is said, also of perspira-
tion.

The peristaltic movements of the intestines are at first increased, but at
length become sluggish, and then paralysis occurs. This explains the fact
tliat several authorities speak of cocaine as acting mildly upon the bowels,
while, as was stated above, those who abuse it by excess suffer from con-
stipation and dyspepsia.

The action of cocaine upon the muscular system is at present uncer-
tain, for while Nikolsky and Yon Anrep expressly state the muscles are
unaffected, Ott and Biichheim and Eisenmenger describe its behavior as
presenting a parallel to that of veratrine.

The quantity of urine is lessened, as is the amount of urea excreted,
and this, coupled with its general behavior in supporting the body under
fatigue and low diet, would suggest that it possesses the power of staying
tissue change throughout the body.

A slight rise in the general temjjerature occurs under cocaine adminis-
tration, large doses are said to raise the rectal temperature considerably,
but as a rule this is preceded hj an initial depression. In poisoning by
cocaine the rectal temperature becomes subnormal Ijefore death.

Elimination of the drug takes place probably by the kidneys, and it is
often accompanied by the production of albumen and sugar in the urine.
Von Anrep regards these as resulting from the asphyxia caused by the
cocaine's paralyzing action on the respiratory muscles, and not from any
direct action of the alkaloid.

All observers appear to agree that the intellect remains unaffected
save by way of exhilaration or depression.

Upon the pupil cocaine possesssed a marked mydriatic effect. This
begins to show itself in from ten to twenty minutes after dropping the
solution upon the conjunctiva, and it reaches a maximum in half an hour,
l^ersisting for another half hour, and then gradually disappearing. Al-
though, according to Dr. Knapp, of New York, cocaine dilates the pupil
as much as atropin, its effects pass off very much more rapidly; and
further, it reduces the power of accommodation, while it does not wholly
do away with it. Even before the dilatation has ceased the power of ac-
commodation returns in full force. It seems that the range of accommo-
dation is shortened by moving the near point from the e3^e, but the far
point is not appreciably affected. Together with this mydriatic action,
cocaine, as Roller first pointed out, renders the conjunctival and sub-
conjunctival tissues wholly insensitive to pain, so that cauterizing, cutting,
etc., may be performed with impunity, so long as the deep structures are
not invaded.

438 COCAINE.

The employment of hydrochlorate of cocaine as an anfestlictic hi
ophthalmic practice has now received ample trial, and has been well
spoken of by the leading ophthalmic surgeons, both at home and abroad.
A four per cent, solution is instilled into the conjunctiva, three or four
times at intervals of five minutes. When the conjunctiva can be picked
\\\) without the patient's experiencing any discomfort the operation may
be proceeded with. In this way iridectomies, extractions and operative
measures dealing with the conjunctiva are rendered painless, although in
some cases section of the iris occasions momentary pain. Dr. Keyser has
met with several cases of panophthalmitis which ensued upon operation
being performed upon cocainized eyes, and he attributes this unhappy
result to the cocaine. Such cases, however, would appear to be very rare.
A further evil consequence, alleged to have followed the use of hydro-
chlorate as a mydriatic, is the supervention of yellow opacity of cornea.
This discoloration was speedily got rid of when atropin was used in place
of cocaine.

In operations for squint, it is not sufficient simply to instil the cocaine.
A few drops of a four per cent, solution are injected by a fine hypodermic
syringe through the cocainized conjunctiva into the muscle which it is
desired to tenotomize. Mr. Walter Jessop adopted a similar plan to
produce antesthesia of the canaliculi, and was able to slit them up with-
out giving any pain. The same surgeon cautions against cocaine in cases
in which it is requisite to remove foreign bodies from the cornea, as it
renders that structure so flaccid that operative measures become very
difficult, and unless great care is taken serious abrasion of the corneal
surface may be caused.

In the treatment of glaucoma by section of the iris cocaine fails, unless
it is injected into the anterior chamber. Mr. Jessop has used with
success a small steel bent cutting needle, the stem being bored and made
to fit a hypodermic syringe. Excision of the eye in most cases in which
cocaine was used proved painful, at all events during the last stages, when
the deep structures were divided. It is well in preparing for these opera-
tions to -inject hypodermically both the sub-conjunctival and subfacial
tissues. The photophobia ensuing upon corneal ulcers or other causes is
relieved completely by instillations of a four per cent, solution of the
hydrochlorate of cocaine. Mr. Frank Hodges, of Leicester, has pointed
out the peculiar merit of cocaine in deep wounds of the cornea, or sclerot-
ic. To remedy such laceration very painful manipulation is needful,
and the employment of a general anesthetic might, he points out, cause
struggling, and so lead to loss of vitreous, whereeas, under the influence
of cocaine, the patient remains quite still, feels no pain, and can assist ^_L
the operator by moving his eye in any required position. When it is de- ^^H
sired to obtain an anesthetic without a mydriatic eifect, it is necessary to ^^
combine pilocarpine with the cocaine. Dr. Bradford employed ten drops
of a five per cent, solution of pilocarpine to a drachm of a four per cent,
solution of hydrochlorate of cocaine and found it answered admirably.

A convenient method of using cocaine is in the form of the officinal
discs, which are composed of gelatine, glycerine, and ^^gr. of hydrochlo-
rate of cocaine. Placed beneath the eyelid while the lids are closed, it
soon exerts its influence. In prolonged operations about the eye, it is
necessary to repeat the dose of cocaine at intervals, and this is easily done
by using a drop bottle. A jieculiarity in the eff'ect produced by cocaine,
and pointed out by Koenigstein of Vienna, is that a certain amount of

COCAINE. 439

exoplithalmos follows its topical application to the eye, but soon passes
off and leaves no untoward consequences. The fundus oculi is unaffected,
nor is the intra-ocular tension altered by the use of cocaine. Another
useful method of applying this anesthetic is to combine it with vaseline,
making a five per cent, ointment and smearing it over the part to be ren-
dered insensitive.

[A three per cent, solution may cause exfoliation of the corneal epithe-
lium or chronic interstitial keratitis and panophthalmitis.]

In examinations and operations about the larynx, cocaine has been
employed for some considerable time. Dr. Semon recommends painting
the larynx, uvula, and neighboring parts with a twenty per cent, solu-
tion. This not only enables the surgeon to obtain a good view of the
jDarts, but allows the painless removal of polypi and other growths. The
ojjeration can be performed in five or ten minutes after this application.

For the treatment of ulcerations on the epiglottis, whether tubercu-
lar or otherwise, painting with a twenty per cent, solution is very useful,
and a like application is of singular service in acute and chronic laryngi-
tis. Dr. Neale states that the small operation of removing the uvula can
be accomplished painlessly, if the part be painted once or twice with a
two per cent, solution.

Tonsillitis is relieved in two ways by the use of a four per cent, solu-
tion of the hydrochlorate painted over the tonsils; the patients are able
to swallow without difficulty, and their pain is assuaged. It is necessary
to repeat the application every hour or so according as the pain returns
or not. Xo fear need be entertained of toxic symptoms appearing, as co-
caine appears not to have ax3umulative action. In other forms of dys-
phagia cocaine painted over the pharyngeal mucous membrane is very
serviceable.

[It is sometimes administered as spray in throat diseases. Forty
minims of four per cent, solution employed in this way has induced
serious symptoms; headache, giddiness, flushed face, dryness and con-
striction of the throat, widely dilated pupils, slow respiration and rapid
pulse, with some cyanosis. Kapidly inhaled and rapidly absorbed by the
lungs, it is conveyed in a concenti'ated state to the heart.]

According to Dr. Bosworth and others, painting the nasal mucous
membrane with a twenty per cent, solution greatly relieves hay fever,
and removes its paroxysms. Dr. Paget, of Great Crosby, finds a four per
cent, solution efficacious; he directs that a few drops should be allowed
to fall into the nostril and be sniffed up Avhile the head is held well
back. In all cases it is important to dry the mucous membrane, as far as
possible, before the application is made. Acute coryza in its early stage
may, it is said, be completely arrested if the nasal mucous membrane is
painted with cocaine.

When cocaine is painted over the mucous membrane lining the mea-
tuses of the nose, it causes a marked constriction of the parts, so that
the mucous membrane clings closely to the bony framework. This pecul-
iarity is of great service in anterior tnid posterior rhinoscopy. Mr.
Cresswell Baber recommends the use of cocaine when there is undue
erection of the turbinate bones, and also for hemorrhage from the nasal
mucous membrane. Oj)erative measures which involve the deeper nasal
structures as a rule require a general anesthetic; but some successful cases
are reported in which pledgets of absorbent cotton-wool soaked in cocaine
hydrochlorate twenty per cent, were sufficient to render the structures

440 cocArsTE.

anaesthetic. It is necessary to delay the operation in order to reapply
the cocaine plugs from time to time.

[Cocaine hydrochlorate is useful in psoriasis of the tongue; thus a
tabloid sucked just before a meal averts the pain from the jiassage of
the food.]

According to Dr. Henry Keden, an atomizer containing a four per
cent, solution of the hydrochlorate, is a sure means of curing otalgia.
He directs the patient to inhale vigorously, then by closing the lips and
expanding the cheeks to force the spray up the Eustachian tubes.
This plan he supplements by spraying the tympanic membrane through
the external meatus. The inhalation was repeated every three minutes.
Perhaps a better plan is to pass a Eustachian catheter and inject a fe^y
drops of a two per cent, solution, taking care to warm it beforehand.

Dr. Weld, of New York, paints the gums Avith a ten per cent, solution
before removing tartar from the teeth, and in dealing with a sensitive
tooth pulp, Merck's method of working up a little of the hydrochlorate,
or, better, the citrate, into a pill, and pressing it into the jminful cavity,
is highly satisfactory. It may also be applied by small cotton-wool plugs
soaked fn a twenty per cent, solution. Fissures, ulcers, and painful swell-
ings on the tongue, lips, and mucous membrane of the cheeks cease to
give trouble after painting with cocaine. As it does not cure the condi-
tion, the pain will return unless frequent paintings be had resort to.

Upon the urino-generative tract cocaine exerts most benign effects.
The injection of a few drops of a two per cent, solution into the urethra
relieves the pain and smarting of acute gonorrhoea. The injection, which
must not be made with alcohol, should be retained for a few minutes, and
repeated before micturition is attempted. It is said to shorten the dura-
tion of the urethritis. A similar manoeuvre may be tried before catheter-
ization, in cases in which instruments are badly borne. When a stricture
is jDresent. it is often difficult to render the urethra insensitive beyond it.
An injection of four per cent, is highly spoken of in irritable bladder.
tSmall cotton-wool tampons soaked with a two per cent, solution relieve
the burning pain of blenorrhcea.

In some cases a five per cent, ointment proves more serviceable. The
intense suffering caused by the itching of scrotal eczema yields at once to
a lotion of cocaine. Pruritus ani and of the pudendum and vaginismus
are also relieved, although of course it is necessary to ascertain and re-
move the cause of these painful conditions.

Dr. Symes, who recommends suppositories and pessaries for the relief
of painful conditions about the rectum and vagimi, cautions that the
former should not exceed five grains, the latter not fifteen grains, as
dilution of cocaine considerably lessens its activity.

Dr. Adelberg Weiss, of Vienna, was able to allay the agonizing jDain
of extensive scalding by painting the skin with cocaine lotion.

As a hypodermic injection the hydrochlorate of cocaine 2:)roves useful
in the treatment of various forms of neuralgia. For this purpose not
more than a third or half a grain should be employed, and the injection
must be practiced in the course of the nerve.

[It is better to begin with even a smaller dose, as the susceptil)ility to
the drug varies in different persons. I have seen the hypodermic injec-
tion afford great relief for several hours in cases of severe neuralgia. It
is especially useful for patients who are disagreeably affected by hypo-
dermic injections of mor^jhia; often the patients experience a very

CINCHONA. 441

pleasant stimulation, which they compare to the effects of champagne, and
so exhilarafing is the result sometimes that they are very reluctant to
discontinue the drug.]

Merck has prepared an artificial cocaine from benzoyl-ecgonin.

The salts of cocaine have been employed internally for their action
upon the heart and nervous system. Thus Dr. Hicks, of New York,
found doses of cocaine relieved the dyspnoea due to weakened respiratory
action. He also found benefit followed its use in cases of palpitation
when a weakened heart, although free from valvular lesions, had become
dilated and atonic. One-half a grain alleviates these symptoms, and proves
serviceable in nervous exhaustion and sick headaches. In the treatment
of alcohol craving and the morphia habit, cocaine has by many careful
observers been pronounced of great benefit. It restores the appetite, in-
duces sleep, and promotes digestion, while it soothes the brain and induces
a feeling of contentment and calm.

[Given in the form of a pill, cocaine sometimes eases painful affec-
tion of the stomach, and averts vomiting. It is sometimes useful in the
vomiting of pregnancy, and maybe taken by the mouth, administered
hypodermically, or applied to the os uteri.

An electrical current assists the absorption of cocaine, like other
alkaloids. The positive pole sliould be dipped in a solution of cocaine
hydrochlorate and applied to the skin, which speedily becomes ana3sthetic.

Administered as an anal injection or suppository, it checks the diar-
rlioea and straining of dysentery. Cocaine is useful in pruritus ani, and
in itching diseases of the skin, like eczema.]

Cocaine hydrochlorate, when kept in solution is liable to uiidergo
changes, and a fungus appears upon the surface, rendering the solution
irritating and unfit for use. The addition of -jj-^ of a grain of salicylic
acid preserves the cocaine, but renders its solution rather irritating, and
so should not be used in ophthalmic practice. Holz has found ten-minim
doses of a three per cent, solution, given three times in twenty-four hours,
useful in the vomiting of pregnancy; and Dr. Si^riman claims that benefit
follows a quarter of a grain in nervous dyspepsia, given three or four
times a day in milk or coffee.

CINCHONA AND ITS ALKALOIDS.

Salts of quiniaare protoplasmic poisons, arresting amoeboid and the
allied movements of the white corpuscles. Even weak solutions are highly
poisonous to protozoa and infusoria (Binz), more so even than salts of
strychnia or morphia. Small quantities of quinia salts destroy septic
germs and arrest putrefaction more thoroughly than most antiseptics,
including even arsenic and creasote. Quinia is not equally destructive
of all micro-organisms ; those of septic fluids resist its action to a great
extent. Moreover, with the exception of strychnia, quinia hinders
alcoholic and butyric fermentations in greater degree than other bittere.
It does not prevent the action of ptyalin on starch, nor the conversion of
amygdalin into oil of bitter almonds. Cinchona possesses the same prop-
erties, but in a weaker degree than quinia.

Powdered bark contains, besides various alkaloids, a considerable

442 CINCHONA.

quantity of tannin, a fact to be borne in mind when we administer bark,
or any of its preparations.

Finely poAvdered bark dusted thickly over foul, indolent, sloughing,
and even gangrenous ulcers, and left to form a kind of poultice, has ajD-
parently promoted the healing process. Hospital gangrene, too, has
been successfully treated in this way.

Bark has been employed as a dusting powder to check profuse forma-
tion of pus, mucus, or the secretion of eczema.

Quinia is employed in the form of spray, and as a strong solution
applied topically to the throat in diphtheria.

Since its adoption by Helmholtz solutions of quinia are employed to
flush the nose in hay fever. This treatment succeeds in some cases, but
in others fails completely.

Dr. Currie finds that he can always arrest excessive sweating by bath-
ing the skin with a solution of alcohol (a pint) and quinine (a drachm).

Cinchona bark audits preparations are bitter to the taste, and, like all
bitter substances, stimulate temporarily the salivary glands. The tannin
of the bark precii^itates the mucus of the mouth, and acts likewise as an
astringent to the mucous membrane itself.

The alkaloids, when swallowed in an insoluble form, combine with
the acids of the gastric juice and become soluble, so that as a mere solv-
ent it is unnecessary to administer quinia and cinchona with acids. A
large dose merely suspended in fluid is far less bitter than when dissolved.

The taste of quinia can be concealed by adding an equal quantity of
powdered ginger to the quinia. Milk, too, covers the taste of quinine.
When large doses, as forty grains, are administered, it is better to give
it in pill, otherwise it may cause sickness.

The alkaloids of bark probably undergo no other change in the stomiich
than that just mentioned. Their action in the digestive tract is similar
to that of bitters generally, being slight irritants to the mucous mem-
brane, and so producing, both in the mouth and stomach, an increase of
mucus. It is generally stated that cinchona increases the amount of the
gastric juice for a short time to a small extent, and further experiments
show that cinchona and its alkaloids check the action of the gastric juice
on the food, and check also fermentations, as that of sugar by yeast. It
appears, therefore, that cinchona increases for a short time the produc-
tion of both saliva and gastric juice, and so in a small measure may aid
digestion; that it is an irritant to the mucous membrane, and promotes
the secretion of the mucus of the mouth and stomach; and that it
checks the digestive action of the gastric juice and fermentation.

Thus our theoretical knowledge would appear to show that quinia
neither increases appetite when the stomach is healthy nor aids in any
marked degree digestion; yet exiDcrience fails to support these views;
for, even when the stomach appears to be healthy, quinine certainly seems
to sharpen appetite and assist digestion, especially in general debility.

These substances are useful to check unhealthy or excessive fermen-
tation in the digestive canal.

These alkaloids if too long employed disorder the stomach, producing
heat and weight at the epigastrium, loss of appetite, nausea, sickness, and
even diarrhoea. Poisonous doses excite great thirst, burning pain at the
epigastrium, and vomiting.

Quinine appears to exert no influence on the secretion of bile.

It is given with benefit in cases of worms; but as decoction of

CINCHONA. 44 :>

cinchona appears to have no direct influence on ascarides and taeniae, the
good effects of quinia must be due to its beneficial effect on the mucous
membrane, by preventing the production of the abundant mucus, which
favors the development and growth of these worms.

When quinia is taken in large quantities some of it is said to pass off
with the fffices,

Quinia reudily passes into the blood, and as it can be detected un-
changed in the urine, sweat and secretioiis of healthy persons and fever
patients, probably very little undergoes decomposition in the body. It is
almost exclusively eliminated by the urine, most of it being excreted in
six hours.

Quinia lessens the power of haemoglobin to convert oxygen into ozone,
and so lessens the ozonizing action of the blood. (Binz, Schntte.)

Large doses affect the sight and hearing, excite subjective noises, as
of bells ringing in the ears, and occasionally produce deafness; sometimes,
but very rarely, a large dose destroys the sense of hearing for life; but
usually, in a short time, possibly in a few days, the noises cease, and the
hearing again becomes natural. Large doses often dim the sight and
sometimes cause total temporary, rarely jDermauent, blindness. I have
noticed on some occasions that the defect of vision is strangely limited to
one eye, or begins first in one eye. The pupil of the affected eye is very
generally dilated, and sometimes to an extreme extent. Severe frontal
headache, with dull, heavy, tensive, and sometimes agonizing pains, are
some of the most distressing and frequent symptoms that follow a large
dose of quinia. While these symptoms last, and, indeed, generally before
they appear, the face is flushed, the eyes suffused, and the expression is
dull and stupid. Even small doses, in persons very susceptible to the
action of this medicine, will produce some of the foregoing symptoms,
especially the headache and mental disturbance.

A small dose of quinia in one of my patients always bring-s ovit a uniform red rash
over the whole body, most marked on the back of the neck, accompanied by very
severe stinging pain, especially on the nape, and in the clefts between the fingers.
Desquamation, as free as after a sharp attack of scarlet fever, always follows the
rash.

In some people quinia produces larg'e patches of erythema with great irrita-
tion, gastric disturbances, and accelerated pulse. A patient tells me that even
small doses always excite violent urticaria, her face swelling till she can scarcely
see. She is so intolerant of this drug that a quinine hair-wash brought out a
crop of urticaria on her head, and a tooth-powder, containing a small quantity of
quinine, caused her lips and gums to swell.

Many of the foregoing symptoms no doubt are due to the action of
quinia on the brain. In toxic doses it excites convulsions. Chirone and
Curci find that the removal of the motor centres of the brain prevent these
convulsions, and if the central hemisphere is removed on one side the
convulsions are unilateral. Albertoni, on the other hand, finds that
quinia will induce convulsions when the central hemisphere or the corti-
cal motor centres are removed.

Small doses increase the reflex action of the spinal cord ; larger doses
lessen reflex action by stimitlating Setschonow's centre; and large doses
destroy the reflex function.

In large doses quinia depresses the heart by its direct action, and prob-
ably also the vaso-motor centre, and hence diminished arterial tension.

Workers in bark sometimes suffer from a scaly papular eruption, or

444 CINCHONA.

from a vesicular wcejoing eruption, and occasionally from great swelling
of the genitals, or of the face, and eyelids, with redness of the eyes. Tiiey
sometimes complain of great itching of the whole body, and it is known
that quinia sometimes produces urticaria.

I find that, like other antipyretics, quinia, when given in toxic doses,
does not reduce a non-febrile temperature, and Dr. Bartholow has con-
firmed my experiments.

• Kerner finds that quinia prevents the rise of temperature from active
physical exercise, and this is not due to increased loss of heat through
the skin by perspiration, as quinia lessens perspiration.

Drs. Wood and Reichert, however, show that cinchona alkaloids
increase both heat formation and heat dissipation, heat dissipation being
much in excess of heat formation. They do not feel justified in deciding
which is the cause of the other, whether increased loss of heat induces
increased heat production or I'ice versa.

Drs. Cutler and Bradford find that quinia diminishes the red and
increases relatively the quantity of white corpuscles of the blood.

Piorry maintains that during a fit of ague quinine at once diminished
the size of the spleen, and it is said that this drug exerts a similar effect
on this organ during other fevers, and even in health. Jerusaliewsky
finds that quinia will reduce the size of the spleen, even when the nerves
going to the spleen are divided before administering the drug.

The influence of cinchona and its alkaloids on the various forms of
intermittent fever is well known, controlling this formerly common com-
plaint more effectively than any known drug. It has been supposed to
check the fever by its influence on the spleen; but, granting this assump-
tion, it yet remains to show how the influence of the quinia on the spleen
prevents the return of the fever paroxysms. It jirobably kills the microbe
on which this disease depends. Osier finds that the infusoria he always
finds in the blood of ague patients disappear under quinine treatment,
the diminution being gradual.

Quinia generally arrests the disease at once. It is well, however, to
bear in mind that this remedy may dissociate the other symptoms from
the elevation of the temperature; or, in other words, it may remove the
shivering, sweating, and quick pulse, while the temperature may remain
as great, or nearly as great, as on previous days. Mere rest will occasion-
ally effect the same dissociation. Unless the unnatural elevation of tem-
perature has been restrained, the paroxysms will speedily return. This
fact it is necessary to recollect, otherwise it may be concluded that with
the removal of the more obvious symptoms the disease itself is cured, and
thus the patient may be i^ermitted to return to his usual avocations.

A still more curious circumstance remains : that is, quinia may check
all the symptoms, even the periodical elevation of the temperature, and
yet about the same time of day that tiie series of symptoms were wont to
take place, an increase in the urea and urinary water may occur as during
a severe paroxysm ; that is, all the symptoms of the paroxysm are absent,
except those pertaining to the urine.

I made two experiments which tend to show that quinia, given after
the commencement of the fit, is powerless to prevent the elevation of tem-
l^erature of that attack, although the drug may effectually prevent the
rise in succeeding paroxysms. It is said that quinia subcutaneously
employed after the paroxysm has begun will arrest the fit. Some hold
that quinia is less ethcacious than the powdered bark, even when the cin-

CINCHONA. 445

chona is allowed for; and it is even held that powdered bark is more tonic
than quinia. On the other hand, no doubt powdered bark, by reason of
its bulk, and of the tannin it contains, frequently upsets the stomach.

There is great variation of practice regarding the administration of
quinia, some giving small doses several times daily; others preferring a
single large dose daily; both methods are useful, but under different cir-
cumstances. In the mild forms of ague, like those now met with in this
country, small doses several times daily are sufficient; but in malignant
forms large doses given even several times a day may be required sum-
marily to arrest the disease. Some say that the drug should be given at
the very commencement of the fit; but this practice is held to be bad,
by making the immediate attack more severe.

Trousseau advised that fifteen grains should be taken immediately
after the fit, and repeated with an interval, first of one, then of two,
three, and four days, and so on. Probably this is a good means to extir-
pate the latent tendency to the disease and to ensure a jDcrfect cure ; for it
must be recollected that, judging by the temperature, a patient may un-
consciously undergo even a severe fit, a fact proving the great importance
of employing the thermometer. Moreover, Trousseau's plan is judicious;,
for even when the quinine has removed all symptoms the patient is liable
to recurrence of the attack, from various causes, as dej^ression of the
health, or a sudden shock, as that from an accident or operation; indeed,
in many instances, this tendency to ague lasts for years.

It is important to recollect that the effect of quinia on the fit bears no
relation to its physiological operation, either in time or degree, for a small
dose may prevent the occurrence of a fit otherwise due twenty-four hours
afterwards, the effects of the dose on the system meanwhile never becom-
ing apparent, or having long ere this passed quite away.

Quinia is of special use in the malignant forms of ague. The dose
should be large, and given in a non-febrile period. In these severe forms
of the disease no circumstances are to be considered as contra-indicating
its use. If it cannot be borne by the stomach it may be given by the
rectum, or hypodermically. For injection it is recommended to dissolve
the quinine in ether, as this solution is less irritating than an acid, alco-
holic, or chloroformic solvent. Salts of quinidine, on account of their sol-
ubility, have been recommended for hypodermic use. Quinidine of com-
merce is generally very impure. Dr. Banking, and others, find the hypo-
dermic method highly successful. Dr. Banking has treated 200 cases
in this way. He uses a warm neutral solution of the sulphate, 1 in 10,
injecting five minims. On an average three injections cure, the fever
being arrested on an average in 2.5 days.

In remittent malarial fever large and often-rejaeated doses should be
administered during the remission.

The more recent the attack the sooner and more certainly will quinia
cure.

It is less efficacious in quartan than in other forms of ague, probably
because old ague generally assumes the quartan type. In obstinate cases
resisting quinia arsenic often succeeds.

In some cases where this medicine apjiears powerless the administra-
tion of an emetic each morning sometimes brings the disease at once
under the control of quinia.

Quinia is used as a preventive of ague, and in the navy it is a very use-
ful sanitary precaution, where this fever prevails, to give sailors sent

446 CINCHONA.

ashore quinia before and after landing. This preventive effect is forcibly
illustrated in some observations recorded by Dr. J. B. Hamilton, of the
Royal Artillery, who treated his men with quinia, and but few succumbed
to ague, and those were attacked mildly; whilst another doctor, disbeliev-
ing in the preventive action of quinia, allowed his men to go unprotected
by quinia, and a large number were struck down with fever, and several
died. Dr. Hamilton believes that cinchona is superior as a pro2:)hylactic
to quinia, and quinidia very inferior to quinia.

The other alkaloids of bark, although inferior to quinia, will check
ague. Cinchona, it is said, must be given in doses one-third larger than
quinia.

The Medical Committee appointed by the Indian Grovernment to esti-
mate the relative value of the alkaloids, cinchona, quinia, quinidinia, and
cinchonidia, decided in favor of the use of all of them in ague. Natu-
rally, there were individual differences of opinion concerning their exact
relative value, but all agreed that they are all efficacious against ague.
The general opinion was that sulphate of quinia and sulphate of quinidia
possess equal febrifuge power; that sulphate of cinchonidia is only slightly
less efficacious; and that sulphate of cinchona, though considerably in-
ferior to the other constituents, is a valuable agent in fever.

It is a fact well known that in the case of persons who have encount-
ered ague, even many years beforehand, that disease in them is i^rone to
take on an intermittent type, and that in such instances quinia is often
of great service.

Again, certain forms of neuralgia not uncommonly depend on mala-
rial poison, and are then apt to assume a type distinctly periodical. Here
quinia in large doses, given shortly before the expected attack, is highly
serviceable. Quinia often proves useful, too, in non-malarial forms of
neuralgia presenting this periodical character. Even when the element
of i^eriodicity is quite absent large doses of quinia often succeed in re-
moving the pain of this distressing malady. Quinia is said to control
neuralgia and ordinary face-ache more effectively when the powder is
taken in minute quantities every fev/ minutes — for instance, as much as
will adhere to the fingers tip dipped into the powder.

It has long been recognized that quinia has most influence on neural-
gia of the supra-orbital branch of the fifth — a branch most often affected
with malarial neuralgia, and non-malarial periodic-neuralgia; but even
non-periodic neuralgia of this branch is probably more amenable to
quinia than neuralgia of the other branches of the fifth, or of other nerves.

Quinia is recommended in other febrile diseases, as ty]3hoid fever,
bronchitis, broncho-pneumonia, pneumonia, and acute phthisis. Nu-
merous observations J)rove that large doses effect a temporary reduction
of temperature, occasionally a considerable fall.

In Germany, quinia treatment, originally introduced by Vogel, is
largely adoj^ted i?i all fevers, especially in typhoid fever. Liebermeister,
who follows him, gives large doses of 20 to 45 grains at nightfall, so as to
increase the morning fall down to the normal, or nearly normal, temper-
ature. If the dose is inadequate to effect this, he increases it. He
strongly insists on the necessity of giving the quinia in one large, rather
than in several divided doses, as the piecemeal method has far less effect
on the temperature. After very considerable experience, he avers that
he has never seen these large doses produce any injurious effects, the de-
cline of the temperature usually beginning a few hours after taking the

CINCHONA. 447

medicine, and the minimum temperature is reached in from six to twelve
hours. The combination of the cold bath with quinia is strongly recom-
mended by some observers, as the quinia reduces the number of baths
necessary to keep down the fever.

Quinia is suj^posed to control inflammation by its destructive influence
on movements of the white corpuscles, and Binz maintains that, after
irritating and inflaming the mesentery by the administration of quinia,
the white corpuscles are killed, and their migrations are, by the tissues,
prevented. It is supposed to lower temperature by lessening the ozoniz-
ing power of the blood and thus checking oxidation.

Quinia in large doses of ten to thirty grains repeated several times a
day has been recommended in rheumatism. Some advocate its use at
the commencement, others at the termination of the attack — at the com-
mencement with the view of shortening the course of the attack, and
diminishing the chance of relapsing, and at the termination with the hope
of preventing the profound anaemia which so generally accompanies acute
rheumatism. Other authorities are altogether averse to the use of this
drug, maintaining that it favors relapses and merely disguises the pain,
and in no degree shortens the attack. Quinine is incomparably inferior
to salicylate of soda. My experience is completely at variance with the
statements relative to the usefulness of quinine in fever. No doubt a
sufficient dose will lower the febrile temperature, and its frequent repeti-
tion will keep the temperature normal; but at the same time the patient
becomes greatly depressed, and greatly inconvenienced by deafness, head-
ache, loss of appetite, etc., so that any advantage arising from the reduc-
tion of the febrile temperature is more than counterbalanced by the toxic
effects of quinine.

Quinine, strongly recommended by Corrigan, is also extolled by others
in pneumonia. Two to three grains should be given every two or three
hours.

Quinine has but little effect in hyperpyrexia.

Maragliano, using the hydroplethysmograph of Mosso, finds that a
febrile temperature is preceded and accompanied by contraction of the
cutaneous vessels, and during the decline of the fever the vessels of the
skin dilate. He therefore concludes that Traube is right in attributing
retention of heat as one cause of fever; though he regards increased
formation as another cause. Maragliano finds that antipyretics, as kairine,
antipyrine, thallene, quinine salts and sodium salicylate dilate the vessels
of the skin both in fever and fever-free persons, and so increase the dis-
charge of heat. They also lessen the expiration of carbonic acid, showing
that they also lessen the formation of heat.

Quinia is often given with decided advantage to check the profuse
sweating of exhausting chronic diseases, such as chronic phthisis. If a
small dose fail to check sweating a large dose of six or eight grains, ad-
ministered at once, or in portions repeated hourly, sometimes succeeds.

In many cases of profuse sweating a night draught, composed of
quinia, sulphate of zinc and sulphuric acid, is very useful.

Quinia is sometimes useful in the vomiting of pregnancy. Many
American writers believe that quinia strengthens the contractions of the
womb during delivery, and some use it in preference to ergot. Other
writers deny this action to quinia, but on the rather inconsequent ground
that, when given during pregnancy, os for ague, quinia does not induce
premature labor, though some writers have asserted the contrary.

4-48 SALICINE.

Quinia is often employed with much benefit in diseases of mal-nutri-
tiou, as in impetigo and ecthyma. It is also of great benefit to the pale
and badly-fed inhabitants of large populous towns. It is at present un-
determined whether its good effects are dependent on its action on the
stomach or on the tissues after its absorption into the blood. Quinia
has been recommended in passive bleeding, undue suj^puration, profuse
menstruation, spermatorrhoea, and in excessive secretion of milk. .

Quinia appears to be useful in some cases, but quite useless in others,
of intermittent haematuria.

Some doctors highly recommend sulphate of quinine, in five-grain
doses, in lumbago.

Quinia is found in the blood, which dissolves more of it than water;
in the saliva, bronchial mucus, milk, and in dropsical effusions. It is
said to be eliminated slightly with the sweat; although Briquet, after
giving large doses, could detect none.

Both quinia and cinchona pass off' in part by the urine, but a i^ortion
appears to be consumed in the blood, or to be eliminated in some other
way. Kerner says that "a respiratory power of 3,000 c.c. destroys fifteen
grains of sulphate of quinia in twenty-four hours; any amount over this
will pass into the urine." Quinia appears in the urine of healthy indi-
viduals in the course of two to five hours, but more quickly in young
than in old persons. In some diseases (intermittents, pulmonary em-
physema, pneumonia, morbus Brightii) its exit is much delayed, and in
three cases in which large doses were given Dietl detected it in the urine
many weeks after the last dose, showing that it is not easily destroyed in
the body.

Kerner finds that large doses of quinine diminish the excretion of
urea, uric acid, creatine, phosphoric and sulphuric acids.

Dr. Ranke has made the important observation that a scruple of di-
sulphate of quinia lessens by one-half the excretion or the formation of
uric acid, the effect continuing about two days after a single large dose,
the other constituents of the urine remaining unaffected. It would seem
likely that the uric acid is not simply retained in the system; for as in
Eanke's cases, no subsequent increased excretion took place after the
effect of the quinia had gone off; its formation was absolutely lessened,
or it must have been converted into some other substance. (Parkes On
Urine.)

Certain circumstances modify the operation of the salts of quinia.
The physiological symptoms appear early in young people, who can resist
the toxical action of the drug; but, on the other hand, the effects of
quinia are more marked in old people. Diffusible stimtilants, as wine
and coffee, are said to counteract the action of quinia.

SALICINE. SALICYLIC ACID. SALICYLATES.

Salicylic acid is a powerful antiseptic. Wagner maintains that it
is a more powerful disinfectant of wounds than carbolic acid. It is said to
be three times more effectual in preventing fermentation than carbolic
acid. Kolbe asserts that salicylates possess no antiseptic properties, the

SALICINE. 449

apparent contradictions to this statement being due to the specimen used
containing some free acid.

It is often used in j)lace of carbolic acid, as an antiseptic for wounds.
A four per cent, sohition is useful in pruritus and chronic urticaria.
Salicylic acid lotions are recommended in some cases of eczema. A one
per cent, solution in vaseline or oleum delina is useful in eczema.

Salicylic acid, given hyj^odermically, is efficacious in anthrax; but is
less effective than carbolic acid.

Bartholow recommends salicylate of soda in gastralgia and fermenta-
tion in the stomach.

Salicylic acid in large doses lowers blood pressure. It destroys life
by paralyzing the respiratory centre; others maintain by paralyzing the
heart.

These substances in large doses produce tonic effects similar to those
from quinine.

In order to produce any characteristic symptoms by salicine, a single
large dose of one drachm or more is necessary, or thirty grains repeated
hourly, two or three times. Given less frequently, or in smaller doses,
it induces no symptoms whatever. Toleration of the drug is soon estab-
lished, so that at last large doses fail to i)roduceany characteristic effect;
though when given at first, without any graduation, these full doses, even
after their discontinuance, produce very decided symptoms, which may
persist one or two days, and may even become intensified the day after
the withdrawal of the medicine. The repetition of large doses may pro-
duce slight fever, shown in delaying and greatly lessening the evening
normal diurnal fall — an effect probably due to irritation of the stomach.

Smaller doses of salicylate of soda are sufficient to induce toxic effects,
as from ten to fifteen grains every hour or two hours.

The aspect of a patient under full medicinal doses is rather character-
istic, being in many respects similar to that of a person suffering from
cinchonism. The expression is dull and heavy, the face quickly flushes
on slight excitement, and the eyes become suffused. The flush, of rather
a dusky hue, suffuses itself uniformly over the who'le face. The patient,
- made more or less deaf, often complains of noises in the ears. He com-
plains, too, of frontal headache, and his hands, when held out, tremble a
little. Ilis breathing is rather quickened and deepened. Not unfre-
quently, especially after large doses, nausea and vomiting ensue. In some
cases one symptom may predominate; thus deafness may be almost com-
plete, without headache or muscular trembling, or the breathing may be
characteristic, and the limbs may tremble, without headache or deafness;
but it rarely, if ever, happens that any symptom is unaccompanied with
the dull, heavy aspect, and the readiness to flush. Under toxic, but not
dangerous doses, the headache is often very severe, so that the patient
buries his head in the pillow. There may be very marked muscular
weakness and tremor, associated with great muscular irritability, so that
a slight tap, say on the shoulder, causes muscular contractions so strong
as to jerk the iirm backwards. There are often slight spasmodic twitch-
ings when a limb is raised. Tingling of the extremities or other parts of
the body sometimes occur, the voice may become thick and husky, the res-
piration is hurried, sometimes deepened, sometimes sighing and shallow,
and almost panting, as though it were performed rather laboriously; but
the patient does not complain of any difficulty of breathing. When the
breathing is deep and hurried, both inspiration and expiration are often
29

450 SALIC I XE.

accompanied by a nasal, sniffing noise. The costal as well as the diaphrag-
matic movements are involved in the exaggerated breathing. Large
doses, often repeated, quicken the pulse to 140 joer minute, and it becomes
very weak. Vision may be aifected, the sight becoming dim, and stra-
bismus or ptosis may occur — symptoms, however, I have never witnessed.

Patients taking salicine or salicylates often complain of great giddiness
and feeling of intoxication on walking.

Sometimes patients are made delirious, the delirium often closely re-
sembling delirium tremens. It may be accompanied Ijy involuntary evacu-
uation of urine and faeces. Delirium is often of the busy kind. In some
cases when salicylate of soda has excited delirium, if the drug be discon-
tinued and in a short time repeated, it does not the second time j^roduce
delirium.

Salicylate of soda sometimes excites acute ne]3hritis, with bloody
albuminous urine containing casts.

In addition, these substances sometimes produce sickness, and more
rarely diarrhoea, so that they cannot be continued; and further, salicylic
acid often causes much distressing burning of the throat. When admin-
istered in fever, salicylic acid and salicylates not uncommonly excite very
abundant perspiration, but this did not occur in our experiments on
healthy persons. While administering these remedies in rheumatic fever,
some observers have seen them produce an urticarial or vesicular erup-
tion. These symptoms, Strieker asserts, appear sooner in old and feeble
than in young and vigorous people. Dr. Dreschfeld describes the case
of a patient suffering from diphtheritic nephritis, in whom salicylate of
sodmm caused rigor, fever, a temperature of 103°, frequent pulse, severe
headache, drowsiness, dry brown tongue, nausea and vomiting, an ery-
thematous rash on the face, chest, and arms, and increase of splenic dull-
ness. I find that salicine does not reduce a natural temperature. Eiets
states that salicylates reduce the normal temj^erature 1° Fah., but I have
not found this to be the case.

Salicine, salicylic acid, and salicylates, however, while influencing the
normal temperature but little or not at all, j^owerfully depress a febrile
temperature, and have been abundantly used for this purpose. With the
fall of temperature profuse perspiration occurs. Salicylate of soda is
now almost exclusively used, for it is more soluble than salic3dic acid and
cheaper than salicine.

Though I have, on very many occasions, given salicine to fever pa-
tients in doses sufficient to produce deafness, headache, and muscular
tremor, I have never seen it induce the quick and great reduction of
temperature which follows the use of salicylic acid.

Salicylate of soda is not much used now as an antipyretic in acute
specific or inflammatory fevers, for though no doubt it will hold down
the temperature, it generally does more harm than good by the depression
and discomfort it produces, and whilst in sufficient doses capable of hold-
ing down the fever temperature, it does not shorten the course of the
disease.

These substances, however, are most valuable in acute rheumatic fever.
Dr. Maclagan, in this country, and Dr. Senator, of Berlin, first employed
them in this disease. Ten to fifteen grains of salicylate of soda hourly is
generally sufficient to relieve pain in a few hours, and to remove all fever
in three or four days. Now, indeed, we never see cases of rheumatic fever
running a protracted course of one or two months.

SALICINE. 451

It is a good plan to give the medicine hourly till slight toxic effects,
as deafness and buzzing, are induced, and then to administer it every
two or three hours. The effect is not jDrompt nor marked unless some
slight toxic symptom is present.

It is claimed for these remedies that they lessen heart complications
in rheumatic fever. No exact observations have been made on this ques-
tion ; but, as Dr. Maclagan observes, it is obvious that a remedy which
greatly shortens tlie duration of the disease must lessen the risk of com-
plications. It does not, however, afford perfect protection to the heart, as
several cases of pericarditis are recorded where this complication set in
after the j)atient was well under the drug's influence. This, indeed, we
should expect, as the pericarditis is similar to the inflammation of the
joints, and while this lasts, risk of heart complication must be en-
countered.

I may draw attention to a fallacy to which, I think, most of the re-
porters regarding these substances have not paid sufficient heed ; nearly
all state that in twenty-four to forty-eight hours these agents exert a
marked influence on the temperature and pain. In all the recorded cases
I have met with the patients were treated in hospital, and on admission
were at once put under salicylic treatment. Now, it is well known that
the movement of the Joints during the Journey to hospital considerably
increases both pain and fever, and that during the first two days in hos-
pital the ixxin greatly diminishes, and the temperature falls one or two
degrees. When the patients have been at once put under salicylic acid
treatment this improvement in the pain and fever, due to rest, has been
credited to the drug.

Acute rheumatism, subdued by the salicine treatment, is very liable
to relapse, and the drug, reduced in quantity, should be continued ten
days or a fortnight after the temperature has become normal.

Dr. Sharkey and Dr. Ord, and my experience confirms them, find sal-
icylates of little use in hyperjoyrexia, for this may occur whilst the patient
is under the influence of the drug. Moreover, even when given in full
doses, at the very onset of the pyrexia, it fails to control it.

A solution of salicylate of soda applied to inflamed Joints in rheuma-
tism gives much relief.

Salicylate of soda is very useful in some forms of chronic rheumatism.
I have not been able to satisfy myself tliat it is of use in rheumatoid
arthritis, or gonorrheal rheumatism. If the pain of chronic rheumatism
is worse at night, then a dose of thirty grains should be given at bed time.
Its action is much helped by adding a full dose, as half a drachm to a
drachm, of citrate of soda. • It is useless in gout.

Salicylate of soda, in my exj^erience, succeeds better in sciatica than
any other remedy. Sometimes its effects are very prompt, at other times
it must be continued for a month or three weeks. It is very useful in
lumbago.

Salicylate of soda is recommended in various forms of neuralgia, but,
with the exception of sciatica, it is certainly inferior to other remedies.

It is extremely useful in migraine. Fifteen to twenty grains will
generally, in a short time, remove headache, sickness, and the dull, stujiid
feeling so often present during these attacks.

Several observers have employed salicylic acid in ague with contradic-
tory results. Several obtained no benefit, whilst others found that it
cured a minority of the cases, being most serviceable in recent cases. It

452 SALOL.

seems useful occasionally as an adjuvant to quinia, Sarzance having
obtained good results from a combination of these remedies.

Ebstien and Julius Miiller report two cases of diabetes mellitus cured
by salicylate of soda. They do not vaunt this remedy as a specific, but
the two' interesting cases they cite, after a prolonged trial of various
drugs, notably of carbolic acid, got well under the salicylate of soda.

Da Costa employs salicylic acid in five grain doses to correct the foul
breath and offensive expectoration sometimes occurring in jihthisis.
Berthold, of Dresden, narrates a case which yielded promptly to salicylic
acid, after the failure of turpentine inhalations, and large doses of quinia.

Berthold has likewise employed salicylic acid topically in " catarrhal
stomatitis,*' and in thrush. He calls attention to the ana?sthetic virtue
of the acid in stomatitis, in calming the gnawing, burning pain of the
erosions after the rupture of the vesicles. The solution he iises is, one
part of acid dissolved in sufficient alcohol, to 2bO parts of water.

Salicylic acid has been used with good results as an injection (1 to 300)
in the dysenteric diarrhoea of children.

Salicylate of soda was first recommended in quinsy by Dr. Hunt.
It is extremely successful, shortening the disease, and almost always
preventing suppuration. It is probably the best remedy for quinsy, ex-
celling even aconite or guaiacum. It should be given in small doses, as
three grains hourly.

I have used the following ointment in pruritus ani and vulvge with
considerable success, though in some cases it caused a good deal of smart-
ing: — Acid salicy., 3ij; ol. theobrom., 3 v; cetac, 3iij; ol. nucis, 3 jss.

Salicylic acid is much used as a local application for corns and warts.
The following is Mr. Gezou's formula: — Salicylic acid, 30 parts; Ext.
Cannab. Ind., 5 parts; Collodion, 240 parts. It is applied with a
camel's hair brush. It is said that the corn comes off in four or five
hours, but no doubt it is simply the collodion film which peels off.

Salicylates sometimes produce rashes, as urticaria, erythema.

Salicine and salicylic acid may be readily detected in the urine, sweat,
saliva, and sputa, by the purple color produced on the addition of a drop
of the solution of perchloride of iron. It apj^ears in the urine in four or
five hours, and seems to undergo speedy elimination, though a trace may
remain after four days' discontinuance of the medicine.

It is stated that these substances appear in the urine in the form of
salicyluric acid. Dr. Sharkey detects salicylic acid in the urine, in the
serum from a blister, in the expectoration, but, strange to siy, not in
the sweat of patients taking salicylates.

Dr. Pye Smith points out that the urine of patients taking salicylic
acid gives the reaction of sugar with Trommer's test.

A little syrup of orange peel covers the mawkish taste of salicylate
of soda. Twenty drops of hydrobromic acid with each dose prevents the
buzzing of the ears produced by salicylates. Bromides would act equally
well.

SALOL.

Salicylic or phenic ether is decomposed in the intestine by the
action of the pancreatic ferment into salicylic acid and phenol. It con-

ANTIPYRINE. 453

tains about two-thirds of salicylic acid. It is insoluble in water, and has
a slight aromatic taste.

It acts just like salicylic acid, and most observers ascribe its action to
the salicylic acid it contains, though some maintain that it is more effica-
cious than salicylic acid as an antiseptic and antipyretic.

As a dusting powder, diluted with an equal part of talc or starch, it
is useful in erysipelas. The same powder sniffed up the nose removes
the fetor of oz^ena. Like salicylic acid, it has been employed as an anti-
pyretic in phthisis, typhoid fever, etc., and some writers highly praise its
action. In my hands, like all other antipyretics yet introduced, salol
has done more harm than good, and I gather that this is the growing
opinions of others, as it is now not much used simjily as an antipyretic.

It is highly useful in acute, subacute, and chronic rheumatism. Some
think it mor<:^ efficacious than salicylic acid. To me it has appeared to
be valuable, simply from its component salicylic acid. It has to some
people a less disagreeable taste than salicylate of soda, and when this salt
disagrees, salol will often be tolerated. It produces the same toxic symp-
toms as salicylate of soda, and in fact affects the patient in all respects like
this drug. It is useful also in neuralgia and lumbago, and jDrobably in
sciatica.

It passes off by the urine as urate of salicyl ; but some would seem to
escape unchanged. At least, the urine and the breath strongly smell like
the powder. Its carbolic acid causes carboluria. It prevents decomposi-
tion of urine, and is said to prevent decomposition of the urine in the
bladder in cystitis, and to keep it acid.

The dose is ten to fifteen grains hourly. It may be taken m wafer-
paper, or suspended in water. Patients, I find, take it easily m aerated
waters. I conclude that it acts simply as salicylic acid, and therefore,
all the good and evil partakes of salicylate of soda, with the one advantage
in taste, and in the fact that it is sometimes tolerated by the stomach
when salicylate of soda induces nausea and sickness.

I may here st.ite that, not uncommonly, Avhen sickness is induced by
large doses of sodium salicylate, given every three hours, an equivalent
quantity given in hourly doses, is well tolerated.

AIS^TIPYEINE.

For some years past therapeutists have striven to discover a drug
capable of reducing febrile temperature, without causing any outward
symptoms. Quinine, salicylate of soda, resorcine, kairine, thallin, etc.,
have been employed for this purpose, but they have been almost discon-
tinued on account of their disagreeable and depressing effects.

Filehne recently introduced a new substance, antipyrine, a synthet-
ically prepared alkaloid derived from chinotine, and speaks most highly
of its usefulness.

It acts promptly as an antipyretic, effecting a fall of several degrees in
two or three hours, which often endures more than twenty-four hours, to
be followed by a very gradual rise, being in this respect superior to kairine.

454 ANTIPYRINE.

The fall in the pulse is not always equal to the reduction of the tem-
perature. With the fall of the temperature the symptoms improve, the
tongue grows clean, delirium disappears, and restlessness ceases. It inter-
feres neither with the appetite nor the digestion. It produces generally
copious perspiration, at other times slight perspiration and increased
secretion by the kidneys. In rare instances it excites vomiting. It
sometimes produces an erythematous rash, somewhat like measles, leav-
ing a brown stain, most marked on the trunk, the face and upper part
of the neck always remaining free. This rash disappears in spite of the
continued administration of the drug. Sometimes the rash is like urti-
caria, sometimes it is hsemorrhagic. It may be followed by desquamation
(Sara Welt).

It may cause some cardiac depression, hence it should be given guard-
edly to prostrate patients.

It is said to reduce the normal temperature one or two degrees,
though it has no effect on the normal daily cycle of temperature.

It has been given in typhoid fever, pneumonia, erysipelas, rheumatic
fever and phthisis.

It may reduce the temperature below normal, even to 93° F., with-
out producing any collapse, and it has succeeded where cold bath, quinine,
and salicylate of soda have failed.

There is no proof at present that it shortens the disease; it appears
to be only a sure and safe reducer of febrile temperature.

Most observers recommend three hourly doses each of thirty grains,
and then to intermit the drug till the temperature again rises. Or,
smaller doses, as fifteen grains, may be taken several times a day.

At first the accounts of its effects were very enthusiastic, but it is
much seldomer prescribed than a while ago, and after many trials, I
must confess I find that, like other antipyretics, it causes so much dis-
tress and depression that in many cases it does more harm than good,
though I think it is less depressing than other antipyretics.

In doses adequate to lower temperature efficiently it often induces
vomiting. The reduced temperature, as it rises again, when the medicine
is eliminated, often produces chilliness, or even violent rigors. However,
some doctors still praise it highly. A single thirty-grain dose given at
intervals of twelve or twenty-four hours appears to depress less than
smaller doses more frequently repeated. It is better to give at first a
fifteen or twenty-grain dose to test the patient's susceptibility to the drug.

It is maintained that antipyrine is as useful as salicylate of soda in
acute rheumatism. This I am sure is an error, and that in this disease
antipyrine cannot compare with salicylate of soda. Antipyrine will lower
the temperature like other antipyretics, but on discontinuing the drug
the fever and pain return.

See draws attention to its great usefulness in many painful affections,
as migraine, neuralgia, sciatica, lumbago, muscular rheumatism, pains of
locomotor ataxy and angina pectoris. It should be given in fifteen-grain
doses three to six times a day, or half that dose twice as often. If given
in doses larger than fifteen grains, it may cause methfemoglobinuria. It
is highly useful in migraine; sometimes it succeeds in twenty-grain
doses, other patients require thirty grains, and in some cases a twenty-
grain dose must be repeated in an hour or two hours.

See administers it often hypodermically to relieve pain in neuralgia,
acute and chronic rheumatism, acute gout, biliary colic, renal colic.

PHENACETIISr. 455

angina. It is also useful in a paroxysm of asthma, promoting expectora-
tion. It is soluble in an equal quantity of water. Five to fourteen
grains may be administered, and if the injection causes much pain, a
little hydrochlorate of cocaine should be added.

It is recommended to relieve dysmenorrhoea and pains after delivery;
also the pains of parturition, lessening the suffering without diminishing
the force of the uterine contractions.

The following is a resume of an able article by Dr. Beyer published in
the American Journal of American Sciences, 1886. Kairin, thallin, and
hydrochinon added to blood changes its color, making it darker than
natural; thallin to dark-brown chocolate, hydrochinon to cherry red,
resorcin makes the color brighter red. These substances produce the
same change when injected subcutaneously. Antip3'rine leaves the color
of the blood unchanged. Kairin, hydrochinon, and antipyrine hasten
coagulation. Kairin, thallin, and perhaps hydrochinon, are destructive
to the hemoglobin All these substances arrest amceboid movements.
Kairin dilates the capillaries and veins much in excess of the arteries; it
greatly weakens the heart, acting directly on the muscle. It reduces
temperature by increasing loss through radiation and by diminishing
heat production through its action on the corpuscles. Thallin is strik-
ingly like kairin, but thallin has a much less injurious effect upon the
ventricle. Thallin, like kairin, reduces temperature by lessening heat
production and increasing loss through radiation.

Kesorcin dilates capillaries and veins, and so reduces temperature by
increasing radiation. Like kairin and thallin, it has a chief affinity for
the venous side of the heart. It paralyzes the auricles in doses that on
the contrary rather stimulate the ventricles. Cappola concludes that
antipyrine lowers body temperature by increasing radiation and not by
lessening production of heat or depressing the heart, for it increases the
strength of the heart's contractions and does not lower blood pressure.
The vascular dilatation does not depend on depression of the vaso-motor
centre, but is peripheral, as it occurs in tissues separated from the central
nervous system. Beyer concludes that it cools by increasing loss of heat,
by dilating the cutaneous vessels. It is tonic to the heart and slightly
heightens blood pressure. It has no injurious effect on the blood. As
regards their action on the heart these various substances act as follows :
kairin and thallin paralyze the ventricles; hydrochinon and resorcin
weaken the ventricles less, but all greatly weaken the auricles and lower
the tone of the vessels, and hence depress by the blood accumulating in
the veins. The animal bleeds into its own veins. Antipyrine, on the
other hand, strengthens both ventricles and auricles.

PHENACETIN.

An" acetyl compound of phenetidin, allied to antifebrin, is the last
antipyretic. It is but little soluble in water or glycerine. It has been
highly praised. My experience regarding it is at present very limited,
and, I am sorry to say, is not favorable. It is given in eight to twelve-
grain doses every four or six hours.

456 PAREIKxV BliAVA.

QUASSIA.

Quassia is poisonous to some of the lower creatures, as flies and other
insects.

It is a bitter tonic. It has been used in intermittent fever.

Infusion of quassia is a very useful injection in ascarides; it is also
efficacious when administered by the mouth.

CHAMOMILE.

These flowers contain both a volatile oil and a bitter substance, and
thus, to some extent, combine the properties of bitters with those of
ethereal oils.

In a case of accidental poisoning by chamomile the symptoms were
diarrhoea of white putty like stools, coated tongue, intense headache,
with a sensation of pressure within the cranium.

Chamomile is not often used as a tonic. An infusion is sometimes
employed to assist the action of emetics.

In the ordinary summer diarrhoea of children, often occurring during
teething, characterized by green, many-colored, and slimy stools, the in-
fusion in doses of half a drachm or a drachm often proves very useful,
especially when given at the commencement. This medicine is likewise
efficient in other kinds of summer diarrhoea. It also subdues restlessness
and peevishness. A mixture is easily prepared by steeping four to six
heads of chamomile flowers in a teacupful of boiling water for an hour,
and then giving a teaspoonful hourly.

It has been used in intermittent fever, in neuralgia of the fifth nerve,
and is a popular remedy for " sick headache."

PAEEIKA BRAVA

contains an alkaloid, buxine, said to be identical with berberine. It
is chiefly employed in chronic catarrh of the bladder, and is in many
cases a most valuable remedy, checking bleeding, and more gradually
muco-purulent discharge. It often ju'omptly arrests bleeding from the
bladder, though, strange to say, it has no control over bleeding from
other organs. It is also a bitter tonic, and often increases the appetite.
It must be given in considerable doses, as a drachm and a half to two
drachms or more of the liquid extract three or four times a day.

I have treated patients who took this remedy with intermissions for
several years, in whom its suspension was immediately followed by a
return of bleeding and considerable increase of muco-pus in the urine.

ALOES 457

ELATERIUM.

This drug has a very bitter taste, and excites free secretion of saliva.

It is a powerful drastic hydragogue cathartic. Its activity is due to
elaterin, a chemically indifferent substance like the resins, and incapable
of forming salts with either acids or bases. It often produces colic, and
not unfrequently vomiting.

In large doses it may excite inflammation of the stomach and intes-
tines, and even of the peritoneum. It is given as a purgative, especially
in dropsies. By carrying off a large quantity of Avater the dropsy some-
times reduces; it is thus used both in ascites and m the dropsy from kid-
ney or heart disease. It must be borne in mind that free purging is very
exhausting, and that elaterium very often disorders the stomach and spoils
the appetite. It is a medicine to be given with caution.

Dr. Hyde Salter strongly recommends purgatives in dropsy depending
on aortic, obstructive, or regurgitant diseases. He says, that although
we cannot alter the heart, we can lessen the quantity of blood it has to
propel, and thus diminish the congestion on which the dropsy depends.
He employs elaterium, and advises a small dose at first, say one-sixth of a
grain, to be given alternate mornings at about 5 a.m., so that the purga-
tion usually ceases by ten or eleven. This treatment, he says, quiets the
heart, relieves the dyspnoea, lessens the pulmonary congestion, and thus
diminishes the hydrothorax.

COLOCYNTH.

This drug has an intensely bitter taste, and occasions an abundant
secretion of saliva.

It produces diarrhoea, colic, and sometimes vomiting. The diarrhoea
is watery, and, after large doses, serous, mucous, and bloody. In large
doses it may excite gastro-enteritis and peritonitis.

It is chiefly used as a purgative, but almost always in combination with
other substances. In obstinate constipation it is a good plan to give a
few drops of the Prussian tincture several times a day. Kohrig, from his
experiments with fasting animals, is led to place colocynth high among
cholagogues. It makes the bile more watery, but also increases the solid
constituents. It powerfully stimulates the intestinal glands.

It has been used as a drastic cathartic in dropsies, and, like most other
powerful purgatives, it has been used for worms, although it has no direct
poisonous influence on them, but merely expels them mechanically.
Purgatives, therefore, are not good anthelmintics.

ALOES.

Aloes has been used as a slight stimulant to wounds, and when thus
employed it often purges. " Dr. Gerhard, of Philadelphia, found it the
medicine best adapted for endermic uses, as its application does not irri-

458

ALOES.

tate a blistered surface very powerfully. Ten grains of aloes thus
employed produced five or six stools, which were generally accompanied by
griping. Infants are purged by the milk of nurses who have taken aloes."
— Stillc.

Aloes is reputed to be a tonic, and to increase the secretion of bile.

Dr. Rutherford confirms Rohrig's statement, that Avhen introduced into
the duodenum of a fasting dog, aloes greatly increases all the biliary con-
stituents, though it purges but slightly.

It is chiefly employed as a purgative. It acts mainly on the large
intestine and rectum. Its action is slow, and six, twelve, or even twenty-
four hours may elapse before it operates. It produces bulky motions,\i
little softened, but not watery. It evidently acts but little on the mucous
membrane of the intestines, and it is merely a fa?cal evacuant. It often
occasions slight griping, and sometimes tenesmus. As its action is tardy,
it is injudicious to combine it with more speedy purgatives. It is well
suited for cases of chronic constipation; for its activity is not lessened by
habitual use, and it is even said that the dose may be gradually decreased.
Sulphate of iron is said to heighten its action.

When both a tonic and a purgative are required, aloes, like senna, may
be usefully mixed with some bitter, as gentian. Purgatives, it is said, act
in smaller quantities when combined with tonics.

Aloes, in a variety of combinations, is in common use as a laxative in
habitual dyspepsia, with constipation. The compound decoction of aloes,
formerly called baume de vie, is a serviceable after-dinner laxative. The
basis of many diniier pills is one grain of watery extract cf aloes. A din-
ner pill containing one grain of watery extract of aloes, combined either
with extract of nux vomica, extract of gentian, or extract of cinchona, is
very useful. '

In habitual constipation aloes is the best and most commonly employed
purgative. Dr. Spender, of Bath, extols the following pill, taken at first
three times, then twice, and afterwards once a day — one grain of watery
extract of aloes, and two grains of sulphate of iron. This pill takes some
days to act. Aloes has been accused of producing piles, and in full or
over-doses will, no doubt, aggravate this disease; but most authorities are
inclined to attribute piles to the constipation aloes is employed to remove,
and not to the aloes itself. Indeed, I am convinced that in many cases
moderate doses of aloes, just sufficient to gently relieve the bowels, are
highly useful in jiiles.

Aloine, injected hypodermically, purges in a few hours. It should be
dissolved in twenty-five parts of water.

By its action on the rectum aloes affects sympathetically the neighbor-
ing pelvic organs, as the uterus; and given at, and just before, the men-
strual period, is useful in many cases of amenorrhcea and deficient
menstruation. Wc cannot here refrain from citing the admirable remarks
of Dr. Graves on amenorrhcea and its treatment. '' The periodicity of
this function,"' he says, "can still be traced, even in cases where suppres-
sion has continued for a great length of time, by means of the menstrual
molimina (pains in the loins, thighs, and hypogastric region, flushing,
colicky pains of the abdomen, general feeling of malaise), which occur at
stated intervals. In endeavoring to bring on the discharge, therefore, we

' Guaiacum is useful in obstinate habitual constipation; and guaiacum mixture will
often relieve the bowels when powerful purgatives tall.

ALOES. 459

must be guided as to the time the attempt should be made^ by an observ-
ance of the period at which these molimina occur. For a few days before
that time our efforts to produce a determination of blood to the uterus may
be judiciously employed, and if they fail the attempt should be abandoned
until a few days before the next menstrual period. Of course I here speak
of the general constitutional treatment, for this must be constantly per-
severed in, one of the chief means of bringing back tliis evacuation being
the restoration of health to the natural standard. In some this is to be
effected by a tonic, and in others by an opposite mode of treatment.

" AYhat I wish to impress on your minds is, that all those reme-
dies, as pediluvia, scupiiig of the genitals, leeches to the inside of the
thighs near the labia, aloes, and other stimulating purgatives, etc., should
be only used at the times already spoken of. To use them at any other
period, either after the molimina have disappeared or during the intervals
between them, tends in most cases still further to derange nature, by
determining to the uterus at an unseasonable time, when there is no nat-
ural tendency to that organ. Under such circumstances the very same
means will frequently fail, and prove injurious, which, applied so as to
coincide with the time of the natural effort, would have been successful.
To illustrate these principles by an example: — We are consulted in the
case of a young woman affected with various hysterical symptoms for sev-
eral months, and during that period more than usually subject to headache,
languor, loss of spirits, diminution of appetite and irregularity, and usu-
ally constipation of bowels; she is pale, and complains of various pains and
uneasy sensations, and has not menstruated since the accession of these
symptoms. Here it is evident that the constitutional treatment must be
strengthening and tonic. The practitioner will therefore recommend reg-
ular hours, much passive exercise in the open air, a nutritious diet, and
afterwards cold shower-baths; he will regulate the bowels, and afterwards
prescribe a course of tonic medicines, chalybeates, preparations of bark,
strychnia, etc., he will likewise inquire carefully Avhen the last period
happened, and Avhen and how often since that occurrence menstrual
molimina were observed. He thus ascertains when they should again
recur, and contents himself with enforcing the constitutional treatment
until about six days before the calculated time. Then he lays aside the
other medicines, and has recourse to those means which determine to the
uterus. Two leeches are applied to the inside of the thigh, near the labium,
every second night, until they have been three times applied. The bleeding
is encouraged by stuping. On the intermediate days the bowels must be
actively moved by aloetic pills, and for three nights before and after the mo-
limina, liot pediluvia. rendered stimulating by mustard seed, may be xised.
During the same time also friction, Avith stimulating liniments, should
be applied to the feet and legs every morning, and oil of turpentine, or
tincture of cantharides may be exhibited internally, while the necessity of
more active exercise is inculcated. If these means fail, they must for a
moment be laid aside, and the constitutional treatment must be again
resumed until the same number of days before the next period, when the
list of remedies above spoken of must be again tried, and in few cases
indeed shall we find them to fail." — Graves' Clinical Lectures.

460 JALAP SCAMMONY.

SQUILL

contains a glucoside, scillitoxin. Squill has a bitter taste. It acts pow-
erfully on the stomach and intestines in full doses, exciting great nausea
and vomiting, with frequent watery and even bloody diarrhcea. Similar
symptoms are likewise produced when the drug is injected into the
cellular tissue or jjeritoneal cavity. Squill acts like digitalis.

Squill is never used as an emetic or purgative, but almost exclusively
as an expectorant in bronchitis, and is often given in heart cases in con-
junction with digitalis, especially when, in addition to cardiac disease,
there is bronchitis with much mucous secretion.

It is a diuretic in heart disease. It is recommended in all forms of
dropsy.

JALAP. SCAMMONY.

BuCHHEiM asserts that these two substances are rendered purgative
only by combining with the bile; unmixed Avith this secretion they are
inert. They are easily soluble in the Ijile, and probably undergo decom-
position, but the products are unknown. Taurin and glycoll exert no
influence on their efficacy, but it is otherwise with tauro-cholate and glyco-
cholate of soda; hence Buchheim conciludes that the activity of these
drugs is determined by the soda of the bile. They excite diarrhoea of
watery motions, with some colic and occasional vomiting, and their use is
often followed by much constipation.

These medicines are used as purgatives in obstinate constipation, and
jalap, in combination with other substances, is employed in dropsies.
Scammony is frequently used with much advantage to destroy the small
thread-worms infesting the rectum.

Kohrig and Rutherford coi:iclude from their experiments on fasting
dogs that jalap is a powerful cholagogue. It increases the watery and
solid constituents of the bile, and powerfully stimulates the intestinal
glands.

Dr. Eutherford finds that scammony given to fasting dogs is a feeble
cholagogue, even when it purges.

Bleeding has recently been employed with great success in engorge-
ment of the right side of the heart from emphysema and bronchitis, mitral
obstructive or regurgitant disease. Now, for some years I have employed
purgatives in these cases with considerable benefit, to produce three or
four watery motions, and I venture to say that this treatment, first
employed by Dr. Graves, saves many lives.

Like bleeding, free purging unloads the distended, and therefore weak-
ened right heart, and it moreover ])ro(luces a very favorable change in the
character of the expectoration, rendering its expulsion easier. The follow-
ing case, one among many similarly benefited by free purging, will illlus-
trate the advantage of this phin.

A woman about forty years of age, suffering from emphysema, was
seized with severe bronchitis. She had been dangerously ill about a fort-
nigiit: her skin was of a deep leaden tint; her eyes were prominent, con-

RHUBARB. 461

gested, and suffused; her jugular veins were greatly distended; the surface
of her body Avas covered with a cold clammy perspiration, profuse on her
face; her extremities were deadly cold; her temperature varied between
97°and 98° Fah, She suffered from slight delirium both night and day.
Her breathing was hurried, and her chest expanded only slightly; expec-
toration was abundant, viscid, airless, and purulent; pulse large, but very
compressible, varied from 96 to 100 beats in the minute. The respiratory
sounds were obscured by an abundance of mucous rhonchus, and physical
examination showed that the right side of her heart was greatly distended.
Her urine contained a trace of albumen; her legs were not oedematous.
So dangerously ill was she that death appeared imminent. After free
purgation with jalap and bitartrate of potash, in a few hours the jugular
veins became much less distended, and next day they were of natural
size; while the deep leaden tint of her skin had given place to a diffused
bright red color, often witnessed in cases treated in this way; this color
being probably due to the capillaries — previously distended by the obstruc-
ted circulation, till, being weakened, they lose their power lo contract —
becoming filled with arterial instead of venous blood. This bright red color
was most marked over the face and hands; her skin became warm, though
she continued to perspire freely, and her hands easily grew cold on expo-
sure. She expressed herself much relieved. In twenty-four hours the ex-
pectoration became slightly aerated, this change being much more marked
on the following day, when the expectoration was observed to be less
purulent, and to contain much mucus. On the third day the expectora-
tion was frothy, and consisted chiefly of mucus; coincidently with this
improvement in the sputa, her chest expanded more perfectly, and the
rhonclius diminished. From this time she steadily improved, and was
discharged cured.

The engorgement of the right heart, with general venous congestion,
is no doubt ix\)t to return, when it becomes again necessary to purge;
indeed, several purgings may be required. It will rarely happen, I
believe, that the venous congestion cannot be removed temporarily by this
treatment.

The change in the expectoration sometimes takes place more slowly
than in the foregoing case, a week elapsing before it becomes frothy, and
composed of mucus. Any tendency of the expectoration to assume its old
characters may be prevented by a repetition of the aperient.

Sometimes these patients complain of very severe dull headache, or of
dull oppressive pain at the epigastrium: bleeding or purging relieve both
symptoms, bleeding giving instant ease.

In persistent tricuspid regurgitation from permanent distention of the
right side of the heart, induced by repeated attacks of bronchitis, pur-
gatives will probably be of no iise except when an attack of bronchitis,
adding to the obstruction of the pulmonary circulation, increases the
dilatation.

EHUBAEB.

Rhubarb is a purgative, and is likewise a tonic. After purging
it constipates, on which account it is often used in the early stages of
diarrhoea, to get rid of any irritating matter from the intestines, and after

462 SENNA CASCARA SAGRADA EUONYMUS.

their expulsion, to check the diurrlioea. It is a very useful purgative for
children, especially when mixed with two or three times its weight of bicar-
bonate of soda.

Eohrig finds tliat rhul^arb, given to fasting dogs, greatly increases all
the constituents of the bile, though the rhubarb either failed to purge, or
purged very slighty; and Eutherford. verifies this observation.

L)r. Stillc, on the authority of Dr. S. Jackson (U.S.), Avhose testi-
mony he indorses, speaks of rhubarb as a. remedy of surprising efficacy in
j)iles, when laxatives are needed. He directs a piece Aveighing about ten
grains to be chewed, or rather slowly dissolved in the mouth nightly, or
less frequently according to the degree of constipation, estimating that rhu-
barb taken in this fashion is five-fold more efficacious than the powder. He
also recommends it in the costiveness and hiemorrhoidal swellings inci-
dent to pregnancy. (Stillc's Tlierapeuticx.)

Ehubarb generally colors the urine reddish yellow, which, on the
addition of ammonia and other alkalies, changes into a purple red. It col-
ors also the sweat, the serum of the blood, and the milk; and it makes
the milk bitter and purgative.

It may be usefully blended with some tonic.

SENNA.

Senna is an active purgative, promoting both secretion and peristaltic
action. It often produces nausea and griping. It may be usefully com-
bined with a bitter tonic, as in the mistura gentianre composita? of former
pharmacopoeias. This mixture is very useful in dyspepsia with constipa-
tion, and contains an ounce of compound infusion of gentian to half an
ounce of compound infusion of senna. Senna renders a mother's milk
jiurgative, and may produce colic in the child.

Eohrig and Eutherford find that in fasting dogs senna slightly in-
creases the secretion of the bile.

CASCAEA SAGEADA.

One of the buckthorn family, derived from Ehamnus Purshiana.
Like the other buckthorns, it is purgative, but less drastic than rhamnus
catharticus, and more active than rliamnus frangula. It acts promptly
and without griping, and is now largely used with great advantage as a
laxative, especially in habitual constipation. It is said to cure functional
habitual constipation. I have not yet met a case of habitual constipation
cured solely by the use of this drug. It may be given as the liquid ex-
tract in ten to fifteen-minim doses tAvice or thrice a day, or in the form
of extract in doses of two to four grains in a pill at bed-time.

EUONYMUS

is used in the form of extract in about two-grain doses, as purgative and
stimulant to the liver, and is said to increase the secretion of bile.
Large doses cause much intestinal irritation. A short time ago it Avas

ANTIIEL.AIINTICS. 463

employed much more than at present, in place of mercury preparations or
podophyllin.

Though much less used now, it is no doubt a useful drug, hut I think
it inferior in most cases to its rivals, mercurial preparations or podophyllin.

SENEGA.

Senega promotes the secretion of the bronchial mucous membrane,
and probably that of the other mucous membranes. It produces a burn-
ing, itching sensation in the mouth and throat.

It is used in chronic bronchitis, especially in the case of aged people,
in whom this disease is usually complicated Avith emphysema. Some give
it in croup and whooping-cough. It is also reputed to be diuretic, and is
used when the deficiency of urine is due to kidney disease. " Infusion of
senega (four to six drachms infused in six to twelve ounces of water, and
taken during the day) produced no effect on the urine in Boker's experi-
ments, conducted on himself and on a pregnant woman." (Parkes 6^^i
Urine. )

Anthelmintics —

FILIX MAS. AEECA NUT.

KOUSSO. BAKK OF THE POME-
KAMELA. GRANATE ROOT.

SANTONIN. POWDERED TIN.

TURPENTINE. MUCUNA, etc.

The intestines are infested by worms of various kinds. The common
kinds are the flat worms (Taenia solium and Bothriocephalus latus), round
wornis (Ascaria lumbricoides), and thread-worms (Ascaria vermicularis).

Worms may be treated in three ways. Drugs, as powdered tin and
mucuna, may be employed to kill the worm by their mechanical action,
or powerful purgatives may be used simply to expel the worm, as jalap,
scammony, etc. ; or true vermicides, having very little effect on the tissues
of the human body, to poison and kill the Avorm. With the exception of
powdered tin and mucuna, all the medicines comprised in the foregoing
group are vermicides. It must, hoAvever, be borne in mind that all are
not equally efficacious against every kind of Avorm, for some are poisonous
to one kind, and harmless to another. Success, in fact, depends not only
on giving the fitting drug, but giving it in the right Avay. These inedi-
cines should reach the Avorms in as concentrated a state as possible; but if
the stomach and intestines are filled Avith food, the poison, being thus
diluted, may fail to destroy the Avorms. It is proper, therefore, to giA^e
overnight a ])urgative, and to direct the patient to take a very light tea
and no supper, and oii the folloAving morning, after the purgative action,
to give the anthelmintic.

FiLix Mas is employed for tape- worm. Kuchenmeister asserts that it
is more poisonous to the bothriocephalus than to the ta?nia. The patient
should eat a very light tea, no supper, and just before bedtime SAvalloAV a

464: ANTHELMINTICS.

dose of castor-oil,, a purgative to be preferred to others on account of its
speedy action. On tlie following morning, about six or seven o'clock,
when the oil will generally have acted, give the liquid extract of male
fern in a dose varying from ten drops to a drachm, according to age. The
patient is then to abstain from food till the bowels have been freely
relieved, when in most cases the worm will be expelled. Some recom-
mend a brisk jiurge to follow the anthelmintic, but this is seldom neces-
sarv, as the foregoing simple plan rarely fails to dislodge the worm.
Too large a dose of the male fern may cause nausea, sickness, and even
colic, effects seldom witnessed with a moderate dose. The liquid extract
of male fern is slightly purgative, and for this reason it is not always nec-
essary to administer a purgative after it. The worm should be carefully
examined in order to ascertain if the head has been expelled; in that case
there is no fear of the re-growth of the worm. It has, however, been
ascertained, that if only the head and a small piece of the neck are left
the worm will die, so that if the head cannot be discovered, it must not be
concluded that the patient is not permanently freed of the worm. If any
piece is found wdiich tapers to a fine point, even if the head is not
attached, it may reasonably be hoped that the worm is destroyed. A
good plan to obtain for examination all the expelled worm is to shake up
the motions, already Avatery and loose from the purgative, with some
Avater, and to filter the whole through a piece of coarse muslin, by which
means the head, even if separated from the trunk, may be detected and
examined.

Male fern is generally considered the fittest treatment for the flat
worm.

Kousso is used for tape-worm of all kinds, and appears to be very suc-
cessful, although not much employed in this country. In Al:)yssinia, where
tape-worm is extremely common, kousso has been in use upwards of two
centuries. The dose is half an ounce of the floAvers suspended in Avater,
and taken after a short fast, as in the previous case. Kuchenmeister
asserts that kousso expels the Avorm sloAvly, and in pieces, and that it rarely
expels the head. It may cause slight nausea and even vomiting. Its
action on the boAvels being very slight it is customary to folloAV this by a
mild purgative.

The bark of the root of punica granatum is the part used. It is em-
ployed chiefly in India for tape-Avorm. Xeligan directs the maceration of
tAVO ounces of briiised bark, of fresh root if possible, for twenty-four hours
in tAVO pints of water, to be then boiled doAvn to half, strained, and di-
vided into three doses, one to be taken -dt half-hour intervals. Vomiting
often occurs, Avhicli, hoAvever, should not prevent the giving of the three
doses. This treatment should be occasionally repeated daily for four or
five days. ]\Iost practitioners find the dried root inert.

LandricAV and Baumetz find the alkaloid of pomegranate, pelletierine,
useful for tape-v\'orm. Fifteen to tAventy grains of the tannate, folIoAved
in. a fcAv hours by castor-oil, sometimes succeeds when other remedies
have failed. Feraud completely cured 7G per cent, of his cases with this
alkaloid.

Saxtonix, the active principle of Avorm seed, is very efficacious for
round and thread-Avorms, but it is inoperative against tape-Avorms. In
the treatment both of round and thread-Avornis, tAvo to four grains, accord-
mgto age, are to be mixed with a drachm or more of castor-oil, and taken
early in the morning before breakfast, repeating the dose tAVO or three

ANTHELMLNTICS. 465

mornings successively. Such treatment seldom fails to bring away any
round or thead-worms. Santonin has been used, mixed with castor-oil, as
an injection into the rectum for thread-worms, and Kuchenmeister found
that santonin in castor-oil, mixed with albumen, killed ascarides in ten
minutes, while without the oil the santonin had no effect. He, therefore,
recommends it to bo given in two to five-grain doses in a ounce of castor-oil.
This quantity is of course intended for adults. Santonin may be conven-
iently given in syrup, lozenge, or ginger-bread. In an obstinate case some
advise the administration of one or two grains twice or three times a day;
but repeated so often this medicine is very apt to occasion sickness and
vomiting, with great difficulty in holding the water, so that children, if
overdosed with it, are apt to Avet the bed at night, are constrained to pass
Avater very frequently, and are even unable to hold it night or day. San-
tonin colors the urine orange, which changes to a brilliant scarlet on the
addition of solution of ammonia. It is curious that this remedy will some-
times stay the nocturnal incontinence of children; and Avlien the incon-
tinence is not dependent on the presence of worms, santonin succeeds
occasionally Avhere other remedies, including even belladonna, fail. It
may produce headache, and sometimes affects smell and taste, and some-
times it makes objects appear of a green or yellow color. Kose finds that
santonin always produces hyperemia of the retina, and he with Dr. Ogs-
ton believes the color is owing to its influence either on the retina or brain,
for it does not color the structures of the eye. Drs. Ogston and Brown
assert that santonin produced cataract in the eyes of young kittens, but
they were unable to induce this condition in adult cats. These gentle-
men recommend santonin in certain eye diseases, as inflammatory and
atrophic alterations in the retina and optic nerve producing deficient sight.

liaimondi and Bertiui record a case Avhere an ounce of santonin
induced vomiting, giddiness, prostration, shivering, lividity, diflficult
breathing, followed by repeated epileptiform convulsions. The patient
recovered.

Mr. Whitehead, of Manchester, finds santonin useful in amenorrhoea.
He gives a ten-grain dose on two successive nights with almost uniform
success, especially when the amenorrhoea is combined with chloro-ana?mia.
Dr. Armand Routh tried santonin in twenty cases of amenorrhoea, giving
ten grains on two successive nights. In seventeen it failed. He thinks
it useless in amenorrhoea with chlorosis. When it succeeds it starts the
discharge without pain.

Santonm may be conveniently given in form of suppository for thread
worms.

Kamela is much used in India for tape-worm. It may be given in
doses from GO to 120 grains, in honey, syrup, or glycerine. It purges
briskly.

Areca nut is much used by veterinarians to expel tape-worms from
dogs, and may be employed for the same purpose in the human subject; it
sometimes succeeds when other remedies fail. Half or a whole nut is to
be powdered, and mixed Avith some syrup, and sAvallowed.

Neligan commends Turpentine for its poisonous effectiveness OA'er
both tape and round Avorms, but it is more deadly to the tape-Avorm. It is
also efficacious used as an injection for thread-AVorms. Kucheimieister
shows that it destroys tape-worm in an hour.

Of all medicines to be sAvalloAved, santonin is, as Ave have said, most
effectual against thread- worms, Avhich infest only the rectum. Scammony,

466 ANTHELMINTICS.

too, is effectual against thread-worms. A variety of substances adminis-
tered by injection will speedily destroy thread-worms. Thus, ateaspoonful
of common salt in solution, infusion of quassia, or a drachm of sesqui-
chloride of iron in a pint of water are very efficacious; so is lime-water,
solution of alum, and, in fact, any substance which will coagulate the
albumen of the worms.

In the treatment of worms it must always be remembered that the
mucous membrane is generally in an unhealthy state, secreting much te-
nacious mucus, which forms a favoring nidus for the development of
worms; for worms will rarely develop in a healthy state of the digestive
canal. The foregoing modes of treatment are therefore only temporarily
remedial, and after the expulsion of the worms, the morbid condition of
the intestinal mucous membrane must be treated. This condition of the
intestines generally occurs in unhealthy ansemic children. Cod-liver oil
and iron preparations soon restore the gastro-intestinal canal to a healthy
condition.

Oils, as is well known, are reputed to be vermicides.

If the foregoing remedies fail, other medicines must be employed to
remove the catarrhal state of the mucous membrane, as common salt,
chloride of ammonium, and salts of antimony. Cold-sponging, out-door
exercise, with a judicious diet, aid the improvement of the general health.

DIETARY FOR INVALIDS.

1, Barley Soup.

One pound of shin of beef, four ounces of pearl barley, one potato, salt and pepper
to taste, one quart and a half of water.

Put all the ingredients into a pan, and simmer gently for four hours. Strain, return
the barley, and heat up as much as required.

2. Bkead Soup.

One pound of bread, two ounces of butter, one qviart of stock.
Boil the brea<l with the butter in stock. Beat the whole with a spoon or fork, and
keep it boiling till the bread and stock are thoroughly mixed. Strain, season, and serve.

3. Tapioca Soup.

Two ounces and a half of tapioca, one quart of stock.

Put the tapioca into cold stock, and bring it gi-adually to the boiling point. Simmer
gently till tender, and serve.

4. Sardinian Soup.

Two eggs, a quarter of a pint of cream, one ounce of fresh butter, salt and pepper
to taste, a little flour to thicken.

Beat the eggs, put them into a stewpan, and add the cream, butter and seasoning,
stir in as much flour as will bring it to the consistency of dough, make it into balls the
size and shape of a nut, fry in butter, and put them into a basin of any sort of soup or
broth, to which they make a verj' nice adtlition.

5. Restorative Beef Essence, 1.

Take one pcnrnd of fresh beef, free from fat. chop it up fine, and pour over it eight
ounces of soft water, add five or six drops of hydrochloric acid, and fifty or sixty
grains of common salt, stir it well, and leave it for three hours in a cool place. Then
pass the fluid through a hair sieve, pressing the meat shghtly, and adding gradually
towards the end of the straining about two or more ounces of water. The liquid thus
obtained is of a red color, ]wssessing the taste of soup. It should be taken cold, a
teacupfid at a time. If preferred warm, it must not be put on the fire, but heated in
a covered vessel placed in hot water.

Should it be undesirable for the patient to take the acid, this soup may be made by
merely soaking the minced beef in distilled water.

G. Another Beef Essence, 2.

Take one pound of gravy beef, free from fat and skin, chop it up very fine, add
a little salt, and put it fnto an earthen jar with a lid, fa.sten up the edges with a thick
paste, such as is used for roasting venison in, and place the jar in the oven for three or
four hours. Strain through a coarse sieve, and give the patient two or three tea-
spoonfuls at a time.

7. Beef Essence, 3.

Cut up in small pieces one pcnmd of lean beef from the sirloin or nunp, and place
it in a covered saucepan, with half a pint of cold water, by the side of the fire for four
or five hours, then allow it to sinuuer gently for two hours. Skim it well, and serve.

468 DIETARY FOR INVALIDS.

8. Beef Tea.

Two pounds of beef without fat or bone, half a breakfast-cup of cold water, place
it in a iar in a saucepan of water. Simmer four hours.

9. MuTTOx Jelly.

Six shanks of mutton, three pints of water, pepper and salt to taste, half a pound
of lean beef, a crust of bread toasted brown.

Soak the shanks in water several hours, and scrub them well. Put the shanks, the
beef and other ingredients into a saucepan with the water, and let them simmer very
gently for tive hours. Strain it, and when cold take off the fat. Warm up as much
as is wanted at a time

10. Beef Tea with Oatmeal.

Mix two table-spoonfuls of oatmeal very smooth with two spoonfuls of cold water,
then add a pint of strong ])oiling beef tea. Boil together for live or six minutes, stirring
it well all the time. Strain it through a sieve, and serve.

11. Baked Soup.

One pound of lean beef, one ounce of rice, pepper and salt to taste, one pint and a
half of water.

Cut up the meat into slices, add the rice and seasoning, place all in a jar with tlie
water, cover it closely, and bake for four hours. Pearl barley may be substituted for
rice if preferred.

12. Mutton Broth.

Two or three pounds of neck of mutton, two pints of water, pepper and salt, half
a pound of potatoes, or some pearl ])arley.

Put the mutton into a stewpan, pour the water over it, pepper and salt. When it
boils, skim carefully; cover the pan, and let it simmer gently for an hour. Strain it,
let it get cold, and then remove all the fat. When required for use, add some pearl
barley or potatoes in the following manner: — Boil the potatoes, mash them very smoothly
so that no lumps remain. Put the potatoes into a pan, and gradually add the mutton
broth, stirring it till it is well mixed and smooth; let it simmer for live minutes, and
serve with fried bread.

13. Soup.

Take three or four pared potatoes, a thick slice of bread, half a teacupful of pearl
barley or rice, a little salt and pepper, two quarts of beef tea or mutton broth. Heat
the beef tea or broth in a pan, and when quite boiling add the rest of the ingredients,
except the pepper and salt, which should be added when nearly done; cover the pan,
and let it boil slowly for an hour. Serve with toasted bread.

14. Rabbit Soup.

Soak a rabbit in warm water, and, when quite clean cut it in pieces, and put it into
a stewpan with a teacupful of veal .stock or broth ; simmer .slowly till done through,
then add a quart of Avater and boil for an hour. Then take out "the rabbit, pick the
meat from the bones, covering it up to keep it white; put the bones back into the
liquor, and simmer for two hours, skim, strain, and let it cool. Pound uj) the meat in
a mortar, with the yolks of two hard-boiled eggs, and the crumb of a French roll, pre-
viously soaked in niilk; nd) it through a tammy, and gradually add the strained li(iuor,
and simmer it for tifteen minutes. If liked thick, mix' some arrowroot with half a pint
of new milk, bring it to the l)()il, mix Avith the soup, and serve. If jireferred thin,
have ready some pearl barley, and vermicelli boiled in milk, and add to the soup,
instead of "the arroAvroot. Serve Avitli little squares of toast or fried bread.

15. Calf's Foot Broth.

One calf's foot, three pints of water, one small lunxp of sugar, the yolk of one Qgg.

Stew the foot in Avater very gently, till the liquor is reduced to half; remove the

scum, set it in a basin till quite Void, then take olT every particle of fat. Warm up

DIETARY FOR IISTVALIDS. 4G9

about half a pint, adding the sugar, taking it off the tire for a minute or two, then add
the beaten yolk of the egg; keep stirring it over the fire till the mixture thickens, but
do not let it boil, or it will be spoiled.

16. Veal Soup.

A knuckle of veal, two cow-heels, twelve pepper-corns, a glass of sherry, and three
pints of water.

Stew all the ingredients in an earthen jar for six hours. Do not open it till cold.
When wanted for use, skim off the fat, and strain it. Heat as much as you require for
use.

IT. Good stock for Soup.

One pound of shin of beef, one pound of knuckle of veal, four white peppercorns,
a lump of sugar, one quart of water.

Simmer gently for six hours, skim well and strain.

18. XouRiSHixG Soup.

Stew two ounces of the best well-washed pearl sago in a pint of water till it
is quite tender and very thick, then mix it with half a pint of good boiling cream and
the yolks of two fresh eggs. Blend the whole carefully with one cjuart of essence of
beef, made according to number 3. The beef essence must be heated scparatelj^ and
mixed while both mixtures are hot. A little of this may be warmed up at a time.

19. Sago Soup.

An ounce and a half of sago, one pint of stock.

Wash the sago. Put one pint of stock on the tire, and bring it to the boil; add the
sago, and simmer till it is entirel}^ dissolved. When cold, it will form a jelly.

20. Rice Soup.

Three ounces of Patua rice, the yolks of two eggs, half a pint of cream or new
milk, one quart of stock.

Boil the rice in the stock, and rub half of it through a tammy, put the stock in a
stewpan, add the rest of the rice whole, and simmer gently for five minutes. Have
ready the cream or milli boiled. Beat the yolks of the eggs, and mix them gradually
with the cream. Take the soup off the fire, add the cream and eggs, stirring them
well together as you mix them. Heat it up gradually, but do not let it boil, or the eggs
will curdle, and the soup be spoilt.

21. Semolina Soup.

Drop an ounce of semolina into one pint of boiling stock, and stir constantly to
prevent burning. Simmer gently for half an hour. Season with salt to taste.

22. Eaw Meat Diet.

Two ounces of nmipsteak, taking away all the fat, cut into small squares, -u-ithout
entirely separating the meat, place in a mortar and pound for five or ten minutes, then
add three or four table-spoonfuls of water, and pound again for a short time, after-
wards taking away all sinew or fibre of the meat, leaving only the creamy substance,
add salt to taste. Before using, place the cup or jar containing the pounded meat in
hot water until just warm.

Or, scrape the beefsteak with a sharp knife, and after remo\'ing all the fat and
tendon, if not already in a complete pulp pound it in a mortar. This may be taken in
the form of sandwich between thin bread and butter, or mixed with water to the con-
sistence of cream.

This diet is excellent for children with diarrhoea, also for adults who suffer from
irritable bowels or chronic diarrhoea.

Or, scrape and pound the meat with cold water to consistency of thin cream, and
then allow to stand, and pour off the supernatant fluid, leaving the sediment behind.

470 DIETARY FOR INVALIDS.

Raw meat may be made more palatable by pouring over it a little warm gravy —
not too warm.

In cases of wasting, anaemia and prostration, it is said fresh blood of animals — as
fowls — mixed with warm wine, or milk punch, warm lemonade, milk of coffee, and
taken immediately, or before coagulation, is very useful.

It relieves prostration, as in flooding, restores warmth and circulation, acts better
and more promptly than transfusion from vein to vein. The blood of two or three
chickeas should betaken in the twenty- four hours.

Take half a pound of lean rump steak, scrape with a knife imtil all the pulp is re-
moved from it, then add to it as much sugar as will be needed to sweeten it to taste,
break the lumps of sugar with the meat in a basin, with a small wooden spoon. Add
gradually as much milk as will make it the thickness of arrowroot, flavor with brandy.
Strain througli a .gravy strainer if there is any fibre of the meat in it, as the mixture
should be perfectly smooth.

23. Beef Tea and Ckeam Exema.

Mix four or five ounces of strong beef tea, one ounce of cream, and half an ounce
of brandy, or one ounce of port vane.

24. Oysters.

Take half a dozen native oysters, and put them into a saucepan (after they have
been well washed in cold water). Put in a lump of butter the size of a walnut, a little
salt and pepper, put the saucepan on the fire for ten minutes, not more, taking it off
now and then and stirring it. Then add a few drops of lemon-juice or vinegar.

25. Lobster.

Take a small claw^ of a lobster or crab, and put on it a little salt, a quarter of a tea-
spoonful of salad oil, and a drop or two of vinegar. This is digestible even for deli-
cate stomachs.

26. Stewed Eels.

One eel, half a pint of strong stock, two table-spoonfuls of cream, half a glass of
port -wine, thickening of flour, a little cayenne.

Wash and skin the eel, cut it in pieces about two inches long; pepper and salt them,
lay them in a .stewpan, pour the stock over, and add the wine. Stew gently for
twenty-five minutes or half an hour, lift the pieces carefully on to a very hot dish,
and place it by the fire, strain the gravy, stir into the cream sufficient flour to thicken
it, mix with the gravy, boil for two minutes and add a little cayenne. Pour over the
eels, and serve. Sometimes the addition of a little lemon-juice is agreeable.

27. Stewed Oysters.

Half a pint of oj'sters, half an ounce of butter, flour, one-third of a pint of cream,
cayenne and salt to taste.

Scald the oysters . in their own liquor, take them out, beard them, and strain the
liquor. Put the butter into a stewpan, dredge in sufficient flour to dry it up, add the
oyster liquor, and stir it over a sharp fire with a wooden spoon. When it boils add the
cream, oysters and seasoning, and simmer for one or two minutes, but not lonf/er, or
the oysters will harden, .serve on a hot dish with croutons or toasted sippets of bread.
A quarter of a pint of oysters, the other ingredients being in proportion, make a dish
large enough for one person.

28. Macaroni.

Two ounces of macaroni, a quarter of a pint of milk, a quarter of a pint of good
beef .gravy, the yolk of one egc:, two table-spoonfuls of cream, half an oimce of butter.
Wash the" macaroni, and l)oil it in the gravy and milk till quilr tender. Drain it, put
the macaroni into a very hot dish, and place it by the fire. Beat the yolk of the egg
with the cream and two table-spoonfuls of the liquor the macaroni was boiled in. ^Make
this sufficiently hot to thicken, but cfo not alloir it to boil, or will be spoiled; pour it
over the macaroni and strew over the whole a little finely-grated Parmesan cheese;
or the macaroni may be served as an accompaniment to minced beef without the
cheese; or it may be taken alone with some good gravy in a tureen served with it.

dietary for iistv^alids. 471

29. Minced Fowl axd Egg.

Cold roast fowl, a hard-boiled egg, salt, pepper or cayenne to taste; three table-
spoonfuls of new milk or cream, half an ounce of butter, one table-spoonful of Hour,
a teaspoonful of lemon-juice.

Miuce the fowl, and remove all skin and bones; piit the ])ones, skin, and trimmings
into a stewpan with one small onion if agreeable, and nearly half a pint of water; let
this stew for an hour, then strain the liquor, chop the egg small, mix with the fowl,
and add salt and pepper, put in the gravy and other ingredients, let the whole just
boil, and serve ■«ith sippets of toasted bread.

30. Fowl and Rice.

A quarter of a pound of rice, one pint of stock or broth, one ounce and a half of
butter, minced fowl, egg, and bread crumbs.

Put the rice into the cold stock or broth, let it boil very gently for half an hour,
then add the butter, and simmer it till quite dry and soft. When cold make it into
balls, hollow out the inside and fill them A\ith mince made according to the foregoing
receipt, but a little stitfer; cover with rice, dip the balls into egg, sprinkle with bread-
crumbs, and fry a nice brown; a little cream stirred into the rice before it cools improves
it very much.

31. Chicken and Eice.

Cut up the meat of boiled chicken, have ready some rice well cooked and seasoned
with salt, put round a small flat dish, or vegetalile dish, warm up the chicken in a
little good gravy, and serve in the middle of the dish with the rice round it.

32. Panada.

Take the crumb of a penny roll and soak it in milk for half an hour, then squeeze
the milk from it; have ready an equal quantity of chicken or veal, scraped very fine
with a knife; pound the bread crumbs and meat together in a mortar. It may be
cooked either mixed villi veal or chicken broth, or poached like an egg,1)y taking it up
in two spoons in pieces the shape of an egg, after seasoning it, and served on mashed
potato.

33. Macaroni boiled in Milk.

One ounce of macaroni, three-quarters of a pint of new milk, a little lemon-rind, a
little white sugar.

Put the milk into a saucepan with the lemon-rind, bring it to boiling point, and
drop in the macaroni. Let it swell gradually over the fire till quite tender, but do not
allow the pipes to break.

34. EicE Milk.

Three table-spoonfuls of rice, one quart of milk.

Wash the rice, put it into a saucepan with the milk, and simmer gently till the rice
is tender, stirring it now and then to prevent the milk burning. Sweeten a little, and
serve with a cut lemon, black currant jam, or apples stewed.

35. Rice Cream, 1.

To a pint of new milk add a quarter of a poimd of ground rice, a lump of butter
the size of a walnut, a little lemon-peel, and a table-spoonful of powdered sugar. Boil
them together for five minutes, then add half an ounce of isinglass which has been dis-
solved, and let the mixture cool. When cool add half a pint of good cream, whisked
to a froth, mix all together, and set it for a time in a very cool place, or on ice. When
used, turn it out of the basin into a dish, and pour fruit juice round it, or some stewed
apples or pear may be served with it.

36. Rice Cream, 2.

A quarter of a pound of whole ijce, well slewed in milk, and put in a sieve to drain
and cool. Mix with the rice a gill of good cream whisked to a frotli, and add a wine-
glass of sherry, a little powdered sugar, and a teaspoonful of lemon- juice.

472 dietary for invalids.

37. Light Pudding.

Boil very smoothly in new milk one table-spoonful of ground rice, let it get quite
cold, then add two eggs, very well beaten up, a lump of white sugar, and, if liked, a
dessert-spoonful of brandy. Line a small tart-dish (sufficient for one person) with
paste, put in the pudding, and bake quicklj-. Serve the moment it is ready, for it
falls directly.

38. EiCE AND Apple.

Boil about two table-spoonfuls of rice in a pint and a half of new milk and simmer,
stirring it from time to time, till the rice is quite tender. Have ready some apples,
peeled, cored, and stewed to pulp, and sweetened with a very little loaf sugar. Put the
rice round a plate, and the apple in the middle, and serve

39. Baked Custard Pudding.

Warm half a pint of milk, or a little more, whisk two eggs, yolks and whites, pour
the milk to them, stirring all the while. Have ready a small tart-dish, lined at the
edges with paste. Pour the custard into the dish, grate a little nutmeg over the top,
and bake it in a very slow oven for half an hour

40. Boiled Custard Pudding.

Prepare the custrard as in the foregoing receipt. Butter a small basin that will ex-
actly hold it, put in the custard, and tie a tloured cloth over it; plunge it into boiling-
water, float it about for a few minutes, boil it slowly for half an hour, turn it out and
serve.

41. Baked Bread Pudding.

Half a pint of new milk, a quarter of a pound of bread crumbs, two eggs, one
ounce of butter, sugar to taste.

Boil the milk and pour it over the bread crumbs, and let them soak for half an
hour. Beat the eggs, mix them with the bread crumbs, and the sugar and butter, and
stir well till thoroughly mixed. Butter a breakfast cup, or small pudding mould, till
it a little more than half full with the mixture, and bake in a moderate oven for about
twenty minutes.

42. Semolina Pudding.

One ounce of semolina, half a pint of milk, one ounce of butter, two eggs, sugar ta
taste.

Heat the milk and mix it with the semolina, sugar, and butter; stir this over the
fire for a few minutes, then take it off and mix Avith it the eggs, which should be well
beaten. Butter a small tart-dish, line it with puff paste, put in the pudding, and bake
in a slow oven.

43. EiCE Pudding.

One ounce of whole rice, three-quarters of a pint of milk, half an ounce of butter,
one egg, sugar, to taste.

_ Let the rice swell in the milk over a slow fire, stir in the butter, and then let the
mixture cool. Well beat the (^gg and mix with the rice, butter a breakfast cup or
small mould, till it three parts fuU, and bake. Turn it out and serve.

44. Tapioca Pudding.

One ounce of tapioca, one pint of milk, one ounce of butter, one egg, sugar to taste.

Wash the tapioca, and let it stew gently in the milk for a quarter of an hour, stirring
it now and then. Let it cool, mix vAW\ it"the butter, sugar, and eggs, which must be
well beaten. Put it into a small tart-dish; bake in a moderate ovem

45. Apple and Rice.

Take three small apples, peel and halve them, take out the cores, put them into a
stewpan with about half an ounce of butter, and strew over them a little white sifted
sugar. Stew them very gently till tender, taking care not to break them. Boil the
rice with milk and.a little sugar till quite soft, an(f when done, dish it with the apples
on the top of it, and a little cream served with it separately.

DIETARY FOR INVALIDS. 473

4G. Vermicelli Pudding.

Two ounces of vermicelli, three-quarters of a pint of milk, quarter of a pint of
cream, one ounce and a half of butter, two eggs, one ounce and a half of sugar.

Boil the vermicelli in the milk till it is tender, then stir in the remaining ingredients.
Butter a small tart-dish, line with puff paste, put in the pudding and bake.

47. Milk Blaxcmaxge.

A quarter of a pound of loaf sugar, one quart of milk, one ovmce of isinglass.

Put all the ingredients into a lined saucepan, and boil gently till the isinglass is
dissolved. Keep stirring it over the tire for about ten minutes, strain it through a tine
sieve into a jug, and when nearly cold pour it into an oiled mould. Turn it carefully
out when required for use.

48. Junket.

To a pint of milk, heated till it is lukewarm, add a teaspoonful of concentrated
essence of rennet, and a small teaspoonful of pounded white sugar. Pour it into a bowl
or mould, cover with a napkin, put it aside to cool when it is ready for use.

Concentrated essence of rennet can be bought at all grocers.

49. EicE Blancmange.

A quarter of a pound of ground rice, two ounces of loaf sugar, one ounce of butter,
one quart of milk, flavoring of lemon-peel.

Mix the rice to a smooth batter with a little milk, and put the remainder into a
saucepan "with the butter, sugar, and lemon-peel. Bring the milk to boiling point, stir
in the rice. Let it boil for ten minutes, or till it comes away from the saucepan.
Grease a mould with salad oil, pour in the rice, let it get perfectly cold, and turn out.

50. Arrowroot Blancmange.

Two table-spoonfuls of arrowroot, three-quarters of a pint of milk, lemon and sugar
to taste.

Mix the arrowroot with a little milk to a smooth batter, put the rest of the milk on
the fire, and let it boil. Sweeten and flavor it, stirring all the time, till it thickens
sufficiently to come from the saucepan. Put it into a mould till quite cold.

51. Fruit Cream.

Apples, gooseberries, rhubarb, or any fresh fruit. To every pint of pulp add one
pint of milk, or cream, sugar to taste. Prepare the fruit as for stewing, put it into
a jar with two table-spoonfuls of water, and a little good moist sugar. Set this jar in
a saucepan of boiling water, and let it boil till the fruit is soft enough to mash. When
cooked enough beat it to a pulp, work this pulp through a colander, and to every
pint stir in a pint of milk or cream. Of course the cream is best, if obtainable.
Sweeten and serve.

52. Bread Jelly.

Take the crumb of a loaf, break it up, pour boiling water over it, and leave it to
soak for three hours. Then strain off the water and add fresh, place the mixture on the
tire, and let it boil till it is perfectly smooth. Take it out, and after pressing out the
water, flavor with anything agreeable.

Put it into a mould, and turn it out when required for use.

53. Milk Porridge.

Put a quart of milk into an enamel-lined saucepan. When on the point of boiling
scatter in by degrees half a pound of coarse oatmeal; stir until the mixture thickens.
When thickened let it continue to boil about twenty minutes. The porridge can be
made thick or thin according to taste. It can be eaten as it is, or with the addition of
salt, sugar, treacle, etc.

474

DIETARY FOR INVALIDS.

54. A Gruel.

Beat up an egg to a froth, add a wine-glass of sherry, flavor with a lump of sugar,
a strip of Icmon-pecl, and a little grated nutmeg. Have ready some gruel, very
smooth and hot, stir in the wine and egg, and serve with sippets of crisp toast. Arrow-
root may he made in the same way.

55. Milk, Egg, and Brandy.

Scald some new milk, bid do not let it boil. It ought to be put into a jug, and the
jug should stand in boiling water. When the surface looks filmy it is suthciently
done, and should be put away in a cool ]3lace in the same vessel. When quite cold
beat up a fresh egg with a fork in a tumbler, with a lump of sugar. Beat quite to a
froth, add a dessert-spoonful of brandy, and fill up the tumbler with scalded milk.

56. Egg and Wine.

One egg, half a glass of cold water, one glass of sherry, sugar, and a very little
grated nutmeg.

Beat the egg to a froth mth a table-spoonful of cold water. IVIake the wine and
water hot, but not boiling; pour it on the egg, stirring all the time. Add sufficient sugar
to sweeten, and a very little nutmeg. Put all into a lined saucepan on a gentle fire,
and stir it one tmy till it thickens, but do not let it boil. Serve in a glass with crisp
biscuits, or sippets of toast.

57. Milk, Eum, and Isinglass.

Dissolve in a little hot water over the fire a pinch of the best isinglass; let it cool,
and mix a dessert-spoonful of rum with it in a tumbler, and fill up the glass with new
milk.

58. Sherry or Brandy and Milk.

To one table-spoonful of brandy, or one wine-glassful of sherry, in a bowl or cup,
add po-\\^dered sugar and a very little nutmeg to taste. Warm a breakfast-cupful of
new milk, and pour it into a spouted jug; pour the contents from a height over the
wine, sugar, etc. The milk must not boil.

59. Egg and Sherry.

Beat up an egg with a fork till it froths, add a lump of sugar and two table-spoon-
fuls of water; mix well, pour in a wine-glassful of sherry, and serve before it gets flat.
Half the quantity of brandy may be used instead of sherry.

60. Demulcent Drink.

Take a pinch of isinglass, and boil it in half a pint of new milk, with half a dozen
bruised sweet almonds and three lumps of sugar.

61. Milk and Isinglass.

Dissolve a little isinglass in water, mix it well with half a pint of milk, then boil
the milk, and serve with or without sugar as preferred.

62. Milk and Cinnamon Drink.

Boil in one pint of new milk sufficient cinnamon to flavor it pleasantly, and sweeten
with white sugar. This may be taken cold with a teaspoonful of brandy, and is very
good in cases of diarrhoea. Children may take it milk-warm without the brandy.

63. Nutritious Coffee.

Dissolve a little isinglass in water, then put half an ounce of freshly-ground coffee
into a saucepan with one pint of new milk, which should be nearly boiling before the
coffee is added boil both together for three minutes; clear it by pouring some of it
into a cup and dashing it back again, add the isinglass, and leave it to settle on the hob
for a few minutes. Beat up an egg in a breakfast-cup, and pour the coffee upon it;
if preferred, drink it without the egg.

DIETARY FOR INVALIDS. 475

64. Arkowroot Drink.

Mix two teaspoonfuls of arrowroot in about three table-spoonfuls of cold water,
then pour in half a pint of boiling water; when well mixed, add by degrees half a
pint of cold water, stirring all the time, so as to make it perfectly smooth; it should be
about the consistence of cream; if too thick a little more water may be added. Then
pour in two wine-glassfuls of sherry or one of brandy, add sugar to taste, and give it
to the patient in a tumbler. A lump of ice may be added if allowed.

65. Mulled Wine.

Boil some spices, cloves, nutmeg, cinnamon, or mace, in a little water, just to flavor
the wine; then add a wine-glass of sherry, or any other wine, and some sugar, bring it
to boiling point, and serve with sippets of toast. If claret is used, it will require more
sugar. The vessel for boiling the wine should be scrupulously clean.

66. To KEEP Milk from turning Sour.
Fifteen grains of bicarbonate of soda to a quart of milk hinders it turning sour.

67. Barley Water.

To a table-spoonful of pearl barley washed in cold water, add two or three lumps
of sugar, the rind of one lemon, and the juice of half a lemon. On these pour a quart
of boiling water, and let the mixture stand for seven or eight hours. Strain it. The
barley should never be used a second time. Half an ounce of isinglass may be boiled
in the water.

68. Lemonade, 1.

Well rub two or three lumps of sugar on the rind of a lemon, squeeze out the juice,
and add to it half a pint or apint of cold or iced water, or, better still, a bottle of soda-
water.

69. Effervescing Lemonade, 2.

Squeeze two large lemons, and add a pint of spring water to the juice, and three
or four lumps of white sugar. When required for use pour half of it into a tumbler,
and add half a small teaspoonful of carbonate of soda; stir, and drink whilst effervesc-
ing.

70. Lemonade, 3.

The juice of four lemons, the rinds of two, half a pint of sherry, four eggs, six
ounces of loaf sugar, one pint and a half of boiling water.

Pare the lemon rind thinly, put it into a jug with the sugar, and pour the boiling
water on it. Let it cool, and then strain it and add the wine, lemon-juice, and eggs,
previously well beaten and strained. Mix all well together and it is ready for use.

7L Lemonade, 4.

Pare the rind of three lemons as thin as possible, add one quart of boiling water,
and a quarter of an ounce of isinglass. Let them stand till next day covered, then
squeeze the juice of eight lemons upon half a pound of lump sugar; when the sugar
is dissolved, pour the lemon and water upon it, mix all well together, strain it and it
is ready for use.

72. Arrowroot and Black-Currant Drink.

Take two large spoonfuls of black-currant preserve, boil it in a qviart of water,
cover it, and scew gently for half an hour, then strain it, and set the liquor again on
the tii'e; then inix a teaspoonful of arrowroot in cold water, and pour the boiling
liquor upon it, stirring meanwhile; then let it get quite cold, and strain.

73. White Wine Whey.

To half a pint of boiling milk add one or two wine-glassfuls of sherry; strain
through a fine sieve, sweeten with sifted sugar, and serve.

476 DEETARY FOR INVALIDS.

74. Caudle.

Beat up an egg to a froth, add a wine-glassful of sherry and half a pint of gruel,
flavor with lemon-peel and nutmeg, and sweeten to taste.

75. Another Caudle.

Mix well together one pint of cold gruel with a wine-glassful of good cream, add a
wine-glassful of sherry, and a table-spoonful of noyau, and sweeten with sugar-candy.

76. EctCt and Brandy.

Beat up three eggs to a froth in four ounces of cold spring water, add two or three
lumps of sugar, and pour in four ounces of brandy stirring all the time. A portion
of this may be given at a time.

77. Sour Milk Diet.

The milk for this food must be good. It must be allowed to stand for forty-eight
hours in a cool cellar; the vessel in which it is kept being upright, as a gallon meas-
ure. The milk becomes solid, and looks like poor blancmange. It carries a cream
on the top, which most people remove as it makes it too rich. To about a pint of this
sour milk, or rather less, add half a pound of grated rye-bread, a good deal of pow-
dered sugar, and a glass of sweet milk, well stirred together. — Hints to tlie Sick

78. Oatmeal Porridge. Whole-meal Bread.

Oatmeal three or four ounces. Water one pint. Boil the water and add a little
salt, about one-sixteenth of an ounce. Sprinkle in the meal very gradually and care-
fullv, till of a sufficient consistency. Stir it well all the time with a porridge stick
(which should be an inch broad at the bottom). Boil gently for fifteen or twenty
minutes, add a little more boiling water, and boil it five minutes longer, this makes it
smooth. Pour it on plates and "serve. The usual way is to make a hole in the mid-
dle, with a spoon, add a piece of butter the size of a nutmeg, and upon it a spoonful
of coarse brown sugar, eat it from the circumference, and dip each spoonful into the
butter and sugar.

Whole-meal bread is often useful in habitual constipation, especially of children.

79. BURGOUT.

A pint of water gradually added to eight ounces of oatmeal. The whole made
Cjuite smooth, and then boiled a quarter of an hour. Butter, salt, pepper to taste.
Indian meal may be used instead of oatmeal if preferred.

80. Port Wine Jelly.

Put into a jar one pint of port wine, one ounce of gum arable, one ounce of isin-
glass, two ounces of powdered white sugar-candy, a small piece of cinnamon. Let this
stand closely covered all night The next day put the jar into boiling water and let it
simmer till all is dissolved, then strain it, let it stand till cold, and then cut it up into
small pieces for u.se.

Time, 15 or 20 minutes. — One pint of port wine, one ounce of isinglass, one ounce
of sugar, a quarter of a pint of water.

Put the isinglass and sugar into a quarter of a pint of water. Set it over the fire till
the isinglass is dissolved, then add the wine. Strain it through a jelly bag or a clean
piece of muslin into a jar or mould, and let it set. It is best to cover till cold.

81. Egg, Rum, and Lemon.

Six new-laid eggs (with shells), the juice of seven lemons: macerate until the shells
are dissolved. Then beat up together with a pint of the oldest Jamaica rum, drain
through muslin, and add a quarter of a pound of sugar-candy. The eggs should aU
be laid the same day. — Give a teaspoonful at a time.

dietary for invalids. 477

82. Linseed Tea.

Two table-spoonfuls of linseed, one pint of water, half a lemon, sugar to taste, a
piece of liquorice the size of a nut. Boil an hour and a half.

83. Butter Milk.

Boil a spoonful of flour for a few minutes in a pint of butter-milk, and add half a
drachm of sugar. This is a good food for infants with an irritable stomach and intes-
tines.

Another diet for children with delicate stomachs and who cannot be suckled is the
following: Boil a tcaspoonful of oatmeal or barley in from three to six ounces of
water for a quarter of an hour. Equal parts of this should be added to skimmed milk.
It is usefufin the case of children suffei-ing from diarrhoea and who pass curdy
stools, to cut off all forms of milk — even mother's milk. Some doctors advise gi\"-
ing ci'eam with barley water, but in my experience this food generally disagrees.
Inileed, I generally find it necessary in all forms of ciiildren's diarrlioea to forbid
milk, and to give instead barley water and veal broth, or chicken brotii, or, best
of all, Nestle's food, which I find the best of all food for children with great deli-
cacy of the stomach and intestines. Thin gruel is often well borne, and, like bar-
ley water, may be added to chicken broth or veal broth.

In case of great prostration, as from flooding, Ponfick, and recently Kaczsrow-
ski, have injected, with much success, defibrinated blood into the peritoneal cavity
instead of intravenous transfusion. They inject 250 to 500 centimetres.

IISTDEX TO THERAPEUTIC AGE:N'TS.

PAGH

Acetate of Alumina 169

" Potash 133

" Soda 135

Acetic Acid 123

Acids 122

Acids and Alkalies, tlieir action on secretions.. . 122

Acid, Benzoic ' 16

" Boric 133

" Carbolic 256

" Chromic 132

" Hydrocyanic 4°4

" Nitric 123

" Salicylic 44^

" Sulphuric 123

" Sulphurous 130

Aconite 338

ActEea Raceniosa 337

Acupuncture 77

Adonidin 359

Affusion 56

Alcohol 261

Alkalies 133

Alkali-.Acid Theory 122

Almond Oil 237

Aloes 457

Alum 169

Ammonia 146

" Valerianate of ....310

Ammoniacum 310

Ammonium, Carbonate of 146

" Chloride 158

" Iodide 107

" Sulphide 92

Amyl, Nitrite of 292

Anaesthetics, Comparison of 278

Anise, Oil of 306

Anthelmintics 463

Antimony, Salts of 210

Antipyrine 453

Apomorphia 327

Areca Nut 463

Arsenic 215

Assafcetida 310

Atropia 400

Balsam of Peru 306

" I'olu 306

Bath, Steam 62

PAGE

Baths, Cold 38

" Cold, in Fevers 45

" Douches 54

" Lamp 61

" Mustard 313

" Sea 38

" Shower 54

" Sponge 54

" Turkish 58

" Vapor and Hot Air 53

" Warm and Hot 50

Belladonna 383

Benzoin 306

Bicarbonate of Potash 133

" Soda 133

Bismuth 180

Bitartrate of Potash 160

Blisters 81

Boracic Acid 133

Borax 133

Bromide of Ammonium 114

" "Sodium 114

Bromides 114

Brucia 419

Buchu 306

Caffeine 432

Cajeput Oil 306

Calabar Bean 365

Calcium, Sulphide of 92

Camphor 301

Canella Bark 3o6

Cannabis Indica 427

Cantharides 81, 311

Capsicum 315

Caraway Fruit 306

Carbolic Acid 256

Carbon (Charcoal) 86

Carbonate of Ammonia 146

" Bismuth 180

" Lime 151

" Magnesia 150

" Potash 133

" Soda 133

Carbonic Acid 88

Carlsbad Waters 162

Cascara Sagrada 462

Castor Oil 244

480

INDEX TO THERAPEUTIC AGENTS.

PAGE

Castoreum 260

Caustic Lime 151

Potash 133

Chamomile 456

Charcoal 86

Chloral, Croton 288

" Hydrate of 281

Chlorate of Potash 168

Soda 168

Chloride of Ammonium 158

" JNIethyl 405

" Potassium 158

" Sodium 158

Chlorinated Lime 98

" Soda 98

Chlorine Gas 9^

" Water 98

Chloroform 269

Chromic Acid 132

Cinchona 44'

Cinnamon 306

Citrate of Potash 133

" Soda 133

Cloves 306

Cocaine 435

Cocoanut Oil 237

Cod-Liver Oil 237

Codeia 4^8

Coffee 432

Colchicura 335

Cold 30

Cold Bath 38

Cold Baths in Fevers 45

Cold Sponging 55

Collodion 236

Colocynth 457

Conium 361

Convallaria Majalis 357

Copaiba 306

Copper 206

Coriander Fruit 306

Coto Bark 253

Counter-Irritation 81

Creasote 253

Croton, Chloral, Hydrate of 2S8

Oil 244

Cubebs 306

Cyanide of Potassium 403

Digitalis 345

Dill 306

Douche Bath 54

Drinks 71

Duboisia Myoporides 403

Elaterium 457

Elder 306

Enemata 74

Epsom Salts 160

Ergot 429

Ether 278

Ethidene 277

Ethyl-Atropium 400

PAGE

Ethyl Strychnia, &c 422

Eucalyptus 309

Euonymus ' 462

Faradization 78

Fats 237

Fennel 306

Fevers, Influence of Cold Baths in 45

Filix Mas 463

Fomentations 62

Freezing by Ether 69, 278

" Mixture 68

Friedrichshall Waters i6t

Galbanum 310

Gallic Acid 248, 251

Galvanism 64

Gelsemium 375

Glonoin Cnitro-glycerine) 298

Glycerine 247

" of Tannin 249

Grindelia Robusta 382

Guaiacum 336

Hamamelis Virginica 252

Hot-Air Bath 53

Hot Bath 50

Hot Fiat-Iron, Application of ;8

Hot-Water Spinal Bag 69, 71

Hydrate of Chloral 281

" Croton Chloral 288

Hydrochloric Acid 123

Hydrocyanic Acid 403

H yoscine ; 402

Hyoscyamus 401

Hypophosphite of Lime 158

" Soda 158

Hyposulphites 130

Ice 67

Ice-bag (Spinal) 69

Incisions (for dropsy) 79

Injections 74

Iodide of Potassium 107

" Sodium 107

" Ammonium 107

Iodine 100

Iodoform 279

lodol 281

Ipecacuanha 316

Iron, Preparations of 172

Irritation 81

Jaborandi (Pilocarpine) 372

Jalap 460

Juniper 306

Kamela 463

Kousso 463

Lactic Acid 125

Lard 237

Laudanum 405

INDEX TO THERAPEUTIC AGENTS.

481

PAGE

Lavender 3°6

Lead Salts i8i

Lemons, Oil of 3°6

Lime 151

" Carbonate of i5i

" Hypophosphite of 158

" Phosphate of iS5

" Water 151

Liniment of Lime iSi

Lithium Bromide 114

Lobelia Inflata 426

Magnesia 15°

" Carbonate of , 150

" Sulphate of 160

Manganese, Salts of 178

Menthol 306

Mercury and its Preparations 191

Methyl-Atropium 400

" Chloride 405

" Strychnia, &c 422

Mezereon 306

Morphia 405

Mucuna 463

Muscarin 368

Musk 260

Mustard 313

Narcein 418

Narcotine 360, 419

Nicotia . .360

Nitrate of Bismuth 180

" Potash 165

" Silver 187

" Soda 165

Nitric Acid 123

Nitrite of Amyl 292

" Sodium 300

Nitro-glycerine 298

Nutmegs 306

Nutritive Enemata 75

Nux Vomica 419

Oils, Castor, Croton 237

" Palm, Dugong, Cocoa-nut, Cod-liver,

Almond, Poppy, Hemp-seed, Linseed.. 237

" Volatile 306

Oil of Tar 253

Oil of Turpentine 303

Oleate of Mercury, &c 191

Opium 405

Oxide of Silver 187

Packing, Cold Wet-Sheet 44

Paper, Nitre 165

Paraldehyde 287

Pareira Brava 456

Peppermint 306

Permanganate of Potash 179

Peru, Balsam of 306

Petroleum 253

Phenacetin 455

Phosphate of Lime 155

Phosphate of Soda 160

Phosphide of Zinc 238

Phosphoric Acid 129

Phosphorus 232

Podophyllum 333

Pomegranate 463

Potash 133

" Acetate of 133

" Bicarbonate of 133

" Carbonate of 133

" Chlorate of 168

" Citrate of 133

" Nitrate of 165

" Permanganate of 179

" Sulphate of , 160

" Tartrate of 160

Potassium, Bromide 114

" Chloride 158

" Cyanide 404

" Iodide 107

" Sulphide .• 92

Poultices 62

Pullna Water 161

Purgative Salts and Waters 160

Quassia 456

Quinia 441

" Valerianate of 310

Quinidinia 446

Raspail's Lotion 147

Rhubarb 461

Rosemary 306

Rue 306

Sabadilla (Veratria) 328

Saccharated Solution of Lime 151

Salicine 448

Salicylates 448

Salicylic Acid 448

Salol 452

Salts, Potassium and Sodium 104

Sandalwood Oil 306

Santonin 463

Sassafras 306

Scammony 460

Sea-bath 38

Senega 463

Senna 462

Shower-bath 54

Silver Salts 187

Sitz-bath 43

Soap 133

Soda, Acetate of 133

' Carbonate of 1 33

" Caustic 133

" Citrate of 133

" Hypophosphite of 158

" Nitrate of 165

" Nitrite of 300

Soda, Phosphate of 160

" Solution of 133

" Sulphate of 160

482

INDEX TO THERAPEUTIC AGENTS.

PAGE

Sodium, Chloride 158

" Iodide 107

" Sulphide 92

Sparteine 358

Spearmint 3°^

Spinal Hot-water Bag 69, 71

" Ice-Bag 69

Spirits of Ammonia 146

Sponge Bath 54

Squill 460

Steam Bath 62

Storax 3°6

Stramonium 4°3

Strophanthus 357

Strychnia 4^9

Suet 237

Sulphate of Magnesia 160

" Potash 160

" Soda 160

Sulphides 92

Sulphites 130

Sulphur 88

Sulphuric Acid 123

Sulphurous Acid 130

Tannin 248

Tar 253

PACK

Tartar Emetic 210

Tartrate of Potash 160

" ■' " and Soda 160

Thebaia 419

Thermic Hammer 78

Tin, Powdered 463

Tobacco 360

Tolu 306

Turkish Bath 58

Turpentine 303, 463

Urethan 288

Valerian 310

Valerianates 310

Vapor Bath 53

Vaseline 253

Veratria 328

Veratrum 327

Volatile Oils 306

Warm Baths 5°

Water 7'

Wax 237

Wet-sheet Packing 44

Zinc, Preparations of 207

I^DEX TO DISEASES.

ABSCESS.

When large and deep-seated abscess is suspected
the thertnometer may assist in diagnosis.
See p. 29.

Belladonna, 387. Internally often successful.

Caustic alkalies, 136. For opening abscesses,
for precautions, see ref.

Counter-irritation, 84. By blisters or iodine
around or adjacent to the disease.

Ether, 278. As spray to produce local anaes-
thesia for opening abscesses.

Fo.mentations, 148. With solution of 20 grs.
carb. ammon. to one pint of boiling water for
threatened mammary abscess.

Iodine, 202. Solution of tinct. injected into cav-
ities of large abscesses after evacuation.

Oleate of mercury anij morphia, 195. Locally,
diminishes induration due to old abscesses and
prevents formation of new ones.

Permangan.\te of potash, 102. A weak solu-
tion for washing out cavities of large abscesses
after iodine injections.

Phosphate of lime, 156. In large abscesses.

Poultices, 63. To check formation of pus or to
assist in maturation. iVIay be covered over with
belladonna or opium.

Sulphides, 94-96.

ACIDITY.

Acids, 122. Given shortly before a meal.

, 125. Hydrochloric or nitric in small me-
dicinal doses before meals for acidity from what-
ever cause it arises, especially for acid pyrosis ;
after meals for alkaline pyrosis.

Alk.\lies, 138. Only palliative ; bicarbonates
best ; if the escape of carbonic acid is trouble-
some, substitute magnesia if bowels confined,
lime-water if relaxed.

Bismuth, 180. The nitrate combined with mor-
phia or opium, and sometimes with magnesia.

Ipecacuhana, 318. In acidity of pregnancy.

Magnesiv, 150. The oxide better than the car-
bonate — only a temporizing remedy — acids far
better.

Mercury, 199. Half a grain of gray powder
three times a day when accompanied by clayey
stools.

Nux voMic.'^, 126. Two or three drops just before
meals in acidity of pregnancy.

ACNE.

Arsenic, 121. |Liq. arsen. given with bromide
prevents its causing bromic acne.

Belladonna, 387. Locally, of some slight service.

Bromide of potassium, 114.

Hot fomentations, 66.

Hot sponging, 67. B'or acne indurata.

Iodide of sulphur, 121. An ointment in a. in-
durata and rosacea, also in bromic acne, 97.

AC N E — con tinned.

Mercury, 193. In early stages a lotion of cor-
rosive sublimate, one part ; alcohol, enough to
dissolve it ; water, 100 parts. A teaspoonful of
this to be added to a quarter of a pint of water
and the face sponged with it night and morning.

Phosphorus, 235. In acne indurata.

Soap, 135. With hot water several times a day.
If this irritates, rub in glycerine of starch after
each washing.

Sulphur, 90. As lotion for young women with
disordered menstruation. In severe forms an
ointment of hypochlorite or iodide of sulphur.

, 90. Sulphur may be used internally.

AGUE.

Arsenic, 230. The best remedy except quinine.
Especially useful in long-standing agues of
quartan type.

Chamomile, 456. Has been used.

Emetics, 212. Many cases may be cured by
emetics, and one each morning will assist the
action of quinine. Ipecac, and other emetics
should be preferred to antimony.

Eucalyptus, 310. Inferior to quinine.

Hyposulphite of soda, 132. Fifteen to twenty
grains every two hours.

Narcotine, 419. Said by some to be superior to
quinine.

Nitrhe of sodium, 301. To avert cold stage.

Nitro-glycerine, 300. To avert cold stage.

Quassia, 456. Has been used.

Quinia, 444. By far the best remedy we possess
for intermittent fevers.

In mild forms small doses several times a day.
I n malignant forms large doses given in a non-
febrile period, 445.

The drug should not be discontinued for some
time after all symptoms have disappeared.
It is of service as a prophylactic against ague.
It may be administered hypodermically or by
the rectum — ether is the best solvent for injec-
tion.

Cinchona, quinidinia and cinchonidinia, are
all useful in ague, but less so than quinia, 446.

Salicylic acid, 451. As an adjunct to quinia.

ALCOHOLISM. {See Dipomania.)

Act.«:a, 337. In drunkard's stomach.

Arsenic, 3. Indicated by red, clean, smooth, ir-
ritable tongue.

, 222. For vomiting.

Cocaine, 440. Internally.

Morphia, 410. With tonics before meals for
pain, nausea, and want of appetite.

Phosphorus, 235. In chronic alcoholism.

Strychnia, 424. Hypodermically in increasing
doses has been highly recommended.

484

INDEX TO DISEASES.

AMAUROSIS. {See Eye Diseases.)

AMENORRHCEA.

Aconite, 345. When menses suddenly checked.

AcT.-EA R.\ciiMOSA, 337. Generally, and when
menses checked.

Aloes, 459. At the periods, together with hot
pediluvia, friction, stimulating liniments, &c.
For general directions see ref.

Chlokide of ammonh'm, 159. For headache.

Cold sponglng, 55.

Ergot, 431. Where anaemia — after the use of
iron.

Hot sitz-bath, 52. For six days before the pe-
riod. Mustafd may be added at the period.
Often effectual in sudden suppression.

Iron, 176. To remedy the anaemia.

Mustard, 314. A mustard sitz-bath a few days
before and during the time the missing dis-
charge is due. A course of these baths assists
the restoration of the uterine functions.

PER.^LA^■G.•^NATE, 179. Useful when flux scanty
or delayed, or even when absent for a long pe-
riod. It may restore it after two years. Also
■when a chill prevents or delays flow. It acts
with plethoric as well as with anaemic patients.
I gr. in pill thrice daily till catamenia, then dis-
continue till four days before next period due
and continue till flow ceases.

Santonine, 465. A 10 gr. dose on two successive
nights, especially when chloro-anaemia.

Spinal ick-bag, 70. Applied to lower dorsal and
lumbar vertebrae.

AN/EMIA.

Acids, 128. Added to purgative salts as tonic to
mucous memb.

Cold sponging, 56.

HvpoPHOSPHiTES, 158. Of lime or soda.

Iron, 173. Some stomachs with irritable mucous
memb. require bland preparations. A flabby
tongue indicates large doses of astringent prep-
arations, as perchloride or sulphate. See also
p. 3. Weak anaemic girls with pain and vomit-
ing after food require larger doses of the tinct.
perchlor., 173. It is sometimes well to humor
the stomach by changing the preparation. Some
persons are quite unable to take iron in any
form, 176. Iron may be given in anaemia with
disturbance of uterine functions, and should be
conjoined with nourishing food, pure air. light,
and if necessary, purgatives. If the anaemia is
due to organic disease, iron at best only pallia-
tive.

Phosphate of lime, 156. In anaemia of grow-
ing persons, and of women weakened by rapid
child-bearing or excessive menstruation.

QuiNiA, 448. For badly fed, pale town-livers.

ANEURISM.

Chloroform, 276. Inhalation, if great dyspnoea.
Iodide of potassium, 112. Combined with re-
cumbent position and restricted diet.

ANGINA PECTORIS.

Arsenic, 230. Lessens severity of attacks.

Ether, 27S. Or spirits of chloroform in full doses
very useful.

Morphia, 407. Hypodermically.

Nitrite of amyl, 294. Inhalation most valu-
able.

Nitrite of sodium, 300. i gr. several times a
day.

Nitro-gyclerine, 300. Often superior to amyl,
being more persistent in its effects. i-iooth
min. in water or in a tablet at stated intervals,
and an additional dose on onset of paroxysm.

ANGINA VY.CT ORIS— continued.

Phosphorus, 235. Often serviceable.
Sodium iodide, 112. Has been tried.

ANTHELMINTICS. {See IVorms.)

ANUS, PAIN AFTER OPERATIONS
AT.

Ice, 68. Applied in bladder.
ANTHRAX.

C.'^RBOLIC ACID, 258. Topically.
Salicylic acid, 449. Less efficacious than car-
bolic acid.

AORTIC DISEASE. {See Heart Dis-

eases.)

APHTHA.

Alum, 170. Applied dry a few times a day to
aphthous ulcers which will not heal —generally,
however, chlorate of potash and a purgative
sufficient.

Borax, 138. With honey or as glycerine of borax.

Chlorate of potash, 168

Glycerine of borax, 247.

Nitric .\cid, 124. In small doses.

APOPLEXY.

Croton oil, 246. As purgative one-fourth or
one-third minim every hour.

APPETITE, LOSS OF. {See Dyspepsia.)

ASCITES.

Copaiba, 308. In some forms of ascites.
Elaterr .M, 457. Must be given with caution.
Calomel, 206.

ASTHMA AND QUASI-ASTHMA.

Aconite, 341. Given at commencement of the
fever often averts the attack. L'seful also in
the asthma following coryza and sneezing in
children.

Alum, 170. Ten grs. powdered and placed on
the tongue said to arrest a paroxysm.

Antimony, 213. In an affection of children like
asthma (see ref.); dissolve a grain of tartar-
emetic in half a pint of water, and give a tea-
spoonful of this every quarter of an hour for
the first hour, then hourly. If vomiting in-
duced, lessen the dose.

Arsenic, 216, 217. As cigarettes, caution re-
quired (see ref.), also one drop of liq. arsen.
three times a day in attacks of sneezing with
coryza, frontal headache and itching of nostrils.
These attacks may be brought on by cold, by
meals, by local irritation, or in children are con-
sequent on bronchitis. These cases are allied
to dyspeptic and bronchitic asthma, and to
hay fever (see ref. 218, 219)

Assafcetida, 310.

Belladonna, 393. Large doses required, but
very satisfactory (see ref.).

Blisters, 83. For oppression of breathing es-
pecially in bronchitic asthma.

INDEX TO DISEASES.

485

ASTHMA, 'E'VC.—cofttimied.

Cannabis indica, 429. Has been found useful.

Carbonic acid gas, 88. As inhalation.

Chamois leather waistcoat, 59.

Chloral, 285. Often useful in a full dose dur-
ing a paro.\ysm.

Chlorate of potash, 166. With nitre to satu-
rate blotting paper, or a pastile may be made of
chlorate and nitrate of potash with lycopodium.

Chlokofokm, 270. Often combined with opium.

, 276. As inhalation if great dys-
pnoea. A few whiffs will sometimes avert a
paroxysm. ' As liniment rubbed on chest for an
hour daily in bronchitic asthma.

Coffee, 433. A small cup of very strong coffee
often useful in a paroxysm.

CoLCHicuM, 330. In gouty subjects.

Counter-irritation, 81.

Ether, 278.

Eucalyptus, 309. As cigarette.

Gelsemium, 382. Sometimes beneficial.

Grindei.ia robusta, 382. Three grs. of extract
thrice daily to prevent attacks, or m. xx to m.
XXX of liquid extract every half-hour or hourly
from onset of paroxysm.

Iodide of methyl, 107.

Iodide of potassiu.m, 107. Two per cent, solu-
tion as spray.

Iodide of potassium, 107. In peptic and bron-
chial asthma.

Ipecacuh.\na, 321. The wine as spray to the
fauces sometimes useful in severe bronchial
asthma, but not of much service in genuine
asthma — for Dr. Hyde Salter s observations on
the general management of asthma, see p. 325.

Lobelia, 426. Ten drops of the simple tincture
every ten minutes or quarter of an hour as soon
as signs of a paroxysm appear till the dyspnoea
gives way.

In bronchitic asthma where breathing a little

tight all day but much worse at night, ten min.

three times a day with additional doses at night.

This drug must be given cautiously when

there is heart disease.

Nitrate of potash, 165. The inhalation of
fumesof burnt nitre paperwill sometimes avert
a paroxysm. Different methods of preparation
useful for different cases (see ref.).

Nitrite of amyl, 293. As inhalation.

Nitrite of sodium, 301. In nervous and bron-
chial asthma and that of Bright's, but useless
where emphysema.

Nitro-glycerine, 300. In the paroxysms.

Opium, 417. In some cases. In others morphia
will induce a paroxysm.

Pilocarpine, 374. Hypodermically.

Silver, nitrate of, 189. Sometimes injected
into trachea (see ref. ).

Stramonium, 403. Twenty grs. of the dried
leaves or ten of the powdered root may be
smoked. Datura tatula sometimes better.
Stramonium preparations often bad. Asthmat-
ics advised to grow the drug themselves.

Sulphurous acid, 131. Inhalation, spray or
fumigation.

Tobacco, 361. Smoking sometimes gives relief.

Turkish baths, 59. In bronchial asthma.

BALDNESS.

Pilocarpine, 374. Locally. With cantharides
«ind soap liniment, (see formula).

BARRENNESS.

Iodide of potassium, hi. When due to syphilis.

BED-SORES.

Alcohol, 261. As brandy or eau de Cologne to
harden skin of parts exposed to pressure.

BED-SORES — continued.

Catechu, 249. The tincture with liq. plumbi lo-
cally to prevent sores.

Charcoal, 66. Sprinkled over the black slough,
which is then covered with a poultice.

Glycerine, 247. Or glycerine cream rubbed over
part exposed to pressure after washing morning
and evening, is one of the best preventives of
bed-sores.

Iodoform, 279. Dusted over sores.

Silver, nitrate of, 187. A solution twenty grs.
to the oz. to be painted on threatened but
unbroken skin as soon as it becomes red to
prevent formation of bed-sores.

If nitrous ether solution used, five grs. to the
oz. enough, 1S8, 189.

BILE, DEFICIENCY OF.

Mercury, 190, 200. Frequent small doses of
gray powder.

BILIARY COLIC. {See Colic.)

BILIOUS HEADACHE. {See Sick
Headache.)

BITES.

Ammonia, 147. Weak solutions in bites of insects
to neutrahze the formic acid.

BLADDER, DISEASES OF.

Copaiba, 308. Also cubebs and buchu in chronic
inflammation of bladder and urethra.

Iodoform, 279. As suppository in painful dis-
eases.

Sulphites, 132. Internally prevent putrefaction
of urine.

BLEEDING. {See Hccmorrhage.)

BOILS.

Belladonna, 96. With glycerine locally to allay
pain.

, 387. Internally often successful.

Camphorated alcohol, 301. Boils in the earli-
est stages to be smeared with this for half a
minute, then, when the skin is dry, it is to be
smeared with camphorated oil. A few applica-
tions said to disperse the coming boil.

Collodion, 236. Applied at papular or pustular
stage. ^Iatter not to be let out except under
Lister's plan (see ref.).

CouNTER-iRKiTATioN, 84. By blisters or iodine
around the boil.

Menthol, 307. As 10-50 per cent, solution lo-
cally

Opium, 408. An extract of the consistence of
treacle locally applied three or four times a day
(see ref.).

Poultices, 63. To assist maturation and allay
pain, may be smeared over with belladonna or
opium.

Silver, nitrate of, 188. In boils beginning as
a papule which maturate into a pustule and in-
flame and extend till large dead core produced.
To be painted on at commencement — collodion,
perhaps, better for these.

Sulphides, 95. Hasten maturation and prevent
formation of fresh boils. No use in the boils o£
diabetes.

486

INDEX TO DISEASES.

BONES, DISEASES OF.

Cod-liver oil, 241. In strumous disease.
Phosphate ok lime, 156. In caries.

BRAIN, DISEASES OF. (See also
Paralysis.)

Bromide of potassium, 117. When over-taxed
from study, or over-application to business.

Phosphorus. 235. In cerebral softening, also in
over-taxation.

BREASTS, INFLAMMATION OF.

Belladonna, 383. Especially as liniment to
check secretion of milk when inflammation im-
minent. When inflammation has set in, con-
tinuous application of belladonna for twenty-
four hours often arrests it. It is also useful
when an abscess has formed. Fomentations
useful in addition, but skin must be dried well
before the belladonna is rubbed in.

DiGiT.ALis, 355. Infusion locally.

BREATH, FOUL.

Camphor, 301.

BRIGHT'S DISEASE.

Aconite, 343. Should be given immediately on
the appearance of inflammation of the kidneys
in scarlatina.

Alkalies, 144. Citrates and acetates in acute and
chronic Bright's, being reputed to act as diu-
retics.

BiTARTRATE OF POTASH, 164. To prevent dan-
gerous accumulations in cellular tissue or
important cavities. Also to draw off effete
matters. Care must be used, as it is a brisk
purgative and so is weakening.

Bromide of potassiu.m, 115. For convulsions.

Cannabis indica, 429. In acute and chronic
forms as a diuretic, said to be specially useful
where bloody urine.

Cantharides, 3:2. After subsidence of acute
stage, a one min. dose every three hours will
stop the hsematuria.
. Cod-liver oil, 241. In chronic forms.

Copaiba, 308. Sometimes useful in removing
dropsy.

Digitalis, 353. Very valuable in some cases ;
only diuretic as long as dropsy exists.

Elaterium, 457. For the dropsy — caution re-
quired.

Incisions, 51. For dropsy better than hot baths.
Hot fomentations with boracic acid may be
employed afterwards.

Iodide of potassium, hi. Possibly only when
due to syphilis.

Iron, 3. Astringent preparations when tongue
flabby and pale.

Jaborandi, 374. Especially on occurrence of
ursemic symptoms. If urjemia urgent, pilocar-
pine may be injected hypodermically.

Le.\d, 186. Diminishes the albumen.

Senega, 463. As a diuretic.

Tan.nin, 251. In chronic Bright's to lessen
albumen.

Tartrates, 164. Excellent diuretics.

Turkish bath, 58.

Warm baths, 51. When uraemic symptoms or
dropsy well marked (see ref.). Discretion
needful.

BRONCHITIS.

Aconite, 343. In measles.

Acids, 130. To lessen secretion in chronic form.

Actea, 337, As an expectorant.

'QRO'y.ClllTlS—cojiiinned.

Ammonia, 148. Inhalation in chronic bronchitis
to lessen over-abundant expectoration.

Ammoniacum, 311. In bronchitis with wheezing
and abundant discharge in old people.

Antimony, 15. Small frequent doses of tartar-
emetic where skin dry and hot.

, 213. To shorten acute bronchitis (see

Inflammation). Also in chronic bronchitis when
expectoration copious and difficult to expel.

Arsenic, 226. Where emphysema, with wheezing
and not much bronchitis, especially where the
wheezing has come on simultaneously with the
retrocession of a rash as of eczema : where
much bronchitis and dyspnoea, belladonna and
lobelia better.

Assafcf.tida, 311. For old people, but ammoni-
acum generally better.

Balsam of tolu or Peru, or copaiba, 307. In
chronic bronchitis to lessen secretion.

Benzoic acid, 307. 3 j in boiling water as in-
halation.

C.\rbolic acid, 254. Or creasote, twelve to
twenty drops as inhalation with boiling water
for abundant expectoration or fcetor.

Carbonate of ammonia, 149. When expec-
toration profuse and patient's strength dimin-
ishing, often given with chloride of ammonium,
which acts similarly ; also useful in severe
bronchitis or broncho-pneumonia of children,
especially when prostrate and livid.

Carbonic acid gas, 88. As inhalation in chronic
bronchitis.

Chamois leather waistcoat, 59. Worn over
flannel in bronchial asthma and emphysematous
bronchitis.

Chloride of ammonium, 159. In chronic bron-
chitis when secretion thick and abundant.
May be applied by atomizer.

CoD-LivER oil, 242. To Control expectoration
in chronic bronchitis.

Colchicum, 332. In gouty subjects.

CoNiUM, 362. Inhalation in boiling water for
irritable cough.

Counter-irri lANTS, 83. For shortness of breath
in bronchitic asthma and bronchitis with em-
physema.

Croton oil, 244, 243. With or without liq.
potassae as counter-irritant to chest — caution
needful.

Essential oils, 307. Balsam of Peru, tolu and
copaiba in chronic bronchitis with copious
secretion of pus.

Eucalyptus, 309, Often relieves cough of chronic
bronchitis.

Gi^\iACUM, 336. Has been employed.

Iodine, 100. The liniment to the chest to lessen
cough and expectoration in chronic bronchial
catarrh. -As inhalation for children with hoarse,
hollow cough after measles, <S;c. Inhalation
sometimes employed in chronic bronchitis.

Ipecacuanha, 317, 318. '1 o produce vomiting in
children with much mucus in bronchial tubes.

, 321. As wine, when expectoration

is profuse and difficult to expel.

The wine used as spray to the pharynx in-
valuable in many cases of bronchial asthma and
winter cough (see ref.).

Iron, 177. To check profuse bronchial secretion.

J.^lap, 461. With bitartrate of potash to free
purgation for cases where the right heart is
engorged from emphysema, bronchitis, &c.

Lead, 186. To check profuse bronchial secretion.

Lobelia, 427. For paroxysmal dyspna:a.

Mustard, 314. As large poultice with linseed or
oatmeal in acute bronchitis, or a tablespoonful
added to a bath, very useful in severe bronchitis
both of children and adults.

Opiates, 409. Where frequent and violent cough
without any signs of obstructed oxidation.

, 417. To check excessive secretion.

Phosphate of li.me, 156.

Poultices, 63. To encircle the whole chest in
children.

INDEX TO DISEASES.

487

BRO'SCniTIS—con^inui^J.

QiiNiA, 446. To reduce temperature.

Senega, 463. Especially for the chronic bron-
chitis of the aged.

Silver, nitrate of, 1S9. Sometimes injected
into trachea (see ref.).

Spinal ice- bag, 70. For excessive secretion.

Squill, 460. As an expectorant.

Sulphur, qi. Five to ten grs. in severe chronic
bronchitis with abundant discharge, especially
where constitutional debility.

Sulphurous acid, 131. Inhalation, spray or
fumigation in chronic bronchitis.

Tar, 255. Two grs. in pill every three or four
hours in chronic paroxysmal winter cuugh. Not
quite equal to the ipecacuanha spray.

Turkish b.\th, 58.

Turpentine, 306. Small doses as a diuretic.

OR terebine, 304. As inhalation.

Zinc, oxide of, 210. For profuse bronchial
secretion.

, ,suLPH.\TE of, 209. As emetic ; others gen-
erally preferred.

BRONCHOCELE. {See Goitre.)

BRUISES.

Capsicum, 315. A strong tincture applied with
gum said to act like a charm on discolored
bruises.

Hamamelis, 252. On lint or cotton wool.

Sulphurous acid, 131. A solution constantly
applied.

BUBO.

Iodine, 102. Applied to produce vesication round

a bubo relieves the inflammation.
Nitric acid, 123. To indolent and broken bubo.
Sulphides, 95. Less useful in maturating than

in the case of ordinary boils or abscesses.

BURNS.

BoRACic ACID, 133. As ointment.

Carbolic acid, 257, A one per cent, solution on

lint frequently renewed relieves pain.
Cocaine, 440. As lotion painted on scalds to

relieve pain.
Collodion, 236. Painted over slight burns

subdues inflammation.
Lime, 152. As lime-water and oil.
P.ARAFFIN, 133.
Soda, 136. A saturated solution of the carbonate

locally for burns and scalds.
Warm b.\th, 52. Immerse for some days.

CALCULI.

Alkalies, 145. To dissolve uric acid calculi

(renal or vesical).
Citrate of pot-^sh, 144. In large doses for

patients with bloody urine containing quantities

of uric acid crystals.
Counter-irrit.-\nts, 83. Relieve pain from

passage of renal and biliary calculi.
Nitric acid, 130. Very dilute as injection for

phosphatic calculi.

CANCER. {See also Stomach and Uterus.')

Arsenic, 215. Arsenious acid, pure or with
starch, as a caustic — enough should be used to
set up the active inflammation (see ref.).

, 231. A long-continued course recom-
mended in epithelioma, scirrhus, and rodent
ulcer.

CANCER — contimied.

Carbolic acid, 257. Pure, as ansesthetic before
applying caustics.

Carbo.nic acid, 88. Injected up vagina in can-
cer of uterus to relieve pain.

Chloral, 285. In ten gr. doses three times a
day, has relieved most severe pain of cancer.

Chloroform, 269. As vapor to raw, painful
surface.

CoNiUM, 362. As poultice to ease pain.

■ — , 364. Internally to relieve pain.

Creasote, 255. Has been employed.

Glycerine of carbolic acid, 247. As applica-
tion to foetid cancers on surface or in uterus.

Glycerine of tannin, 247. With glycerine of
carbolic acid checks discharge and stench of
uterine cancer.

Iodofor.m, 279. Applied locally relieves the pain
of cancerous sores.

Morphia, 406. Dissolved in glycerine and spread
on lint, very useful where there is much pain.
Opium is also used in cancer of the stomach.

Opium, 406. To cancerous sores.

Poultices, 65. Of starch applied cold.

Warm enem.^ta, 76. To relieve pain and strain-
ing in intestinal cancer.

CANCRUM LABIALIS AND ORIS.

Arsenic, 216. In cancrum oris.
Nitric acid, 123. To surface.

CANKERY TASTE.

Mercury, 334. If podophyllin fail.
Podophyllin, 334. When unconnected with

alcoholism.
Purgatives, 334. Mercury and podophyllin

generally best.
Water, 73. Half a tumbler of pure cold water

daily half an hour before breakfast.

CARBUNCLE.

Arnica, 237. Ointment on plaster, also inter-
nally.

Belladonn.\, 96. With glycerine as local appli-
cation to allay pain.

Carbolic acid, 258. Lint soaked in glycerine
or oil and carbolic acid to be thrust into dis-
charging sinuses, the whole to be covered over
with more lint similarly prepared.

Iodine, 84. Applied so as to produce vesication
round the carbuncle, reduces inflammation.

Me.nthol, solution of, 307.

Opium, 408. An extract of the consistence of
treacle applied three or four times a day (see
ref.)

Poultices, 63. The inflamed surface having
been previously smeared with belladonna and
glycerine.

Strapping, 236. Plaster concentrically from
border inwards, will sometimes arrest extension.

Sulphides, 95.

CARDIAC DROPSY. {See Heart Dis-
eases and Dropsies. )

CARIES.

Phosphate of lime, 156.

C AT .-V R R H . {See also Bronchitis.)

Aconite, 341, 343. In catarrh of children and in
measles.

488

INDEX TO DISEASES.

CATARRH — continued.

AcT.'EA RACEMOSA, 338. Has been given, it is
said, with much success, when headache, stiff-
ness of muscles, and dull aching pain in bones.

Antimony, 214. As tartar-emetic in acute catarrh
of children, which is often accompanied by
vomiting and diarrhoea.

Chlor.ate of potash, 168. Should be taken
early and frequently, eight or ten lozenges in
the twenty-four hours.

Chloride of a.mmonium, i5g. In chronic catarrhs
of bronchial and urinary mucous membrane
when secretion thick and abundant.

CuBEBS, 308. 3 ss. to 3 j. of the tinct. in linseed
tea thrice daily. Very useful in coughs due to
chronic catarrh, or those following influenza,
or a simple acute catarrh, or occurring in em-
physematous patients.

EucALVPTOL, 309. In chronic bronchial catarrh
and bronchorrhoea.

Hamamelis, 252. Snuffed up nose in colds of
the head and catarrh of mucous membrane.

Hot spoNcrNG, 52. For headache.

Iodide of potassium, 109. Five grs. of, % gr.
tartar emetic, i oz. syrup of orange peel, 3 ozs.
of water in teaspoonful hourly doses for acute
febrile catarrh, specially for children.

Iodine, 100. Painted over back — front in chronic
bronchial.

Iodoform, 280. In spirits of turpentine.

Ipecacuanha, 317. In catarrh of stomach or
lungs, especially when secretion from lungs
abundant and tenacious.

Lamp b.\th, 61.

Opiim, 409.' Or morphia may be given when
there is violent and frequent cough but no signs
of obstructed o.xidation.

Sulphides, 94. As natural waters highly effica-
cious in chronic catarrh of the pharynx.

Turkish bath, 59. la chronic catarrh.

Warm foot-bath, 52. Before going to bed.

CATCH IN THE BREATH.

Cold sponging, 55. For infants waking with a
catch in the breath at night.

CEPHALALGIA. {See Headache.)

CHANCRE. {See Syphilis.)

Caustic alkalies, 134. To hard edges.
Eucalvptol, 309. With iodoform applied to

both kinds of sores.
Iodoform, 279. Dusted over soft chancres.
lODOL, 281.
Nitric acid, 123. To soft chancres.

CHANGE OF LIFE.

AcT.tA, 338. For headache.

Ammoni.\, 147. As Raspail's sedative lotion to
be applied to the painful part of the head in
the headaches of this period.

Bromide of potassium, 117. For despondency
with sleeplessness and irritability, often also
with heats, flushings and perspirations.

Calabar BEAN, 367. For flatulence.

Camphor, 302. For drowsiness and headache,
eau de Cologne saturated with camphor to be
rubbed into the head.

Change OF air and scene, 118. Where other
treatment only partially successful.

Euc.\lvptol, 309. For various symptoms, as
palpitations, flushings, flatulence.

Hot SPONGING, 58. To spine, following by appli-
cation of cold sponge.

CHANGE OF 'LIYY.— continued.

Iro.v, 118. For flutterings of the heart.

, 177. Large doses of sesquichloride three

times a day in fluttering of heart with fullness
of head, heat, and weight on the vertex, fre-
quent flushings and hot and cold perspirations.
If symptoms limited to head and face, nux
vomica, opium and belladonna more successful.

Nitrite of amvl, 297. In small doses when the
heats predominate.

Valeri.\nate of zinc, 210. For hysterical symp-
toms.

Vinegar and water sponging, 58. Every
morning to spine.

War.m bath, 52. Once a week.

CHAPS. {See Nipples, Sore.)

Collodion, 236. Sometimes used, but for
chapped hands and lips glycerine of starch,
arnica cerate or eau de Cologne and glycerine
better ; for chapped nipples sulphurous acid
and glycerine.

Glycerine, 247. Or, better still, glycerine of
starch.

Sulphurous acid, 131. As solution or fumiga-
tion.

V.aseline and petroleum, 253.

CHEST, PAINS IN, NON-INFLAM-
MATORY. (.S-^-^ Myalgia and
Pleurodynia.)

Belladonna, ioi. When tenderness is in skin,

pleurodynia.
Iodine, ioi. As ointment in muscular pains,

myalgia.

CHILBLAINS.

Balsam of Peru, 306. In ointment for broken
chilblains.

C.ajeput oil, 306. Locally.

Capsicum, 315. The tincture painted over un-
broken chilblains, but this is inferior to iodine.
For De Rheims's preparation (see ref.)

Iodine, ioi. Ointment is best.

Sulphurous acid, 131. As solution or fumiga-
tion.

CHLOASMA. {See Pityriasis Versicolor.)

CHLOROSIS.

Hvpophosphites, 158. Of lime or soda.
Iron salts, 175. When flabby tongue.

CHOKING.

Bromide of potassium, 115. In children who
choke with liquids from their birth (see ref.)

CHOLERA AND CHOLERAIC DIAR-
RHCEA.

Arsenic, 222. Has been recommended for the

vomiting of cholera and in collapse in'he later

stages.
Camphor, 302. Four to six drops of the strong

spirit of camphor every ten minutes at the

commencement till the symptoms abate, and

hourly afterwards.

-An admirable remedy for summer diarrhoea

and cholera.
Chloral, 284. Hypodermically in cholera.

May be combined with morphia.

INDEX TO DISEASES.

489

CHOLERA, 'E.TC— continued.

Copper, 207. The salts have been given.

Lead, 183. The acetate has been recommended
in early stages.

Mercury, 201. A si.\th of a gjain of gray pow-
der hourly is of great service in infantile cholera
with incessant sickness, profuse almost con-
tinuous diarrhoea, offensive and nearly colorless
stools. A starch injection with a minute
quantity of laudanum assists the gray powder,
and should be given in urgent cases.

Morphia, 408. One-eighth to one-fourth of a
grain hypodermically of the greatest value even
in the stage of collapse.

Spinal ice-bag, 71. For cramps.

CHORDEE.

Aconite, 345. In drop doses hourly. Said to

remove chordee.
Camphor, 303.
Cantharides, 313. A drop of the tincture three

times a day.

CHOREA.

AcT^A RACEMOSA, 337. Sometimes succeeds
when rheumatic history. — Inferior to arsenic.

Antimony, 214. As tartar-emetic in increasing
doses ; other remedies better.

Apomorphi.\, 327.

Arsenic, 230. When uncomplicated very suc-
cessful.

Calabar bean, 366. Three to six grains of the
powder three or four times a day for children,
or ten to twenty grs. for adults.

Chlor.\l, 284. Sometimes useful, especially
where the violent movements render sleep im-
practicable.

Chloroform, 276. Inhalations, — commence with
them three times a day, often of great service
in severe cases.

Cod liver oil, 243.

Cold sponging, 55. Not if rheumatism, fever,
or pain in joints. Often well to use water tepid
first.

CoNiUM, 364. Apparently only palliative.

Ether spray, 278. Has been recommended.

Hyoscyamia, 401. i-50th gr. hypodermically or
by stomach.

Morphia, 407. Hypodermically when the move-
ments prevent sleep.

Silver, 190. Both the o.xide and nitrate occa-
sionally useful.

Spin.\l ice-bag, 71.

Sulphate of zinc, 209. In large and increasing
doses. (See ref.)

Valerian, 310. The preparations are said some-
times to restrain the movements of chorea.

Veratrum viride, 328. Has been employed.

CLAVUS.

Chloride of ammonium, 159.

COLD FEET.

Sponging, 58. With vinegar and water, or first
with hot then with cold water.

COLD, FEVERISH.

Turkish bath, 59. At commencement will cut
short, also useful later on.

COLD IN HEAD. {See Coryza.)

COLDNESS.

Cold water, 58. Cold feet should be immersed
in cold water nightly for a few minutes, rub-
bing them all the time, they should then be
dried and warm woolen socks put on.

Spinal ice-bag, 71. For cold feet.

Strychnia, 424. For coldness of hands and feet.

COLDS, TENDENCY TO CATCH.

Cold sponge bath, 59. Supplemented by wet-
sheet packs, or Turkish bath.

COLIC.

Alum, 171. Large doses (ten grs.) every hour
given by many in lead colic.

Ammonia, 148. In spasm of intestinal canal and
in colic of children or infants from bad feeding.

Belladonna, 389. In colic of intestines, es-
pecially of children.

Bro.mide of pot.^ssium, 115. In a peculiar form
in young children. (See ref.)

Chloral, 285. Sometimes relieves.

Chloroform, 270, 276. Inhalation in renal and
biliary colic, inferior only to morphia injection,
superior to opium, warm baths, &c., two or
three administrations may be required.

, 277. lll,v-lx. every 4 or 6 hours in

biliary colic said to dissolve calculus.

, SPIRIT OF, 270. In all colics, often

combined with opium.

Counter-irritation, 83. For renal and biliary
calculi.

Essential oils, 307. Especially of cloves and
cinnamon.

Ether, 278. For biliary or intestinal colic.

Fo.mentations, 62. In all forms.

Lime-water, 153. For young children who eject
much of their milk in lumpy masses, some of
these lumps passing through the intestines
causing colic and wind.

Opium, 411. Or morphia in frequently repeated
small doses for colic of intestines. Where, as
is usual, there is constipation a purgative should
be given.

, 416. Small doses with spirit of chloro-
form every five or ten minutes till the pain
gives way in renal or biliary colic, or morphia
hypodermically.

Phosphate of sod.\, 164. In hepatic coHc to
prevent formation of gall-stones — must be con-
tinued for months.

TtHi ACCO , 360. As clyster or by the stomach in
colic of intestines.

Turpentine, 306. Has been given with advan-
tage in biliary colic.

Warm bath, 51, To ease pain in biliary, renal,
or other colic.

COMA.

Bitartrate OF potash, Sulphate of soda, and
Tartrate of soda, 163. As purgatives when
blood poisoned.

Blisters, 81. In a comatose condition large
blisters^r mustard poultices should be applied
in quiot succession to different parts of the
body — chest, abdomen, thighs, and calves —
often very valuable in the critical condition
near the end of an acute illness.

Cold douche, 56. For stupor of drunkenness
or of opium poisoning. Alay have to be re-
peated if relapses occur. It should be kept up
for a long time if pulse and breathing improve
or even become no worse.

Croton oil, 246. A purgative- -one-quarter or
one-third mm. every hour.

490

INDEX TO DISEASES.

CONDYLOMATA.

Arsenic, 215. Arsenious acid as a caustic. (See

ref.)
Mercury, 191. The nitrate locally.

, 194. Oleate (20 per cent.).

1 196. Calomel dusted over.

Nitric acid, 123. As a dilute wash constantly
p applied.

Zinc, 208. Chloride, iodide, and nitrate locally.

CONFINEMENT. (See Puerperal

Fever. )

ACT.EA RACEMOSA, 337. Strengthens contrac-
tions of uterus without prolonging them as

ergot does, and so endangers less life of child

and soft structures of mother. Sometimes

given for after-pains, but ergot preferable here.
Beneficial in mental disturbance before or

after confinement, 3:17.

Useful when lochia are suppressed.
Castor oil, 246. As purgative afterwards.
Chloral, 284. In fifteen gr. doses every quarter

of an hour till sleep induced — applicable towards

termination of first stage.
Chloroform, 275.
Cold douche, 56. In insomnia.
Emetics, 326. Or mechanical irritation of

pharyn.x in flooding.
Ergot, 431. In tedious labor where uterus is

becoming exhausted, but where there is no

obstruction to the passage of the child. (See

ref.).

Extremely useful in post-J>artum ha;mor-

rhage.
Hamamelis, 252. For long-continued oozing of

blood afterwards.
Ipecacuanha, 326. In flooding— also recom-
mended after delivery to promote natural

functions.
Iron, 178. Injection of four ozs. of liq. ferr.

perchlor. with twelve ozs. water in grave cases

of flooding after delivery— care to be taken not

to introduce air.
Morphia, 408. Hypodermically in tedious labor

produced by rigid os uteri.
Opium, 418. A drachm of the tinct. with brandy

in profuse flooding.
QuiNiA, 447. To strengthen uterine contractions

— used by some American writers in preference

to ergot.

CONJUNCTIVITIS. {See Eyes, Dis-
eases of.)

Belladonna, 388. Locally and internally.

Blisters, 84. Behind the ear.

Castor oil, 246. A drop in the eye often allays

pain and intolerance of light caused by an

irritant.
Mercury and morphia, oleate of, 194. Outside

the eyelid in palpebral conjunctivitis.
Opium, 409. The wine of the 1864 Pharmacopoeia

dropped into the eye relieves pain and improves
^ condition of the membrane.
Silver, nitrate of, 189. Solutions of various

strength dropped into the eye.
Zinc, 208. A weak solution of sulphate as drops.

CONSTIPATION.

Aloes, 458. In chronic cases. Often combined

with iron. ♦

Belladonna, 388. One-sixth to one-fourth of a

grain of the extract once a day, especially when

dyspepsia. Sometimes a suppository of one or

two grs. efificacious in severe cases.
Bitari rate of potash. Sulphate of magnesia,

and Phosphate of soda, 164. In broth for

children.
Carlsbad water, 162. In habitual constipation

—best to use a system as at Carlsbad. (See ref.)
Cascara sagrada. 462.

CONSTIPATION— f^«//««,'rt'.

Castor oil, 246. A speedy, certain, and mild
purgative. Not good for habitual constipation.
3 ss. of the oil if rubbed up with. 3 ss. glycerine
a sufficient dose.

Cop LIVER oil, 243. In the obstinate constipa-
tion of children.

Coffee, 432. Is slightly purgative in some per-
sons.

Colocvnth, 457. A few drops of the Prussian
tincture several times a day in obstinate con-
stipation.

Croton oil, 246. A very powerful purgative,
sometimes employed in obstinate constipation
where other purgatives fail.

Diet, 162. Porridge, brown bread and exercise
when busy, worried men become irritable and
suffer from headache, unless the bowls act
every day. If these remedies fail, try fruit be-
fore or after breakfast, or natural purgative
waters.

Enemata, 75, 76. To unload the bowels, but the
habitual use of warm enemata will increase the
torpor of the bowels.

Glycerine, 248. As an anal injection.

Guaiacum, 336. Obstinate constipation.

Ipecacuanha, 320. A grain every morning fast-
ing for constipation from great torpor of intes-
tines. It is said to assist the action of the other
purgatives.

Jalap, 460. And scammony in obstinate con-
stipation.

Kneading of the abdomen, 76. Night and
morning for 10 minutes often overcomes chronic
constipation, especially in children.

Lime, 154. As saccharated solution— this must
not be taken on an empty stomach.

Magnesia, bicarbonate of, 151, i.e., fluid mag-
nesia. A useful and mild aperient. Often
combined with rhubarb.

Mercury, i, 2. Calomel, or gray powder, as a
purgative, especially if stools light. Nitric
acid and nux vomica assist its etlicacy. (But
see p. 199.)

Natural waters, 61. Pullna, Friedrichshall,or
Hunyadi— fromawineglassfulto half a tumbler
or more, with an equal quantity of hot water
before breakfast.

PuUna or Friedrichshall mixed with milk a
good purgative for children.

Ntat- Vowte^t, 421. The extr. with rhubarb or
colocynth shortly before dinner, aids digestion
and the unloading of the bowels. One or two
drops of this tinct. two or three times a day will
do instead.

Oranges, 161. One or two before breakfast for
moderate habi'ual constipation, or a glass of
cold water before and an orange .soon after
breakfast.

Podophyllum, 334. One or two drops two or
three times a day of the solution of one grain of
the resin in one drachm of alcohol for children
with hard, clayey, perhaps mottled stools
occurring after an attack of diarrhoea (often
observed in infants who are spoon-fed). Gen-
erally the best purge when stools are dark.
Nitric acid and nux vomica should be given
simultaneously.

For remarks on indications of the tongue,
see p. I.

Rhubarb, 462. A useful purgative for children,
especially when mixed with two or three times
its weight of carbonate of soda.

Senna, 462. Well combined with a bitter tonic,
as gentian.

Senna leaves, 75. Steeped first in hot then in
cold water, an excellent evacuant.

Sitz-bath, 58. Cold or tepid, followed by fric-
tion with rough towel.

Soap, nq. Added to anal injections to suspend
castor oil or turpentine, or a piece the size of
the thumb whetted with castor oil or water
may be thrust up the rectum to produce a
motion, especially in infants and children.

INDEX TO DISEASES.

491

CONSTIPATION— f^«//««ev/.

Sl'LPHATES, 164, 165. In purgative natural waters
—small doses often repeated. Sulphate of
potash has in some cases proved poisonous.

SiLi'HLR, 91. Ten grs. with conf. sennje, or as
the German comp. liquorice powder in milk —
the latter good for children.

Tobacco, 36-^. A smoke after breakfast some-
times beneficial in habitual constipation.

Whole-meal bkead, 476. See Dietary.

CONVALESCENCE.

Alcohol, 262. Before or at meals.
Fats, 241. Especially cod-liver oil.
Lime, 154. As lime-water or carbonate of lime,

in convalescence from serious diseases.
Oi'iTM, 411. As laudanum injected into the

rectum for the wakefulness of convalescents.
Sea-uaihs, 38.

CONVULSIONS.

Bitartrate of potash. Sulphate of soda, and

Tartrate of potash, i 3. When due to poi-

soned'blood.
Bromide of potassium, 115. In all forms.
Chloral, 2S4. In children— five grs. by mouth

or rectum.
Chloroform, 276. Inhalations of great service

in children, also in puerperal convulsions.
Ice, 68. To head.
MorphL'V, 408. Hypodermically sometimes arrests

puerperal convulsions.
Spinal ice bag, 71. In infantile convulsions.
Veratrum viride, 328. Has been employed.

CORNS.

Salicylic acid, 452.

(For formula see ref.)

CORYZA AND HAY FEVER.

Aconite, 341. In severe colds with much chilli-
ness, aching of limbs, a hot dry skin and a quick
pulse.

, 221. In true hay fever.

Ammonia, 148. Inhalation in early stage.
Arsenic, 220, 221. In chronic coryza. Also in peri-
odical attacks of persistent sneezing, with
coryza, frontal headache, and often an itching
of the nostrils ; sore throat, wheezing, and pro-
fuse expectoration may supervene. Often this
affection, allied to peptic asthma, may be
brought on by food or by irritation of dust or
pollen. Aconite liniment may be applied to the
Itching part of the nose.

Arsenic of little use in true hay fever, then
aconite internally best. (See ref. )
Camphor, 301. Inhaled or taken by the mouth

at the very beginning sometimes arrests it.
Carbolic spray, 258. To nose in contagious

coryza.
Chlor.\te of potash, 168. Eight or ten lozen-
ges a day will stop many a cold at its com-
mencement.
Cocaine, 439. Solution for painting nasal mucous

memb., also for arrest of acute coryza.
Glycerine, 248. Vaseline preferable.
Ha.mamelis, 252. Snuffed up nose in colds and

hay fever.
Iodide of potassium, 109. Ten grains at bed-
time at onset to cut short acute cold in head ;
also useful in chronic colds.
Iodine, 103. Inhalation in daily attacks of cold
accompanied by itching of nose or inner can-
thus.
Ipecacuanh.\, 324. In hay asthma.
Opium, 417. At night at the very beginning will
often cut short an attack of coryza. A glass of
hot grog assists its action.

CORYVA, 'Eic.—continufJ.

Piece of cotton-wool, 307. Saturated with
menthol placed in each nostril directly sneezing
and itching commence.

Quinia, 442. Strong solutions to flush nose.

Sulphurous acid, 131. Inhalation, spray or
fumigation in coryza.

Turkish bath, 59. In coryza.

Veratrum viride, 328. If arsenic unsuccessful.

COUGH.

Alcohol, 268. As brandy or wine. Porter and

beer often aggravate coughs.
Alum, 171. '1 en grs. to one drachm of water as
spray in chronic cough ; also internally in spas-
modic coughs.
Belladonna, 393. Often useful — no rules can

be given.
Carbonic acid gas, 88. As inhalation in irrita-
ble cough.
Chloroform, 270, 271. With morphia and treacle
when cough paroxysmal and violent with very
slight expectoration ; when it arises from morbid
condition of throat this mixture may be painted
on.
Cod-liver oil, 243. In chronic coughs.
CoNiUM, 364. Supposed useful in whooping and
ther coughs.
Inhalation for irritable cough.
Creasote, 255. In winter cough.
Cubebs, 308. 3 ss. to 3 j. of tinct. in linseed tea
in acute or chronic catarrh, influenza, or em-
physema — often acts " like a charm."
Gelsemiu.m, 379. When excessive excitability of
respiratory centre— ether, chloroform, and
opium also useful.
Glycerine, 247, 248. Lemon-juice may be added.
Glycerine of tannin, 250. As application to
the throat when chronically inflamed and so
productive of cough, which is often the case in
children.
Hydrocyanic acid, 405. For irritable coughs.
Iodine, 103. Inhalation for children with hoarse,
hollow cough, accompanied by hoarseness and
wheezing at the chest.
Iodoform, 280. Cough of phthisis diminishes.
Ipecacuanha, 321. In obstinate winter cough
with wheezing the wine applied as spray to the
fauces is very efficacious.
Opium, 409. When cough due to inflamed or
even ulcerated throat. Morphia lozenges or
morphia with glycerine in these cases, which
are common in chronic phthisis, very useful,
409. Sometimes also opium and morphia admin-
istered so that the medicine clings for some time
in contact with structures just outside the
larynx effectual in coughs entirely dependent
on lung disease.
Tar, 255. In winter cough, especially when

paroxysmal.
Turkish bath, 59. In winter cough.

CRACKED

Sore.)

NIPPLE. {See Nipples,

CRICK IN THE NECK.

CROUP.

Aconite, 341. Valuable in catarrhal croup (spas-
modic laryngitis).

Alum, 171. One drachm in honey or syrup every
ten or fifteen minutes till vomiting induced. In
severe cases vomiting should be caused three or
four times a day, treatment to be begun ear'y-

Copper, Sulphate of, 207. In small and fre-
quent doses as a vomit.

Lobelia, 427. Has been employed.

492

INDEX TO DISEASES.

CRO\3V— continued.

Senega, 463. Given by some.

Sulphurous acid, 131. Spray hourly or oftener

in acute attack.
Tannin, 250. A spray containing 5 per cent, of

tannin several times a day for fifteen or twenty

minutes.
Zinc, sulphate of, 209. As emetic, but others

generally preferred.

CYSTITIS.

Alkalies, 144. Citrates and bicarbonates used
to make urine alkalme, when urinary organs
irritated or inflamed. When urine already
alkaline, alkalies must be intermitted.

BucHU, 308. Also copaiba and cubebs in chronic
inflammation of bladder and urethra.

C.antharides, 312. A drop of the tincture (five
sometimes required) three times a day.

Carbolic acid, 258. And sulpho-carbolates
may possibly be used in preserving the urine
sweet in cystitis.

Euc.\LYPTOL, 309.

Hot enemat.^, 76. To relieve pain.

Hot sitz-b.'\th, 52. Allays pain and incessant
desire to micturate.

Iodoform, 279. A suppository for painful dis-
eases of rectum and bladder.

Opium, 411. An injection of laudanum with
starch will subdue pain and frequent micturi-
tion.

Pareira, 308. In chronic cystitis.

Turpentine, 306. Has been useful in chronic
cystitis.

DANDRIFF. {See Pityriasis of Scalp.)

Borax, 135. Head to be sponged several times
a day with a saturated solution, or the glycerine
of borax may be used.

Tannic acid, glycerine, lard, bals.\m of peru,
and OIL of bitter al.monds, 249.

DEAFNESS. {See Ears, Diseases of.)

Glycerine, 247. For dryness of meatus — also
to form a film to cover ruptured tympanum.

Glycerine of tannin, 250. As application for
throat deafness.

DEBILITY.

Alcohol, 3. In aged patients with dry tongue
great care must be exercised and alcohol given
in small quantities, the effect on the dryness of
the tongue being carefully watched.

■ , 265. A wine with much ether in de-
bility of old age, especially where sleeplessness,
indigestion and stomach cramps.

, 268. Stout or rum and milk, especi-
ally in town-living women.

Arsenic, 226. For swelled feet of old or weakly
persons and for breathlessness from weakly act-
ing heart.

Cod-liver oil, 241. In chronic degenerative
diseases of old age.

, 243. In chronic diseases of chil-
dren.

Hvpophosphites, 158. Of lime or soda in ner\--
ous or general debility.

Iron, 173, <S:c. In anaemic subj

Morphia, 415. Hypodermically when due to on-
anism, and in great hysterical depression.

Phosphate of lime, 156. When from prolonged
town life or overwork, a grain each of phosphate
o{ lime, phosphate of iron and carbonate of lime
for a dose.

DY.m'LlTY— continued.

Quinia, 448. For pale, badly fed town-dwellers.
Sea-bathi.ng. 38. In chronic illness with debility.
Soporifics, 3. In aged patients if tongue is dry

great caution must be exercised.
Turkish baths, 59, 60. When caused by the

tropics—caution necessary. When town-dwellers

become stout and flabby.

DELIRIUM.

Antimony', 214. In delirium of typhus and other
fevers. (See fevers.)

Bell.'VDONN.'v, 394. In delirium of typhus and
other fevers.

Bromide of potassiu.m, 119. In delirium re-
sembling delirium tremens, also in acute m<inia.

Camphor, 303. In large doses.

Chloral, 282. In violent delirium of fevers.

Cold douche, 57. In maniacal delirium— place
patient in warm bath during the application.

Opium, 411. Best given in traumatic delirium as
a rectal injection.

, 414. Combined with tartar-emetic in

fevers, or, better still, morphia may be given
hypodermically. Laudanum in low muttering
delirium.

DELIRIUM TREMENS.

Antimony, 214. Tartar emetic with opium to
control mania and sleeplessness.

Bromide of potassium. 316. Especially in
earlier stages, and in dispelling delusions re-
maining after partial subdual of attack.

Capsicum, 316. To induce sleep in early stages.

Chloral, 283. Especially when administered
at the onset of the symptoms.

Chloroform, 276. Inhalation has been ad-
vised to procure sleep.

Cold douche, 56. For insomnia.

Digitalis, 355. Half an ounce of the tincture,
repeated if necessary in four hours and again in
six, and afterwards when needful in two-
drachm doses. (See ref.)

Hyoscyamus, 401. Or hyoscyamia, probably
useful where delirium like that of acute mter-
mittent delirium.

Ice, 68. To head.

Musk, 261. With laudanum.

Opium, 411. Given as a rectal injection.

, 415. Hypodermically or with porter or

spirits. Test urine first.

Strychnia, 424. Hypodermically to calm ex-
citement and induce sleep.

Wet pack, 57. For insomnia. May be repeated.
If patient strong, delirium boisterous and pulse
full, tartar-emetic or aconite should be added.

DEPRESSION AND DESPONDENCY.

Bromide of pot.^ssium, 117. Especially in

towns-people.
Phosphorus, 235. In depression from overwork.

DIABETES.

Caution. — The sugar reaction is given by urine
oj" patients taking salicylic acid. See p. 452.

AwcAttfis, 140. Have been suggested.

Ergot, 431. The best remedy in diabetes in-
sipidus. Large doses required.

Glycerine, 247. To be used in place of sugar.

Lactic acid, 130.

Opium, 417. Very successful.

Salicylate of soda, 452.

Tepid drinks, 72.

Valerian, 310. Large and increasing doses in
diabetes insipidus.

INDEX TO DISEASES.

493

DIARRHCEA.

Alkalies, 139. Bicarbonates of potash, soda or
magnesia when due to excess of acid in intes-
tines.

Alum, 171. Sometimes useful in acute and
chronic diarrhoea, and in that of typhoid and
dysentery.

Ammi)NL\, 148. In after stages when mucous
membrane continues to pour out watery secre-
tion which perpetuates the diarrhoea.

Arsenic, 222. One drop of liq. arsen. before
meals for dyspeptics when diarrhoea excited by
food.

Also useful in other chronic forms of diarrhoea,
even when due to organic disease.

, 231. For copious discharge of mem-
branous shreds from bowels and uterus with
emaciation, neuralgia, dysmenorrhcea, &c.

Attention to feeding, 202. Small quantities
of food frequently.

Bismuth, 180. Half a drachm to a drachm of the
nitrate in chronic diarrhoea as in that of phthisis
sometimes valuable when all else has failed —
should be given in milk.

A grain hourly with milk with sometimes
one-si,\th gr. gray powder in various forms of
diarrhoea of young children.

Camphor, 303. In summer diarrhoea, in acute diar-
rhoea of infants (may be given in milk), in diar-
rhoea caused by effluvia of drains, or exposure
to cold.

Capsicum, 316. In summer diarrhoeas and in those
persisting after expulsion of exciting irritant.

Castor oil, 246. In early stages to carry away
irritant.

Children's diarrhoea sometimes yields to eight
or ten drops suspended in mucilage.

Chamomile, 456. An infusion useful in summer
diarrhoea of adults, or of children from teething.

Chloride of ammonium, 159. In catarrhal con-
ditions of intestines.

Chloride of c.^lciu.m, 154. In chronic diar-
rhoea with weak digestion.

Chloroform, 270. As sp. chloroformi combined
with astringents and opium after removal of
excitant.

Cocaine, 441. As anal injection or suppository
to check diarrhoea.

Cod li\ek oil, 243. In chronic diarrhoea of
children with pale stinking motions, wrinkled
skin and perhaps vomiting.

Cold ok teitd packing, 45. In summer diar-
rhoea of children.

Copper sulphate, 207. By mouth or as an in-
jection in severe chronic or acute diarrhoea with
or without organic disease.

COTO BARK, 253.

Flannel hinder, 202. Round the belly in in-
fantile diarrhoea.

Injections, 76. Of starch water at 100 degrees
F. with laudanum and acetate of lead or sul-
phate of copper. Invaluable in urgent cases
such as the choleraic diarrhoea of children.

Ipec.'Vcuanha, 320. Hourly drop doses of the
wine, especially if vomiting be present, in dys-
enteric diarrhoea of children.

Iron, 174. Astringent preparations, especially the
pernitrate.

Le.\d, 183. A fewgrs. of the acetate with a small
dose of morphia, a sure and speedy remedy for
summer diarrhoea; the acetate with opium in
purging due to dysentery, typhoid, or tuber-
cular disease of intestines.

It increases the efficacy of a starch injection.
It may be used as a suppository.

Lime, carhonate of, 154. In the later stages
when the irritant got rid of. As chalk mix-
ture in diarrhoea from more serious causes, as
typhoid or phthisis.

Lime-water, 88, 154. In chronic vomiting with
diarrhoea in young children.

"Mercurv. 2. Generally best when stools are
light-colored. Nitnc acid and nux vomica
assist its action.

BlARRUaiA—confiHiiet/.

For indications afforded by condition of
tongue, see p. i.

, 200. A third of a grain of gray pow-
der every hour or two in diarrhoea of children
with bad digestion, flatulent distention and
clayey stinking motions.

, 200. Where children or adults suffer

from acute or chronic diarrhoea with slimy,
perhaps bloody stools and pain and straining,
give frequent teaspoonful doses of a .solu-
tion of one grain of bichloride in ten ozs. of
water.

Gray powder, a sixth of a grain hourly, then
every two or three hours, m infantile diarrhoea
with watery and offensive, muddy or green
stools to the number of ten or twelve a day —
vomiting is an additional indication for this
treatment.

In all cases of infantile diarrhoea little food
should be given, but frequently.

When children pass large, acid, offensive
curdy stools, mercury of little use^here milk
should be entirely withheld.

, 202. The chronic diarrhoea of adults

with watery pale stools often yields to the hun-
dredth of a grain of corrosive sublimate every
two or three hours; this may be employed in
diarrhoea of typhoid or phthisis.

Nn Kic .^ciD, 2. With nux vomica to assist action
of mercury or podophyllin.

, 128. For straining diarrhoea of chil-
dren when motions green, curdled and mixed
with mucus; also in chronic diseases of children
with sour-smelling, pale and pasty motions, es-
pecially if acid combined with pepsin.

Opium, 410. Or morphia in acute forms after
expulsion of offending matter, also in chronic
diarrhoea of tuberculosis, dysentery, and other
organic diseases. In typhoid fever, where there
is wakefulness, delirium and diarrhoea, it will
often subdue the symptoms.

In dyspepsia with diarrhoea, common in
children where there is sinking at the stomach,
relieved for a short time by food, and the occur-
rence of an evacuation of partially digested food
immediately after the meal. I'wo to five drops
tr. opii a few minutes before each meal very
efficacious, but arsenic even more so.

An injection with starch in acute and chronic
diarrhoeas, including those severe forms which
sometimes carry off young children in a few
hours. .Also in typhoid tubercular ulceration
of intestines and dysentery (p. 411).

Phosphate of lime, i56. In chronic diarrhoea,
tubercular 01 otherwise.

, 157. In chronic diarrhoea,

especially that of young children, may be
given with carbonate of lime and lactate of
iron.

Podophyllum, 335. In chronic diarrhoea with
high-colored motions and cutting pains ; also
in morning diarrhoea ; also in chronic diarrhoea
with watery, pale, frothy motions, with severe
cutting pain. (See also p. 2.)

R.JtW- MSAT diet , 469, 470. For children and
adults.

Rhubarb, 461. In early stages to get rid of irri-
tant and afterwards to check the diarrhoea.

Salicylic acid, 452. As an injection in dysen-
teric diarrhoea of children.

SiL\ER, mtr.ate of, 190. In acute and chronic
diarrhoea.

Spinal ice-bag, 69. For cramps. Also when
due to excessive action of mucous membrane.

Sulphuric acid, 128. In summer and choleraic
diarrhoea. Small doses in chronic diarrhoea,
also in hectic.

Tannin, 251. As catechu, kino, red gum, rhatany
and hsematoxylum in acute and chronic diar-
rhoea, internallv or as injections.

Veratrum album, 328. Has been used with
advantage in the vomiting and purging of
summer diarrhoea.

494

INDEX TO DISEASES.

BlARRHCEA—coiiOutnc/.

Wet pack, 45. Daily in chronic diarrhoea, due
to chronic catarrh of the intestines.

Zinc, oxide of, 2og. Two to four gr. doses every
three hours in diarrhcea of children.

(See Throat, Diseases

DIPHTHERIA.

of.)

BoRACic ACID, 133. In glycerine as local appli-
cation.

Chlorinated sod.\, 99. Strona; solution to throat.

Chlorine solution, 99. For sloughing of throat.

Eucalyptus oil, 309. To the throat and as in-
halation.

Glycerine of carbolic acid, 258. Twice a day
to diseased portions of mucous memb.

Hydrochloric acid, 125. Locally.

Ice, 68. To be sucked especially at commence-
ment and continued constantly till disease
declines.

Ice poultice, 69. To throat, especially when
glands threaten to suppurate.

Iodine, 103. As inhalation. (For formula see
ref.)

Iron, 177. Large doses of perchloride — solution
better than tincture — every hour or oftener.
Solution also to be gently painted on throat or
applied with atomizer.

Lactic acid, 125. 3 ss to 3j in 5J of water as
spray or application to membrane every hour.

Lime, 153. Solution as spray. Recommended
by many, but of doubtful efficacy.

Per.m.-\nganate, 178. Has been given internally.

Pilocarpine, 374.

Quinia, 442. As strong solution of spray topic-
ally.

Silver nitrate, 189. Of doubtful benefit.

Strychnia, 420. Hypodermically for paralysis
after diphtheria.

Tannin, 250. As spray (5 per cent, solution).

DIPSOMANIA.

Arsenic, 222. For distressing vomiting — one
drop of liq. arsen. before breakfast.

Capsicum, 316. Large doses before meals, and
whenever depression and craving for alcohol
occurs. With bromide or arsenic and bitters to
assist in overcoming habit.

DROPSIES.

Nature and causes o/, see f>. 32.
Mode 0/ action 0/ remedies, p. 34.

Acupuncture, 79. Or, better still, incisions
from three-quarters to an inch long — one over
each external malleolus generally sufficient.
Keep a hot moist sponge containing carbolic
acid to incisions, and put feet and ankles into
hot bath for an hour night and morning. More
useful in liright's disease and in aortic than in
tricuspid mischief.

Adonidin, 360.

Arsenic, 226. For swelled feet from debility.

BiTARTRATE OF POTASH, 163. Especially in gen-
eral dropsies; useful in Bright's disease to
prevent watery accumulations and to draw off
effete matters.

Calomel, 206. Powerful diuretic in renal and
cardiac dropsy.

Colocynth, 457. Has been used.

CoNVALLARiA, 357. Used by Russian peasants.

Copaiba, 308. In some cases of ascites and
Bright's disease.

Digitalis. 347. The fresh infusion is best in
heart disease.

Elatekium, 457. In kidney and heart disease:
must be employed cautiously. (See ref.)

DROPSIES— <:^«/?«M^a'.

Iodide of potassium, in. In some cases of
Bright's disease.

Jal.\p, 460. In combination with other sub-
stances.

Juniper, 309. Esteemed by some in scarlatinal
dropsy.

Squill, 460. Recommended in all forms.

Sulphate of magnesia, 163. 3ij-lj in Jj
water before food.

DYSENTERY.

Alum, 171. For the diarrhoea.

Arsenic, 222. (See Diarrhoea.)

Cocaine, 441. As anal injection for straining.

Ham amelis, 252. When discharges contain much

blood.
Injections, 77. A pint of water with ten to

twenty grains of sulphate of copper in the

diarrhcea of chronic dysentery.

Large emollient enemata useful in early

stages of dysentery.
Ipecacuanha, 320. Large doses required. The

dysenteric diarrhoea of children will often

yield to hourly drop doses of ipecacuanha wine,

especially if vomiting present.
Lead, 183. The acetate with opium for purging.
Mercury, 200. A hundredth of a grain hourly

or every two hours of the bichloride in acute or

chronic dysentery, if stools are slimy and

bloody.
Opium, 410. For the purging.

DYSMENORRHCEA.

ACT.-EA, 337.

Axtipyrin, 455.

Arsenic, 231. When accompanied by copious
discharge of membranous shreds from bowels
and uterus.

Cajeput, 307.

Cannabis indica, 292. Very useful.

Croton chloral, 289. In dysmenorrhceal neu-
ralgia.

Gelsemium, 382. Said to be useful.

Hamamelis, 252. Often relieves pain.

Hot sitz-bath, 52. Two or three times a day.

Nitrite of amyl, 298. Inhalation.

DYSPEPSIA.

AcT.eA, 337. For the dyspepsia of drunkards.

Alcohol, 262. In loss of appetite and digestive
power from fatigue, a glass of wine or a little
ijrandy-and-water before food ; useful also in
indigestion during convalescence from acute
diseases or in town-dwellers. During acute
disease alcohol should be given with food, little
and often.

Alkalies, 125, 126. Shortly before a meal in-
crease gastric juice, usually better than acids
in atonic dyspepsia. (See also p. 122.)

, 138. Bicarbonate of soda best.

Aloes, 458. In combination, for habitual con-
stipation with dyspepsia.

The compound decoction a good after-dinner
la.xative. One grain of the water)' extract with
nux vomica, gentian or cinchona, a good din-
ner pill.

Arsenic. 3. Indicated by a too clean, too smooth
red tongue with prominent papillae.

, 222. One drop of liq. arsen. before food

in'irritative dyspepsia and dyspepsia in which
diarrhoea is excited by food.

Belladonna, 388. One-sixth to one-fourth of
the extract once a day when there is constipa-
tion.

Bismuth, 180. Mixed with vegetable charcoal
in flatulent dyspepsia.

INDEX TO DISEASES.

495

Charcoal, 87. Where there is flatulence. (See
ref.)

Cocaine, 441. In nervous dyspepsia J^ grain
three or four times a day.

Cod liver oil, 243. In the "craving" at the
epigastrium of the aged if intestinal canal not
in an irritable condition.

CoLCHici'M, 332. In gouty subjects.

Cold water, 73. Half a tumbler half an hour
before breakfast.

Creasote, 255. Often relieves stomach pains
occurring after food.

Drinking little and only some time after
MEALS, 72. In "indigestion of fluids" (see
ref.)

Eucalyptus, 309. In atonic form.

Hot water, 73, 74. A tumbler twice or thrice
daily between meals in flatulent and acid dys-
pepsia.

Hydrochloric acid, 126. Dilute, after a meal
increases gastric juice.

Ipecacu.xnha, 317. In irritative dyspepsia, acute
and chronic, 320. When associated with con-
stipation, depression, and food lying on stomach
" like a heavy weight."

Manganese, 178. As permanganate when flatu-
lence.

Merci ry, 2. Asgray powder if constipation with
light colored stools. Nitric acid and nu.\
vomica may be given simultaneously.

For remarks on indication of the tongue see
p. I.

, 202. A grain of gray powder three or

four times a day in dyspepsia occurring during
chronic disease or in convalescence.

-, 202. If constipation, half a grain of

calomel with three grains e.xtract hyosc. in pill
for three nights is better.

Mineral .\cids, 126. For eructations of offen-
sive gas with or without o.xaluria.

Morphia, 407. Hypodermically, when dyspepsia
of an irritable kind in an irritable subject.

Nux vomica, 420. Where flatulence, weight on
head and heartburn.

Opium, 410, 411. When sinking at stomach re-
lieved temporarily only by food which produces
an evacuation almost immediately of partially
digested matters, common in children, two to
five drops of tr. opii a few minutes before meals
very useful, — arsenic even more so.

, 417. In nervous people with weight on

head, flushings, perspirations, and depression.
A drop of laudanum with two of tr. nucis vom.
three or four times a day.
In phthisis, not febrile.

Podophyllum, 334. Useful when tongue furred,
especially if stools dark. This holds good
whether bowels open or constipated, but in
latter case i-3oth to i-2oth grain doses only. A
mi.xture containing nu.x vomica and nitric acid
should be given at the same time. If disagree-
able taste persists, rinse the mouth with solu-
tion of permanganate of potash.

— , 334. For cankery taste, espe-
cially in the morning. If this fail, try mercury.

Quinia, 448. Especially in elderly people living
in towns. Checks excessive fermentation in
the alimentary canal.

Senn.^, 462. Combined with gentian when there
is constipation.

Sulpho-carbolate of soda, 258. And carbolic
acid both useful in flatulence, especially when
it occurs immediately after a meal or gives rise
to "spasms." In these cases phosphorus is,
however, better.

Tannin, 250. In irritative dyspepsia.

Turkish bath, 59. For slight indigestion and
malaise after dining out.

DYSPHAGIA.

Cocaine, 439. Painted over pharynx.

DYSPNdA.

Cocaine, 441. Internally when due to weakened
respiratory action.

EAR DISEASES. {See also Otorrhcca
and Deafness.^

Aconite, 345. In otitis.

Cocaine, 440. As spray in otalgia (see ref.)

Counter-irwitation, 84. By blistering fluid or

croton-oil liniment behind the ear often relieves

earache.
Glycerine, 247. For dryness of meatus and as

a film to cover the tympanum when ruptured.
Strychnia, 420. Hypodermically.

ECTHYMA.

Quinia, 448. For mal-nutrition on which the
ecthyma depends.

ECZEMA,

Alk.vline lotion, 122. Weak, often useful in
weeping eczema.

Ah:m, 169. Applied to check profuse discharge,
but usually insufficient to heal of itself.

Arsenic, 226, 227. In chronic forms, especially
of vulva, anus and scrotum. Largest dose five
min. of liq. arsenicalis three times a day, never
on an empty stomach. For rules to be ob-
served in giving arsenic (see ref.)

Be.nzolx, 307. I'he compound tincture painted
on the skin to allay itching.

Bismuth, 180. Nitrate or carbonate, as dusting
powder, but generally greasy applications pre-
ferable.

Blisters, 84. Especially in eczema of hands,
applied around or near the disease.

Boracic acid, 133. As ointment or lotion in
ecz. vulva;, and mixed with starch as a dusting
powder for infants.

, 137. A teaspoonful dissolved in a

pint of boiling water as a lotion in eczema of
the vulva.

Bor.\x, 135. As glycerine of borax in eczema of
ears and scalp.

Camphor, 301. As addition to dusting oowders
to allay heat and itching.

Carbonate of pot.^sh or soda, 135. A weak
solution applied when raw surface weeps copi-
ously. (See ref.)

Carbolic acid, 253. In chronic eczema or, bet-
ter still, liq. carbonas detergens, oil of cade,
and oleum rusci. In the weeping stage if in-
flammation not great ten min. carbolic acid to
one oz. of lard, also in eczema capitis. Some-
times tar better than its ointment ; on the back
of hands undiluted petroleum, but rather pain-
ful.

C.^VRBOLic .^CID, 253. Petroleum, cade and car-
bolic soaps useful.

Caustic potash, 135. As liquor potassse locally
in chronic eczema.

Cinchona, 442. Powdered bark locally to check
profuse secretion, probably cheaper prepara-
tions of tannin as useful.

Cocaine, 440. A lotion for scrotal eczema.

CoD-LiVER OIL, 135. Or glycerine applied at
night to obviate brittleness of skin when caustic
lotions used.

Cyanide of potassium, 404. Or hydrocyanic
acid. (See Itching.)

Euc.\lyptol, 309. With iodoform and vaseline.
Useful in dry stage.

Glycerine, 135, 247. Or, better still, glycerine
of starch for rough skin left after eczema.

Glycerine of i'axnin, 249. In most forms.

Lead, 181. Soluble salts as lotions when much
inflammation and copious discharge.

496

INDEX TO DISEASES.

ECZ E M A — continued.

If great inflammation, surface to be covered
constantly with rags soaked in the lotion. In
some cases a poulticeat night and lotion during
the day. A strong lotion best in diffused ecze-
ma without weeping, but with much itching.
A we^k alkaline or sulphur bath assists action
of lotion. Equal parts of emp. plumb, and
linseed oil applied on soft linen twice a day
invaluable in sub-acute stage. (See ref.)

Ll.ME, CARBONATE OF, 152. As dusting powder.

LlME-w..\TER, 152. As sedative and to check
discharge. After inflammation subdued lime-
water and glycerine a comforting application.

Menthol, 307. Ointment.

Mercury, 192. Citrine ointment, especiallj' when
skin healed, very useful when eczema attacks
hairy parts of face, sometimes well to mix it
with tar ointment.

Milk, 135. With water as local application.

Oil of cade, 135. Equal parts soft soap, recti-
fied spirit and oil of cade night and morn.

Oils and f.\ts, 238. To prevent irritation from
the discharge, generally mi.\ed with oxide of
zinc.

Simple oils facilitate the removal of scabs.

Paraffin and v.aseline, 133. For eczema.

Petroleum and vaseline, 253. For chronic
eczema.

Potato poultice, 66. Cold, sprinkled with pow-
der composed of camphor, talc and oxide of
zinc, when much inflammation and sensation of
heat, or the powder alone may be dusted over
the surface.

Poultices, 63. If skin is much inflamed.

Salicylic .\cid, 449. As lotion.

Silver mtr.\te, 188. To be painted on limited
patches, most serviceable after weeping stage.

Soap, 135. Moist, weeping surface to be washed
with soap and water night and morn.

Sulphides, 92, 93. As baths, not in acute stage.

Sulphur, 92. Internally.

Tar, 256. In treacle, pills or capsules, from three
to fifteen min. for a dose in chronic eczema.

Turkish bath, 58.

Vaseline, 253. When skin dry and hard in
chronic eczema.

War.m bath, 52. Especially in acute stages —
rain-water best.

Yolk of egg, :35. With water as local applica-
tion.

2inc, 208. The ointment of the oxide as a mild
stimulating application after inflammation sub-
sided when raw surface indolent.

Oxide and carbonate used as dusting powders,
generally greasy applications better. (See
P- 152-)

EMETICS, DEPRESSION FROM.

Ammonia, 148. Combined with other emetics to
obviate depression.

EMISSIONS. {See Spermatorrhea.)

EMPHYSEMA. {See Bronchitis.)

Arsenic, 226. For emphysematous persons who
on catching cold are troubled with slight
wheezing and some dyspnoea. If bronchitis or
dyspnoea very severe, lobelia or belladonna
better. Arsenic especially useful where this
affection can be connected with the recession
of a rash.

Chloral, 284. For the shortness of breath
brought on in emphysematous persons by catch-
ing cold. If obstructed circulation, caution
required.

CoD-LivER oil, 243. Checks degeneration.

EMPHYSEMA.— ^^;;//«M^a'.

CuBEBS, 308. 3 ss to 3 j of tinct. thrice daily in
linseed tea often cures cough " like a charm."

Lobelia. 427. Allays the dyspnoja which accom-
panies capillar)' bronchitis in emphysema.

Purging, 460. In obstruction of right heart.

EMPYEMA.

Carbolic acid, 258. A weak solution to be

injected after evacuation.
Chlorine solution, 99. For washing out

cavity.
Iodine, 102. Solution to be injected after tapping.

ENERGY, LACK OF.

Turkish b.^ths, 59. Useful to town-dwellers,
with soft flabby tissues and mental depression.

ENURESIS. {See Incontitietice of Urine.)

EPIDIDYMITIS.

Oleate of mercury and morphia, 194. Locally.

EPILEPSY.

Arsenic, 230. Sometimes useful.

Belladonna, 392. For method (see ref.).

Bromides, 115.

Copper, 207. The salts have been given.

Counter-irritation, 81.

Musk, 260. Has been given.

Nitrite of amvl, 295, 296. As inhalation or in

two to five min. doses in mucilage, especially

where fits are \-er>' frequent.
Nitrite of sodiu.m, 300. In 3j doses thrice

daily.
Nitro-glycerine, 300. In epilepsy and the

status epilepticus.
Paraldehyde, 287.
Silver, 190. Nitrate or o.xide occasionally given

' with benefit.
Spinal ice-bag, 69.
Valeri.-vn, 310. Has been used with occasional

advantage.
Zinc, iog. As oxide or sulphate — bromide of

potassium better.

EPISTAXIS. {See Hemorrhage.)

Aconite, 345. Small and frequent doses often
quickly check epistaxis in children and plethoric
people.

Alum, 170. May be injected or snuffed up in
powder.

Cocaine, 439. Locally in hamorrhage from nasal
mucous membrane.

Compression of facial artery, 326.

Digitalis, 355. The infusion best.

Ergot, 430. Hypodermically if urgent in two to
five grain doses. May also be given by the
stomach.

H.\.MAMELls, 252. (See Haemorrhage.)

Hot foot-b.ath, 52. With or without mustard.

Ipecacuanha, 326.

Spinal hot-w.\ter bag, 69. To cer\ical and up-
per dorsal vertebrae.

ERUCTATIONS, OFFENSIVE.

Mineral acids, 126. To correct the oxaluria
on which the eructations depend.

INDEX TO DISEASES.

497

ERYSIPELAS.

Aconite, 344. Administered at commencement,
often at once cuts short the attack.

Very useful in the erysipelatous inflammation
following vaccination — belladonna ointment
may likewise be used.

Ammonium carbonate, 149. In typhoid condi-
tion.

Belladonna, 394. Internally and externally
may be used with aconite.

Carbolic acid, 258. Hypodermically (see ref.).

, 257. A one per cent, solution on

lint frequently renewed relieves pain.

Collodion, 236. Painted over superficial ery-
sipelas, but this often cracks and is inferior to a
solution of nitrate of silver in water or in
nitrous ether.

Digitalis, 355. Infusion locally.

Hot fomentations, 67. When limb extensively
aflected.

Iodine, 100, 102. Paint affected and circumjacent
skin with solution to prevent spreading.

Iron, 173. Tincture locally, especially in vac-
cinal form.

, 177. Large doses of perchloride very

fiequently.

Permangan.\te, 178. Has been given internally.

Salol, 453. As dusting powder with talc.

Silver, nitrate of, 188. The skin to be well
washed with soap and water, then with water,
and to be wiped quite dry — next a solution of
eighty grs. of the brittle stick to four drms. of
water, to be applied two or three times to
inflamed surface, extending two or three inches
beyond it.

Sulphurous acid, 131. Equal parts of P.B. acid
and glyoerine.

EXHAUSTION.

Ammonia, 149. Internally its influence is but

brief.
Cocaine, 440. Internally in nervous exhaustion.
Coffee, 432, 433. Or tea, both in hot and cold

climates.
Phosphorus, 235. For physical and mental

exhaustion. Influence questionable.

EXOPHTHALMIC

Goitre.)

GOITRE.

{See

{See Conjunc-

EYE, DISEASES OF.

tivitis.)

Atropia, 388. In iritis locally. Hypodermically
in glaucoma.

Belladonna, 388. Locally and internally in iritis,
conjunctivitis, and other inflammations.

Blisters, 84. Behind ear or to temple in rheumat-
ic, gouty and simple inflammation — blistering
paper enough. Obstinate forms of tinea tarsia
sometimes yield to flying blisters on the temple.

Castor oil, 246. Applied to allay pain from an
irritant, as sand.

Chloroform, 269. Vapor of, close to a photo-
phobic eye, relieves.

Cocaine, hydrochlorate, 438. Instillation of
a four per cent, solution as local ansesthetic in
various operations, sometimes injection re-
quired. Discs are a useful form. Ihe mydri-
atic effect may be neutralized by pilocarpine.

Mercury, bichloride of, 205. Of great service
in iritis.

and morphia, oleate of, 154. Out-
side the eyelids in palpebral conjunctivitis and
hordeolum ; also in syphilitic iritis.

Strychnia, 420. Hypodermically in muscular
asthenopia, amblyopia, tobacco amaurosis, and
in progressive nerve atrophy not dependent on
intra-cranial disease, also in traumatic amau-
rosis.

F^CES, HARDENED.

Enemata, 74. A tube may be passed through

the mass (see ref.).
Extraction, 74. By finger.

FAINTINGS.

Alcohol, 266. As brandy or wine when heart

suddenly enfeebled from fright, etc.
Ammonia, 148. Breathed into the air-passages.

, 149. Internally.

Chloroform, 270. Internally, but effects more

transient than those of alcohol ; — often given to

hysterical people.
Cold water 37. Sprinkled on face.
Position. 266. Patient should lean forward with

the head as low as possible between the legs.

FATIGUE.

Act.«a, 338. For headache from over-study or

excessive fatigue.
Arnica, 45. A few drops of tinct. internally for

aching of muscles.
Coffee, 432. And tea both in hot and cold

climates.
Cold water, 44. Rubbing with wet towel.
Dripping wet cold sheet, 45. As a restorative

and to prevent aching of muscles.
Ether, 278. For syncope.
SiTz bath, 43. At 60° to 80°.

FAVUS. {See Tinea.)

FEVER, CHRONIC.

This occurs tn Abscess^ Ague^ Leucccyihaittia,
Phthisis, Kheumatistit, Syphilis ; see under
each heading, also p. 24.

FEVERS, ACUTE.

Condition 0/ pulse, see pp. 4-15.
Condition 0/ skin, see pp. 15, 16.
Remarks on tetnperature, ivith hints as to

diagnosis, see pp. 17-24.
Condition 0/ tongue, see pp. 1-4.

Acetate of ammonia, 149. Is a good diapho-
retic, and is especially useful in the milder
forms, as in common catarrh.

Acid drinks, 71. Such as raspberry vinegar,
citric, or tartaric acid. (See also p. 125.)

Aconite, 15. In small often-repeated doses while
temperature high and skin hot and dry — most
successful when no lung complication. Where
there is, tartar-emetic better.

, 341. Has a marvellous power of con-
trolling inflammation and subduing fever.

Alcohol, 2. When nervous depression, indicated
by dry tongue, delirium, and sleeplessness.
When wakefulness is the cause, it is better to
try soporifics first.

, 7. When pulse shows cardiac weak-
ness. Effect on pulse to be watched. ,

, 15. May be indicated by profuse

sweating at commencement (see ref.).

266. When tongue and skin become

moist, the breathing more tranquil, and sleep
gained under its use. For rules see ref.

Alkalies, 144. Citrates and acetates are consid-
ered as febrifuge. They possibly eliminate
urinary waters.

Ammonium carbonate, 149. In typhoid condi-
tions of all fevers. Also given through whole
course of scarlatina and measles (see ref.).

498

INDEX TO DISEASES.

FEVERS, AC\]i:Y.—conli,tued.

Antimony, 212. Tartar-emetic wine as a diapho-
retic; large doses are given by some to cut short
acute specific fevers and inflammations. Ague
may sometimes be cured by antimony, and this
often assists quinine in curing it. Ipecacuanha
and other emetics should be preferred.

, 214. When much excitement and

delirium, tartar-emetic in full, with opium in
small doses, but if wakefulness predominates
with not very boisterous delirium, the antimony
to be reduced, and the opium increased.

Antipyri.ne, 453. To reduce temperature.

Arsenic, 226. Sometimes given in prostrating
acute fe\-ers to strengthen pulse and invigorate
patient.

Bell.\donna, 394. In delirium.

BiiTERS, 125. As orange-peel or cascarilla mi.\ed
with acid drinks to quell thirst.

Blisters, 81. Flying, or mustard poultices in
the semi-comatose state sometimes following
fevers, &c.

Camphor, 302. In adynamic fevers and where
there is delirium.

Carbolic acid, 259. Inferior to other antipy-
retics.

Castor oil, 246. As purgative.

Chloral, 283. In violent delirium of typhus.

Cold afflsion, 47. At the beginning of acute
fevers.

, 57. Applied gently over fore-
head for headache.

Cold b.aths, 46. 47. Employed early diminish
frequency of pulse, strengthen heart, prevent
delirium, produce sleep, lessen risk of bed-sores
or exhausting suppuration. The only remedy
in hyperpyrexia (see p. 48).

Cold doiche. 57. In insomnia.

Cold packing, 44. In specific fevers and acute
inflammatory diseases — especially useful on
retrocession of the rash.

CoNii'M, 363. Has been recommended as it re-
duces the frequency of the pulse.

Digitalis, 355. Large doses often required to
reduce temperature, much used in fevers on the
continent, especially recommended in typhoid.

Ether, 278. F"or prostration from fever.

EfC.\LYPTUS, 309. In intermittent, but inferior
to quinine.

Glycerine, 247. For keeping moist the lips,
tongue and gums when dry, and coated with
mucus in acute diseases.

Hot AFFi'SiON, 57. Over forehead for headache,
sometimes better than cold.

Ice, 71. To be sucked for allaying thirst.

IcE-B.\G, 57 and 67. To forehead for head-
ache.

MrsK, 261. And castoreum have been given in
fevers to prevent prostration.

, 261. With laudanum in acute specific

fevers.

MisTARD, 314. As bath on recession of the rash
of an eruptive fever.

N.\RCOTics, 2. Chloral, bromide of potassium or
opium when ner\-ous depression, indicated by
dry tongue or delirium with sleeplessness.

Oprm, 414. For delirium, either noisy or mut-
tering, with picking of bed-clothes. If furious,
tartar-emetic should be combined with the
opium. Morphia hypodermically is often the
best way of administering an opiate. In ex-
treme weakness with sleeplessness, and brown,
<iry tongue, laudanum helps a patient over the
critical stage with less alcohol than would
otherwise have been required.

Phenacetin, 455.

Phosphate of lime, 156. In hectic.

QiiNi.\, 446. Especially in typhoid, but little use
as anti pyretic except in rheumatic fever.

Salicylic acid and s.\licvlate of soda, 450,
451. In large (one drachm) doses every night,
or in smaller and more frequent doses, reduce
temperature in most febrile diseases, especially
in rheumatic fever.

FEVERS, ACVTY.— continued.

Strychnia, 419. Hypodermically for paralysis

after low fevers.
Sulphate of magnesia, 164. Or phosphate of

soda as purgative (see ret.).
Tart.ar emetic, 212. Wine as diaphoretic in

fevers.
Veratrum viride, 328. Has been employed.
Warm b.\th or warm sponging, 51. In simple

fe\'er of children.

FISSURE.

Belladonna, 387. The extract locally.
Bro.mide of potassium, 114. In five parts of

glycerine as local application in fissures of

rectum.
Castor oil, 246. In fissure of anus.
Ice, 68. As a local application to remove pain

after operation.
Opium, 411. With a gall ointment for fissures of

anus. Mild purgatives should be simultaneously

employed.
Sulphur, gi. As a mild purgative to cause soft

motions.

FLATULENCE.

Abstention from sugar and starchy food,
87, 88. Also from tea.

A.mmonia, 148. In alkaline preparations for flat-
ulent distension of stomach and intestines
(palliative).

Ass.\FCETiDA, 311. When unconnected with con-
stipation or diarrhoea — useful for children, — one
drachm of a mixture of one drachm of the tinct.
to half a pint of water.

Bismuth, 88 and 180. Mixed with charcoal in
flatulent dyspepsia.

C.\LABAR bean, 367. At change of life.

Capsicu.m, 316.

Carbolic acid, 258. Most successful when no
acidity.

Carlsbad water, 162. Where acidity, constipa-
tion and pain at epigastrium, over liver or
between shoulders, with sallow complexion and
jaundiced conjunctivae.

Charcoal, 86. Five or ten grs. soon after meal,
if wind half-hour or more after, but just before
meal if wind formed during or immediately after
it. Obviates both wind and acidity.

Chloroform, 270. Drop doses, pure.

Essenti.'\l oils, 307. Especially of cajeput and
cloves, or spirit of horse-radish.

Eucalvptol, 309. In change of life.

Glvcerine, 248. In tea or coffee with food.

Hot-water, 73. A tumbler between meals.

Ipecacuanha, 320. When constipation, depres-
sion and weight on stomach, especially in preg-
nancy.

Mercury, 200. Half a grain three times a day
when flatulence accompanied by clayey stools.

Nux vomica, 87 and 424. When constipation,
heartburn and weight on head.

SULPHO-CARBOLATES, 258. MoSt SUCCeSSful whcH

no acidity.
SuLPHO-CARBOLATE OF SODA, 258. Or carbolic

acid in flatulence occurring immediately after

meals, also when accompanied by " spasms ; '

here, however, phosphorus better.
Sulphurous acid. 132. In five to ten min. doses

when produced by fermentation.
Turpentine or assafcetida, 76. One or two

tablespoonfuls of turpentine well mixed in

injection.

FLUSHING HEATS.

Bromide of potassium, 118. Where mental de-
pression at change of life.
Eucalvptol, 309. In change of life.

INDEX TO DISEASES.

499

FLUSHING Yl'EA.T?>— continued.

Nitrite of amvl, 298. A tenth to a sixth of a
minim in thirty times its volume of rectified
spirit.

Nux VOMICA, 417. The tinct. combined with
small quantities of laudanum in so-called hys-
teria of middle-aged people with flatulence,
weight on head and perspirations.

Valerli^nate of zinc, 3in. At change of life.
Some prefer valerian or its tincture.

GAti-S TONES.

Carlsbad waters, 163. A system required.

(See ref.)
Chloral, 284. Sometimes relieves the pain.
Chloroform, 277. Internally.
Gelsemium, 382. Five drops of the tincture

every quarter of an hour. Relief quicker if

patient walk about.
Phosphate of soda, 164. To prevent formation.
Soda, carbonate of, 382. A teaspoonful in a

tumbler or two of hot water.

GANGRENE.

Carbolic acid, 257. Locally.

Charcoal, 86. Poultices — efficacy doubtful.

GASTRALGIA AND GASTRITIS.

{See Stomachy diseases of.)

GIDDINESS.

Cod-liver oil, 243. In giddiness of the aged
when no serious brain disease.

GLANDS, ENLARGED.

Blisters, 84. Or iodine, loi.

Creasoie, 257. Has been employed in diseases
of glands.

Iodide of potassium, 107. As ointment.

,111. For mamma and tes-
ticle, but especially for thyroid.

Iodink, 102. Tincture injected into gland itself.

Mercury and morphia, oleate of, 194. In
obstinate and painful tonsillitis and inflamma-
tion of lymphatic glands.

Soft-soap, 138. Applications in both scrofulous
and non-scrofulous and syphilitic enlargements.

Sulphide of calcium, 95. For hard, swollen
glands behind angle of jaw with deep-seated
suppuration.

GLAUCOMA. {See Eye, diseases of.)

GLEET.

Bismuth, 181. (See Gonorrhoea.)

Blister, 84. To perinseum in obstinate gleet.

Cantharides, 312. Drop doses.

Copaiba, 308.

Copper, 208. Solution of the sulphate as injec-
tion.

Eucalvptol, 309. In chronic catarrh of passage.

Glycerine of tannin, 251. With an equal
quantity of olive oil or mucilage as injection —
two drachms of this mixt. enough. Persevere
eight or ten days after discharge ceased, and
do not use at bedtime.

Iron, 178. (See Gonorrhoea.)

Lead, 182. (See Gonorrhoea.)

Lime-water, 154. As injection.

Oil of sandal wood, 309. Fifteen minims
three times a day.

G LEET — continued.

Turpentine, 306.

Zinc, 197. Half a grain bichloride of mercury in
water.

, 208. The sulphate or chloride as injec-
tion.

GOITRE.

Belladonna, 392. Five min. of the tinct. hourly,
of great service in exophthalmic goitre.

Iodide of potassium, hi. Internally and ex-
ternally in hypertrophy of thyroid.

Iodide, 102. Tinct. hypodermically into the
gland Itself.

, loi. Liniment applied as often as state

of skin will permit.

Mercury, biniodide of, 195. As ointment as-
sisted by the sun's rays, remarkably useful in
India. (See p. 196.)

GONORRHCEA.

Aconite, 345. A drop of the tincture each hour
in acute stage.

Alkalies, 144. As citrates or bicarbonates to
make urine alkaline.

Avoidance of alcohol, 268. Very important.

Bismuth, 181. Half an ounce with equal weight
of glycerine and three ounces water, useful as
injection in chronic stage.

Blistering, 85. A flying blister every night for
gonorrhoeal rheumatism.

Cannabis indica, 429. Occasionally useful.

Cantharides, 312. Drop doses.

Cocaine, 440. Injection of a few drops of two
per cent, solution. (See ref.)

Tampons soaked in cocaine relieve pain of
blenorrhoea.

Copaiba, 308. Best in chronic form.

Copper, sulphate of, 208. Solutions are em-
ployed as injections.

Cup.ebs, 308. In large doses at commencement.

Glycerine of tannin, 251. One drachm with
equal quantity of olive oil or mucilage, as in-
jection in after stages. Persevere eight or ten
days after discharge ceased. Do not use any
urethral injection at bedtime.

Iron, 178. I'inct. perchlor. half a drachm, tinct.
opii one drachm to a pint of water as injection,
or ferr. sulph. gr. xii., tinct. opii half oz. to
eight ozs. of water to be used three times a
day.

Lead, 182. As injection sometimes employed.

Oil of sandal wood, 309. Fifteen min. three
times a day in acute and chronic gonorrhoea.

Silver, nitrate of, 191. An injection of twenty
grs. to the oz. said to cut short the attack — or
one of one or two grs. to the oz. may be used
several times a day.

Probably tannin is better both for gonorrhoea
and gleet.

Sulpho-carbolate of zinc, 260. Twenty grs.
to eight ozs. of water as injection two or three
times a day.

Turpentine, 306.

Zinc, 208. A grain or two of chloride in a pint
of water injected hourly, often removes the
disease in twenty-four to forty-eight hours if
used at the commencement. Rest should be
observed if possible If the frequent injection
causes pain in testicles, suspend them in hot
water and foment them frequently —if, notwth-
standing, the pain and swelling increase, use
injection less often.

GOUT.

Aconite, 344. For gouty pains.
Alkaline poultice, 67. Nine parts linseed
meal to one bicarbonate of soda.

500

INDEX TO DISEASES.

GOUT — continued.

Antipyrine, 454. Hypodermically in acute gout.

Blisters, 85. A flying blister every night in
chronic or subacute gout.

Brine baths, 52. At Droitwich very useful.
Also brine baths at home.

Carbonate of lithia, 137. Five grs. to the oz.
on lint applied round gouty enlargements and
joints, especially if skin broken.

Calsbad waters, 163. A system required. (See
ref.)

Citrate of lithia or of potash, 138. Used in
same way as the carbonate of lithia when skin
broken.

Cod-liver oil, 243. In chronic gout.

Colchicum, 332. A drachm of the wine often
removes the severest pain in an hour or two.

Useful in bronchitis, asthma, urticaria, dys-
pepsia, &c., occurring in gouty persons.

CoLLODKJN, 236. The contractile variety with
or without iodine, painted over inflamed part
in acute gout, soon relieves the pain. Too
many coats must not be applied.

Gu.MACUM, 336. Has been used.

Iodide of potassium, hi. Especially when
pain worse at night.

Iodine, 100. Pamted round joints in chronic
gout.

Iodoform, 279.

Oil of peppermint, 306. To be painted on
painful part.

Packing, 44.

Strychnia, 419. Hypodermically for later stages
of gout paralysis.

Sulphides, 92. As baths in chronic gout.

Sulphurous acid, 131. After fumigation, pa-
tient to be covered with bed-clothes which have
been exposed to strong fumes ; this produces
perspiration, sleep and relief.

Turkish baths, 60. In subacute and chronic
gout.

Hot followed by cold sponging may be use-
ful as a substitute.

Veratria, 330. A strong ointment to painful
joints at onset.

HAY FEVER. {See Coryza.)

H/EMATEMESIS. {See Hccmorrhage.)

Alum, 171. Other astringents better.
Ergot, 430. (See Haemorrhage.)
Hamamelis, 252. (See Haemorrhage.)
Ice, 68. To be sucked.
Iron, 172. The astringent preparation.
Lead, 182. Soluble compounds sometimes used.
Sulphuric acid, 127. Other astringents surer.
Tannin or gallic acid, 250.
TuRPENTiNK, 304. In five to ten drop doses very
frequently.

HiEMATURIA.

Camphor, 312. Two to five grains when bloody,
coagulable urine due to oil of mustard, turpen-
tine, copaiba, or cantharides.

Cannabis indica, 429. Said to relieve dysuria
and strangury. Bloody urine considered by
some to be a special indication for its use.

Hamamelis, 252.

QuiNiA, 448. Useful in some cases of intermit-
tent haematuria.

Tannin or gallic acid, 250.

Turpentine, 304. In very small doses.

HEMOPTYSIS. {See I/u-tfiorr/ia-r.)

Common salt, 159. Half a teaspoonful taken
dry and repeated occasionally, till nausea in-
duced.

Digitalis, 355. The infusion in large doses very
useful.

UMUOVTY'^.l'i— continued.

Ergot, 430. Thirty or forty min. of the liquid
e.xt. every three or four hours or hourly in
severe cases. Ergotine should be used hypo-
dermically in very urgent haemorrhage, in two
to five gr. doses.

Hamamelis, 252. (See Haemorrhage.)

Ice, 68. To be sucked.

Ipecacuanha, 326.

Iron, 173. The acetate. (See Haemorrhage.)

Morphia, 408. Small doses hypodermically have
been employed successfully.

Spinal hot-water bag, 70. To cervical and
upper dorsal vertebrse.

Sulphuric acid, 129. Supposed to be useful.

Tannin or gallic acid, 250.

Turpentine, 305. In drachm doses every three
hours. This may, however, cause unpleasant
symptoms.

HEMORRHAGE.

Acids. 124, e. g.. Diluted vinegar to leech bites,
piles, cuts, &c.

Alcohol, 266. Brandy or wine when heart sud-
denly enfeebled by haemorrhage.

Alum, 169. In slight haemorrhages, as leech
bites or piles, it may be dusted on after wiping
dry.

, 171. Will often check bleeding from

stomach ; other astringents better.

Blood, 470. Fresh for prostration.

Copper, sulphate of, 206. In stick, solution,
or ointment, to arrest bleeding from small
vessels.

Creasote, 257. Or carbolic acid.

Digitalis, 355. The infusion best — large doses
may be needed.

Ergot, 430. Most valuable for haemoptysis,
epistaxis, haematemesis and intestinal haemor-
rhage in typhoid fever. In urgent cases ergo-
tine should be administered hypodermically in
from two to five gr. doses. In less urgent
cases It may be given by the stomach.

Ether, 278. Hypodermically in heart failure
from haemorrhage.

Hamamelis, 252. In haemoptysis, haematemesis,
htematuria, epista.xis, bleeding piles, varicocele,
and the oozing of blood persisting after a con-
finement. Dose, one or two minims of the
tincture every two or three hours.

Ice, 68. In haemorrhage generally ; when from
stomach small pieces to be swallowed.

Ipecacuanha, 326. In flooding after delivery.

Iron, 172, 173. The sulphate and ferric chloride
solid or in solution. The chloride controls
bleeding from small vessels, but irritates the
surface of wounds and prevents union by first
intention, which carbolic acid does not.

, 173. Spray of subsulphate or insufflation

of powdered sulphate in bleeding from nose
or lungs.

, 173. Astringent preparations in haemor-
rhage of stomach.

, 177. In haemorrhage from lungs and kid-
neys the acetate is best ; add sufficient water
to make it taste, but not disagreeably, and let
patient constantly sip this.

. 177. Injection of perchloride in postpar-
tum haemorrhage.

Lead, 182. The liquor may be used to check
haemorrhage from small vessels ; other as-
tringents better.

Opiu.m, 418. Tr. of opium in a large dose (one
drachm) with brandy in profuse flooding after
parturition.

Quinia, 448. In passive bleeding.

Saline transfusion, 154.

Silver, nii rate of, 187. Bleeding leech bites
may be touched with a stick of caustic.

Spinal hot-water bag, 71. Apply to cervical
and upper dorsal vertebrae for epistaxis or
haemoptysis.

INDEX TO DISEASES.

501

KJEUORRHAGE—cc»itimie</.

Sulphuric acid, 127. In bleeding from stomach.

, 129. Supposed to check hoEraor-

rhage from lungs or womb.

Tannin, 250. In haemorrhage from stomach,
lungs, uterus and kidneys.

Transfusion, 154. Of saline fluid.

— — , 470. Of defibrinated blood.

Turpentine, 305. A drachm every three hours
when from lungs, nose, uterus or bladder. If
from kidneys much smaller quantities must be
given.

Reported to be useful in hsemorrhagic dia-
thesis.

HAEMORRHAGE, POST-PARTUM.

Compression of aorta, 326. Might possibly
be of service.

Ice, 68. Pushed into uterus or rectum.

Ipecacuanha, 326. Large doses recommended.

Iron, 177. Perchloride, diluted, as injection.

Mechanical ex-citation of vomiting, 32 >.

Opium, 418. 3 j with brandy when much ex-
haustion of uterus.

HEMORRHOIDS. (See Files.)

HEADACHE. (See Sick Headache.)

AcT/EA racemosa, 337. In nervous or hysteri-
cal women, especially when it occurs at the
menstrual period ; also when from over-study
or fatigue.

Ammonia, 148. (See Change of Life.)

Aksenic, 230. For throbbing pain in one brow.

IjElladonna, 394. When pain over brows and
in eyeballs — often due to stomach or uterine
derangements — met with especially in young
women. Three minims of the tincture every
three hours.

Bit.artrate of potash, 163. Sulphate of soda,
and tartrate of potash and soda control head-
ache.

Bromide of potassium, 118. A large dose in
nervous or sick headaches.

Camphor, 301. A saturated solution in eau de
Cologne rubbed on the head in headache of
uterine origin.

Chloride of .\mmonium, 159. When due to
menorrhagia or amenorrhoea.

Citrate of caffeine, 435. For sick headache.

Cold affusion, 57. Water poured gently over
forehead, sometimes warm affusion better.

Ether spray, 69. P"or frontal headaches after
acute illness or fatigue.

Friedrichsh.all w.-\ter, 161. A wineglassful in
a breakfast-cupful of hot water in bilious sick
headache.

Hot sponging, 52. To face, temples, and neck
in influenza, catarrh, &c.

Hot water, 52. To feet and legs.

Ice-bag, 67. i'o head.

Mercury, 205. As blue pill for sick headache.

, 205. A looth of a grain of bichloride

three times a day when sick headache accom-
panied by a light-colored diarrhoea. (See also
p. 2.)

Mustard, 314. In a hot foot-bath, or as poultice
or "mustard leaf" to nape of neck in various
forms of headache.

Paraldehide, 287. In cerebral tumors.

Podophyllum, 335. In nervous headaches near

the menstrual periods with constipation and

dark stools. Purgative doses often give relief.

(See also p. 2.)

Salicyl.\te of soda, 451. Useful in 15-20 gr.

doses.
Sitz-bath, 43. At 60° to 80°.
Tea, 433. And coffee in headaches from ner-
vousness or e.xhaustion.

H E AD AC H ¥.— continued.

Veratrum viride, 328. Tincture in the con-
gestive headache at the menstrual period.

Zinc, oxide of, 210. In two to five grain doses
for nervous headache. Bismuth also useful.

HEART, DISEASES OF. (See Angina
Pectoris.)

Aconite, 340. When violent throbbing and ex-
treme pain in pericarditis.

Adonidin, 360. Similar to digitalis — useful in
mitral disease.

Alcohol, 266. Brandy or wine when heart sud-
denly enfeebled by fright, loss of blood, acci-
dent, etc.

Arsenic, 226. For breathlessness on exertion
from weakly-acting heart.

Blisters, 82. Flying, over prsecordial region to
stimulate the action of the heart in extreme
weakness.

Cocaine, 441. In palpitation of dilated atonic
heart.

Cod-liver oil, 242. In chronic inflammation.

, 242. With quinine, for giddiness

due to weak heart in the aged.

Convallaria, 357. Somewhat similar in action
to digitalis.

DiGiTAiis, 347. Of eminent service where
dropsy, dyspnoea, livid face, frequent irregular
pulse and dilatation of left ventricle. The
freshly-made infusion best. These cases re-
quire alcohol — gin best.

, 350. Where much dilatation and

hypertrophy of left ventricle without valvular
disease. It is not contra-indicated when aortic
disease.

, 350. Where, though the heart beats

tumultuously and strongly, the pulse is weak
and dyspnoea great.

, 340. Irregularity of pulse best indi-
cation for digitalis.

, 351, 352. A slight palpitation much

increased by catching cold often cured by digi-
talis — sometimes aconite better.

Da Costa strongly recommends

'■ ' 351- . . , - .

digitalis for "irritable heart." (See ref.)

, 352. Very useful in pure hyper-
trophy due to valvular disease or excessive
muscular exertion. Also in aortic regurgitant
disease when compensatory hypertrophy ex-
cessive, 352. Two to five minims of the tincture
enough — aconite often better.

Elaterium, 457. In dropsy. Caution needful.

Ether, 278. Hypodermically in heart failure
(see ref.).

Morphia, 407. Hypodermicilly for dyspnoea of
disease of heart and large vessels and of in-
trathoracic tumors. More useful in mitral
than in aortic disease.

Nitrite of amyi., 294. In cardiac dyspnoea due
to hypertrophied and dilated heart ; also in
syncope.

Poi'LTicES, 63. Large, hot, and frequently re-
newed, in pericarditis.

Purging, 460. With jalap, etc., in engorgement
of right side of heart from emphysema and
bronchitis, mitral obstructive or regurgitant
disease. Where severe headache and pain at
epigastrium, bleeding gives instant ease.

In persistent tricuspid regurgitation from
permanent distension of the right heart ; pur-
gatives only useful when an attack of bron-
chitis causes an exacerbation, 461.

Sparteine, 359.

Strychni.\, 423. In medicinal doses it is said to
strengthen the heart beats.

Strophanthus, 358.

Veratria, 330. As ointment to chest when rapid
irregular pulse, hurried breathing, much lividity
and dropsy, palpitation and inability to lie
down.

502

nSTDEX TO DISEASES.

{Sc'e Stomach, Dis-

HEARTBURN.

cases of.)

HERNIA.

Chloroform, 276. Inhalation to assist reduc-
tion.

HERPES.

Acetic acid, 123. Applied to a patch of herpes

circinnatus to cut it short.
Blisters, 83. For obstinate neuralgia following

shingles.
Collodion, 236. Painted over patches before

vesicles developed, but inferior to nitrate of

silver.
Hot fomentations, 67. Will often disperse or

restrict development of herpes labialis.
Iodine, 102. Liniment once applied enough for

herpes circinnatus. #

Morphia, oleate of, 195. Locally without

friction in herpes zoster.
Silver, nitrate of, 188. To be painted on the

warning patch of erythema, before or as soon

as the vesicles begin to form.
Veratria, 329. The ointment, one scruple to

two scruples to the ounce in neuralgia follow-
ing shingles.

HICCUP.

Apomorphia, 327.

Camphor, 303.

Chloroform, 270. Often combined with opium.

Morphia, 408. Hypodermically often arrests

persistent hiccup.
MiSTARD, 315. A drachm infused in four ounces

of boiling water has cured most obstinate cases.
NiTRO-GLVCERiNE, 300. Sometimes cures.

HOARSENESS.

Alum, 171. Ten grains to one ounce of water in
chronic coughs and hoarseness as spray.

Borax, 138. A piece the size of a pea allowed to
dissolve in the mouth.

Glycerine of tannin, 250. Locally in chronic
inflammation of the throat.

Ipecaclanha wine, 325. As spray when con-
gestion of vocal cords.

Sllphlrous ACID, 131. Inhalation, spray, or
fumigation, in clergymen's hoarseness.

Tl'Rkish BATH, 59. At commencement of a
feverish cold will often cut it short, together
with the accompanying hoarseness.

HORDEOLUM.

Mercury' and morphia, oleate of, 194. The
20 per cent, ointment with lard outside the eye-
lid.

HYDROCEPHALUS.

Croton oil, 246. Said to remove fluid from
ventricles.

HYDROCELE.

Iodine, 102. Tincture to inject into cavity after

paracentesis.
Tincture, 102. To inject.

HYDROTHORAX. {See Pleurisy.)

Pilocarpine, 374. Probably useful in removing
effusion.

HYPERESTHESIA.
Bromide of potassium, 118, 120.

HYPOCHONDRIASIS.

Bromide of potassium, 117. Where great des-
pondency amongst males but especially amongst
female subjects who live in towns.

HYSTERIA.

Aconite, 345. For " fluttering of the heart " in
nervous persons.

AcT.t.'^, 337. For headache.

Alcohol, 265. With plenty of volatile ether ; —
care must be taken that it does not lead to
tippling.

Apomorphia, 327.

Assafcetida, 311.

Bro.mide of potassium, 120. Gives control and
prevents paro.\ysms. When verging on nym-
phomania large doses required.

CANNABIS Indic.\, 429. In some cases.

Chloroform 270. Often combined with opium.

Cod-liver oil, 243. In middle-aged people with
dyspepsia or "craving " at epigastrium.

Iron 177. A course often useful, especially
when anaemia or uterine obstructions.

Morphia, 415, 416. Hypodermically when flit-
ting neuralgia with great depression.

Musk, 260. Has been given.

Nux vo,Mic.\, 424. The tincture, especially when
combined with small quantities of laudanum,
of great use in the so-called hysteiia of middle-
aged people, with flatulence, weight on head,
flushings and hot and cold perspirations.

Opiu.m, 417. A drop of laudanum with two of
the tr. of nux vomica three or four times a day
for weight on head with flushings, perspira-
tions, depression, &c.

Par.\ldehiue, 287. As hypnotic dose, 30 to 50
min.

Phosphorus, 233. In hysterical paralysis.

Valerianate of zinc, 310. Especially at the
change of life,

Volatile oils, 307.

Zinc, 210. Especially the valerianate in some
forms of hysteria.

ICHTHYOSIS.

War.m bath, 51.

IMPETIGO.

Glycerine of tan.nin, 248.

Oils, 238. To facilitate removal of scabs.

Poultices, 249. At night, to remove scabs.

QUINIA, 448.

Sulph.xte of copper, 206.

Sulphur, 92. Internally.

Zinc, 208. The ointment of the oxide after in-
flammation subsided, when raw surface indo-
lent ; oxide and carbonate used as dusting pow-
ders, but greasy applications generally better.

IMPOTENCE.

C.antharides, 313. In large doses (twenty or
thirty drops of the tinct. or half a grain of the
powden with iron and phosphoric acid or nux
vomica.

Strychnia, 424. Sometimes useful in large doses
when spermatorrhoea.

INCONTINENCE OF URLNE.

Bell.\donn.\, 394. The best remedy for children
— ten 10 twenty drops of the tinct. three times
a day. If unsuccessful, and no worms or other
irritation exist, try strychnia, cantharides, tur-
pentine, santonine, or galvanism.

N. B. The child should drink but little
some hours before going to bed, and should be
waked in the middle of the night to pass water.

INDEX TO DISEASES.

503

INCONTINENCE, 'E.ic.— continued.

Cantharides, 313. One or two drops of the
tinct. three or four times a day in middle-aged
women or the aged, even when due to paralysis ;
sometimes also in children, but for them
belladonna is generally better.

Chloral, 284. In children.

Collodion, 237. Painted to forma cap over end
of prepuce.

Ergot, 431. Said to be useful.

Iron, 177. Sometimes useful even when no
worms.

Nitrate of potash, 167. Has been recommend-
ed for children.

Strychnia, 424. Sometimes useful for old
people with paralysis of the bladder ; also for
the incontinence of children.

INDIGESTION. {See Dyspepsia.)
INFLAMMATION.

Aconite, 341. Gives most brilliant results when
inflammation not very e.xtensive or severe, as
in catarrh of children, tonsillitis and acute sore
throat. In the graver inflammations, as pneu-
monia, pleurisy, &c., the effects are equally
manifest though less rapid, 343. In pericarditis,
with violent throbbing and extreme pain,
aconite will quiet the undue action and relieve
the pain, 344. It has a beneficial influence in
acute specific fevers ; it is of marked service in
erysipelas and the inflammation sometimes
following vaccination. It is also of use in acute
rheumatism, otitis, and gonorrhoea.

Antimony, 213. Should be given at the begin-
ning a quarter to half a grain every two or
three hours, or a lesser proportionate dose
every hour ; useful in tonsillitis, pleurisy,
orchitis, bronchitis, puerperal peritonitis, in-
flammation of breast, whitlow, &c.

Atropia, 400. In inflammations of eye.

Belladonna, 388.

Cod-liver oil, 242. In many chronic inflam-
mations, as of the heart, lungs and kidneys.

Digitalis, 354. Large doses asserted to be
capable of subduing acute inflammations, if
used at the commencement. (Aconite much
safer and better.)

Fomentations of a small teaspoonful of the
leaves in half a pint of boiling water said to be
valuable for acute inflammation of joints and
of the breast, and for erysipelas. (P. 355.)

EucALYPTOL, 309. In chronic inflammation of
bladder.

Fomentations, 66.

Ice, 67. In very small pieces in a bladder ap-
plied to inflamed part.

Iodine, 102. The liniment in the neighbor-
hood of local inflammation so as to produce
vesication.

Menthol, solution of, 307. Painted several
times a day over inflamed tissue of boils and
carbuncles.

Also for excessive inflammation after vaccin-
ation.

Merciry, 205. Bichloride in iritis, and inflam-
mations of deep-seated parts of eye and in other
inflammations, especially those of serous mem-
branes.

Nitrates, 164. Opinions concerning the efficacy
of these in acute inflammation discrepant.

Opium, 405. Poultices containing laudanum allay
pain in superficial and deep-seated inflamma-
tion. Mqrphia injections sometimes needed in
pleurisy, pneumonia, &c. An extract of opium
has been recommended as a local application
for carbuncles and boils (see p. 408). Opium
wine of the 1864 Pharmacopoeia, which contains
no spices, is very useful in the pain of conjunc-
tivitis dropped into the eye. Opium mixed with
tannin or creasote may be introduced into the
hollow of a painful tooth if the pain is produced
by inflammation of exposed pulp.

INFLAMMATION— fW2//«M^^.

Packing, 44. In acute inflammatory diseases.

Poultices, 62. I o check formation of pus or
assist in maturation.

Sulphides, 95. In boils abscesses, and deep-
seated suppuration.

INFLUENZA.

CuBEBs, 308. 3 ss. to 3 j. of tinct. in linseed tea
for subsequent cough.

Hot sponging, 52. For headache.

Sulphurous acid, 131. Fumigation or inhala-
tion. (See ref.)

INGROWING TOENAIL.

Liquor potass.^:, 136. Diluted, constantly ap-
plied on cotton-wool.

INSOMNIA. {See S/eep/essness.)

Cold douche, 57. A large sponge, soaked with
cold water, iced if possible, is dashed against
the head, face, and chest several times. The
skin is then rubbed dry with a towel.

Paraldehide, 287. Dose 30-50 min. Much less
action on heart than chloral. Useful as hyp-
notic in mania and hysteria.

INTERMITTENT FEVER. {See Ague.)

INTERTRIGO.

Bismuth, 180. Nitrate or carbonate, as dusting

powder.
Camphor, 301. As addition to dusting powders,

to allay heat and itching.
Carbonate of lime, 152. Or oxide of zinc or

bismuth sometimes useful as dusting powder.

More often greasy applications better.
Glycerine of tannin, 249. Sometimes useful.
Lime-water, 152. To prevent irritating urine.
Soap, 136. Free ablution with, when caused by

acid secretions, smear afterwards with greasy

application.

lODISM.

Arsenic, 109. Combined with iodide mixtures
will modify or prevent skin eruptions.

IRITIS. {See Eye^ diseases of.)

IRRITABILITY.

Chloral, 284. Five grains two or three times a
day in irritability with nervousness and rest-
lessness.

Sitz-bath, 43. At 60° to 80°.

ITCH.

Alkalies, 134. As soap or ointment to remove

cuticle and break up burrows.
Baking of clothes, 131. Must not be forgotten.
Iodide of potassium, 107. As ointment.
Storax, 306.
Sulphur, 88, 90. Ung. sulph. after bath. (See

ref.)
Sulphur and lime, 93.
Sulphurous acid, 131. As gaseous bath. This

is the quickest method.

ITCHING. {See Pruritus.)

504

INDEX TO DISEASES.

JAUNDICE. ( See Liver, diseases of. )

Mercikv, 200. In attacks of jaundice lasting
three or four days accompanied by depression
and preceded by sickness and coated tongue,
one-sixth or one-third of a grain of gray powder
taken at the onset and repeated three or four
times a day very valuable. If obstinate con-
stipation, a course of Carlsbad waters some-
times more efficacious.

Phosphate of sou.a, 164. In catarrhal form

JOINTS, DISEASES OF.

Aconite, 344. For pains in inflamed joints.

Aksenic, 231. Often serviceable in rheumatoid
arthritis, and nodosity of joints. Large doses
long continued necessary. Action capricious,
sometimes useless, at others remarkably good.

Cod-liver oil, 242. When strumous.

Cold douche, 57. For stiffness.

Digitalis, 355. As fomentations. (See Inflam-
mation.)

Galvanism, 61. For stiffness.

Iodine, 102. Solution injected into white swell-
ings.

Merci'RV, 193. Locally applied, as Scott's oint-
ment, in chronic inflammation of knee — better
still as oleate of mercury.

Salicviaie of soda, 451. Locally, relieves in-
flamed joints.

Turkish b.\th, 61. For stiffness.

KIDNEYS, EXCESSIVE ACTION OF.

Spin..\l ice-bag, 69.

LAGTATI^N, EXCESSIVE.

Alcohol, 268. As stout often useful — not always.
Belladonna, 383. Internally or externally, or

both.
Quinia, 448. Has been recommended.
Tobacco, 360. With lard extemallv said to arrest

secretion of milk.

LARYNGISMUS STRIDULUS.

Bromide of potassium, 114. When uncompli-
cated except with convulsions.

Cod-liver oil, 243.

Cold sponging, 54. Twice or thrice daily —
sometimes immediately successful — prevents
convulsions. Take care no laryngitis.

Cold water dashed in face, 54. Often arrests
paroxysm.

Lancing gu.ms, 55. If swollen, red and hot, may
require repetition.

Lobelia, 427. Has been employed.

Spi.nal ice-bag, 69.

WoR.vts, removal of, 54, 55. Treat faulty state
of mucous membrane.

LARYNX, DISEASES OF.

Aconite, 341. In spasmodic laryngitis or catar-
rhal croup very valuable.

Caffei.xe, 435. As anaesthetic.

Cocaine, 439. A 20 per cent, solution locally.
As anaesthetic for examinations and operations.

Silver, nitrate of, 189. Powdered or in solu-
tion to chronically inflamed larynx, as in
phthisis.

Sulphurous acid, 131. Inhalation, spray, or
fumigation.

LEAD COLIC. {See Poisoning by Lead.)

LEAD POISONING. {See Poisoning.)

LEPRA. (See Psoriasis.)

LEUCORRHCEA.

Alk.^lies, 122. A weak injection when excessive
secretion from glands of os.

Alum, 172. A drachm to a pint of water as injec-
tion. (See p. 136.)

Bell.adonna, 387. With tannin as bolus where
neuralgia or ulceration of os.

When disease due to over-secretion of mucous
glands about the os, and much pain present,
inject sodse bicarb, one drachm, tinct. bellad.
two ounces, aq. one pint, (hee ref.)

Bicarbonate of potash or soda, 136. One
drachm to a pint of water as an injection, es-
pecially when discharge alkaline and copious.
(See ref.)

BoRACic .\ciD, 137. As lotion.

Carbolic acid, 260. Diluted as- injection for
vaginal leucorrhoea.

Cold sponging, 56.

Copper, 207. Solutions of the sulphate as injec-
tions.

Ergot, 431. Said to be useful in some cases.

Iro.v, 177. Internally.

Lead, 182. As injection.

Lime-water, 152. As injection.

Phosphate of lime, 156.

Spin.-\L ice-bag, 69.

Tannin, 387. As injection. If os ulcerated a
suppository of tannin and cocoa-nut fat to
mouth of uterus.

Zinc, sulph.^te of, 208. Sometimes added to
alum injections.

LICE.

Essential oils, 306. (For formulas, see ref.)
Mercury, 192. Nitrate of mercury ointment or
corrosive sublimate wash for lice on all parts
of the body.

The body louse may be killed by essential oils,
as rosemary, or by powdered pyrethrum, or by
ointment of staphisagna.

The under-linen should always be boiled.
Mercury, 194. The oleate destroys lice immedi-
ately, and simultaneously kills the ova.

LICHEN.

Alk.^lies, 134. (See Pruritus.)

Arsenic, 227. Sometimes useful.

Cantharides, 312. Internally.

Chlorofor.m, 269. As ointment to allay itching.

Cyanide of potassium, 404. Or hydrocyanic
acid. (See Itching.)

Mercury, 192. Calomel and nitrate of mere.
oint. may be mixed, and tar oint. is sometimes
added in patches of obstinate lichen, especially
of the hands, even when not syphilitic.

Silver, nitrate of iSS. The nitrous ether so-
lution to be painted every day or second day on
a patch of lichen the size of the palm with ex-
cessive irritation.

Sulphides, 92. As baths.

War.m bath, 50.

LIVER, DISEASES OF.

Euonvmus, 462,463. As hepatic stimulant — prob-
ably inferior to mercury and podophyllum.

Nitric acid, 127. In long-standing diseases, as
congestion and cirrhosis, will augment flow of
bile after liver has struck work from excessive
use of mercury.

Phosphate of soda. 164. 10 gr. doses in milk for
children passing pasty white stools.

Sulphates, 164. In purgative natural waters —
small doses oft repeated — sulphate of potash
occasionally poisonous.

INDEX TO DISEASES.

505

LOCOMOTOR ATAXY.

Antipyrine, 454. For pains.

Calabar bean, 367. Has proved very beneficial.

LOINS, PAINS IN.

Lead, 182. As plaster, when pain due to weak-
ness, better than a pitch plaster.

Also useful when pain due to uterine disease
or piles.

LUMBAGO.

AcT.iiA RACEMOSA, 337. Said to subdue lumbago
more effectually than pry other remedy.

Acupuncture, 77, 78. Succeed? best when loin
muscles of both sides afiected, pain being most
severe on to-and-fro movement. Needle to be
run an inch or more over seat of greatest pain
on each side. Sometimes on withdrawal cure
is complete. When sciatica associated with it,
lumbago hard to cure. Acupuncture useless
when high fever, or when acute rheumatism is
commencing.

Belladonna, 383. As plaster very valuable for
persistent remains affecting a small spot.

Capsicum, 316. A strong infusion applied on
lint.

Ether spray, '
mixture.

Faradization,
acupuncture.

Galvanism, 64, 69. Highly useful.

GUAIACUM, 336.

Hot flat iron, 78. The back to be ironed, a
piece of brown paper intervening.

Ice and salt, 68. Locally applied as freezing
mixture.

Iodide of potassium, hi.

Morphia, 407. Hypoderraically injected, often
successful at once.

Nitrate of potash, 167. Ten grains hourly or
every two hours when urine scanty and high-
colored, becoming turbid on cooling.

Plaster of lead or pitch, 78. Applied after
cure effected.

Poultices, 64. Very hot. Should be continued
for three hours, then the skin covered with
flannel and oiled silk.

Salol, 453. 10 to 15 grs. hourly.

Thermic hammer, 77.

Turkish bath, 61.

Turpentine, 304. In twenty-drop doses.

Veratri'M vikide, 32S. As tincture, said to be
useful.

Locally applied as freezing
Almost as successful as

LUNGS, HYPOSTATIC CONGES-
TION OF.

Blisters, 82. Flying blisters to chest and per-
haps along pneumogastric nerves.

LUPUS.

Arsenic, 216. Arsenious acid as a caustic.

Blisters, 82. In erythematous lupus.

Cfeasote, 257

Iodine, 101. As tincture or liniment to edges
and around.

Lead, 182. Liq. plumbi with one or two parts
glycerine, applied warm after crusts removed
in milder forms.

Mercury, 195, iq6. Ointments in erythematous
lupus — calomel oint. in scrofulous and tuber-
cular lupus of children.

Acid nitrate for touching summit of tubercle ;
if application painful, cover spots with collo-
dion.

Silver, nitrate of, 188. A weak solution grad-
ually strengthened in superficial kinds of lupus.

Zinc, 208. Chloride, iodide and nitrate locally.

MALARIA. {See Ague.)

Iodine, 104.

Quinia, 445, 446. And allied alkaloids (see

Ague), also for neuralgia dependent on malarial

poison.
Turkish bath, 60. The cautious use of for those

suffering from various diseases caused by long

residence in a tropical climate.

MAMMARY ABSCESS.

Belladonna, 383. (See Breasts, inflammation
of.)

Mercury and morphia, oleate of, 194. Local-
ly-

Sulphide of calcium, 95. Internally — occasion-
ally the pain is temporarily increased.

Tobacco, 360. The leaves as a poultice.

MANIA, ACUTE,

Act.ba, 337. After confinement or during preg-
nancy.

Bromide of potassium, 119.

Cannabis indic.a, 429. A drachm of the tinct.
with a drachm of bromide of potassium.

Chloral, 283. In acute and puerperal mania.

Cold douche, 57. In maniacal delirium — place
patient in a warm bath during the application.

Croton oil, 246. As a purgative — a quarter or
third of a minim every hour.

Gelsemium, 382. When sleeplessness.

Hvoscyamia, 401. In violent intermittent
forms.

Hyoscyamus, 401. To produce sleep and calm
violent delirium.

Morphia, 407. Hypodermically to induce sleep.

Opium, 415. Many cases may be satisfactorily
treated with opium and tartar-emetic.

Paraldehide, 287. Dose 30-50 rain, as hyp-
notic.

MEASLES.

Aconite, 343. To moderate the catarrh and

bronchitis.
Carbonate of ammonium, 149. In three or five

grain doses, every two or three hours.
Cold affusion, 56. At commencement. ^
Fat, 238. Hands and feet to be rubbed with a

firm fat to remove heat and tightness produced

by rash.
Iodine, 102. Tinct. inhal. for hoarseness and

wheezing.
Mustard, 314. As bath on sudden retrocession

of rash.
Packing, 44. Especially on retrocession of rash.
Purgatives, 165. Must be given with caution.
Veratrum viride, 328. Has been employed.

MEGRIM AND MIGRAINE. {See
Sick Headache.)

MELANCHOLIA.

Bromide of potassiu.m, 117. For townspeople,
especially women, with unendurable despon-
dency.

Camphor, 303.

Morphia, 408. Hypodermically useful in
patients with a peculiar idiosyncrasy.

MisK, 260. Also castoreum.

Phosphorus, 235.

MENIERE'S DISEASE.
A ural. )

( See Vertigo,

506

INDEX TO DISEASES.

MENINGITIS.

Antimony, 210. Tartar-emetic ointment as
counter-irritant to scalp in tubercular men-
ingitis.

Bromide of potassium, 117. In the convulsions
after simple meningitis.

Croton oil, 246. Internally in hydrocephalus
supposed to remove excess of fluid.

Ice, 67. In a bag as a cap.

MENORRHAGIA.

Act^ea, 337. For headache accompanying pro-
fuse menstruation.

Bromide of potassium, 120. Most useful in
young women ; if loss only at natural period
commence bromide a week before, and dis-
continue when it has ceased till a week before,
next time.

If loss occur every two or three weeks, give
bromide continuously — ten gr. dose, but more
when organic changes in womb.

Cannabis indica, 429. Very useful.

Chloride of ammonium, 15Q. For headaches.

Digitalis, 355. Permanently efficacious when no
organic disease, often temporarily so when
there is.

Ergot, 431. Of great use in all forms, even when
the haemorrhage proceeds from tumors.

Hamamelis, 252. Or hazeline.

Lemons, 130. Sucking — a domestic remedy.

Oil of cinnamon, 308. Drachm doses,

Phosphate of lime, 156. In anaemia from ex-
cessive menstruation.

Quinia, 448. Has been recommended.

Spinal hot- water bag, 71. To lower dorsal and
lumbar vertebrae.

Tannin and gallic acid, 251.

MENSTRUATION, DISORDERS OF.

(See Amenorrhcea and jMenorrhagia.)

MICTURITION, FREQUENT. {See
Incontinence of Urine.)

Cantharides, 313. In women who micturate too
frequently or involuntarily on coughing from
weakness of sphincter. t)neor two drop doses.

MICTURITION, PAINFUL.

Alkalies, 140. When caused by uric acid in
spicular crystals in young male children.
The citrates are best suited for this.

Camphor, 304.

Cannabis indica, 429. Said to relieve dysuria
and strangury ; bloody urine said to be a special
indication for this.

Cantharides, 313. A drop of the tincture (some-
times five required) three times a day for fre-
quent desire to micturate with pain.

MIGRAINE. ( .S-^^ Sick Headache. )

MOSQUITOES.

Carbolic acid, 260. A weak solution sponged
over the body to keep off mosquitoes.

MOUTH, DISEASES OF.
titis.)

{See Sloma-

Arsenic, 216. In a peculiar circular rash on the
tongue, usually in children associated with
stomach or intestinal disturbance, or a body
rash ; also in sloughing of the mouth or throat,
cancrum oris, &c.

MOUTH DISEASES— r^«/?««^^.

Chlorate of potash, 168. In ulceration of gums
and the parts of the tongue and cheek in con-
tact with this.

In follicular and phagedenic ulceration.

Chlorine solution, 168. In ulceration.

Cocaine, 439. A solution painted over fissures,
ulcers, and painful swellings on tongue, lips, or
mucous membrane of cheeks. Must be repeated.

Creasote, 254. Or carbolic-acid gargle or wash
in sloughing.

Lime-water, 153. In inflammatory and ulcera-
tive diseases.

Salicylic acid, 452. One part (dissolved in al-
cohol) to 250 of water in catarrhal stomatitis
and thrush.

Silver, nitr.\te of, 189. Applied to ulcers of
mouth.

Sulphate of copper, 206. Applied solid to in-
dolent sores of tongue.

Solution painted over edges of gums in ulcer-
ative stomatitis, but generally dried alum is
better.

MUCOUS MEMBRANE, DISEASES
OF.

Nitric acid, 124. When reddened, inflamed and
glazed.

MUCOUS TUBERCULES. {See

Syphilis.)

MUMPS.

Mercury, 198. The third of a grain of gray
powder three or four times a day very useful
relieving pain and swelling.

Pilocarpine, 374.

MUSCLES, ACHING OF, FROM EX-
ERTION.

Arnica, 45.

Dripping wet sheet, 45. Well rub afterwards.

Turkish bath, 60.

MUSCULAR RIGIDITY.

Spinal ice-bag, 70. If due to disorder of ner-
vous centres.

MYALGIA.

Belladonna, 383. Often successful as liniment,
though sometimes an opium liniment better.

Chloride of ammonium, 159.

Ether, 64. As spray.

Iodine, ioi. The ointment for pain in the mus-
cles of the chest, these being tender on pressure,
but the skin may be pinched without pain.

Opium, 405. Poultices or frictions with laudanum.

Poultices, 64. Very hot, followed by applica-
tion of lint and oilskin.

N^.VUS.

Zinc, 208. Chloride, iodide, and nitrate locally.

NEPHRITIS. {See Brishi' s Disease.)

NERVOUS HEADACHE. {See Sick
Headache.)

INDEX TO DISEASES.

507

NERVOUSNESS.

Bromide of potassium, 117. Especially for
women who are despondent, irritable and sleep-
less, from overwork, grief, worry, &c., often
connected with migraine.

Chloral, 284. When restlessness and debility.

Chloroform, 270. As spirits of chloroform in-
ternally.

Cold sponging, 56. When from close rooms, &c.

MoRBHiA, 415. (See ref.)

NETTLE RASH. {See Urticaria.)

NEURALGIA.

Aconite, 338 As ointment or liniment, espe-
cially when fifth nerve affected, also in neural-
gic sick headache — sometimes veratria better,
339. Spinal irritation and intercostal neuralgia
generally yield better to belladonna prepara-
tions.
Acupuncture, 79. At "corresponding spot"

on the opposite side.
Alcohol, 265. With much volatile ether — care

must be taken in prescribing it.
Arsenic, 230. In various neuralgias, also in an-
gina pectoris.
Atropi.a, 392. Trousseau's method — give one
fifth gr. extr. bell, every hour till giddiness in-
duced, then lessen dose, but continue the medi-
cine for several days.
Belladonna, 383 and 388. The liniment, or the

ointment of atropia sometimes useful.
Cannabis indica, 429. Has been found useful.
Capsicum, 316. A strong infusion on lint covered

with gutta percha.
Carbonic acid gas, 88. Injected into vagina

for neuralgia of uterus.
Chamomile, 456. In neuralgia of the fifth nerve.
Chlor.\l, 285. Sometimes relieves.

Rubbed with an equal weight of camphor
and painted on painful part or gently rubbed
in, often useful in neuralgia, pleurodynia, and
toothache.
Chlorate of potash, 169. Has been recom-
mended in facial neuralgia.
Chloride of ammonium, 159. In half-drachm
doses in facial neuralgia, much used also for
all neuralgias.
Chloroform, 269. Occasionally useful locally.
As spray for neuralgia of uterus. 'i'wo or
three drops on cotton-wool in ear for faceache
and toothache.

, 276. Inhalation.

■ , 277. Subcutaneously. (See ref.)

Cocaine, 440. ^ to 1,4 gr. in solution hypoder-

mically in course of nerve.
CoNiUM, 364. Internally.

Counter-irrit.\tion, 83. A blister to temple or
behind the ear of the greatest service in frontal
and facial neuralgia — that depending on a dis-
eased tooth often yields to a blister, also the
migratory neuralgic pains in nervous women
and intercostal neuralgia left by shingles.
Blisters should be applied, according to Anstie,
to a posterior branch of the spinal nerve-trunk
from which the painful nerve issues.

If blistering paper does not succeed in neu-
ralgia a stronger preparation to be tried.
Croton-chlokal, 291. Five-gr. doses, especially
in facial neuralgia, in that due to carious teeth,
in that of the neck and back of head, in dys-
menorrhoeal neuralgia, and in epileptiform tic.
Ergot, 431. Said to be useful.
Ether, 278. As spray sometimes relieves per-
manently, often only temporarily.
Gelsemium, 375. In non-inflammatory tooth-
ache and neuralgia of nerves supplying teeth
and alveolar processes.

, 382. When dental nerves affected

even where carious teeth. Sometimes to.xic
doses required. Said to be useful in ovarian
neuralgia.

'^'E\5KKLGIA— continued.

Hydrocyanic acid, 404. And cyanide of potas-
sium formerly employed locally.
Hvoscyamus, 401.

Ice, 68. Locally in neuralgia of testes.
Iodoform, 279. As saturated solution in chloro-
form locally.
Iron, 176, 177. When associated with ansmia,
but no organic cause. Moderate doses only
required.

Methyl chloride, 278. As spray especially in
sciatica (see ref.)

Morphia, oleate of, 194. One or two grains to
a drachm, locally.

Nitrite of amvl, 295. Inhalation when fifth
nerve affected.

Oil of peppermint, 306. To be painted over
the part in facial neuralgia.

Opium, 407. Or a hypodermic injection of mor-
phia — sometimes a single injection will cure
old-standing cases, if not it may be repeated
every second day or so for some time.

Phosphorus, 234. From i-iooth to i-i2th gr.
every three hours. Very useful in all forms of
neuralgia, especially when uncomplicated.

QuiNiA, 446. In periodical neuralgia, whether
malarial or not, large doses should be given
just before the expected attack.

Useful also in small frequently repeated
doses in other neuralgias, especially of the
supra-orbital nerve.

Salicylate of sod.a, 451. Inferior to other
remedies.

Spinal ice-bag, 70.

Stramonium, 403. Has been used.

Valerianate of zinc, 310. Or of ammonia in
neuralgia of face or head.

Veratria, 329. An ointment of the pharmaco-
pceial strength enough for the face, but stronger
ones necessary for sciatica and other neural-
gias, also for the pain consequent on shingles.

, 328. Tinct. of veratrum viride said

to be useful.

NIGHTMARE.

Bromide of potassium, 119.

NIGHT SCREAMING.

Bromide of potassium, 119. In children's at-
tacks of night screaming often associated with
squinting. Digestive organs to be attended to
also.

NIPPLES, SORE.

Arnica, 236. The cerate.

Brandv-and-water, 152. To be used as lotion
before delivery and after each sucking to pre-
vent cracking. Nipples should be washed and
dried immediately after child is removed. (See
p. 261.)

Collodion, 236. Sometimes applied to chapped
nipples.

Glycerine, 247. Of starch or with eau de Co-
logne.

Lime-water, 152. As lotion.

Sulphurous acid, 131. Solution neat or dilu-
ted, constantly applied.

, 236. With equal quantity of

glycerine as lotion.

Zinc shield, 152, Constantly worn.

NODES.

Iodide of potassium, 107. As ointment in con-
junction with internal use.

Mercury, oleate of, 195. Externally very
valuable.

508

INDEX TO DISEASES.

NOSE, DISEASES OF.

Ammonia, 148. Inhalations, in pain and inflam-
mations of nose and frontal bones.

COD-LIVEK OIL, 242. For chronic discharge.

Glycerine of t.anmn, 248. For brushing out
inside of nose when excoriated after measles,
scarlatina, <S:c. Also for impetiginous erup-
tions of inside of nose, most severe where hair
grows— epilation sometimes needful. Glycerine
of starch or zinc ointment applied often is a
good supplementary application.

, 249. In the discharge

of greenish-black stinking mucus.

NUTRITION, IMPAIRED.

CoD-LivEK OIL, 243. Especially in children.
Lime, 154. As lime water or carbonate of lim
Small doses as good as large.

NYMPHOMANIA.

Bromide of potassium, 120. Large doses re-
quired, at least twenty grs. three times a day.
Ca.mphor, 303.

OBESITY.

Alkalies, 140. Solutions of oxides or bicarbon-
ates. Use very questionable.

, 140. Liquor potassse. This usually,

however, fails.

Vinegar, 127. A remedy to be strongly con-
demned, as it only reduces obesity at the ex-
pense of serious injury to the body.

OESOPHAGUS, STRICTURE OF.

Nutritive enemat.a, 77. When swallowing im-
possible. For directions (see ref .)

ONYCHIA. {St-e Paronychia.)

OPHTHALMIA.

Alum, 170. Eight grains to one ounce applied
every quarter or half hour in simple and es-
pecially in purulent ophthalmia of children.

Antimony, 214. As tartar-emetic 1-36 to i-48th
grain three or four times a day in strumous
ophthalmia. Sharp purgation at commence-
ment useful.

Cakbonic acid gas, 88. Said to relieve pain
and photophobia of scrofulous ophthalmia when
applied to the eye.

Cod-liver oil, 242. When strumous.

OPIUM, DISAGREEABLE SYMP-
TOMS OF, {See Poisoning by
Opitim.)

ORCHITIS.

Antimony, 213. As tartai'-emetic in acute orchi-
tis. (See Inflammation.)

Ice locally applied, 68. Also in neuralgia of
the testis.

OTITIS. {See Ear, diseases of, and Otor-
rhea.)

OTORRHCEA. (.S'^-.f Ear, diseases of.)

Aconite, 345. In otitis.

All'.m, 170. Strong solution (sixty grains to one
ounce) but inferior to glycerine of tannic acid.

Cod-liver oil, 242. When chronic.

Glycerine of tannin, 249. Meatus to be filled
and plugged with cotton-wool — not in acute
inflammation of meatus.

Lead, 182. Solutions of acetate or dlacetate as
injection, especially when acute stage just sub-
sided—in later stages stronger astringents
needed.

Lime-water, 152. As a wash when active in-
flammation present. In chronic cases far in-
ferior to astringents such as glycerine of tannin.

OVARIAN NEURALGIA.

Gelsemium, 382. Said to be useful.

OVARIAN TUMORS.

Iodine, 102. Ten oz. of tincture injected after
tapping.

OVERWORK.

Bromide of potassium, 117. When insomnia,

bad dreams and irritability.
Cocaine, 441.
Opii'm, 417. A drop of laudanum with two of

tinct. nucis vom. three or four times a day for

headaches with flushings and dyspepsia.
Phosph.\te of lime, 156. jNIay be combined

with phosphate of iron and carbonate of lime.

A grain of each for a dose.
Phosphorus, 235. In depression from overwork.
Se.\-bathing, 38.
SiTZ-B.\TH, 43. For ten minutes at 70° to 80° on

return from business tired and irritable. Half

hour before dinner.

OXALURIA.

Mineral acids, 126. When eructations of sul-
phuretted hydrogen.

OZ.FINA.

Acetate of alumina, 171. Irrigation.

Alum, 170, 171. Nose to be well irrigated with
a solution, a drachm to a pint.

Bismuth, 180. With equal quantity of Venetian
calc in chronic non-syphilitic oza:na to be
snuffed up after clearing the nose by strongly
blowing it. Mercurial powders better.

BoRO-GLVCERiDE, 133. As injection.

C.-\RBOLic acid, 258. A weak solution as injec-
tion.

Glycerine of tannin, 171. Irrigation.

Iodine, 103. Tinct. chronic with solution of
common salt.

In chronic forms nose to be flushed with
solution of salt containing a few drops tinct.
iod.

Iron, 173. Spray of the subsulphate in chronic
form.

Mercury, 197. White or red precipitate with 58
times its weight of sugar snutfcd up after
clearing the nose in the non-syphilitic form.

— , 197. Ointment of the nitrate in syphi-
litic form. (See Syphilis.)

S.ALOL, 453. As snuff.

Tannin, 248. Or glycerine of tannin, even if
syphilitic.

INDEX TO DISEASES.

509

PAIN. {See Co lie ^ Gall-stones, Neuralgia^
&^e.)

Atropia, 388. Hypodermically in local pain, in

neuralgia, sciatica, glaucoma, &c. When it

succeeds, effects more lasting than those of

morphia.

Belladonna, 392. Best remedy for every kind

of pain in pelvic viscera (Anstiei.
Carbolic acid, 257. As local anaesthetic.
Chloral, 285. Sometimes relieves neuralgia,
chronic rheumatism, gall-stones, colic, gas-
tralgia, and even cancer.
Chlorofok.m, 269. Locally, generally inferior to

other anaesthetics,
, 269. Two or three drops on cotton-
wool introduced into the ear for faceache or
toothache.

Vapor on raw surface of cancers, neuralgia
of uterus, a photophobic eye, &c.
, 271. As vapor to produce gen-
eral anaesthesia. (See ref. for full directions.)
, 270. Inhalation in renal and bili-
ary colic.
CoNluM, 364. In cancer, rheumatism, neuralgia,

&c.
Ether, 278. As spray for local anaesthesia, also
inhalation to produce general anaesthesia. (See
ref.)
Iodoform, 279. A suppository in painful diseases

of rectum and bladder.
Mustard, 314. For localized pain.
Opium, 405. Poultices containing laudanum
used in inflammation. Linim. opii rubbed in
relieves neuralgias, pleurodynia and myalgia ;
preparations of opium or morphia are applied to
irritable, cancerous and simple sores.
, 406. The hypodermic injection of mor-
phia extensively employed to relieve pain. The
unpleasant symptoms often accompanying its
administration may usually be obviated by
combining it with a twentieth part of atropia.
At first not more than a si.xth of a grain of
morphia should be injected. A single injec-
tion sometimes cures recent and even long-
standing sciatica and neuralgia. Useful in
lumbago, pleurodynia and toothache. Oc-
casionally required in pleurisy or pneumonia
if the suffering is severe or persistent. Valuable
in renal, biliary and intestinal colic.

, 411. An injection of laudanum and

starch useful in pain of bowels or organs near
the rectum, such as cystitis or uterine diseases ;
opium and gall ointment excellent for painful
bleeding piles and fissures of anus.

, 416. In chronic cases it is best to try

first all other methods of easing pain, as an
opiate soon loses its influence.
Stramonium, 403. As ointment.
W.\RM injections. 76. Soothe the pain of cystitis,
prostatitis, abscess of the prostate and pelvic
and abdominal pains generally.

PALPITATION.

Aconite, 345.

Camphor, 303. In nervous palpitation.
Eucalyptus, 309. At change of life.
Hot foot-bath, 52.

PARALYSIS.

Belladonna, 392. When depending on chronic
inflammation of the cord. Brown-Sequard
gave ergot internally, applying belladonna as
plaster or ointment along the spine.

Calabar bean, 366. In general paralysis of in-
sane, also in progressive muscular wasting with-
out much mental disorder. Also in some cases
of long-standing hemiplegia ; sometimes in
paraplegia, locomotor ataxy, and writer's cramp.

Cannabis indica, 429. For retention of urine
from spinal disease.

PARALYSIS — continued.

Counter-irritation, 84. By blistering fluid in
peripheral paralysis of seventh nerve.

Ergot, 431. Said to be useful in paraplegia.

Hvoscvamia, 401. i-5oth gr. daily hypodermic-
ally, or i-5othgr. night and morning by stomach
in paralysis agitans. But symptoms recur on
discontinuing drug.

HvosciN, 402. In paralysis agitans.

Nux VOMICA, 423. Or strychnia recommended by
Brown-Sequard in paraplegia from softening
and wasting of cord. Often useful in motor
paralysis.

Phosphorus, 235. In hysterical paralysis.

Strychnia, 419. In all forms.

PARONYCHIA.

Mercury, 193. As ointment applied for ten
minutes every hour. Poultices at other times.

Nitrate of lead, 193. Dusted on diseased
tissues night and morning.

PARTURITION. {See Cottfinement.)
PEDICULI. {See Lice.)

PEMPHIGUS.

Arsenic, 227. Largest dose five min. liq. arsen-
icalis three times a day, not on empty stomach.
(See ref.)

PERICARDITIS.

of.)

{See Heart, diseases

PERIOSTITIS. {See Nodes.)

Iodide of potassium, 109, no. In syphilitic
children ; also in non-syphilitic periosteal thick-
enings.

Mercury and morphia, oleate op, 194.
Locally.

PERITONITIS. {See also Puerperal
Peritonitis.)

Opium, 411. To quiet intestinal movements.

Poultices, 64. Large, hot and frequently re-
newed. Should be thin and covered with cot-
ton-wool.

PERSPIRATION, EXCESSIVE.

Atropia, 374. In sweating of phthisis and ex-
hausting diseases. (See Phthisis.)

Belladonna, 383. As liniment locally to affected
part', also tincture internally, especially in
weakly children who perspire profusely. Also
very useful where the perspiration has cau-ed
the skin of the feet to peel off, leaving the der-
mis red and tender.

Ergot, 431. Said to arrest sweating.

Hyoscin, 403. Checks the sweating of phthisis.

Iodoform, 280. Diminishes phthisis.

Lead, 182. As ointment of equal parts of emp.
plumb, and linseed oil spread on linen and
wrapped round the feet when they sweat — to be
renewed every third day for nine days.

Oils, 238. Rubbed into the whole skin to pre-
vent sweating accompanying exhausting dis-
eases, as phthisis ; but sponging with a weak
acid wash better.

Opium, 374, 417. As Dover's powder may suc-
ceed after zinc has failed.

510

INDEX TO DISEASES.

FERSFIRAT ION— continued.

PiCROTOXiNE, 374, 375. In 1 gr. doses.
Pilocarpine, 374. In 1 gr. doses thrice daily.
QuiiNiA, 447. In exhausting diseases, as chronic

phthisis. If a small dose fail, one of six or

eight grs. at once or in portions repeated hourly.
In many cases a night draught of quinia,

sulphate of zinc, and sulphuric acid very useful.

• , 442. Z )■ in (Jj. alcohol for bathing skin.

Spinal ice-bag, 70.

Sponging, very hot, 52. In phthisis.

Sponging with acidulated water, 124.

Tannin or gallic acid, 250.

Zinc, oxide of, 210. In two-grain doses nightly

to control profuse colliquative sweating.

PHARYNGITIS. (See Throat, Sore.)

PHLEBITIS.

A BLISTER, 82. Over course of inflamed super-
ficial vein.

PHLEGMASIA DOLENS.

Ha.mamelis, 252.

PHOTOPHOBIA. {See Eye, diseases of;
also Conjunctivitis.)

PHTHIRIASIS. {See Lice.)

PHTHISIS.

dj'c.)

(See Cough., Hemoptysis,

Brandy and milk before break-

ACT.«A, 338
Alcohol, 26

fast.
Arsenic, 3. When red, smooth, clean " irritable"

tongue.

216. As cigarettes — caution required.

Useful in the diarrhoea.
Probably diminishes temperature.
i-2ooth to i-iooth hypodermically,
or i-7oth to i-5oth, or even, in exceptional cases,
i-2oth in pill, to check excessive perspiration.

Belladonna, 383. Liniment or plaster for
hypersensitiveness of the muscles of the
chest.

Benzoic acid, 307. As inhalation.

Blisters, 83. In chronic or fibroid phthisis.

Brandy, 268. Or rum and milk before breakfast.

Chloride of calcium, 154. Recommended as
inhalation.

Chloroform, 270. With glycerine or honey for
the cough in fibroid phthisis.

CoD-LivF-R oil, 242. Very valuable in nearly all
forms of this disease, especially at commence-
ment. (See ref.)

Coto-bark, 253. To check sweating. Also as-
serted to be useful in diarrhoea.

Counter-irritation, 82, 83. Only to relieve
pain in acute forms, as iodine liniment ; quiets
cough and diminishes expectoration in chronic
or fibroid phthisis.

Creasote, 256. Tar, or carbolic acid to check
expectoration. In full doses in non-febrile
cases increases appetite.

Croton oil, 244, 245. With or without liq. po-
tassae as counter-irritant to chest. Caution
must be used.

Enemata, 411. Of starch and laudanum for the
diarrhoea.

VllT\l\?>l'i— continued.

Eucalyptus, 309. Twenty drops of, inhaled for
cough of chronic phthisis.

Gelsemium, 379. For the cough.

Glycerine, 247. In last stage with water as
wash for dry shiny mouth.

, 248. t or cough.

Hypophosphites, 158. Of lime or soda, — should
be given alone. Most useful m early stage
and in young subjects.

Iodine, 100. As liniment painted under clavicles
in chronic forms to allay harassing cough and
to check secretion.

, 102. As inhalation in chronic phthisis to

lessen expectoration and cough.

Iodoform, 280. In turpentine as spray. Also
given internally.

,280. With spirits of turpentine. Also

given internally with extract of gentian.

Ipecacu.\nha, 323. Spray to throat when bron-
chial asthma and emphysema combined with
fibroid phthisis.

Mercury, 202. The hundredth of a grain of
corrosive sublimate every two or three hours in
diarrhoea

Opium, 409. Or morphia in a viscid vehicle for
cough, especially where this is due to inflamed
condition of throat — morphia lozenges very
useful here.

,^l^. As Dover's powder for night sweats.

Phosphate of lime, 156. In diarrhoea.

, 136. In chronic forms of

phthisis with little or no fever.

Picrotoxine, 374. (See Perspiration, excessive.)

Pilocarpine, 374. (See Perspiration, excessive.)

Quinia, 446. In acute phthisis to reduce temper-
ature.

, 447. In chronic phthisis to check sweat-
ing. If a small dose fail, a dose of six or eight
grs. administered at once or in portions re-
peated hourly.

S.vLiCYLic acid, 452. In five-gr. doses for foul
breath and offensive expectoration.

S.^LOL, 453.

Sea-b.\thing, 43. If chronic, little or no fever,
without active deposition of tubercle or scrofu-
lous pneumonia.

SiLVEK, nitrate OF, 189.

into trachea. (See ref.)

Sponging, very hot, 52.
spiration.

Sulphides, 94. As natural water.

Sulphurettkd hydrogen, 94. Intestinal injec-
tion of, mixed with carbonic acid gas.

Sulphuric acid, 129. With sulph. zinc, to check
perspiration.

Sulphurous acid, 131. Inhalation, spray or
fumigation in chronic phthisis.

Turkish baths, 59. For the cough.

Vinegar, 129. With laurel water to check sweats.

PILES.

Aloes, 458. To gently relieve bowels.

Bro.mide of potassium, 114. In five parts glyc-
erine locally to ease pain.

Calomel, 251. As ointment.

Castor oil, 246.

Chlorate of potash, 169. ^^s. to 5 J- of satu-
rated solution with five to ten drops of lauda-
num as injection when inflamed and painful.

Cold injection, 58. Half a pint before going
to stool every morning.

Gallic .^cid, 251. With opium as ointment.

Ha.mamelis, 252. As lotion or injection as well
as by mouth in piles, whether bleeding or not.

Ice, 67. Locally applied for pain after operation.

Le.\d, 182. As plaster for pain in back due to

Nitric acid, 128. Strong, applied to internal
piles, also to granular or ulcerated piles. Half-
ounce or one ounce to half a pint of water as
lotion for bleeding piles.

Sometimes injected
For excessive per-

INDEX TO DISEASES.

511

PILES — continued.

Opium, 411. Mixed with gall ointment, an ex-
cellent application for painful bleeding piles.
Mild purgatives also required.

Rhubarb, 462. About ten grs. of the root to be
chewed nightly if a laxative is needed.

Useful also in haemorrhoidal swellings of
pregnancy.

Sulphur, 91. Five to ten grs. with one drachm
conf . senn. in the morning as a laxative.

PITYRIASIS.

Borax, 135. Saturated solution locally several
times a day in pityriasis of scalp. If not suc-
cessful try it as glycerine of borax.

Glycerine of borax, 247. In pityriasis of scalp.

Lead, 182. Liq. plumb, two ozs., glycerine two
ozs., to four ozs, of water as lotion.

Mercury, 192, 193. Citrine ointment especially
when pityriasis of hairy parts of face. Often
well to add tar ointment.

Sulphurous acid, 131. With glycerine in con-
junction with warm baths.

PITYRIASIS VERSICOLOR.

Mercury, 193. The bichloride in solution two
grs. to the oz. of water as a lotion.

Mercury, 194. The oleate of mercury with ether
applied with a camel-hair pencil.

Sulphurous acid, 131. The B. P. acid with
glycerine; warm baths should also be employed.

PLEURISY.

Aconite, 342. Has marked effect.

Antimony, 213. As tartar-emetic. (See Inflam-
mation.)

Blisters, 82. Large and flying after subsidence
of inflammation and fever, to further absorption
of the fluid. The vesication, if any, should be
healed at once.

CoD-LiVER oil, 242. In chronic form.

Iodide of potassium, hi. To quicken absorp-
tion of inflammatory effusions.

Iodine, 100. As liniment to chest to promote
absorption.

, 102. Solution (weak at first) injected,

after tapping the injection, — may contain other
disinfectants.

MoRPHi.\ injection, 407. Occasionally needed
for severe pain.

Mustard, 314. To affected organs in pleurisy.

Packing, 44.

Pilocarpine, 374. To remove effusion.

Potash, 142. As liquor potassae is occasionally
employed in pleurisy to promote the absorption
of the inflammatory formations, but it is unad-
visable to use it long.

Poultices, 63. Large, hot, and frequently re-
newed.

Purgative salts, 163, 164. 3 vj.-5J- sulph.
magnes. in 5 J- water before food.

Sin.\pisms, 314. Large.

Veratrum viride, 328. Opinions differ as to
whether it should be used in sthenic or asthenic
forms.

PLEURODYNIA.

AcT/EA RACEMOSA, 337. When pleurodynia due

to uterine derangements.
AcupuNCTiRK, 79. At " corresponding spot " on

opposite side.
Belladonna, 64, 383. Generally liniment best,

sometimes the plaster better.
Blistering, 85. Sometimes strong vesication

necessary.

PLEURODYNIA— r^«/e««^a'.

Chloral, 285. Made liquid with equal weight
of camphor, and rubbed gently in.

Ether, 64. As spray sometimes immediately
and permanently removes pain.

Iodine, 103. As a liniment.

Mustard, 100. As poultice.

Opium, 405. The liniment may be rubbed in, or
sometimes a hypodermic injection of morphia
may be necessary.

Poultices, 64. Very hot ; followed by applica-
tion of lint and oilskin ; belladonna liniment
generally better.

PNEUMONIA.

Aconite, 342. Has marked effect.

Antimony, 15. Small frequent doses of tartar-
emetic when skin hot and dry — better here than
aconite.

, 214. At commencement. If patient

weak, must take alcoholic stimulants as well.

Blisters, 82. Lessen the pain ; should be used
m moderation.

Ether, 278. In adynamic pneumonia hypoder-
mically.

Morphia injection, 407. Sometimes needed for
severe pain.

Must.\rd; 314. To affected organs.

Packing, 45. Some pack the chest only, renew-
ing hourly.

Phosphorus, 235. Especially when typhoid
symptoms.

Poultices, 63, 64. Large and hot. To encircle
whole chest in children.

Quinia, 446. To reduce temperature.

Sinapisms, 314. Large.

Veratrum viride, 328. Opinions differ as to
whether it should be used in sthenic or asthenic
forms.

POISONING GENERALLY.

Apomorphia, 327. Hypodermically, Ji gr., to

produce prompt emesis.
Sulphate of zinc, 208, 209. The best emetic.

POISONING BY ACIDS.

Alkalies, 139. The least irritating to the stom-
ach to be selected.
Magnesia, oxide of, 150.

POISONING BY ALCOHOL.

Cold douche, 56, 57. Poured for some time from

a height on to the head.
Cold water, 37. Smartly sprinkled on face.
Maintenance of temperature, 37.

POISONING BY ALKALIES.
Acids, 127. Dilute.

POISONING BY ANTIMONY.

Alkalies, 138, 139.

Tannin, 250. Or strong tea or coffee.

POISONING BY ARSENIC.

Bicarbonate of magnesia, 139. Or other al-
kalies.
Charcoal, 87. Half an ounce or more.
Oxide of magnesia, 150.

512

INDEX TO DISEASES.

POISONING BY BELLADONNA OR
ATROPL^.

Alkalies, 139. Especially bicarb, of magnesia

in poisoning by alkaloids.
Ammonia, :48. Breathed into air passages.
Charcoal, 87. In poisoning by belladonna. Half

an ounce or more must be given.
Lime-water, 399. Has been recommended.
Physostigma, 397. Doubtful.

POISONING BY CHLORAL.

Maintenance of temperature, 37.
Physostigma, 367.

Strychnia, 286. The antidote according to
Liebreich.

POISONING BY LEAD.

Alkalies, 139. Especially bicarbonate of mag-
nesia in poisoning by metallic salts.

Iodide OF potassiu.m, iii. I n chronic cases.

Lukewarm drinks, 183. Or sulphate of soda,
.sulphate of magnesia, or freshly precipitated
sulphide of iron ; promote vomiting — use stom-
ach-pump — give milk with white of egg in acute
lea d po {son ing.

Sulphides, 93. As baths in chronic form.

POISONING BY MERCURY.

Alkalies, 139. Bicarbonate of magnesia best.
Baths, 203. Simple or sulphurous.
Charcoal, 87. In poisoning by corrosive subli-
mate, half an ounce or more must be given.

POISONING BY NITRATE OF SIL-
VER.

Alkalies, 139. Especially the bicarbonate of

magnesia.
Chloride of sodium, 159.

POISONING BY OPIUM OR MOR-
PHIA.

Ammonia, 148. Breathed into air passages.

Atropia, 395. Quarter to half a grain hypoder-
mically.

Bicarbonate of magnesia, 139.

Bromide of pot.assium, 120. Controls disagree-
able effects of medicinal doses of opium ; 20
grains an hour before, and the same dose two
hours after, the opiate.

Charcoal, 87. Half an ounce or more.

Cocaine, 440. Internally.

Cold douche, 56, 57. Poured for some time
from a height on the head.

Cold water, 37. Smartly sprinkled on face.

Stomach pump, 183, 413. Rouse patient, keep
him constantly moving to prevent sleep, give
strong coffee, apply cold affusion to head, and
if necessary adopt artificial respiration.

POISONING BY OXALIC ACID.

Lime, 153. Salts of.
Oxide of magnesia, 150.

POISONING BY PHOSPHORUS.

Copper salts, 236. Better than turpentine.

Repeat till vomiting.
Transfusion, 233.
Turpentine, 305.

POISONING BY PHYSOSTIGMA.

Atropia, 396. One-fiftieth to one-thirtieth of a
grain hypodermically, repeated till effects evi-
dent.

Chloral, 286. The antidote.

POISONING BY PICROTOXINE.

Chloral, 286. The antidote.

POISONING BY SALTS OF POTAS-
SIUM, SODIUM, AND AMMO-
NIUM.

Rffect depends tnainly on percentage dose. (See

P- 105.)
Bleeding, 105.
Drinking freely, 105. To dilute blood.

POISONING BY STRYCHNIA.

Alkaline bicarbon.^tes, 139. Magnesia best.

Calabar be.\n, 366. As an antidote.

Charcoal, 87. Half an ounce or more.

Chloral, 286. The antidote.

Nitrite of amyl, 295. Inhalation.

Stom.\ch pump, 422. If available before tetanic
symptoms, animal charcoal^ tannin solution
of iodine, chloroform inhalation^ injection of
curare, or of methyl and ethyl compound of
strychnia, of brucia, or of thebaia, artificial
respiration, fats.

PREGNANCY. {See Vomiting.)

AcT.*:.^, 337. To prevent miscarriages in irritable
or prolapsed uterus.

Bromide of potassium, 119. For frightful de-
lusions in later months.

Cocaine, 441. Internally in vomiting.

Ipecacuanha, 126. Sometimes for acidity.

Sea-b.-\thing, 39. In earlier months, unless
there have been several miscarriages or the pa-
tient is of very excitable temperament.

PROLAPSUS.

Alum, 170. In solution, six grains to the ounce,
in prolapsus ani and uteri.

Ergotin, 431. Injections in prolapsus of rectum.

Ice, 68. Locally applied in prolapsus of rectum
or uterus when parts inflamed.

Nux vomica, 126. For acidity two or three
drops.

Strvchni.\, 424. In prolapsus ani, especially in
children. If there is constipation nu.\ vomica
may be added to a purgative, as tincture of
rhubarb. If there is diarrhoea it should be
checked.

Sulphur, 91. In prolapsus recti has a beneficial
effect in addition to that due to laxative prop-
erties.

Tannin, 250. As catechu, kino, red gum, rha-
tany ; haematoxylum injections to restrain pro-
lapsus ani.

PROSTATITIS.

Cantharides, 313. A drop of the tincture (five

may be required) three or four times a day.
Hot injections, 76. To relieve pain.

PRURIGO.

Borax, 137. (See Pruritus.)
Cantharides, 311. Internally.

INDEX TO DISEASES.

513

VRVRIGO— continued.

Carbolic acid, 257. Oil of cade, &c. (See

Pruritus.)
Chloroform, 269. As ointment to allay itching.
Cyanide of potassium, 404. Or hydrocyanic

acid. (See Pruritus.)
Ice, 67. For prurigo of vulva.
Iodoform, 279. As ointment. One drachm to

the ounce.
Sui.i'HUK, 90. With tar and benzoated lard as

ointment in genuine prurigo.
Turkish bath, 61. When unconnected with

lice.

W.ARM BATHS, SI, 52.

PRURITUS.

Alkalies, 134. An alkaline solution such as a
drachm of carbonate of potash or soda to a
pint of water applied with a small piece of
sponge in itching of urticaria or lichen. Solu-
tion of cyanide of potassium, same strength,
better still.
Alum, 171. A strong solution for pruritus vulvae.
Arsenic, 217. In itching of the nose accompany-
ing asthma-like affections. (See Asthma.)
Benzoin, 307. The comp. tinct. painted on the

skin in eczema, urticaria, &c.
BoRACic acid, 133. As lotion in pruritus pu-
dendi.

, 137. A teaspoonful dissolved in

a pint of boiling water, used tepid or cold as
lotion in pruritus pudendi.
Borax, 137. Five to ten grains to the ounce of
hot water in pruriginous eruption on mucous
membrane of vulva and vagina. In this com-
plaint '.nfusion of tobacco, iodide of lead as
ointment, bismuth and morphia as ointment,
chloroform as vapor, liniment or ointment ; lead
lotion ; nitrate of silver ; alum in solution, tan-
nin in solution, are often useful, especially
when alternated.
Camphor, 301. An addition to dusting powders
to allay heat and itching of eczema and inter-
trigo.
Carbolic acid, 257. Solution as topical applica-
tion, even when itchint due to jaundice.

, 254. In chronic eczema, psoriasis

and erythema, or, better still, liquid carbonas
detergens, oil of cade, or oleum rusci.

; 258. A weak lotion (i in 100) in

pruritus ani and pudendi.
Chloroform, 269. As ointment to allay itching

of skin diseases.
Chro.mic acid, 137.

Cocaine, 441. Lotions in pruritus ani and pu-
dendi.
Cold .\nal douche, 58.

Cyanide of potassium, 404. A drachm in a
pint of water as lotion for urticaria, lichen,
eczema, and prurigo where the skin is unbroken.
Hydrocyanic acid, 404. Thirty drops of B. P.
acid in one ounce of water or glycerine may be
used instead of the cyanide of potassium solu-
tion.
Iodine, 103. In itching of the nose or inner

canthus.
Lead, 182. Lotions ease itching of urticaria. A
strong lotion useful in pruritus pudendi, es-
pecially where mucous membrane red and ex-
coriated. If this is dependent on worms or
tumor, lotion useless.
Menthol, 307. Ointment in pruritus ani.
Mercury, 191. Strong solutions of bichloride,
black wash, yellow wash or mercurial ointment
in itching of skin affections.

An ointment of a drachm of calomel to one
oz. of lard is best, not however in urticaria.

Calomel ointment useful in pruritus ani, but
less so in pruritus pudendi. In obstinate cases
of these, blisters to thighs or leeches useful.

Calomel ointment useful in itchy scabbiness
of scalp and in pityriasis of scalp.

PR U R I T U S— continued.

Nitrate of mercury ointment will destroy
lice.

Salicylic acid, 452. As ointment in pruritus
ani and vulvae.

Silver, nitrate of, 188. To be painted every
day or second day on a patch of lichen the size
of the palm causing excessive irritation. A
weak solution often relieves pruritus ani and
pudendi ; apply well with camel-hair brush
three or four times a day.

A strong solution in pruritus cutaneus of the
meatus auditorius without eruption on skin ;
the memb. tymp. to be carefully avoided. If
itching from dryness of ear or deficient secre-
tion of wax, try first almond oil or glycerine.

PSORIASIS.

Arsenic, 227. At first apparently aggravates
the disease but soon heals it. Largest dose
required five min. liq. arsen. three times a day
— never on empty stomach. For rules for giv-
ing arsenic, see ref.

Calomel ointment, 191.

Cantharides, 311. Internally.

Carbolic acid, 254. Or, better still, liquor car-
bonas detergens, oil of cade, oleum rusci.

Copper, sulphate of, 206. Applied solid to
spots of psoriasis, simple or specific.

Mercury, 192. Calomel and nitrate of mercury
ointment may be mixed, and tar ointment may
be added, in patches of obstinate psoriasis, es-
pecially of hands, even when not syphilitic.

Oils and fats, 238. To lubricate skin, used in
conjunction with warm baths.

Silver, nitrate of, 188. Or sulphate of copper.
An occasional application useful in psoriasis of
the tongue and mucous membrane of mouth.
If these are syphilitic, mercurials best.

So.AP, 134. Assists removal of scales.

Sulphides, 93. In baths— not in acute stage.

Sulphur, 92. Internally.

Tar, 254. In obstinate forms may be painted on
the patches and left on, or creasote ointment,
petroleum, cade, and carbolic soaps of various
strengths useful.

Turkish bath, 59.

Vaseline, 253. Locally.

Warm bath, 51. Especially in acute stage, rain
or boiled water.

PUERPERAL FEVER, ETC.

Antimony, 214. As tartar-emetic for mania, but
bromide and chloral better.

Bromide of potassium, nq. For mania.

Chloral, 283. For mania and convulsions.

Morphia, 408. Hypodermically, sometimes ar-
rests puerperal convulsions.

Permanganate, 178. Has been given internally.

Turpentine, 305. Has been used.

PUERPERAL PERITONITIS.

Antimony, 213. As tartar-emetic. (See also
Inflammation.)

Chlorine solution, 99. For washing out va-
gina.

PURPURA.

Arsenic, 109. When due to iodism.

Ergot, 430. Has been strongly recommended.

Turpentine, 305. Has been used.

PYEMIA AND SEPTICEMIA.

Ammonium carbonate, 149. In typhoid condi-
tion.
Perm.\nganate, 178. Has been given internally.
QuiNiA, 446. Supposed to diminish temperature.

514

INDEX TO DISEASES.

PYROSIS.

Bismuth, i8o. Useful in the various forms,
whether acid, alkaline or neutral.

Lead, 182. Soluble preparations are recom-
mended.

Mang.\nese, 178. Black oxide.

Nitric acid, 125. Or hydrochloric acid in small
medicinal doses shortly before meals when
pyrosis acid, — after when pyrosis alkaline.

Sulphurous acid, 131.

QUINSY. {See Throat, diseases of.)

RECTUM, DISEASES OF.

Bromide of potassium, 114. Locally in five
parts glycerine in fissures of rectum and pain-
ful growths.

Cocaine, 440. Suppositories and pessaries in
painful conditions.

Iodofor.m, 279. As suppository in painful dis-
eases.

Phosphorus, 235. In chronic inflammation.

RENAL COLIC. {See Colic.)

RESTLESSNESS.

Aconite, 345. One drop of tincture at bed-time,

repeated if needful.
Warm sponging, 51. To induce sleep and calm

restlessness of convalescence.

RETENTION OF URINE.

Cannabis indica, 429. When from spinal disease.

RHEUMATISM, ACUTE.

Acid steam-bath, 62. Relieves pain and checks
perspiration.

Aconite, 344. Often subdues pain in inflamed
joints and perhaps shortens the fever.

AcTAi.K racemosa, 337. Has been much used,
said to quell the pain speedily.

Acupuncture, 79. At " corresponding spot " on
opposite side to relieve pain.

Antipvrine, 454. Cannot compare with salicy-
late.

Benzoic acid, 308. Inferior to salicylic acid.

Bicarbonate or citrate ok potash, 141. Opin-
ions very divergent. Seems, however, to re-
lieve pain.

Blistering, 84. Large flying blisters to inflamed
joint.

Cold-water treatment, 48. Invaluable in
hyperpyrexia. (See p. 49.)

Cold wet compress, 45. To painful joints.

Coniu.m, 364. Internally to relieve pain.

Li.ME-juiCE, 129. Eight ozs. daily ; lemon-juice
inferior.

NiTR.\TE OF potash, 167. In large doses (half
oz. to one oz. in the day) freely diluted in
water or lemonade — thought highly of by some.

Opium, 416. Hypodermically to relieve pain and
induce sleep.

Packing, 45. If patient cannot be moved front
of body may be packed.

Poultices, 64. Very hot on the painful part.

QuiNiA, 447. Recommended by some (see ref.)

Salicine, 449, 450. Thirty grains every two
hours or even hourly at first. Improvement
goierally in one or two days, and course of
fever much shortened. Mitigation of pain first
sign of improvement. Liable to relapse.

S.^licvl.^te of soda, 451. Behaves as salicine.
Also used locally to joints.

RHEUMATISM, AC\ji:'E—contimied.

S.\LiCYLic acid. 451. Behaves as salicine, but is
very slightly soluble and liable to impurities.

Salol, 453.

Sulphurous acid, 131. After fumigation, patient
to be covered with bed-clothes which have been
exposed to strong fumes ; this produces perspi-
ration, sleep and relief.

Tepid or cold sponging, 45. If prejudiced
against packing.

Turkish bath, 60. For modified form, see p. 62.

Veratria, 329. Veratrum viride as tinct. is said
to be useful.

— — , 330. As ointment to rheumatic joints.

It often, however, fails.

RHEUMATISM, CHRONIC.

Antipvrine, 454. Hypodeimically.

Blistering, 85. Nightly in gonorrhoea! form.

Brine baths, 52. At Droitwich.also home baths.

Capsicu.m, 316. A strong infusion applied on lint
for rheumatic pains.

Carbonic acid, 8S. Natural waters containing
much carbonic acid used externally.

Chloral, 285. Often relieves the pain.

Cod-liver oil, 243.

Cold douche, 57. Salt may be added.

Galvanism, 61. For pain and stiffness.

, 64. For pains remaining after acute

rheumatism.

Guaiacum, 336.

Ice and s.\lt, 68. Apply for six minutes to dis-
eased joints, then replace for short time by
pounded ice.

Iodide of pot.assium, hi. Especially when pain
worse at night, or of syphilitic origin.

Iodine, 100. Paint round joints.

La.mp-bath, 61.

Mercury and morphi.\, oleate of, 194. For
joint affections (locally).

Nitrate of potash, 167. Ten grains hourly or
every two hours when urine scanty and high-
colored, becoming turbid on cooling.

Oil of mezereon, 307. And of sassafras reported
useful.

Packing, 44.

Poultices, 64. In so-called rheumatic pains at-
tacking one part of the body.

S.\LOL, 453.

Sulphides, 93. As baths.

Sulphur, 92. Locally applied. Internally in
chronic and muscular rheumatism,

Turkish baths, 60. Generally and for circum-
scribed stiffness in shoulder.

Hot followed by cold sponging may be used
as substitute.

Veratria, 330. As ointment to rheumatic joints ;
often fails.

RHEUMATOID ARTHRITIS.

AcT.«;.A RACEMOSA, 337. Especially when con-
nected with uterine derangement — also in other
cases (see ref.).

Arsenic, 216. .As a bath containing four ozs.
washing soda and twenty grs. arseniate of soda.

, 230. Large doses continued for some

time sometimes of great benefit, but action
capricious.

Bro.mide of potassium, 120. Sometimes allays
the severe pain.

Cod-liver oil, 243.

Cold douche, 58. May be slightly warmed in
winter, use for one or two minutes and rub dry.

Iodide of potassiu.m, hi. Sometimes large
doses required (seep. 113.)

Iodine, 104. Tinct. internally said to be better
than pot. iod.

Sulphides, 93. In baths.

Turkish e.aths, 61.

INDEX TO DISEASES.

515

RICKETS.

Cod-l:ver oil, 243.

Cold sfonglng, 55. If the child is weak or very

impressionable he should be allowed to stand

up to the ankles in warm water before a fire

while Deing sponged.
Iron, 176. Must be continued along time.
Lime, 154. As lime-water or carbonate of lime.
Pho.sphate of lime, 156. Small doses as good

as large.

RINGWORM. {See Tmea.)

SALIVATION.

Acids, 124. As astringents in salivation. Small
medicinal doses.

Alcohol, 262. Diluted, as gargle.

Atkopia, 387. Hypodermically.

Bromide of potassium, 117. For salivation of
pregnancy.

Chlorate of potash, 168, Whether mercurial
or simple salivation.

Chlorine solution, 99.

Goto bark, 253.

HvosciN, 402.

Iodide of potassium, 110. Sometimes beneficial
in mercurial salivation, but sometimes aggra-
vates it.

Iodine, 103. Gargle, two drachms of tinct. to
eight ozs. of water.

SARCIN.-E.

Sulphites, 132. And hyposulphites have been
employed to destroy sarcinse and torulse in the
stomach.

SCABIES. {See Itch.)

SCARLET FEVER.

Aconite, 343. To control accompanying in-
flammatory affections. Should be given if dur
ing convalescence any rise of temperature oc-
curs.

Arsenic, 3. With nitric acid in convalescence if
"strawberry" tongue persists.

Belladonna, 394. Has been recommended as a
preventive.

Cariionate of ammonia, 149. In three or five
grain doses hourly or every two or three hours
in al! forms, especially if given early.

Chlorine water, 99. In sloughing of throat.

Cold afi usion, 56. During first few days when
skin hot and red.

Cold wet compress to throat, 44. Through-
out whole course, renew every three hours.

Fat, 238. Rub hands and feet with a firm fat to
remove heat and tightness produced by rash.

Some anoint whole body two or three times a
day with fat or oil, such as almond oil, to pre-
vent desquamation, sequelae and diffusion of
branny particles of the skin.

Ice, 68. Sucking, in the sore throat, especially
at beginning.

Ice poultice, 69. To throat.

Ji*NiPER, 309. Esteemed as a diuretic in scar-
latinal dropsy.

Mercury, 198. The third of a grain of gray
powder every hour has marked effect on in-
flamed tonsils.

Mustard, 314. A general mustard bath on the
recession of rash to bring it back.

Nitric acid, 125. Strong to sloughs in throat.

Packing, 44. Throughout us course, especially
on recession of rash.

Permang.\nate, 178. Has been given internally.

SCARLET VE\Y.K— continued.

Salicylic acid, 451. And salicylate of soda
lessen temperature. Not much used now.

Strychnia. 423. Hypodermically for paralysis,
after scarlet fever.

Sulphate of magnesia, 164. And other pur-
gatives prevent sore throat and other sequelae.

Sulphurous acid, 131. Inhalation, spray or
fumigation in malignant sore throat.

Veratrum viride, 328. Has been employed in
convulsions.

SCIATICA.

AcoN ite, 339. As ointment, generally belladonna
better.

Act.i-:a, 337.

Acupi ncture, 69, 78. Along the course of sciatic
nerve, often cures long-standing cases.

Antipyrine, 454. Internally.

Atropia, 38-. Hypodermically, but generally
morphia better.

Belladonna, 392.

Brine baths, 52. At Droitwich and at home.

Chloride of ammonium, 159.

Chloroform, 276. Inhalation.

Counter-irritation, 84. Free vesication by
cantharides — acupuncture sometimes very ser-
viceable.

Ether 6q, 278. As spray, sometimes removes
pain permanently — generally only temporarily.

Galvanism, 69.

Guaiacum, 336. Has been employed for sciatica.

Iodide of potassium, m. Sometimes relieves,
but often fails.

Methyl chloride, 278. As spray.

Morphia, 406. A single hypodermic injection
sometimes permanently cures long-standing
cases. If not it may be repeated every second
day or so.

Needle, 84. On the sciatic nerve.

Poultices, 64. Applied very hot.

Salicylate of soda, 451.

Salol 453.

Sulphur, 92. Locally.

Turkish baths, 59.

Turpentine, 305. In half-ounce doses for four
or eight successive nights, has been very suc-
cessful.

Veratria, 329. As strong ointment. Veratrum
viride as tinct. has also been recommended (p.
328).

SCREAMING AT NIGHT. {See Night
Screaming.)

SCROFULA. {See Sores.)

Blisters, 84. For scrofulous glands.

Calomel, 191. As ointment for sores.

Chloride of calcium, 154. Ten to twenty grain
doses in milk after food when glandular en-
largement of neck and chronic diarrhoea.

, 154. With glandular en-
largements.

Cod-liver oil, 242. Of great service in the
various manifestations of this disease, as chronic
discharge from ears and nose, strumous ophthal-
mia, strumous disease of bones, abscesses, &c.

Iodine, 102. Tinct. or ointment applied over
scrofulous glands — take care not to increase
inflammation.

Iron, 176. Must be long continued.

Phosphate of lime, 156. Of great use for scrof-
ulous sores.

Soft soap, 138. As application in acute and
chronic inflammations, mesenteric diseases,
caries, and periostitis, when of a scrofulous
nature.

Sulphides, g6, 97. For sores, abscesses, suppu-
rating glands. (See ref.)

516

INDEX TO DISEASES.

SCURVY.

Acms, 129. Especially vinegar to prevent scurvy
in the absence of lime-juice or fresh vegetables.
Alcohol, 262. Diluted as a gargle.
Atropia, 387. Hypodermically.

SEA-SICKNESS. {See also Vomiting.)

Chloral, 284.

Chloroform, 270. Drop doses of pure chloro-
form.

Nitrite OF AMVL, 296. Inhalation for prevention
of sea-sickness. Internally for a peculiar affec-
tion allied to sea-sickness.

Nitro-glycerine, 300.

Spinal ice-bag, 71.

SEMINAL EMISSIONS. {See Sperma-
tori'hcca.)

SENILE DECAY.

Cod-liver oil, 235. With phosphorus.
Phosphori;s, 235. Many cases improve.

SEPTICEMIA. {See PycEmia.)

SEXUAL DESIRE, INORDINATE.

Camphor, 303.

SHINGLES. {See Herpes.)

SICK HEADACHE.

Aconite, 338. The ointment to be rubbed over
the painful brow at commencement.

, 338. As ointment in neuralgic sick

headache.

Antipyrine, 454. Highly useful.

Bromide of potassium^ 118. When associated
with "nervous" state, which it often is at the
" change of life."

• ,290,291. When due

to uterine disorder.

Caffhine, 435. As effervescing citrate useful in
sick headache.

Cannabis indica, 428. E.specially valuable in
preventing attacks when from fatigue, &c.,
they become unusually frequent. Useful where
much or little sickness, also sometimes in the
severe continuous forms. One-third to half a
grain of the extract at commencement of attack
will sometimes cut it short.

May be combined in pill with iron or aloes.

Chamomile, 456. A popular remedy.

Chloride of ammonium, 159.

Cocaine, 441. Internally.

Croion-chloral, 291. Especially in the milder
forms without severe vomiting and retching.
Often bromide useful afterwards.

• , 291. When the headache pre-
dominates.

Friedrichshall water, 161. A wineglassful
in a breakfast-cup of hot water for bilious sick
headache.

Mercury, 205. As blue pill.

Nitrite ok amyl, 296. As inhalation.

Nitro-glycerine, 300. A tablet every hour
immediately headache begins. May be given
in a paroxysmal period — often successful, but
frequently fails.

Nux VOMICA, 420, 421. A drop of the tincture
very frequently in acute gastric catarrh with
much headache and slight nausea.

Phosphorus, 235.

SICK W^AXihCYiY.— continued.

Podophyllum, 335. When there is either diar-
rhcEa or constipation, with dark-colored mo-
tions. If the diarrhoea is of a light color the
hundredth part of a gram of bichloride of mer-
cury three times a day.

Salicylate of soda, 435.

Valerianate of zinc or of ammonia, 310. In
two to five gr. doses three times daily.

Veratria, 330. The ointment to be rubbed ovei
the painful brow at commencement.

• , 329. As ointment where tenderness

of skin present. It often subdues pain, pre-
vents vomiting, and shortens the attack.

SICKNESS. {See Vomiting.)

SKIN AFFECTIONS, CHRONIC.

Cod-liver oil, 242. When syphilitic or other-
wise.

SKIN, TORPID.

Acids, 124. Greatly diluted nitric or hydro-
chloric, as bath.

SLEEPLESSNESS.

Alcohol, 267. In fevers if it produce sleep and
quell delirium.

Bromide of p<)Tassium, 118. Especially when
delirium like that of delirium tremens or ac-
companying mental anxiety, hysteria, preg-
nancy, and general nervous irritability. Dose
20 to 30 grs. It increases hypnotic effect of
hyosc, cannabis ind., ether and chloroform.

Cannabis indica, 428. Rather uncertain.

Chloral, 283. In old people, delirium tremens,
paralysis of insane, acute mania, puerperal
mania, puerperal convulsions, typhus, phthisis,
convulsions of children.

CoDEiA, 418. And narcein, both soporifics.

Croton-ch LORAL, 292. One drachm may be
given.

Ether, 278. Or spirits of chloroform in a full
dose.

Gelsemium, 382. In mania, drunkards, and over-
excitement.

HvoscYAMUs, 401. When opium disagrees.

Morphia, 407. Hypodermically injected in acute
mania, delirium tremens, chorea, &c.

Opium, 411. A rectal injection .'-onetimes suc-
ceeds best, e.g., for dyspeptics or convalescents
from acute disease, also used in delirium tre-
mens and traumatic delirium.

■ , 414. In fevers.

, 416. The time of administration impor-
tant — should be given so as to act at the time
when the patient is naturally inclined to doze.

It should not be given in chronic sleepless-
ness independent of any very notable disease ;
chloral and bromide of potassium much better
in dyspepsia and uterine derangements.

Phosphorus, 235. When depending on cerebral
anaemia — also in the aged.

Removal inland, 42. When restlessness at night
is produced by sea-bathing.

Srrz-MATH, 43. At 60° to So°.

Tartar-emetic, 214. In the delirium of typhus
and other fevers.

Warm bath, 51. Or sponging, in fever and con-
valescence.

, 51. In inflammatory affections.

SMALL-POX.

Collodion, 237. Or solutions of india-rubber or
gutta-percha in chloroform prevent pitting in
small-pox.

INDEX TO DISEASES.

517

SMALL-FOX— continued.

Lime, 152. Cotton-wool cut in proper shapes is
dipped into lime-liniment and applied to face
and neck to prevent pitting.

Mercury, 197. Formerly used in ointments or
plasters to prevent pittmg.

Packing, 44. Especially on retrocession of rash.

Silver, nitk.\te of, 187. By fourth or fifth day
puncture vesicles with needle dipped in solution
20 grs. to I oz., or simply paint the skin. This
plan prevents pitting.

SNEEZING.

Arsenic, 217. A drop of the liquor three times a
day in paroxysmal sneezing allied to asthma.

Camphor, 301. In incessant sneezing with pro-
fuse running from eyes and nose. The powder
should be sniffed or the alcoholic solution in-
haled.

Iodide of potassium, 109. In paroxysmal sneez-
ing ten grs. several times a day.

Iodine, log. Inhalations in paroxysmal sneezing
with itching at the nose.

SOMNAMBULISM.

Bromide of potassium, 119. In the somnambu-
lism of children, which is allied to epilepsy.

SORE FEET.

Washing soda, 145. A tablespoonful in half a
gallon of wanm water as foot-bath for half an
hour in tenderness of soles.

SORE NIPPLES. (See Nipples, Sore.)

SORES. {See also Ulcers.)

Alcohol, 261. To cover sores with thin protect-
ing layer of coagulated albumen.

Alum, 169. Dry or in solution to relaxed and
abundantly secreting sores.

Camphor, 301. For dusting on indolent sores.

Carbolic acid, 257. Applied as stimulant and
antiseptic.

Caustic alkalies, 134. Applied to hard edges.

Charcoal, 66. Locally to sloughing sores.

Chloride of lime, 66. Added to poultice for
offensive gases.

Chlorine solution, 99. For sloughing and in-
dolent sores, as a. wash.

Cinchona, 442. The powdered bark dusted over
sloughing ulcers, &c.

Copper, 206. The sulphate as stick, solution, or
ointment to indolent sores.

Glycerine of carbolic acid, 247. A good ap-
plication to fcetid sores.

Hamamei.is, 252. On lint or cotton-wool when
oozing.

Iodide of starch, 66. Asa poultice, cold. (See
ref.)

Iodine, 103. Sores of throat, syphilitic and sim-
ple.

Iodoform, 279. Dusted over spreading or
sloughing sores.

loDOL, 281. Dusted over sores prevents suppu-
ration. Very useful in syphilitic and gangren-
ous sores.

Lead, 181 The soluble salts as lotion to un-
healthy over-secreting sores.

Lime, 152. As carbonate or lime-water to check
discharge.

Mercury, 196. Calomel ointment or black wash
in scrofulous or tubercular lupus, and in open
scrofulous sores.
Nitric acid, 124. To surface of unhealthy and
indolent sores.

SORE S — C071 tin tied.

Opium, 406. Or morphia with glycerine as an
application to cancerous or simple sores, to re-
lieve pain.

Phosphate of lime, 156.

Sulphide of calcium, 96. When thin ichor
discharged.

Tannin, 248. Or glycerine of tannin to coat over
wounds and profusely discharging sores.

Yeast, 66. As poultices, in sloughing sores.

Zinc, sulphate of, 208. To unhealthy free se-
creting sores.

SORE THROAT.

of.)

{See Throaty diseases

SPASMODIC AFFECTIONS.

Aconite, 341. In spasmodic laryngitis rapidly

produces good effects.
Ammonia. 148. Useful in children's intestinal

colic, &c.
Camphor, 303.

Chloroform, 269. Vapor in spasm of intestines.
Hot sand, chamomile flowers or tile, 67.

Locally in painful "spasms."
Opium, 416. Very useful as an antispasmodic,

especially if given with a stimulant, as alcohol,

ether, or chloroform.
Sulpho-carbolates, 259. In flatulent "spasms;'

sometimes phosphorus better.

SPERMATORRHCEA.

Belladonna, 394. A quarter grain of the ex-
tract with one-and-a-half grain zinc sulphate
three or four times a day, often successful in
cases of nocturnal seminal emissions.

Bladder to be emptied after first deep
sleep, 120.

Bromide of potassium, 120. Supplemented by
cold sponging of scrotum and perinaeum and
suspension of testes in water ; use of a hard
mattress and abstention from suppers ; patient
to be waked up after six or seven hours' sleep.

C.\ntharides, 313. With iron internally in
emissions.

Cold douche, 58. To perinseum and buttocks
with suspension of testicles in cold water.

Cold sponging, 57.

Digitalis, 355. One or two drachm doses of the
infusion very efficacious.

Hypophosphites, 158. Of lime or soda.

Phosphorus, 235. For physical or mental de-
bility induced by spermatorrhoea.

QuiNiA, 448. Has been recommended.

Spinal ice-bag, 70.

Strychnia, 424. In large doses, especially when
associated with impotence.

SPINAL IRRITATION.

Aconite, 339. As ointment.

Belladonna, 339. Preparations locally applied
generally better than those of aconite.

SPRAIN.

Cold douche, 57. Salt may be added. The
force must be regulated by condition of tissues.

STINGS.

Ammonia, 147. Weak solutions in stings of in-
sects to neutralize the formic acid.

518

INDEX TO DISEASES.

STOMACH. DISEASES OF. {See also
Vomiting.)

Acids, 126. Nitric or hydrochloric in small doses
for acid eructations, heartburn, and discomfort
in chest and epigastrium due to excess of acid
in stomach.

Alkahf.s, 139. In pain of stomach. Liquor
potassae generally used.

Am.monia, 14S. Internally as an excitant when
functions of stomach and upper intestines de-
pressed.

Arsenic, 222. A drop of liq. arsen. before food
in irritative dyspepsia, and in vomiting of
drunkards. Useful in chronic ulcer and can-
cer ; also in heartburn and gastralgia, and in
chronic dyspepsia with diarrhoea which is ex-
cited by food.

Bellado.v.n.\, 388. In some painful affections.

Bismuth 180. Especially the nitrate, eases the
pain in both organic and functional diseases —
as cancer, chronic ulcers, chronic inflammation,
especially chronic gastritis of drunkards, also
in gastrodynia and cramp ; acute and chronic
catarrh of stomach in children causing vomiting
yield to this, also the vanous forms of pyrosis.

Carbonic acid water, 88. In painful and irri-
table conditions, may be mixed with milk ; use-
ful where constipation.

Charcoal, 87. In ulcer of stomach, also in
neuralgia.

Chloral, 285. Sometimes relieves pain of gas-
tralgia.

Chloroform, 270. Drop doses in flatulent dis-
tention, sea-sickness, and other vomitings.

Cocaine, 441. In form of pill averts vomiting
and eases pain of disease of stomach.

CoNiu.M, 364. Sometimes relieves pain of cancer.

Cou.NTER-iKRiT.\TioN, 84. At epigastrium often
allays pain and obstinate vomiting due to dis-
ease of stomach.

Cre.\sote, 255. Checks pain after food, also
many forms of vomiting.

Eucalyptus, 309. In chronic catarrh and in
vomiting from sarcinae.

Glycerine, 248. 3 j or 3 ij in tea, &c., in flatu-
lence and acidity.

Hydrocyanic acid. 404. Much used in painful
diseases, as chronic ulcer, cancer, chronic gas-
tritis, gastralgia, &c. May check vomiting as
well as relieve pain.

Ice-bag, 68. To epigastrium, for pain and vom-
iting in cancer, ulcer, &c.

Ikon, 174. Astringent preparations in haemor-
rhage from stomach.

Lead. 182. Soluble preparations have been rec-
ommended in pyrosis.

Li.ME-wATER AND MILK. 153. When disease.

Mag.nesia. 151. As oxide and carbonate — action
mild — very suitable for children — often com-
bined with rhubarb.

Bicarbonate, or. as it is often called, fluid
magnesia, is a useful and mild aperient.

Manganese, 178. Black oxide in gastrodynia
and pyrosis.

Nutrient e.nemat.^, 77. In painful diseases as
chronic ulcer and when persistent vomiting.

Nux VOMICA, 420. One or two drops of the tinct.
every two hours or oftener when tongue coated
and there is chronic catarrh of stomach in the
course of chronic disease, also when there is
flatulence and indigestion, or heartburn.

, 420. One drop every five or ten

minutes for eight or ten doses in acute gastric
catarrh with headache or sick headache.

Qpiu.M, 410. Or morphia, to quell pain of many
stomach affections, and to relieve the vomiting ;
thus it is use^l in cancer, chronic ulcer and
chronic gastritis from excessive indulgence in
alcoholic drinks.

, 410. For the pain, nausea, and want of

appetite accompanying alcoholism, small doses
of morphia combined with tonics very effica-
cious. For gastrodynia with heartburn, small
doses of morphia with bismuth.

STOMACH, DISEASES OY— continued.

Salicylate of .soda, 449. In gastralgia and
fermentation in the stomach.

Silver, nitrate of, lop. Given in solution to
check pain and vomiting of chronic inflamma-
tion, chronic ulcer, and even cancer.

Strychnia, 419. Hypodermically for gastralgia
and gastrodynia.

Sulphites and hyposulphites, 132. To destroy
sarcinae and torulae.

Tannin 250 Sometimes given for irritative
dyspepsia, also in haemorrhage.

Turpentine, 304. In ha;morrhage from chronic
ulcer, &c., five to ten drops frequently repeated.

Zinc, sulphate of, 209. In less than emetic
doses in painful affections due to chronic in-
flammation of mucous membrane.

STOMATITIS. {See Mouth, diseases of.)

Acids, 124. As astringents in ulcerative stoma-
titis ; others, however, are preferable.

Alum, 170. In ulcerative stomatitis, applied dry
with the finger many times a day, especially
where disease affects one-half the jaw.

Boracic acid, 133. As lotion, one in fifty.

Chlorate of potash, 168. In ulcerative stom-
atitis.

Copper, sulphate of, 206. Solution painted
over edges of gums in ulcerative stomatitis.
Generally dry alum better.

Glycerine of tannin, 250. In ulcerative stom-
atitis.

Li.me-water, 153.

Salicylic acid, 452. One part (dissolved in suf-
ficient alcohol) to 23o parts of water eases pain
of catarrhal stomatitis.

STONE. {See Calculi.)
STOUTNESS. {See Obesity.)

STRICTURE.

Opium, 417. In spasmodic stricture.

STRUMA. {See Scrofula.)

SUNBURN.
Vaseline and petroleum, 253.

SUNSTROKE.

Cold affusion, 57. When patient struck down
unconscious.

SUPPURATION.

Quinia, 448. Has been recommended in profuse
suppuration.

Sulphide of calcium, 94. When ichor instead
of pus is secreted. It will also arrest suppura-
tion, or, if that is impossible, will hasten ma-
turation.

ANIMATION AT

Cold water, 37. Smartly sprinkled on face.

SUSPENDED
BIRTH.

SWALLOWING LIQUIDS. CONGEN-
ITAL DIFFICULTY IN.

Bromide of potassium, 115. When no diph-
theria or malformation.

INDEX TO DISEASES.

519

{See Perspiration^ ex-

SWEATING.

cessive. )

SYCOSIS.

Mercury, 193. Bichloride, two grains to one
ounce of water applied as lotion after each
epilation.

, 194. The oleate.

SYNCOPE. {See Fainting.)

SYNOVITIS.

Blisters, 85. A flying blister every night in
chronic synovitis.

Iodine, 100. Painted round joint in chronic
synovitis.

Mercury and morphi.\, ole.a.te of, 193. Lo-
cally applied.

SOFT-SOAH, 138. Applications.

SYPHILIS. {See Chancre.)

Cod-liver oil, 242. In chronic skin affections.

Iodide of iron, 177. Where ansemia.

Iodide of potassium, ho, hi. In secondary
and tertiary syphilis. (See ref.) Large doses
required for some syphilitic sores. (Caution,
p. II3-)

loDOL, 281. In secondary syphilis.

Lamp-bath, 61.

Mercury, ho. For secondary syphilis of chil-
dren. Iodine sometimes best.

, 195. Corrosive sublim. half an ounce,

ammon. chlor. one ounce, in a bath for obsti-
nate rashes.

, iq6. Black wash very useful in syphilitic

sores generally, in mucous tubercles, and in the
elevated indurations, larger and more irregular
than mucous tubercles, occurring near the anus
of children. Calomel or citrine ointment may
be substituted for black wash.

Calomel dusted over condylomata will re-
move them.

The cyanide, ten to fifteen grains in an ounce
of water, may be applied to rashes and sores on
throat, tongue, penis, anus, &c. For those on
the prepuce five grains to the ounce quite
strong enough. Should be applied with soft
brush to chancres, and these should be kept
moist with lint soaked in black wash.

Mercurial applications mixed with tar, &c.,
are useful in syphilitic psoriasis.

Mercurial fumigations, moist or dry, for erad-
icating syphilis. These sometimes produce
prostration.

, 196. Mercurial and calomel ointments

may be rubbed into delicate parts of the skin to
mercurialize the system.

Bichloride has been injected subcutaneously.
In syphilitic ozsena nitrate of mercury oint-
ment, partially melted, may be applied twice a
day after nose well cleared.

For discussion on the use of mercury in
syphilis, see pp. 203, 204.

, 194. The twenty percent, ointment of

the oleate in the axilla useful for both children
and adults.

Nitric acid, 129. In secondary syphilis.

Oils of mezereon and sassafras, 307. Re-
ported useful.

Soft-soap, 138. Applications in glandular swell-
ings.

Zinc, 208. Chloride, iodide, nitrate, locally to
syphilitic ulcers.

TEETH, AFFECTIONS OF.

Aconite, 338. Ointment or liniment for facial
neuralgia due to diseased teeth ; will succeed
quickly if at all.

TEETH, AFFECTIONS OF— f(w//««f^/.

Arsenic, 216. Asescharotic to destroy pulp.

, 216. When for pain may be mixed with

opium. It sometimes at first aggravates pain.

Bromide of potassium, 117. For irritability and
convulsions in teething.

Capsicum, 316. A strong infusion applied on lint
for toothache.

Chloral, 285. Rubbed up with equal weight of
camphor and rubbed gently in externally or put
into cavity.

Chloroform, 270. Two or three drops on cot-
ton-wool in ear, or into tooth, or hold over hol-
low tooth a bit of rag moistened with chloro-
form.

, 270. Equal parts of chloroform

and creasote a good application.

Coc.-mne, 440. 1 he citrate pressed into a painful
cavity, and before removing tartar.

Collodion', 237. Mixed with crystallized car-
bolic acid, which has been melted in a test-tube,
may be inserted into a tooth with exposed and
inflamed pulp on cotton-wool : the pain may be
at first increased but is soon abolished.

Creasote, 254. With tannin or opium into hol-
low of decayed tooth often gives relief.

Croton chloral, 289. Sometimes relieves tooth-
ache. Of use if with neuralgia.

Gelsemium, 375, 382. In some forms of tooth-
ache.

Hot water, 72. Rinse with — sometimes cold
better.

Hyhophosphites, 158. Of lime or soda in teeth-
ing.

Iodine, 103. Tincture painted over gums close
to teeth when these begin to recede and expose
teeth. Also to remove tartar from teeth.

Morphia, 407. Hypodermically injected for
severe toothache.

Opium, 409. Mixed with tannin or creasote and
inserted into the hollow of a painful tooth,
where inflamed pulp exposed.

Volatile oils, 306. In toothache.

Zinc, chloride of, 208. To destroy exposed
painful pulp.

TETANUS.

Calabar bean, 366. If possible by mouth, if
not, hypodermically or by anus. It must be
pushed till just short of arresting the breathing,
and should be given at the very beginning.
The liquid extract is used.

Chloral, 2S5. In large doses has sometimes
cured.

CoNiA, 364. Hypodermically.

Ether, 278. Spray to spine every two hours for
tetanus.

Gelsemium, 382.

NicoTiA, 361. By rectum or hypodermically,
appears to be useful in many cases.

Nitrite of amvl, 295. Inhalation maybe tried,
or it may be given subcutaneously.

Spinal ice bag, 71.

THIRST.

Acid drinks, 122. In fevers, promote secretion

of saliva.
Ice, 68. Sucking ice allays thirst.
Tepid drinks, 72. in diabetes.

THREAD WORMS. {See Worms.)
THROAT, DISEASES OF.

Aconite, 341. In tonsillitis and acute sore
throat, when temperature high, drop cr half-
drop doses of the tincture every quarter of an
hour for two hours, then every hour, will al-
most certainly prove efficacious.

520

INDEX TO DISEASES.

THROAT, DISEASES OY—contimu'J.

Alcohol, 262. Diluted, as gargle in relaxed
throat, scurvy, salivation, &.c.

Alum, 170. Dry or in solution, in simple or scar-
latinal sore throat, in tonsillitis, and even diph-
theria.

Gargles in chronic inflammations, but glycer-
ine of tannin better.

Antimony, 213. One-quarter to one-half a grain
of tartar-emetic every hour in tonsillitis.

Antiseptic solutions, 99. In sloughing.

Arsenic, 216. In medicinal doses in sloughing
of throat or malignant sores.

Belladonna, 388. Internally in severe inflam-
matory diseases, especially when throat and
tonsils acutely inflamed and much swollen —
may be given with aconite.

Capsiclm, 316. One drachm of the tinct. to half
a pint of water as a gargle in some sore throats,
and in the very early stage of tonsillitis and
pharyngitis, also in malignant sore throat and
in relaxed throat.

Carbolic, 258. Spray to nose or gargle in con-
tagious sore throat.

Cocaine, 430. Painting with a 20 per cent, solu-
tion in ulcerations of epiglottis. A 4 per cent,
solution in tonsillitis rapeated every hour re-
lieves pain. Sometimes as spray.

Cold compress, 342. Used nightly to harden
throat, when tendency to catarrh. It should
be swabbed daily with glycerine of tannin.
Inhalations of sulphurous or carbolic acid
useful.

Creasote, 254. Or carbolic acid gargle in sloughs
of throat.

Glycerine of tannin, 250. After acute inflam-
mation ; in ulceration in aphthous sore throat ;
in chronic inflammation ; often when accom-
panied by deafness or cough, provided no ca-
tarrh or phthisis or teething irritation.

Guaiacum lozenges, 336. In follicular pharyn-
gitis.

Ice, 68. Very valuable, constantly sucked in
tonsillitis, sore throat, &c.

, 69. A poultice of broken ice in an india-
rubber bag in tonsillitis, scarlet fever and diph-
theria, especially when lymphatic glands much
swollen.

Iodine, 103. Tincture injected into hypertro-
phied tonsils.

, 104. Tincture applied locally to sores,

whether syphilitic or not.

Ipecacuanha wink, 325. As spray in non-inflam-
matory sore throat and hoarseness from conges-
tion of vocal cords.

Mercury, 198. In acute tonsillitis when tonsils
almost meet, the third of a grain of gray pow-
der every hour benehcial even if an abscess has
formed.

Mercury and morphi.\. oleate op-, 194. In
obstinate and painful ttmsillitis.

Nitrate op" potash, 166. Crystals sometimes
sucked in acute inflammation, but other reme-
dies preferable.

Nitrate of silver, 189. In 'early stage of in-
flammation locally applied may cut it short.
Solutions are used in chronic sore throat, but
generally tannin and other astringent but non-
irritant applications better unless in a sloughing
condition. Sometimes used in diphtheria on
inflamed patches only. Sometimes applied to
chronically inflamed larynx, as in phthisis, by
brush or spray.

Sometimes injected into trachea in asthma,
bronchitis and phthisis (see p. 189).

Nitric acid, 124. Applied undiluted to foul
sloughs.

Salicylate of soda, 452. Extremely successful
in quinsy.

Sulphides, 94. As natural waters, especially
useful in follicular pharyngi'is.

Sulphurous acid, 131. Inhalation, spray, or
fumigation, for malignant sore throat, whether
scarlatinal or otherwise.

THROAT, DISEASES OY— continued.

Tannin, 250. A spray of five per cent, tannin

in diphtheria and croup.
Zinc, sulphate of, 208. As gargle occasionally

employed in relaxed throat.

THRUSH.

Borax, 133. With honey or as glycerine of

borax.
Copper, sulphate of, 206. A weak solution to

be painted over mucous membrane.
Glycerine, 247. Will sometimes cure.
Glycerine of borax, 247.
Salicylic acid, 452. One part (dissolved in

alcohol) to 250 of water.
Sulphurous acid, 131. As solution, strong or

diluted, locally applied.

TIC. {See A^euralgia.)

TINEA FAVUS.

Mercury, 193. A lotion of two grains of the bi-
chloride in an oz. of water applied after each
epilation.

, 194. As oleate, see Tinea sycosis.

Oils, 238. To facilitate removal of scabs — poul-
tices used also preparatory to epilation.

, 238. Head to be greased freely to prevent

spreading. Other members of family should
also grease freely. A mild mercurial pomade
or quinine in glycerine best.

Sulphurous acid, 131. The Pharmacopoeia acid
with glycerine. If the case is obstinate epila-
tion assists.

TINEA SYCOSIS.

Mercury, 193. A lotion containing two grains
of the bichloride to an ounce of water to be ap-
plied after each epilation.

, 194. The five per cent, solution of

oleate in oleic acid with the addition of an
eighth part of ether.

TINEA TARSI.

Blisters, 83. To temple, frequently repeated
in obstinate cases.

Mercury, 193. The irritant ointments. Eye-
lashes to be cut short and ointment applied
night and morning after picking off scabs.
Ung. hydrag. nit. should not be diluted to more
than half its strength. Sometimes best un-
diluted.

, 194. As oleate, see Tinea sycosis.

Silver, nitrate of, 189. Solid in obstinate cases
after removal of scabs.

Sulphate of copper, 206. As nitrate of silver,
but milder.

TINEA TONSURANS.

Acetic acid, 123. Strong, locally.

Croton oil, 245. Liniment applied with brush,

followed by poultice.
Iodine, ioi. Two drachms with an oz. of oil of

wood tar, as a local application.
Glycerine of carbolic acid, 258. In early

stages.
Mercury, 193. For lotion, see Tinea favus.

, 194. As oleate, see Tinea sycosis.

Oils, 238. See Tinea favus.

SuLPHO-CYANiDR OF POTASSIUM, 404. Half an

ounce with one oz. glycerine and seven ozs. of

water as lotion. (See ref.)

INDEX TO DISEASES.

521

TINEA TONSURANS— r«?«//««<^d'.

Sulphurous acid, 131. See Tinea favus.
Turpentine. 303. Followed by iodine. (See
ref.)

TOE-NAIL, INGROWING.

PoTASSA, 136. Cotton-wool kept moist with
liquor potassae pressed down between nail and
soft parts.

{See Throat, diseases

{See Teeth, affections

TONSILLITIS.

of.)

TOOTHACHE.

of-)

TORTICOLLIS.

Capsicum, 316. A handful of the crushed pods
are infused for 36 hours in a pint of hot or cold
water and applied on lint covered with gutta-
percha.

TORUL.E, {See Sarcince.)

TUBERCULOSIS. {See Phthisis.)

Arsenic, 231. Appears to reduce temperature,
and is perhaps beneficial in many ways.

TUMORS.

Chloroform, 276. In diagnosis of abdominal
tumors, also in that of phantom tumors.

TYMPANUM, RUPTURE OF.
£ar, diseases of.)

{See

TYPHLITIS.

Ice poultice, t
of abdomen.

Chloral, 283.
Opium beiter.

!. To right side of lower part
Often employed for typhoid.

TYPHOID FEVER. {See also Fevers.)

Alum, 171. For the diarrhoea.

Cold affusion, see p. 47.

Cold compresses ok packing. 47.

Digitalis, 355. Recommended by Wunderlich
to lower temperature and slacken pulse.

Ergot, 430. For intestinal haemorrhage — hypo-
dermically if urgent.

Hydrochloric acid, 129.

Ice poultice, 68. To right side of lower part
of abdomen.

Lead, 183. The acetate with opium for the
purging.

Mercury, 202. Corrosive sublimate, the hun-
dredth of a grain every two or three hours for
the diarrhoea.

, 205, 206. Calomel, in small doses at

commencement, not to be pushed so as to touch
the gums.

Opium, 410. In small doses at night for wake-
fulness with delirium, and also for the diar-
rhoea.

,411. May be given as injection for diar-
rhoea.

TYPHOID Y'EX'EK—contimted.

QuiNiA, 446. To reduce temperature.

Salol, 453.

Sulphurous acid, 131.

Turpentine, 304. In five to ten drop doses fre-
quently repeated for haemorrhages ; and in ten
min. doses every two hours in the advanced
si age with a dry tongue, or drachm doses every
six hours may be given when tympanitis and
prostration but without diarrhoea. (See also
p. 2)

Veratrum viride, 328. Has been employed.

TYPHUS FEVER. {See also Fevers.)

Antimony, 213. In the delirium with wakeful-
ness— tartar-emetic combined with opium. (See
Fever.)

Belladonna, 388. Said to clean the tongue.
(See also p. 394.)

Chloral, 283. To produce sleep and allay vio-
lent delirium.

Cold affusion, 48.

QuiNiA, 446. To reduce temperature.

ULCERS. {See also Sores.)

Chlorate of potash, 168. In solution as a wash
to clean and stimulate foul ulcers — other reme-
dies better.

Cinchona, 442. The powdered bark dusted over
foul, indolent, sloughing and gangrenous ulcers
promotes the healing process.

CoNiUM, 362. Locally applied by means of a
poultice, will ease the pain and improve the
character of the sore.

Glycerine of tannin, 248. If not sloughing.

Nitric acid, 124. Locally to destroy foul, un-
healthy surface. As lotion to indolent and
painful ulcers.

Silver, nitrate of, 189. .Applied to unhealthy
ulcers. Also to ulcers of mouth.

URETHRITIS.

Boro-glyceride, 133. As injection.

URIC ACID, EXCESS OF, IN URINE.

Alkalies, 140. Citrates are best.

URINE, INCONTINENCE OF. {See
Incontinence.)

URINE, SUPPRESSION OF.

Copious injections, 76. Beneficial in some cases.

URTICARIA.

Alkalies, 134. (See Pruritus.)
Benzoic acid, 307. In eau de Cologne.
Benzoin, 307. The comp. tinct. painted on the

skin for itching.
Chloroform, 269. As ointment to allay itching.
Colchicum, 332. In gouty persons.
Cv.anide of potassium, 403. Or hydrocyanic

acid. (See Itching.)
Lead, 182. Lotions to ease itching.
Nitric acid, 124. A dilute wash controls itching

and prevents wheals.

\V.\RM baths, 51.

UTERINE DISEASES.

AcTyEA racemosa, 337. To prevent miscarriages
in irritable uterus and prolapsus.

522

INDEX TO DISEASES.

UTERINE DISEASES— r<w//;;«.<?'.

Belladonna, 387. With tannin as suppository
in neuralgia of uterus.

Camphor, 302. A saturated solution in eau de
Cologne to be rubbed into the head for drowsi-
ness or headache of uterine origin.

Carbolic .\cid, 258. A wealc solution as injection
in cancer, &c.

, 259, 260. Pure in ulcer of os and

cervix and chronic inflammation of uterus or
cervix. (See ref.)

Carbonic acid g.-iS, 8S. Injected up vagina for
pain of ulceration of os, cancer and neuralgia
of uterus.

Caustic lime, 152. Mixed with caustic potash
as escharotic in affections of neck of uterus.

Chloroform, 269. As spray in cancer, ulceration
of OS, and neuralgia, must be continued some
minutes.

Ergot, 430. Hypodermically for fibrous tumor.

, 431. The most valuable medicine known

for uterine haemorrhage — must be given in full
doses and repeated every hour or so. Dry cup-
ding over the sacrum useful, perfect rest nec-
essary.

Glycerine, 247. In congested neck of womb a
pledget of cotton-wool saturated with glycerine
and applied for several hours will induce a co-
pious discharge of serum which will give as
much relief as leeches, — a piece of twine should
be fastened to it.

Glycerine of tannin, 251. Checks discharge
and stench of cancer, better still if mixed with
glycerine of carbolic acid.

Iodoform, 279. As bolus with cocoa fat inserted
into excavation produced by cancer.

Iron, 178. Locally in uterine catarrh.

Lead, 182. As plaster for pain in back due to
uterine disease.

Opium, 411. An injection into the rectum of
laudanum and starch will subdue the pain of
uterine diseases.

VACCINATION.

Aconite, 344. For erysipelatous redness after
vaccination. This treatment may be supple-
mented by the local application twice daily of

• belladonna ointment.

VAGINA, DISEASES OF.
T/iiis. )

{See Vul-

Boro-glyceride, 133. As injection in vaginitis.

Cocaine, 440. Suppositories and pessaries in
painful conditions. A lotion relieves vaginis-
mus.

Glycerine of tannin, 249. In chronic vagin-
itis of children.

VARICOCELE.

Cold douche, 59. To perinaeura and buttocks,

with suspension of testicles in cold water.
Hamamelis, 252.

VERTIGO, AURAL.

Gelsemium, 382. The tincture in 10 min. doses
thrice daily.

VOMITING.

Acids, 126.

Alum, 171. In six to ten gr. doses in obstinate
vomiting of phthisical patients excited by cough-
ing.

VOMITING— r()////«?/^^/.

Arsenic, 222. One drop of liq. arsen. before
food in vomiting of drunkards, also in chronic
vomiting without pain or nausea, has been rec-
ommended in vomiting of cholera.

Bicarbonate of soda, 153. Half-drachm to a
drachm to a pint of milk for infants, especially
if constipated. If lime-water and bicarbonate
of soda both fail, stop all milk and feed on sop-
ped bread, water gruel and chicken or veal
broth.

Bismuth, 180. In many forms of vomiting in
children, especially when due to acute or chron-
ic catarrh of the stomach.

Carbonic acid water, 88. With milk.

Chlor.i^l, 284. In pregnancy.

Chloroform, 270. In drop doses, pure, in sea-
sickness and other vomiting.

Counter-irritation, 84. At epigastrium often
allays pain and obstinate vomiting due to dis-
eases of the stomach.

Creasoi E, 255. In sea-sickness, pregnancy, can-
cer, ulcer of stomach, and Hright's disease.

Eucalyptus, 309. When sarcinae.

Gelatine, 153, 154. With milk, cream, and ar-
rowroot, as food for young children. (See ref.)

Hydrocyanic acid, 404. Sometimes checks vom-
iting as well as relieves the pain of chronic ul-
cer, cancer, chronic gastritis, gastralgia, &c.

Ice-bag, 68. To epigastrium for pain and vom-
iting of cancer, &c.

Ipecacuanha, 151. In sympathetic vomiting.

■ ,326. In pregnancy (see ref.), at

menstrual times, in the morning vomiting of
drunkards, but here arsenic generally better.
In morning vomiting from weakness, and in
convalescents, in acute catarrh of the stomach
in children — may be combined with aconite if
inflammation great, in whooping cough — here
sometimes alum better. In the vomiting oc-
curring without nausea immediately after meals
— here arsenic better.

Lime-water, 153. In chronic forms, as from
chronic ulcer, mixed with milk — if vomiting in-
cessant, patient should be fed on this only in
frequent small quantities. Milk with one-eighth
of lime-water often sufficient for infants in
■whom the gastric juice coagulates milk causing
vomiting, wind and colic. If they are consti-
pated bicarb, of soda better. (See above.)

Magnesia, 151. In sympathetic vomiting — ef-
fects very transient.

Mercury, ig8. As calomel, or, better still, gray
powder, one-third grain every two hours in the
sudden forcible vomiting of children. Small
doses frequently given are useful when vomit-
ingaccompanied by clayey stools.

Morphia, 408. Hypodermically in pregnancy as
well as other severe forms. Often arrests per-
sistent hiccup.

NiTRO-GLYCERINE, 300.

Nutrient enemata, 77. In persistent vomit-
ing.

Nux vomica, 318. When tongue coated with
thick fur — may be given with ipecac.

Oxalate of cerium, 151. One grain ever^- three
hours in sympathetic vomiting.

QuiNiA, 151. In sympathetic vomiting.

, 447. Sometimes useful in vomiting of

pregnancy.

Spinal ice-bag, 71. In pregnancy and sea-
sickness.

Veratrum album, 32S. In vomiting andjpurg-
ing of summer diarrhoea.

VULVITIS.

Alum, 170. A lotion, or if inflammation higher
up an injection, of sixty grains to a pint of
water, to be used every hour or oftener. The
strength is occasionally too much.

Glycerine of tannin, 249. In chronic vaginitis
of children.

INDEX TO DISEASES.

523

VXJhVITlS—coniinm'i/.

Lead, 182. Solutions of the acetate or diacetate
as wash when acute stage just subsided — later
on stronger astringents needed.

Lime-water, 152. As a wash.

WARTS:

Arsenic, 215. Arsenious acid as a caustic —
enough to be used to excite active inflamma-
tion. (See ref.)

, 216. Liquor arsenicalis may be painted

over warts.

Caustic alkalies, 134. Undiluted or mixed
with caustic lime, locally.

Chromic acid, 132. A solution of 100 grs. to one
OE., applied with a glass rod so as just to satu-
rate the diseased growth, any superfluous acid
to be removed ; dress with dry lint.

Glacial acetic acid, 123. Very effectual.

Mercury, nitrate ok, igi. Locally applied.

Nitric acid, 124. A drachm or two of the dil.
acid to a pint of water, as a wash to keep small
syphilitic wartF and condylomata constantly
moist.

Salicylic acid, 452.

Silver, nitrate of, 187. As caustic, but too
superficial.

Zinc, 208. Chloride, iodide and nitrate locally.

WASTING DISEASES.

Phosphate of lime, 156. In chronic cases.

WHEEZING.

Arsenic, 226. In emphysematous persons —
(see Emphysema). In the wheezing of children
with oppressed breathing.

WHITE SWELLING.

Iodine, 102. A solution injected into the joint.

WHITLOW.

Antimony, 213. As tartar-emetic. (See Inflam-
mation.)

Carbolic acid, 257. To benumb the surface
during incision.

WHOOPING-COUGH.

Alum, 172. When acute stage is over and there
is no complication, two to six grs. every three
hours, or less every hour in glycerine or honey.

Belladonn.^, 393. Especially during third week.
Children bear this drug well ; ten minims of the
tinct. may be given hourly to a child two or
three years old.

Of little use if complications exist.

Bromide of potassium, 114. Especially in sum-
mer. When uncomplicated, except with con-
vulsions.

Cannabis indica, 429. Has been found useful.

Carbo.nate of potash, 142. In one or two grain
doses.

Chloride of ammonium, 159.

Chloroform, 269. Or ether, to lessen violence
of paroxysms.

Clover, ^27. A wineglassful occasionally
through the day of an infusion made of two
ounces of carefully dried red blossoms steeped
in a pint of boiling water for four hours.

Cod-liver oil, 243. In middle and after stage.

CONIUM, 364.

Ergot, 431. Said to be useful.
Ipecacuanha, 326. Useful in many cases.

WHOOPING-COUGH— f^'^Z/wM^a'.

Lime-water, 154. Useful from its astringency,
as in some forms alum and tannin advantageous.

Lobelia, 427. In spasmodic stages. Children
very tolerant of this drug ; for a child two years
old, ten min. of the tinct. every hour and an
additional dose each time the cough is immi-
nent, provided the paroxysm gives sufficient
warning.

Musk, 260. Has been given.

Musi AKD, 315. Said to be useful.

Opium, 416. In convulsive stage. Sufficient
should be given to produce slight heaviness,
which should be maintained. (See ref.)

Sbnega, 463. Given by some.

Silver, nitr.\te of, 189. A solution for spong-
ing out throat or as spray. As spray when pa-
tient more than two or three years old.

Tannin, 250. Applied to throat.

Valerian, 310. Preparations said to control
paro.\ysras.

Zinc, 209. As oxide or sulphate.

WORMS.

Alum, 466. As solution for injection.

Areca nut, 465. For tape worm.

Bromide of potassium, 117. In convulsions

caused by worms.
Chioride of a.mmonium, 159. To prevent

formation of thick mucus which serves as nidus

for worms.
Chloroform, 277. For tape worm.
Common salt, 465. Chloride of ammonium and

antimony to remove catarrhal state of mucous

membrane.
EucALVPTOL, 309. Injection for thread worms.
FiLix MAS, 463. For tape worm, to be taken on

an empty stomach and followed by a purge.

(See ref. for directions.)
Injections, 76. For thread worms ; enough

liquid should be used to reach a little higher

than the rectum. Half a pint enough for an

adult. Solution of salt, iron, &c., mu!-t not be

too concentrated lest inflammation ensue.
Iron, 174. Tinct. ferr. sesquichlor. half an ounce

in a pint of water, a good injection for thread

worms, coagulating albumen.
Kamela, 465. For tape worm.
Kousso, 464. For tape worm.
Lime-water, 154 and 466. As injection for

thread worms.
Oils, 466. Reputed vermicides.
Pelletierine, 464. The tannate in tape

worms.
PuNiCA gran.a.tum, 464. As infusion for tape

worms.
Quassia, 456. The infusion useful for ascarides,

as injection or by mouth.
Santonin, 464. For round and thread worms, in

castor oil by mouth or as an injection or sup-
pository.
ScAMMONY, 460. For thread worms in the rec-
tum.
Tannin, 250. As catechu, kino, red gum, rha-

tany, ha;matoxylum, in injections to destroy

thread worms.
Tonics, 466. As cod liver oil and iron to restore

intestinal canal to healthy condition.
TuRPENTi.NE, 304. As poison to tape and thread

worms. (See also p. 465.)
Valerian, 310. Especially when convulsions.

WOUNDS.

Aloes, 457. Topically as a slight stimulant— of-
ten purges.

Carbolic acid, 257. Locally.

Collodion, 238. Paint over to adjust edges and
exclude air.

524

INDEX TO DISEASES.

\\0\]'SD^—conlinued.

On lint or cotton-wool when
Applied to wound prevents

Hamamelis, 252
oozing.

Ice and salt, 6i
inflammation.

Iodoform, 279.

loDOL, 281. Cleans gangrenous wounds.

Opium, 411. To quiet intestinal movements in
wounds of the abdomen.

Sui.PHUKOus ACID, 131. Solution constantly ap-
plied, diluted or not.

Tannin, 248. Or glycerine of tannin to coat over
wounds.

WOUND S— con tin ued.

Turkish bath, 59. For pain in the seat of old
wounds.

XERODERMA.

Glycerine, 247. Glycerine of starch to be rub-
bed in daily after a bath.

Oils and fats, 238. In conjunction with warm
baths to lubricate skin.

Vaseline and petroleum, 253.

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