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THE PRINCIPLES OF 
THERAPEUTICS 



BY 



OUVER T. OSBORNE. M.A.. M.D. 

'apeutics, Departs 
Yale University 



Professor of Therapeutics, Department of Medicine, 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 
1921 

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PMNTEO IN AMERICA 



PREM OF 

W. B. BAUNOERS COMPANY 

PHILADELPHIA 






PREFACE 



This book has been written with the one viewpoint constantly 
in mind, namely, to present the data necessary for the advanced 
student to well understand the objects of scientific treatment, 
the rational use of active drugs, and the physical methods used 
in the treatment of disease. It is also aimed to present even 
under-graduate subjects tersely and concisely, so that the practi- 
tioner may w^ell fijid the book of value as a review of up-to-date 
practical therapy. 

A brief section on prescription writing is offered, a commen- 
tary on the valuable drugs and preparations of the Umted 
Stales Pharmacopoeia is presented, a therapeutic classification 
of drugs, and a description of their action and uses are given in 
some detail. Foods and organotherapy are carefully discussed. 
The various physical methods of treatment, electricity, mas- 
sage, exercise, climate, and medicinal springs are described. 
Special treatments for acute and chronic poisoning by drugs, 
and the treatment for most emergencies are outlined. Rational 
treatments for simple external disturbances are suggested, 
practical ad\ice concerning equipment and preparedness is 
given the young practitioner, the National drug laws are 
described, reportable contagious diseases are listed, and, finally, 
a chapter on Medical Ethics completes the book. 

The author wishes to record his sincere appreciation for the 
help and advice given him by Professor Lafayette B. Mendel 
in the preparation of the section on foods and especially of the 
chapter on vitamines. 

The index has been carefully prepared, and it is hoped that 
both for study and for reference the book will be found of 
value. 

Oliver T. Osborne, 

Nkw Haven, Conn,, 
Aprils J921. 



,51 322, 



CONTENTS 



PART I 
THE ART OF WRITING PRESCRIPTIONS 

Pagb 

iNTBODUCnON l^ 

Ofticial Dkugs and Preparations 2x 

United States Pharmaoop<xia 22 

Preparations of the United States Pharmacop<£IA 2a 

Latin in Prescription Writing 25 

Weights and Measures 26 

Tes Decimal System 27 

The Old System 28 

Table of Equivalents • . . • 29 

Method of Writing PAescrxftions 29 

Abbreviations 3a 

Prescriptions ". .' 33 

Incompatiklity 36 

Dosage 37 

Conditions Modifying the Action of a Drug 40 

Cumulative Effects of Drugs 42 

Drugs That Cause Eruptions 43 

Drugs that Change the Color of the Urine and Feces 44 

Methods of Administering Drugs 44 



PART n 

THE VALUABLE DRUGS AND PREPARATIONS OF THE 

UNITED STATES PHARMACOPCEIA WITH 

COMMENTS 

United States Pharmacopoial Drugs and Preparations 46 

Synonyms loz 

7 



8 CONTENTS 

PART III 

A THERAPEUTIC CLASSIFICATION OF USEFUL DRUGS 

AND A DESCRIPTION OF THEIR ACTION, USES 

AND ADMINISTRATION 

Page 

Dkugs Used to Destroy Micro^xganisics xio 

Disinfection no 

Antiseptics ii6 

Sterilization X19 

Parasiticides 125 

Drugs Used Externally for Action on the Skin 125 

Dusting Powders 126 

Emollients 128 

Counterirritation 132 

Escharotics 138 

Drugs Used For Action on Mucous Membranes 140 

Demulcents 141 

Astringents 141 

Drugs Used for Local Action in the Stomach 148 

Drugs Used to Increase the Appetite X43 

Digestants 150 

Antacids 152 

Drugs Used to Relieve Irritation in the Stomach 153 

Emetics 156 

Drugs Used for Local Action in the Intestinal Canal 157 

Carminatives 157 

Cathartics 158 

Laxatives 161 

Purgatives 166 

Saline Purgatives 168 

Irritant Purgatives 171 

Drugs Used to Diminish Intestinal Putrefaction 173 

Anthelmiptics 175 

Drugs Admin;sterep Internally for Their Action ON THE Skin . . . .183 

Drugs Used to Stimulate the Activity of the Skin 183 

Diaphoretics 183 

Drugs Used to Decrease Perspiration 186 

Drugs Used For Their Action on the Genitourinary System 187 

Drugs Used to Increase the Amount of Urine 188 

Drugs Used to Render the Urine Alkaline 190 

Drugs Used to Render the Urine Add 192 

Drugs Used to Prevent the Growth of Bacteria in Kidneys and Bladder. 193 

Drugs Used to Stimulate the Mucous Membranes 195 

Emmenagogues 195 

Ojcytocics 196 

Drugs Used FOR Action ON THE Respiratory Tract 198 

Drugs Used to Increase the Secretion of the Mucous Membranes. . . 201 
Expectorants 201 



CONTENTS ^ 

Pack 
Dru^s Used to Decrease the Sccredon of the Mucous Membranes , . » 305 
Drugs Used to Relax Spasm .*.,...*, 206 

DeuGS Used for AcnoM on the Cikculation . .207 

Dnjgs Used to Accelerate the Heart ....♦, 211 

Drugs Used to Depress the Heart 212 

Drugs Used to Strengthen the Heart 314 

D rugs Used to Con tract the Blood- vessels tVasocoDstrictorg .231 

Drugs Used to Dilate the Blood-vessels: Vasodilators . 255 

DauGS UsEJ> FOR Action on the Central Nervous System , .... 247 

Drugs Used to Stimulate the Brain and Spinal Cord 248 

Drugs Used to Depress the Brain and Spinal Cord . .... 257 

Drugs Used to Stop Pain .... 259 

Drugs Used to Cause Sleep: Hypnotics 270 

Drugs Used to Cause Genera! Anesthesia: Anesthetics . 284 

Drugs Used to Cause LocaJ Anesthesia 316 

Drugs Used to Lower the Temperature of the Bodv. 325 

.Antipyretics 32$ 

Drugs and Preparations that are Specific 338 

Prevention and Treatment of Syphilis ... .... 343 

The Specific Treatment of Tetany 352 

The Specific Treatment of Malarial Fevers ,,.,..* 362 

Serums as Specifics in Hemorrhage 369 

Drugs Used as Specifics ...... ,....,.,...... 371 

Colchicuro in the Treatment of Gout . 57^ 

Salicylic Add in the Treatment of Rheumatism .375 

Drugs Used to Modify Metabousk 383 

Arsenic , , , . 382 

To Stimulate Metabolism 38B 

Iodine. 389 

Iron 394 

Treatment of Anemia. 397 

To Increase Uric Add Excretion . , 398 

Pbenyldnchoninic Acid 398 



PART IV 
THE ENDOCRINE GLANDS AND ORGANOTHERAPY 



General Considerations . .... 399 

Insanity . . , . 403 

Vasomotor Disturbances ,,...., 405 

Endocrine Glands Teat Have Positive TBerafeutic Value 406 

Thyroid Gland 406 

Hypersecretion 420 

Treatment of Graves' Disease . 426 

Hyposecretion - . 430 

Parathyroid Glands, . 440 



XO CONTENTS 

Page 

Pituitary Gland . 44S 

Hjrpersecretion. .•...•.-.•.•..• 450 

H3fposecretion . .• . . 452 

Suprarenal Glands 458 

Hjrperadrenalism . 461 

Hypoadrenalism 463 

Corpus Luteum 473 

Ovaries ..•..- 478 

Placenta 48s 

Mammary Glands 485 

Testicles 489 

Prostate Gland . . 492 

Thymus Gland. 493 

Pineal Gland 500 

Pancreas 504 

Secretin. . . 506 

Spleen ...-.•... 507 

liver . 507 

Kidneys 508 

Parotid Glands •.....,... 508 

Brain. . . '. 509 

Nuclein 510 

Lymph Glands 511 

Bone Marrow 511 

Meat Extracts ! 511 



PART V 

PRACTICAL THERAPEUTIC MEASURES 

Inhalation 513 

Atoiozation 517 

Insufflation 5x8 

Nasal Douchino 519 

Gakgling 520 

Gavage. ........ 524 

Gastric Lavage 524 

Enemata 526 

Enteroclysis 527 

Urethral Injections 529 

Bladder Irrigations 531 

Vaginal Irrigations 532 

Intra-uterine Irrigation 533 

Hypodermic Medication 533 

Aspiration 535 

Wet CiJPPiNG . 537 

Leeching 537 



CONTENTS II- 

Pack 

VsNESEcnoM 538 

Intkavenous iNjEcnoN OP Saline Solutions 540 

Hyp(h>ermoclysis 542 

Enteroclysis . 543 

T^LAMsrusiOM OF Blood 543 



PART VI 

VACCINES AND SERUMS 

Immunity 547 

Alleegy 550 

Pkotein Poisoning — Anaphylaxis 553 

VACX3NES 555 

Protective and Curative Vaccines 557 

Prevention of Small-Pox 557 

Prevention of Typhoid and Paratyphoid Fevers 559 

Prevention and Treatment of Whooping-cough 560 

Prevention and Treatment of Hay Fever 561 

Test and Treatment of Tuberculosis 561 

Treatment of Gonorrhea 563 

Treatment of Boils and Carbuncles 563 

Prevention of Rabies 564 

Protective and Curative Serums 564 

Antitoxins 564 

Prevention and Treatment of Diphtheria 566 

Schick Test 566 

Prevention and Treatment of Tetanus 568 

Treatment of Pneumonia 568 

Treatment of Badllary Dysentery 569 

Lumbar Puncture 569 

Treatment of Cerebrospinal Meningitis 573 

Treatment of Anterior Poliomyelitis 574 

Treatment of Chorea 574 



PART VII 

FOODS AND DIETS 

General Discussion 576 

Proteins 578 

VlTAMINES 582 

PURINS 586 

Milk 587 

Cheese 590 



12 CONTENTS 

Page 

Eggs 590 

Nuts 591 

Carbohydrates 591 

Sugar 593 

Alcohol 595 

Fats 596 

Salts 599 

Water 601 

Fruits 602 

Coffee and Tea 603 

Nutrient Enemata 605 

General Diet Considerations 607 

Diets 611 

Indigestion 612 

Constipation 613 

Gastric H)rperacidity 615 

Intestinal Bacteria 616 

Diet in Fever 619 

Diet in Anemia 621 

Diet in Heart Disease 622 

Salt-Free Diet 622 

Diet in Hypertension 623 

Diet in Pregnancy 623 

Diet in Tuberculosis 624 

Diet in Diabetes Mellitus 624 

Diet in Obesity 627 

Relation of Scurvy to Diet 629 

Relation of Rickets to Diet 630 

Relation of Beriberi to Diet 630 

Relation of Pellagra to Diet 631 

Relation of Xerophthalmia to Diet 631 



PART VIII 
GENERAL PHYSICAL MEASURES 

Hyperemic Treatment 632 

Heliotherapy 634 

Electricity 638 

Galvanism 640 

Cataphoresis 643 

Electrolysis 644 

Faradism 644 

Sinusoidal Current 645 

High Frequency Currents 646 

Diathermy 647 



CONTENTS 13 

Page 

Sudc Electricity 648 

Roentgen Ray 649 

Radiotherapy 650 

Radio-active Substances 652 

Radium 654 

Hydrotherapy : 656 

Massage 673 

Physical Exercise 680 

Rest Cure 690 

Climate 698 

Mineral Springs 706 



PART DC 
CHRONIC DRUG POISONING 

Alcohol 711 

Delirium Tremens 711 

Morphine Habit 716 

Heroin 718 

Cocaine Addiction 722 

Regulated Treatment op Drug Addicts 723 

Tobacco Habit 725 



PART X 
INDUSTRIAL POISONING 

Lead Poisoning 732 

Poisoning prom Paints 737 

Brass and Zinc Poisoning 738 

Phosphorus Poisoning 738 

Poisoning prom Dye-stupps 740 

Trinrrotolttene Poisoning 741 

PART XI 
TREATMENT OF EMERGENCIES 

Sudden Death 743 

Coma 743 

iLLUMINATIlfG GaS (CaRBON MONOXIDe) POISONING 745 

War Gas Poisoning 748 



14 CONTENTS 

Page 

Caisson Disease 750 

Drowning 751 

Burns 753 

Treatment op Acute Poisoning by Drugs 757 

Corrosive Sublimate (Mercuric Chloride) Poisoning 761 

Wood Alcohol (Methyl Alcohol) Poisoning 764 

Botulism 766 

Toadstool (Muscarine) Poisoning 768 

Convulsions of Young Children 768 

Sunstroke — ^Insolation 771 

Heat Prostration — Heat Stroke 773 

Freezing < . 773 

Seasickness 774 



PART XII 

TREATMENT OF SIMPLE DISTURBANCES OF THE 
SURFACE OF THE BODY 

The Relation of the Skin to the Systemic Condition 776 

Itching — Pruritus 777 

Pruritus Vulv^ 779 

Urticaria 780 

Mosquito Bites 780 

Ivy Poisoning 781 

Primrose Poisoning 782 

Eczema 782 

Chapped Hands 783 

Chilblains 784 

Acne 785 

Impetigo Contagiosa 786 

Sty — Hordeolum 786 

Boils 787 

Carbuncles 788 

Psoriasis 789 

Ringworm — Tinea Trichophytina 790 

Tinea Cruris 791 

Itch — Scabies 791 

Head Lice — Pediculosis 793 

Hygiene of the Hair 794 

Warts 795 

Sweating OF THE Feet AND Axilla — ^Localized Hyperidrosis 796 

Ingrowing Toe-nail . 797 

Inflammation of the Middle Ear — Otitis Media 797 

Leucorrhea 799 



CONTENTS IS 

PART xin 

PRACTICAL ADVICE TO YOUNG PHYSICIANS 

Pagb 

Some Tkuths About Dxugs 800 

Dkug Aphokisms 803 

Drug Fallacies 805 

Thekmometric Equivalents 806 

Clinical Histories 807 

Tberapeutic Chart 809 

The Hypodermic Case 810 

The Pocket Medicine Case 810 

The Always-ready Handbag 810 

Drugs por Office Dispensing 812 

Life Extension 8ia 

PART XIV 

MEDICAL LAWS AND DEPARTMENTS OF HEALTH 

The Harrison Narcotic Law 815 

The Prohibition Law 8x5 

Reportable Diseases 817 

State Department of Health 8x8 

PART XV 

MEDICAL ETHICS 

Principles OF Medical Ethics of THE American Medical Association . 819 

The Oath of Hippocrates 830 

Ethical Suggestions to the Young Practitioner 831 

Index 837 



THE PRINCIPLES OF THERAPEUTICS 



PART I 
THE ART OF WRITING PRESCRIPTIONS 

INTRODUCTION 

UEtil recent years therapy was the most studied branch of 
medicijie. It was first surrounded by mysticism of all kinds, 
but embodied, even in earlier times, management as well as 
the actual giving of drugs. All good results, however, were 
accredited to the ingested or applied remedy, and, like the 
'Mack of sufficient faith'' plea of the Christian Scientists for 
their unsuccessful cases, failure to cure in these times was 
ascribed to the special devil or special de\ilishness of the 
disease. After this period of amulets, talismans, and elaborate 
mixtures of almost everj' thing available, and the wonderful 
panaceas and cures by all kinds of mental impression, came the 
chemical age, then the age of wonderful cures by multitudi- 
nous dilutions of nothing, and its wonderful success on the mind, 
next came Magendie, the Nestor of physiologic investigation of 
drugs, and finally more scientific medication* 

Rational therapy is the hardest of the practical subjects to 
master^ and it is safe to say that the young physician, even 
after a hospital course, is less prepared in the bedside manage- 
ment and the office treatment of disease than in any other 
branch of medicine. In hospital and dispensarj^ cases the treat- 
ment necessarily is much restricted to general routine and to 
formulary preparations; the patient is not individualized, and 
other therapeutic measures are not often available, especially 
in dispensary cases. Students rarely learn in this manner fine 
individualized scientific therapy for private practice. In the 
hospital, the diet, bathing, electricity, massage, drugs and 
preparations are always given and used according to some one 

17 




l8 THE PRINCIPLES OF THERAPEUTICS 

rule which can not well be varied in these institutions to suit 
an individual taste or need. Hence the graduate, and even the 
post-graduate, unless he has especially studied therapy, starts 
his individual practice of medicine positively handicapped. 
He has no resources if his first dogmatic treatment has failed 
or has not been suited to the patient. 

Each and every clinician well knows that it is only the con- 
sultant who can ignore the treatment of troublesome symptoms. 
All successful quackeries succeed because of their ability to 
relieve symptoms or to cause such mental suggestion as will 
relieve overtaxed minds, and many a loyal patient is driven to 
employ quackery by scientific neglect. 

The physician must carefully study his patients, their 
symptoms, and the result of his treatment, and especially the 
results of medication. He must never confound his patient 
• with the disease; it is the patient who has the disease that he is 
called upon to treat. Hence the therapist must individualize 
the man, woman or child who comes to him for treatment. 

Fred Shattuck, of Boston, once said, "The surgeon's knife 
is in reality a confession of failure in so far as it is used for the 
relief of pathological surgery." We should go a step farther 
and still call it therapy when the physidan decides that opera- 
tive intervention is needed and is advisable. But the internist 
should not wholly release his patient to the operating surgeon, 
but should control and manage his pre-operative, post-opera- 
tive, and convalescent periods with, of course, consultation 
with the surgeon. Surgeons are often not alert to physiologic 
disturbances in their operated cases, and hence do not properly 
manage such disturbances, and many a surgical patient gets 
well in spite of the post-operative treatment rather than on 
account of it. Also, the operated patient is often a "case" to 
the skilled, busy operator; but it is a fact that proper medical 
care after the operation will very many times prevent long, 
tedious convalescence, and may even prevent permanent 
invalidism. 

We hear of natural bom physicians, of intuitive sense, and 
of great success in medicine without much medical education, 
and often without even accurate diagnoses. This is true; a very 



THE ART OF WT^ITING PRESCRIPTIONS 



^9 



scientific practitioner may fail at the bedside, while a man with 
broad, keen, intuitive sense will succeed. 'Xommon sense'* 
as it has been termed, or slangly ''horse sense/* is that ability 
to visualize all the knowledge applicable to the given case and 
then to note all of the individualities of the patient and to 
modify the treatment accordingly. 

In spite of all diagnostic acumen and diagnostic measures, 
many a patient gets well without a diagnosis, and some die with 
negative autopsy findings. 

Good therapy is an art. It requires high training, stored 
knowledge, and good judgment to decide the proper hygiene, 
diet, exercise, rest, eliminative or antidotal treatment, and the 
physical measures, drugs, or surgery needed to cure a given 
patient. It also requires good judgment to decide that a 
patient needs only psychic treatment* Also, after the diagnosis 
is made, no two patients can be successfully treated in exactly 
the same way* 

We have not sufficiently studied the various "pathies" and 
appropriated to our own use the modicum of value which each 
may possess* 

Unfortunately for the determination of what is rational and 
scientific therapy, we cannot dissociate ourselves from a deeply 
imbeded belief in mystery in the treatment and cure of disease, 
hence mankind, and the physician is no exception, is impressed 
by cures by physical methods and by multiple or secret mix- 
tures, when the cure is really caused by mental impression. 

A cure for a great e\d] to-day would be to compel every mental 
healer, Christian scientist, osteopath, chiropractor, or pseudo- 
practitioner of any other fraud or cult, to pass an examination 
in pathology and bacteriolog}". No one of these people, unless 
he were a rascal and subject to prosecution for trifling with 
human life, could study gross and microscopical pathology and 
bacteriology, and then make grossly absurd statements to their 
patients and to the public as to the cause and method of cure of 
disease, or could promise to cure incurable diseases. Also they 
would not use methods of treatment that either neglect or 
aggravate a diseased condition. 

The old hobby of letting Nature cure the patient has been 




20 THE PRINCIPLES OF THERAPEUTICS 

ridden too long. Nature is a good mother, but she will do just 
as much to propagate a pathologic germ as she will do to pro- 
mote the welfare of the human being infected by that germ. 
Consequently, neglect will not cure a patient. On the other 
hand, because a patient has an incurable disease, or has a disease 
for which there is no specific treatment, is no excuse for neglect- 
ing every other discomfort that he may be enduring. Neither 
should a complaining individual be neglected because we find 
nothing the matter with him as far as we with our limitations 
can determine. Such an individual needs mental, moral, or 
physical aid of some kind. 

Besides all sanitary and hygienic advice, providing proper 
nourishment for the baby, advice for the proper management 
of the child, and protective vaccinations and serum treatment, 
there still remains a large field for the proper use of proper 
drugs, given in a proper manner, not only to prevent the 
progress of disease, but to improve the physiology, to correct 
and aid elimination, and to modify the various disturbances to 
which human flesh is heir. 

We have not yet eliminated mystery from medical practice, 
and still have a belief, unless we very carefully eliminate it, in 
a multiple mixture, although it may not be a mythical mixture, 
we may know its contents. It is so easy to believe when we are 
told that a drug in this particular combination has a particularly 
pleasant and efficient activity, or that this particular kind of 
a drug or preparation will not cause the disturbance that the 
well-known and well-tried basic drug causes. 

We rarely need mixtures, whether Pharmacopoeial, National 
Formulary, or proprietary. Such mixtures may have value, 
but the active drug of the mixture can generally be given in a 
very simple manner and the results obtained be perfectly 
satisfactory, and the treatment be much more scientific. 

A part of good therapy consists in the right use of the right 
preparation of the right drug. This object can only be obtained 
by a knowledge of the pharmacologic and toxic action of the best 
drugs, by a knowledge of their best preparations, and by a 
knowledge of how to administer them in prop>er doses. Con- 
sequently, Part I of this book aims to briefly teach good pre- 



THE ART OF WRITING PRESCRIPTIONS 



L 



scrip lion writing, Part II is devoted to comments on the best 
drugs and preparations of the Pharmacopceia, and Part III is 
devoted to a description of the acti\ities, uses, and the best 
methods of administration of the valuable drugs. 

OFFICIAL DRUGS AND PREPARATIONS 

The National Pure Food and Drug Law recognizes the United 
States Pharmacopoeia and the National Formulary as standards 
for drugs, their preparations and their doses. 

The Ninth Re\ision of the United States Pharmacopoeia is 
the last volume issued of this book, and is naturally the best 
ever issued, but owing to commercial desire and to the desire 
of Government drug officials for standards for ever>^thing used 
in medicine, whether medicinaUy useful or not, and also from the 
desire of many physicians who w^ish a supposed standard for 
drugs and preparations that have no action and cannot be 
standardized, the book is altogether too large and contains 
too many drugs and preparations for an up-to-date physician, 
who wishes standards of only the best drugs. 

The National Formularj- is a book primarily produced to offer 
certified formulas for many really useful proprietary mixtures, 
so that any druggist could reproduce these preparations. It 
consists largely of multiple mixtures (mostly out of date) and of 
mixtures left over from the United States Pharmacopoeia after 
house-cleaning. 

The contention of the United States Bureau of Chemistry 
that a standard was needed for aU drugs, whether useful or not, 
in the last re\dsion of the United States Pharmacopoeia was not 
valid, as a standard can always be found in the volume of the 
United States Pharmacopoeia in which the drug was last 
mentioned. 

It is always best to individualize a patient and to write a 
prescription for one or more drugs especially for him. How- 
ever, many Pharmacopoeial, some National Formulary, and 
some proprietary mixtures are elegant methods of combining 
or administering drugs, and in proper cases should be used. 
A valuable useful book is entitled "New and NonoflScial 
Remedies.-' This book is revised and published annually by 




22 THE PRINCIPLES OF THERAPEUTICS 

the American Medical Association. It describes all new 
drugs and preparations that are found to be as represented 
and that are not advertised to "cure" or "guaranteed to help," 
but that really have good therapeutic uses. 

UN HKD STATES PHARMACOPCBIA 

The first National Pharmacopoeia of the United States was 
developed by a convention which met in Washington, in 
1820. The second edition appeared in 1828, and from 1830 
there have been decennial conventions of representatives from 
the professions of medicine and pharmacy, with delegates 
from state medical societies, medical and pharmaceutical 
colleges, and from the army, navy and marine hospital service 
of the United States. At these conventions, held in Washing- 
ton, are appointed revision committees whose labors develop 
the decennial editions of the Pharmacopoeia. 

The last, now official, is the ninth revision, and the one 
representing the standard from which the physician's pre- 
scription will be filled, unless he otherwise orders. This 
ninth revision was prepared by a committee of fifty, appointed 
by the delegates at the convention held in Washington in 1910. 
This book did not appear or become standard until 1916, and 
will be standard imtil the tenth revision appears some years 
subsequent to the meeting of the Pharmacopoeial Convention, 
which was held in Washington, in May, 1920. 

This book contains 778 drugs, substances and preparations, 
very, very many of which are of no value to the modem practi- 
tioner. 

The drugs and preparations appear alphabetically imder 
their Latin and English titles. The average doses are given in 
both the metric and the apothecaries systems. The United 
States Pharmacopoeia has for three revisions urged the use of 
the metric or decimal system, but only a small minority of the 
physidans of the United States have adopted this system of 
weights and measures. 

A drug or preparation described in the United States Phar- 
macopoeia is termed "official." The ninth revision of tVii<^ 
book recognizes the following types of preparations: 



THE ART OF WltlTING PRESCRIPTIONS 



^3 



Aceta (Vinegars) are solutions of the active principles of 
drugs in dilute acetic add. One is official. 

Aquae (Waters) are solutions of volatile substances in water. 
Seventeen are offidal. 

Cerata (Cerates) are semisolid preparations made with 30 
per cent, of white wax and 70 per cent, of benzoinated lard. 
They do not melt when applied to the skin. Four are 
official. 

CoUodia (Collodions) are liquid preparations for external 
use ha\ing collodion as a base. Three are offidai. 

Decocta (Decoctions) are liquid preparations made by boiling 
vegetable substances in water. Unless otherwise ordered, 
decoctions are made to represent 5 per cent, strength of the drug. 
None is official. 

Elixira (Elixirs )are sweet, aromatic, alcoholic preparations 
containing small amounts of medicinal substances. Two are 
offidal. 

Emplastra (Plasters) are preparations for application to the 
skin and are adhesive at the body temperature. Seven are 
offidal. 

Emulsa (Emulsions) are liquid preparations in which oily sub- 
stances are suspended in water by the aid of a gummy or albumi- 
nous substance. Four are official. 

Eictracta (Extracts) are solid, semisolid, or dry fine powders 
intended mostly for internal medication. Twenty-five semisolid 
and two powdered extracts are offidaL 

Fluidertracta (Fluidextracts) are concentrated liquid pre- 
parations made of such strength that i mil (cubic centimeter) 
represents the medicinal properties of i gram of the drug. 
Forty-nine are official. 

Glycerita (Glycerites) are mixtures of medidnal substances 
with glycerin. Five are offidal. 

Infusa (Infusions) are weak hquid preparations made by 
treating a drug w^th hot water but not boiling the mixture. 
Unless otherwise ordered, they represent 5 per cent, strength of 
the drug. Two are offidaK 

Lmimenta (Liniraents) are mostly Hquid preparations for 
external use. Eight are offidal. 




24 THE PRINCIPLES OF THERAPEUTICS 

Uquoies (Liquors) are solutions of non-volatile substances 
in water. Twenty-five are official. 

MflBBie (Masses) are semisolid preparations of the consis- 
tency to roll into pills. Two are offidaL 

Mella (lIone>'s) are thick liquid preparations with honey as a 
base. Three are offidaL 

Mistnrse (^lixtures) are liquid preparations containing sub- 
stances held in suspension in water. Two are offidaL 

Mticitagines (MucDages) are solutions of gum in water, used 
as demulcents or to suspend insoluble substances or oils in 
mixtures. Two are offidaL 

Oleata (Oleates) are combinations of medicinal substances 
with oleic add. One is offidal. 

Oleoresmas (Oleoresins) are extracts containing a volatile 
oil and a resin. Six are offidal. 

Olea (Oils) are dther volatile or fixed. Thirty-dght are 
offidaL 

Pihike rPills) are small round solid preparations of drugs 
for internal administration. Seven are offidal. 

Puhreres (Powders) are finely powdered preparations of two 
or more drugs. Seven are offidal. 

Resinae (Resins) are solid preparations. Three are official. 

Spiiitus (Spirits) are strong solutions of volatile substances 
in alcohol. Fifteen are offidal. 

Suppositoria (Suppositories) are medicated preparations for 
insertion into the different orifices of the body. The vehides 
used in their preparation are cacao butter, glycerinated gelatin, 
or sodium stearate. A suppository for the rectima should wdgh 
about 2 grams; a suppository, or bougie, for the urethra should 
weigh from 2 to 4 grams; and a vaginal suppository should wdgh 
from 4 to 10 grams. One is offidaL 

Syrupi (Symps) are concentrated solutions of sugar in 
water medicated with one or more drugs. Twenty-two are 
offidaL 

Tinctuxsd (Tinctures) are solutions of non-volatile substances 
in alcohol. 100 mils of a tincture of a potent drug should 
represent 10 grams of the drug. Tinctures of weaker, non- 
potent drugs vary in strength. Fifty-four are offidal. 



THE ART OF WTUTING PRESCRIPTIONS 



25 



Trituratioiies (Triturates) are solid preparations made with 
sugar of milk. One is official, 

Trochisci (Troches) are medicated lozenges for solution in the 
mouth, Five are officiah 

Uiiguenta (Ointments) are semisolid preparations made with 
20 per cent, of white wax and 80 per cent, of benzoinated lard. 
Twenty are official 

LAJm 

There has been a slowly progressive change from prescriptions 
written entirely in correct Latin, to abbreviated Latin, to 
part Latin and part English^ to incorrect Latin and abbre\^ated 
English, until now it seems advisable to advocate that the whole 
prescription be written in good English with the use of the 
abbreviations of tJie Latin titles of drugs as authorized by the 
United States Pharmacopoeia and the use of such technical 
abbreviations as seem ad\'isable. It would also seem well to 
write the names of the common simple drugs and preparations 
in English rather than in their high sounding mysterious Latin 
titles; for instance, to ^Tite peppermint water instead of aqua 
menihm piperita. The patient knows that the taste is that of 
peppermint, hence the camouflage is absurd. 

The decision to ad\^se that prescriptions be written m 
English has been arrived at because Latin is not now an entrance 
requirement in most medical schools, and incorrect Latin is an 
abomination. Also the physician should do his part in com- 
pleting the laying of the ghost of mysterj'. Education and 
public health instruction have removed much of the mystery 
of disease and, hence, most of the belief In mysterious means 
of prevention and of cure, and the physician should do the 
rest. Most nostrums and most irregular methods for the cure 
of disease thrive only by their appeal to the long inherited 
belief in mystery and magic. Therefore it is urged that we 
inaugurate the plan of writing prescriptions simply, as well as 
writing simple prescriptions. The age of multiple mixtures of 
one or two useful drugs befogged by many useless and unneces- 
sary ingredients is passing. Let the exit of such unscientific 
combinations be hastened. On the other hand, more time 
and thought should be given to determining the most efficient 





26 THE PRINCIPLES OF THERAPEUTICS 

method, and at the same time the pleasantest mamier, of 
administering, active, useful drugs. 

WEIGHTS AND MEASURES 

It should not be necessary to declare that the metric, decimal, 
system is the best with which to compute prescriptions. The old 
apothecaries system is the only attachment modem medicine 
now has to more or less ancient medicine. Many a physician is 
technically equipped up-to-date in all branches of medicine 
except in that of writing prescriptions. 

The decimal system of prescription writing is universal ex- 
cept in England and the United States. Our monetary system 
is the decimal system, and one has only to think of doses in 
terms of dollars, cents and mills, i.e., in grams, centigrams, and 
milligrams for solids, and mils (cubic centimeters) and fractions 
of mils for liquids, to readily understand this method of 
meaurement. 

Two causes have kept the majority of physicians from adopt- 
ing the decimal system. First, because most books have taught 
exact equivalents of doses in the two systems, namely, a grain 
was .065 grams, and half a grain was .0325 gram, etc., and most 
doses were translated into impossible figures. If a dose is 
learned as .05 gram, for instance, but few would try to translate 
it as 5/6 and a fraction of a grain. When it is recognized that 
the dose of a drug may vary from one to three grains, it should 
also be recognized that the dose of that drug is just as accurately 
expressed as from .05 to .20 gram. 

The second reason that the decimal system has not been 
generally adopted in the United States is because of the inertia 
of hospitals and disp>ensaries. They will not change their 
stock mixtures, and some of the best hospitals in this country 
have the most ancient formularies. Therefore the young 
graduate in medicine, though he may have been taught the 
decimal system, soon forgets it and learns the old weights and 
measures used in the hospital in which he becomes an interne, 
and this very hospital will accurately describe how many cubic 
centimeters of blood were transfused, how many parts to one 
thousand a given solution of corrosive sublimate contains, and 



THE ART OF WRITING PRESCRIPTIONS 



27 



still have nitrate of silver solutions of **sd many grams to the 
ounce/- Let us hope that the hospitals will purge themselves 
of their ancient formulas and surgically eradicate the old 
apothecaries system of weights and measures. 

The United States Pharmacopoeia gives the average doses in 
both systems but still insists on the accuracy of a fluid drachm 
equalling 4 mils (ex.), which is correct; but the contention 
seems good that any average dose stated as 4 mils would be 
equally accurate, on the average, if it was stated as 5 mils. 
Also the equivalence of one fluid drachm to 4 mils depends upon 
where the meniscus is read. Such accuracy in doses of drugs 
and their preparations^ the dose of which is as large as one fluid 
drachm, is refined absurdity. Also, physicians write in the 
apothecaries system for so many fluid ounces and order the 
dose as a teaspoonful, and compute the doses of the active in- 
gredients on a basis of 8 fluid drachms to the ounce, i.e., 8 
teaspoonfuls. The patient most always gets more than a fluid 
drachm (4 mils) at a dose, as most teaspoons readily hold 5 mils 
(5 cc). Hence another contentionj that most every patient 
given a liquid preparation written in the old system and pre- 
scribed in teaspoonful doses receives more of the active in- 
gredients of the prescription than was intended* The above 
discussion is really almost superfluous, for the dose of any drug 
is enougkj and too much at any sized dose is too much. 

To repeat, fine fractional equivalents of doses, though 
chemically correct, are therapeutic nonsense. Every student of 
medicine and every practitioner, who still uses the old system, 
should learn the doses of drugs in the decimal system and 
radicaJly dissociate the two systems: namely, a teaspoonful may 
be considered equal to 5 mils; i gram may be considered equal to 
15 grains; .05 gram may be considered equal to i grain; ,01 gram 
may be considered equal to }4 of a gram; and .001 gram may be 
considered equal to ^o of a grain. 

THE DECIMAL SYSTEM 

The United States Pharmacopceia directs that solid drugs 
shall be weighed in the decimal system, and that liquid drugs 
and preparations shall be measured in the decimal system. 




28 THE PRINCIPLES OF THERAPEUTICS 

The base of this system is the tneiefy an established length 
representing one-forty milKonth part of the earth's circumfer- 
ence around the poles, and eqxiivalent to 39.370432 inches. The 
tmit of volume is the liter, sl cube having the length of its side 
equal to Ko of ^ meter, and eqxiivalent to 2.056716 pints. The 
unit of weight is the graniy the weight of a cube of water at 4^C. 
having the length of its side equal to Koo of a meter, and 
equivalent to 15.432 grains. A smaller unit of volume is used, 
namely, the cubic centimeter (decreed by the last revision of the 
United States Pharmacopoeia to be termed "mil")* The 
cubic centimeter, or mil, equals Ho 00 of a liter, that is a 
cube having for its side Koo of a meter. A larger unit of 
weight is used, namely, the kilogram (1000 grams) which equals 
about 23^ pounds. 

Although the United States Pharmacopoeia recognizes ded- 
mils and decigrams, for dosage and prescription writing the 
following fractional terms are suflGicient, more simple, and 
accurately agree with the pharmacists' metric weights and 
measures. 

Table for Liquids 
o.oi = I centimil. 
o.io = 10 centimils. 
I . = 100 centimils or i mil (i c.c). 
1000. = 1000 mils or i liter. 

It should be remembered that i mil is the same as i c.c, and xooo mils as 
1000 c.c. 

Table for Solids 
o.ooi = I milligram, 
o.oio or 0.01 = 10 milligrams, or i centigram 

0. 100 or 0.10 — 100 milligrams, or lo centigrams (or i decigram). 

1 . = 1000 milligrams, or 100 centigrams, or i gram. 
1000. = 1000 grams, or i kilogram (i kilo), 2}^ pounds. 

OLD SYSTEM 

For ready reference the tables of the old system are given; 
the complicated and easily mistaken symbols should be com- 
pared with the clear figures of the decimal system. 

Troy, or Apothecaries, Table 

60 grains (Gr. be) « i drachm (3i). 
8 drachms (Sviii) = i oimce (5i). 
12 ounces (5xii) - i pound (i lb.) 



^^^^^V THE AKT OF WRITING PRESCHrPTIOKS 29 

' Wine, or Apothecaries, Measure 

60 minims (M Ix) = i Ouid draclim (Q. ^i). 
8 fluid drachms (fl. 5vm) = 1 fiuid ounce (fl. ^i). 
16 fluid ounces (fl, Jjcvi) — i pint (O i). 

For ready reference the foDowing tahle of approximate equivalents of the two 
systems will be found useful: 

1 grain - approadmately 0.065 gram. 

1 minim — approximately 0.065 mils. 

15 grains = approximately i gram. 

15 minims = approximately i mil, 

I drachm - approximately 4 grams. 

I fluid drachm = approximately 4 mils* 

I ounce == approximately 30 grams. 

I fluid ounce = approximately 30 mils. 

1 tcaspoonful - approximately 5 mils. 

I pint = approximately 500 mils. 

I quart '^ approximately 1000 milB, or i liter. 

f PRESCRIPTION' WRITOTG 

Even if surgical, special and specific treatments are the only 
correct methods of effecting a cure of disease, and even if 
most acute diseases tend to recoveryj and even if correction of 
the diet, hygiene, etc., tends to eradicate abnormal conditions of 
the body, the patient wiU still require more or less medicinal 
treatment to stop pain, to promote nutritioUi to increase 
general elimination, to decrease any abnormally profuse 
eliminative activity, to produce sleep, to supply or aid the 
acti\'ity of some internal secreting gland, and to soothe, stimu- 
late, or otherwise treat the external surface of the body. Hence, 
however much the surgeon may state that he does not need 
drugs, and however much the consultant may deplore the use 
of drugs, they must be, and are, used legitimately for the vast 
majority of aU patients. 

Nothing in the above statements is intended to declare that 
many chronic conditions, especially of the nervous system, 
are not better treated by physical methods than by drugs, or 
that it is not a fact that too much medicine is often given to 
acutely sick patients* However, the absolutely drugless treat- 
ment of acute and really tangible chronic illness is a myth. 
If there is nothing the matter with an individual, of course he 
can be cured of what he did not have by what he does not get. 





30 THE PRINCIPLES OF THERAPEUTICS 

That there are useful drugs and that such drugs have a known 
and demonstrable activity is doubted by no one of sane mind. 
That these drugs can produce the symptoms and signs of their 
action in patients is known by everyone who has had laboratory 
and subsequent dinical experience. These facts should compel 
two restrictions in the use of drugs: (i) a drug should not be 
used that is not known to have some definite, safe activity; 
(2) only one who has the knowledge of the action of a drug on 
the human being in health and in disease should prescribe that 
drug for a patient. 

A self-evident corollary of the above is that a mixture of 
drugs cannot be prepared or "kept in stock" to fit a patient who 
may need treatment some time in the future. Each patient 
should be individualized and should receive the drug needed, 
in the amount necessary to cause the effect desired, and he 
should not receive a mixture of drugs that was made to fit a 
series of patients who will vary in age, size, nutrition, strength, 
and in the severity and complications of their disease, even if 
they have the same disease. Hence proprietary, drug-store, 
hospital, dispensary and office mixtures are unscientific, and 
at times may even be dangerous treatment. 

Many official (U. S. P.) preparations of useful drugs repre- 
sent good methods of administering such drugs, and these 
should be more frequently ordered rather than to have recourse 
to proprietary 'preparations of no more value, efficiency, or 
elegance. Some of these preparations are kept ready prepared 
in the drug shops, and some are compounded by the pharmacist 
at the time of receiving prescriptions calling for them. In 
either case, the physician expects the preparation to be standard 
and always the same. Some ready-made preparations, and 
especially if in unsealed packages, may deteriorate, and hence 
freshly prepared preparations are, and should be, demanded. 
In spite of the pharmacal elegance and perfection of the prep- 
arations of the United States Pharmacopoeia and National 
Formulary, generally a prescription should be written especially 
individualized for the particular patient. This does not mean 
that a drug must necessarily be combined with something else, or 
that some mixture be ordered by the physician when there 



THE ART OF WRITING PRESCRIPTIONS 



31 



Is almost an exact copy of his combination — only more elegant- 
official in the United States Phannacopoeia. Hence every 
physician should study the United States Pharmacopoeia, 
and for quick reference the reader is referred to the list of 
useful ofl5dal drugs and preparations in Part II of this book. 

The aim of prescription ^Titing should be for efficiency 
(activity of an active, useful drug), for simplicity, and for 
corapatability. Toward these ends one sees that the prescrip- 
tion writer, the physician, must know w^hich are the useful 
drugs; must have an accurate knowledge of the activities of 
these drugs; must know which one, or more, meets the indica- 
tion it is desired to meet; and must know the best preparation 
of the drug to use, the best combination in which to give it, 
and finally, the best method of administering it. The physician 
must also know the proper dose, the rate of absorption, the 
rate of excretion, and hence the proper frequency of the dose* 
Therefore, before one should write an individual prescription 
for a patient he must be fully trained to practice medicine. 

The physician should always have a copy of his prescriptions, 
and a stub is better than a carbon copy, as on the stub may be 
written the size of each dose, w^ith the name, age, and address of 
the patient, and the date. The main prescription may then be 
(after computing) written, signed and dated. The stub 
then kept becomes a record of the drugs and doses given such a 
patient at a given date. 

The physician should write simple prescriptions of useful 
drugs in the best official preparation^ and, if soluble, in the most 
agreeable solurion possible. A pharmaceutical firm that offers 
a pleasant preparation of a disagreeable but valuable drug, or 
presents a purer valuable drug, should be commended, and such 
preparations should be used* Also, if a chemical firm offers a 
new synthetic or a purer alkaloidal product of a useful drug, 
and if such have been approved by the Council on Pharmacy 
and Chemistry of the American Medical Association, they 
should be used in suitable cases. 

A large number of elaborate combinations are made and sold 
under different names to cover the taste of simple, useful, but 
disagreeable-to-take drugs. The physician should remember 



J 



32 THE PRINCIPLES OF THERAPEUTICS 

that not always does sweetness make a bad tasting drug 
taste less disagreeable. Many a more or less nauseating drug 
is much better tolerated by dissolving it in a sour mixture, as in 
syrup of citric add and water. Also, a drug dissolved in simple 
water may be added to fresh lemonade or orangeade. Pepper- 
mint has a very pleasant taste for most people, and as disagree- 
able a drug as potassium chlorate when used as a gargle, may 
be well dissolved in peppermint water. 

Effervescing water, either simple carbonated, or better an 
alkaline water as vichy, is a pleasant method of administering 
many drugs, even insoluble powders; the powder is suspended, 
as bismuth for instance, by the air globules. 

An oil like castor oil, or cod liver oil, may be disguised by 
placing a little salt in the bottom of a wineglass, then filling the 
glass half full with cold water without stirring to dissolve the 
salt, and then placing the oil carefully on top of the water. If 
this mixture is rapidJy swallowed the only taste is that of the 
salt. Castor oil is variously disguised by the addition of a 
small amount of saccharin and a little oil of anise or oil of 
wintergreen, and may then be given in orangeade. Or, it may 
be further disguised by adding flxiid extract of licorice. 

The disagreeable taste of epsom salt may also be disguised 
by a little saccharin and oil of peppermint or wintergreen. 

A pleasant method of administering many disagreeable drugs 
to children is to give them in a teaspoonful or tablespoonful of 
freshly made cocoa or chocolate. Or, a little sweetened choco- 
late may be crushed by the mother and given with the powder 
or solution. 

Evolution of a Prescription 

While it is advised to write prescriptions as far as possible in 
English, it is also advised to use a few Latin abbreviations. 
The numerals used should always be in Arabic. 

Abbreviations 

aa ana (Greek) of each 

a.c ante cibum before meab 

ad ad up to 

b.i.d bis in die twice a day 

cap capsula a capsule 



THE ART OF WMTING PRESCRIPTIONS 



33 



chart chartula 

F fac 

Gm gramma 

M misce 

no in numero 

p.c post dbum 

pil pflula 

p.r.n pro re nata 

q.8. quantum sufficit 

9 recipe 

S. or Sig signa 

t.i.d ter in die 



Stub 



^ Salt 

Water 

M. 

5. In water, after meals. 



a paper 

make 

gram 

mix 

in number 

after meals 

a pill 

when required 

a sufficient quantity 

take 

mark 

three times a day 

Prescription for lo Doses 



Gm. Gm. 

mil mil 

I. IJ Salt 10. 

S. Water 50. 

M. 

S. A teaspoonful, in water, three 
times a day, after meals. 



Same prescription with U. S. P. names, abbreviated: 

Gm. 
mil 

Q Sod. chlorid 10. 

Water 50. 

M. 

S. A teaspoonful, in water, three times a day, after meals. 



For more than One Ingredient 



9 



M. 

S. 



Stub 

Gm. 

mil 

Sod. chlorid i. 

Sod. bicarb o. 50 

Syrup 2.50 

Water up to S- 

t.i.d., p.c. 



M. 

S. 



Prescription for 10 Doses 

Gm. 
mil 

Sod. chlorid 10. 

Sod. bicarb 5. 

Syrup 25. 

Water q.s. ad 50 . 

A teaspoonful, in water, three 
times a day, after meals. 



Prescription for an Official Pill 



Stub 



^ Pil. ferr. carb. 
S. U.d., p.c. 



Prescription 
9 Pil. ferr. carb. No. 20 
S. One three times a day, after meals. 



A pill should rarely contain more than 0.30 gram, and a 0.20 gram pill is 
better. In other words, a pill should not be large. 
3 



34 ^^HE PSINCIPLES OF THEKAPEUTICS 



Pkescuption for a Pill with Several Ingredients 

Stub Prescriptian for 20 Doses 

Gm. Gm. 

mil mil 

9 Strych. sulph o.ooi Q Strych. sulph 0.02 

Ferr. reduct o . 05 Ferr. reduct 1 . 

Quin. sulph *. o.io Quin. sulph 2. 

M. et F. piL M. ct F. ptL 90 

S. A pill t.i.(L, px. S. One three times a dmy, after 

meals. 



Capsules are often ordered instead of pills, and are frequently 
preferable, because Ihey prevent the taste of disagreeable drugs, 
and because the drugs may be ordered in dry powder, and hence 
are more qxiickly absorbed after the capsule dissolves. To 
hasten solution or action, the cap may be taken off the capsule 
just before swallowing. Ordinarily a capsule should not contaia 
more than 0.30 gram. Most pills, capsules and tablets should 
not be taken on an empty stomach, unless plenty of water is 
taken with them. Most tablets should be crushed with the 
teeth before swaDowing. 

Some drugs are well prepared and sold in elastic capsules, i.e., 
soft gelatin capsules. It has been shown that sometimes these 
soft capsules do not well dissolve, not as well as hard capsules. 
Hard gelatin capsules will dissolve in the stomach in five 
minutes, if there is no alcohol in the stomach. Soft gelatia 
capsules will generally not dissolve in pepsin solution at body 
temperatures until four hours or more, and may not dissolve 
at all. It is also uncertain how soon they will dissolve in the 
duodenal fluid, but if there is no desire for immediate action, 
flexible capsules will generally dissolve sooner or later in the 
alimentary canal and allow the activity of the drugs they 
contain. 

If one or more drugs are to be given in a larger dose than 
0.30 gram as a total weight, and a liquid preparation is unsatis- 
factory or inadvisable, the drugs should be given in powder, as 
follows: 



THE ART OF WRITING PRESCRIPTIONS 



SM 



Prescfiption far 30 Doses 



9 


f^^^ 


Gm. 




Gm. 






mil 




mU 


^ 


Bi&m. subc&rb . . 


I. 


I» 


Bism. subcarb 30. 




Sod- bicarb, . , » 


. , . . ^ o . <o 


M. 


Sod- bicarb ..,*,...,«. , to 


M. 


et F. Chart* 




et F. Chart. 20. 


S. 


tJ.d., a.c. 




S, 


A powder three limes a day^ be- 
fore meals. 



Stuh 



If a rectal suppository is ordered, it should be remembered 
that generally the size for an adult represents a weight of 2 or 
3 grams. 

Pft-scriplion far 10 d<fscs 

Gm. 
mil 

^ Codcin. sulpb 0.40 

Atrop. sulph .,. 0.006 

01 theobrom 20. 

M. et F. suppos, 10. 
S. Use one as directed. 



Gm. 

mil 



^ Codein. sulph , 0*04 

Atrop. sulph o . 0006 

01. theobrom. 2 . 

M. et F. suppofi. 

S. Use as directed. 



The drop is a measure belonging to no one system, and 
though it is inaccurate as an exact dose, it is a very useful dos- 
age for many preparations. No official dropper for a patient 
or a nurse to use is more accurate than a simple drop from the 
bottle. Of course the size of the drop depends on the size of 
the bottle's mouth and the character of the liquid, but a ten- 
drop dose to-day dropped from the same bottle of medicine 
to-morrow will pretty closely represent the same amount. As 
so many times stated, an absolutely accurate, unvar)dng dose 
of any preparation of any drug, prepared in any drug store, in 
any town, in any climate, for a patient with any disease, is 
impossible. Tlie dose of any drug is the amount that wUl 
produce the efifect desired; hence the dose should be increased 
if there is no action from it, and diminished if there is too much 
action. 

Stub Prescnptian 

Gm. 
mil 
Acid. hydrochK diL ..... 25. 
10 drops, in water, three times a 
day, after meals. 



Gm. 
mil 



s. 



Add. hydrochi. dil 

to drops in water, ti.d., 
p.c. 

A number of ointments are official 



They may be combined 



or other ingredients may be added to them. 




36 THE PRINCIPLES OF THERAPEUTICS 

Stub PrescripUon 

Gm. Gm. 

mil mil 

IJ Ung. zincox ^ Ung. zincox 15. 

Ung. aq. ros aa Ung. aq. ros 15. 

M. M. 

S. Use externally. S. Use externally. 

INCOMPATIBILITY 

The art of writing good prescriptions presupposes a knowl- 
edge of the antagonistic action of drugs, and a working, practical 
knowledge of ordinary chemical reactions. The administration 
of two drugs whose physiologic action is antagonistic, such as 
the coincident administration of strychnine and a bromide, or of 
digitalis and aconite, represents therapeutic incompatibility. 
However, a physician skilled in the use of drugs may modify an 
unpleasant action of a drug by giving coinddently another 
drug that coimteracts such action, as, for instance, a bromide 
will control the unpleasant head symptoms caused by quinine. 
Bromide is a sedative to the central nervous system, and quinine 
is a stimulant to the central nervous system. Or, atropine 
may be given with morphine to antagonize the sedative action 
of the latter on the brain and respiratory center. Though cer- 
tain kinds of therapeutic incompatibilities are advisable, others 
are inexcusable — for instance, it is inexcusable to give a quinine 
and strychnine tonic after the evening meal, or to allow tea or 
coffee at the evening meal, and then to give a hypnotic at 
bedtime because the patient cannot sleep. 

Chemical incompatibility is closely related to Pharmacol 
incompatibility, and the latter can be avoided only by writing 
simple prescriptions and studying new combinations with the 
help and advice of a pharmacist. Many of the United States 
Pharmacopoeial and National Formulary preparations are so 
carefully chemically balanced as to be thrown out of balance 
by the addition of most anything, and often even by more or less 
dilution; the change occurring may be precipitation, efferves- 
cence, or the formation of new chemical compounds. 

Gross chemical mistakes should not occur in prescription 
writing. To avoid such errors, the following brief list of 



■ THE ART OF WRITrNG PRESCRIPTIONS $J 

**do" and "don'ts" should be memorized. The chemical 
reason for such advice is not given, as reference to books on 
chemistry will elaborately outline the reactions. 

Prescribe alone: 

■ Adds, unless very dilute. 

H Alkalies and alkaline carbonates in solution. 

■ Alkaloidal salts. 

H Arsenic in solution. 

H Ferric and ferrous salts. 

m Iodides. 

H Mercuric chloride, 

B Tannic add, tannates, and preparations containing 

B tannates. 

Do not prescribe mercurous chloride (calomel) in a mixture 
that contains chlorides. 

Do not add water to preparations of resins, oleoresins, or 
to extracts or tinctures containing resins. 

Do not add water to official spirits. 

Do not add water to the tincture of strophanthus. 

■ DOSAGE 

The average dose of a drug or preparation for an adult is 
given in the United States Pharmacopoeia. This dose must be 
reduced for children, but must be increased in many instances to 
obtain desired results. Also, medical opinion is often at vari- 
ance as to an average dose of a given drug, due, perhaps, to 
varying inertness or activity of a drug or preparation (and but 
few are really standardized), or due to some unusual personal 
experience. There is no one absolute dose of any drug; the 
dose is enough to do the work required; and, on the other hand, 
the s>Tnptoms of over-action or of cumulative effect should be 
quickly recognized. The average dose is modified by: (i) the 
age; (2) the weight; (3) abnormal physiology; (4) the pathologic 
condition present; (5) the frequency with which the dose is to 
be repeated. 





38 THE PRINCIPLES OF THERAPEUTICS 

1. Age. — This is, of course, of importance in administering 
drugs to children, and the following is a simple rule for comput- 
ing the dose: 

At 20 years the adult dose. 

At 10 years, half the age, half the dose. 

At s years, one-quarter the age, one-quarter the dose. 

At 2)^ years, one-eighth the age, one-eighth the dose. 

At I year, one-twelfth the dose. 

If the child's age is between the ages given in the table, a 
little more or a little less, as the case may be, than the dose 
called for at the age in the table nearest the child's age will 
be the average dose. The table is simple and easy to remember, 
and represents the proper dosage for children, except when 
strong narcotic drugs are prescribed. The child's brain and 
central nervous system are relatively larger to its weight than in 
the adult, hence drugs that act strongly on the brain should be 
given in smaller doses than the above table would indicate. 

In old age the adult dose of strong drugs should often be 
reduced, as in the senile the physiologic processes are impaired, 
even if actual degeneration is not present, and hence a drug 
may cause excessive action. 

2. Weight. — The weight of a patient is really the scientific 
factor in determining the proper dose, hence the dose for an 
underweight child of five years should be less than that called 
for by the table, while an over- weight child of three years should 
often receive a dose for the five year period. A six-foot man 
requires a larger dose than a five-foot woman, if physiologic 
action of the drug is desired. However, over-weight due to fat 
and not size does not call for an increase in the dose, as fat does 
not represent an increase in the quantity of the blood, and it is 
the bulk of the blood (normally about one-thirteenth of the 
body weight) that really determines the dose. 

For ready reference it may be noted that: 

A normal baby five months old weighs about 15 poimds; at the 
end of a year, about 20 pounds; at the end of two years about 
30 pounds; and from then on he should gain from four to six 
pounds a year, until at fifteen the child should weigh not far 



TH3E ART OF WRITING PRESCRIPTIONS 



39 



from IOC pounds. Up to this period the boy and the girl 
weigh about the same. 

Careful investigation of many thousands of accepted insur- 
ance risks — in other words, of well individuals — has developed 
the following average weights for age and height : 



Men 



Afe^ycais 


5 feet 


sHfcet 


6 feet 


6K feet 


20 


117 


140 


t6o 


176 


30 


I as 


145 


172 


190 


40 


150 


150 


180 


100 


50 


iJS 


iSi 


183 


205 



t 



A man's clothing weighs about seven pounds, his shoes with 
heels increase his height about one inch. 

Women on the average weigh about five to ten pounds less 
than men. An individual may weigh from twenty-five pounds 
below the average to twenty-five pounds above the average, 
and still be within the range of normal Far below the average 
weight is more significant of latent disease under the age of 
thirty than above that age. Far above the average weight is 
more objectionable over the age of thirty than under that age, 

A family tendencj' to under- or over-weight is of importance 
in detennining whether, or not, the individual is really abnormal 
and hence more likely to acquire disease or to become disabled, 

3. Abftormal physiology. — Any abnormal physiologic process 
may modify the dose of a drag, such as any stomach or intestinal 
disturbance that delays absorption; a li%^er disturbance that 
impairs its antidotal action; or any impairment of the excretory 
organs, especially of the kidneys. 

4. The pathologk condition present. — If any of the disturb- 
ances of physiolog^^ just suggested are caused by real pathologic 
conditions, the dose of a drug may need to be much less than the 
average, else poisoning may be caused. This is especially true 
in liver and kidney disease. On the other hand a pathologic 
condition may be present that requires a much larger dose than 




A 



40 THE PRINCIPLES OF THEKAPEUTICS 

the average to overcome that condition and cause the effect 
desired, such as an hypnotic action in cerebral excitement; for a 
narcotic effect in colic; or for the effect of digitalis on the heart 
in broken compensation or in auricular fibrillation. 

5. The frequency of the dose. — If a drug is slowly excreted, 
one dose of it a day may be of good size, while three or more 
doses a day must be smaller. A drug that is rapidly excreted 
may be given in full doses repeated as rapidly as it is known to be 
excreted. 

Alcohol, ammonia, and camphor act rapidly and are more or 
less rapidly excreted or rapidly destroyed in the body. Caffeine 
chloral, iodides, morphine, salicylates, strophanthus, and strych- 
nine act rapidly, but are more or less slowly excreted or slowly 
destroyed in the body. 

Arsenic, atropine, bromides, digitalis, mercury, quinine, and 
most synthetic antipyretic and hypnotic drugs act slowly, and 
are excreted slowly. 

On accoimt of the slow excretion, and because only fractional 
parts of one or more doses are excreted in twenty-four hours, 
certain drugs when daily repeated, tend to accumulate in the 
system. Such drugs are arsenic, atropine, bromides, digi^^^lis 
and mercury. 

CONDITIONS MODIFYING THE ACTION OF A DRUG 

1. Condition of the stomach, if a drug is given by the mouth. 

2. Intolerance : idiosyncrasy. 

3. Tolerance. 

I. The condition of the stomach really means the wtrying rate 
of absorption. — Theoretically, a drug received into an empty 
stomach should be more quickly absorbed than when the stomach 
contains food. This is generally true, as the drug is more 
rapidly passed into the intestine, where most absorption occurs. 
The stomach probably absorbs but few drugs, imless they long 
remain in the stomach, except alcohol and alcoholic prepara- 
tions, probably morphine, and most alkaloidal salts. 

When for any reason there is inertia of the stomach, from 
shock or dilatation, or from sluggish circulation, a drug may 
remain for a long time in the stomach unabsorbed. Conse- 



THE ART OF WRITING PRESCRIPTIONS 



41 






¥ 



¥ 
P 



quently, in all such conditions a drug whose action is immediately 
desired must be given by some other avenue than the stomach. 

Most drugs are satisfactorily given after meals, unless they 
are known to seriously delay digestion, and many drugs retard 
digestion more or less. A drug known to greatly delay digestion 
should be given two hours after meals^or long before a meaL An 
irritant drug or preparation should ordinarily not be given on an 
empty stomach, unless the drug is well diluted. A drug that 
irritates the stomach may cause pain and vomiting, or may 
cause inflammation and even ulceration. Some drugs may 
irritate, and at the same time not cause recognizable pain. 
This is true of some tablets, such as bromides, chloral, potas- 
sium chlorate, etc* Hence only tablets known to be absolutely 
non-irritant should be swallowed whole. 

Some drugs are destroyed in the stomach, or are at least 
changed so that their activities are impaired, or they may cause 
nausea. Such drugs may be given in pills coated with some 
protective covering that is not acted upon by the gastric juice. 
The hydrochloric add of the stomach may chemically change 
many drugs and preparations, but generally not to their impair- 
menty and such changes often hasten absorption. It is obvious, 
if the mucous membrane of the stomach is to be treated, that 
medicaments must be given on an empty stomach. It is also 
obvious that a bitter tonic, or a gastric stimulant or appetizer 
should just precede the meal. The more soluble the drug is 
in add media and the better the solution of the drug, the quicker 
it must be absorbed. However, speed of absorption is not 
always a necessary requirement, hence verj^ many drugs are 
given in less soluble, but more pleasant, forms than solutions. 

2. Intolerame. — ^Many conditions may cause an intolerance 
to a drug. In other words, an average dose of a drug may cause 
unexpected, unpleasant, or severe s>Tnptoms, Certain diseases, 
especially of the central nervous system, of the Uver, of the 
kidneys, and some diseases of the endocrine glands may cause 
an intolerance to certain drugs. On the other hand, some in- 
dividuals who are well are intolerant to certain drugs and remain 
so aU their lives. This is termed an *'idiosjmcrasy" against 
such drugs. The drugs against which there is most frequently 




42 THE PRINCIPLES OF THERAPEUTICS 

an idiosyncrasy, or intolerance^ are belladonna and iodides. 
Drugs against which there is less frequently intolerance, but 
common enough to be noted, are opium and its alkaloids; 
mercury, espedaUy calomel; bromides (even a single dose of ten 
causing an eruption); quinine; and salicylates. An individual 
who cannot take morphine or any other narcotic for severe 
pain is very unfortimate, but such a patient is occasionally 
foimd. Some patients cannot take quinine without being 
severely poisoned. Others, after the first poisoning symptoms 
from quinine or some other drug, become more or less tolerant 
and can take ordinary doses of it for that particular period, to 
be again poisoned at some other time. Some of these excessive 
reactions from drugs are anaphylactic in character, being ac- 
companied by fever and other symptoms of anaphylaxis. An 
individual found to have an idiosyncrasy against any particular 
drug should be informed of the fact, that he may warn his 
future physicians and not be again unnecessarily poisoned. 

3. Tolerance. — Certain diseases cause a tolerance for certain 
drugs, such as most patients with malarial fever will tolerate 
large doses of quinine; those with syphilis, large doses of mer- 
cury and iodides; those with epilepsy large doses of bromides. 
Also, certain diseases of the endocrine glands cause a tolerance 
to drugs. A tolerance to a drug is acquired by long taking of 
that drug, and such tolerance is found in drug addicts, those 
who use morphine or cocaine, in excessive users of tobacco, and 
even in those who constantly use cathartics. Such individuals 
become tolerant to the class of drugs to which they are accus- 
tomed, and may be intolerant to other drugs. 

CUMULATIVE EFFECTS OF DRUGS 

The cumulative action of a drug is evidenced by sudden un- 
expected mild symptoms of poisoning. This occurs when 
certain drugs are given in too rapidly repeated doses, so that 
excretion of one dose cannot occur before the next one or more 
doses are taken. The result is an accimiulation of the drug in 
the system until there is developed a sudden intolerance, and 
more or less severe poisoning occurs. At other times, owing to 



THE ART OF WTilTING PRESCRIPTIONS 



43 



some sudden disturbance of the orgaas of excretion a drug 
ordinarily well excreted is retained, and poisoning occurs. 

Another form of cumulative action takes place when certain 
drugs have been long taken and symptoms of chronic poisoning 
occur. At times certain drugs are pushed to the degree of 
primary poisoning, or until full physiologic limit is reached, to 
^obtain desired therapeutic results. This is done deliberately, 
and the first sjinptoms of poisoning are watched for and quickly 
noted, and the administration of the drug is stopped. 

The recognition of the over-action of a drug, the recognition 
of chronic drug poisoning, perhaps not even suspected, and the 
treatment of these conditions can be acquired only by book and 
laboratory study of the pharmacologj' of drugs. 

It should be borne in mind when giving drugs to nursing 
mothers that many drugs are excreted in the milk, and may 
L affect the child. These drugs are opium and its alkaloids, most 
hypnotics, bromides, arsenic, mercury, iodides, quinine, thyroid 
extract and probably other organ extracts, and most cathartics. 
At times, however, it is desirable to treat a babe through its 
mother's milk. 

Many drugs cause eruptions on the skin, most frequently an 
urticaria or an efflorescence, similar to the scarlet fever rash. 
Part of this action is due to duodenal irritation quite similar 
to a food poisoning, as from fish or strawberries, which foods so 
frequently cause eruptions in some individuals. The drugs 
most likely to cause eruptions are arsenic, atropine, chloral, 
coal-tar drugs as antipyrine and phenols, copaiba, opium, 
quinine, mercurj', salicylic add and some salicylates, santal oil, 
s>Tithetic hypnotics as sulphonal, thjToid, and volatile oils. 
At times these drugs, in a few individuals, may cause real 
anaphylactic conditions, with serious eruption and swelling of 
the skin, or a dermatitis, giant urticaria, or angioneurotic 
edema. Antitoxins and serums may cause such symptoms, 
and may even cause death from protein poisoning. 

Some drugs cause irritation of the skin during their excretion 
through the glands of the skin. Bromides, especially if long 
taken, often cause pustular acne, and at times more serious skin 
eruptions. Iodides cause non-pustular acne. 




44 THE PRINCIPLES Or THERAPEUTICS 

DRUGS WHICH MAT CHANGE THE COLOR OF THE URINE 

Drugs that increase the amount of urine cause it to be 
lighter, while drugs that irritate the kidneys cause the urine to 
be darker. Methylene blue causes the urine to be green, if it is 
acid. Phenol, or any phenol containing drug, may cause 
the urine to be dark brown. Santonin causes it to be yellow, 
if acid; purple, if alkaline. Senna may cause it to be red, if 
alkaline; yellow, if acid. Sulphonal and other synthetic 
drugs may cause the urine to be dark. 

DRUGS WHICH COLOR THE FECES 

Bismuth salts color the feces black or dark gray; iron colors 
them black; colchicum and mercury in suflSdent doses to 
cause purging color them green; and vegetable purgatives 
cause them to be darker than normal. 

ADMINISTRATION OF DRUGS 

Some drugs act locally only, when applied to the skin and 
mucous membranes, or to the gastrointestinal canal. Even- 
many cathartics act as such on account of the irritation of the 
intestinal walls that they cause. Drugs that act on some part 
of the general system must first be absorbed into the blood, and 
they reach the blood: (i) by absorption from the stomach and 
intestines after their administration by the mouth in capsules, 
pills, tablets, liquids, or powders; (2) by absorption from the rec- 
tum after their administration as suppositories or enemata; (3) 
by absorption from any other mucous membrane with which 
they are in contact; (4) by absorption after their inhalation; 
(5) by absorption from the skin after their inunction or after 
their prolonged contact with the skin; (6) by absorption from 
the subcutaneous tissues after their hypodermic injection; 

(7) by absorption from muscular tissue after their deep injection 

(8) by their direct introduction into the blood stream by 
intravenous injection. 



the art of writing prescriptions 45 

Rapidity of Absorption 

This occurs in the following order, the most rapid route 
heading the list: 

1. When the drug is given intravenously. 

2. When the drug is given hypodermatically. 

3. When the drug is brought into contact with mucous 
membranes, especially the nose. 

4. When the drug is given by the stomach. 

5. When the drug is given by the rectum. 

6. When the drug is rubbed into the skin. 

The size of the dose depends on the rapidity of the absorp- 
tion; in other words, the dose should be the smallest when it is 
given intravenously, and the largest when it is rubbed into the 
skin. The length of time before a given dose will be excreted 
is in the inverse order of the above list. 

For certain diseases and conditions drugs and serums are 
administered intraspinally. 



PART n 

DRUGS 

In this age of antitoxins, serums, vaccines and organotherapy, 
and the consequent tendency to drug nihilism, it is well to 
study from a therapeutic standpoint the really useful drugs. 
These drugs are presented in three ways: 

First, as the valuable drugs and preparations of the United 
States Pharmacopoeia. 

Second, as a classification of useful drugs, based on their 
therapeutic uses. 

Third, as a brief description of the action, uses, and methods 
of administration of the most therapeutically active of these 
drugs. 

Alphabetical List 

OF 

Valuable Drugs and Preparations of the U. S. ?♦ 

ACACIA — Gffm Arabic 

Preparations. — Mucilago Acacia; Syrupus Acacia, 
Comment — ^AU preparations of acacia should be freshly 
made. 

ACETANILIDUM— Antifcbrfn 

Acetanilid occurs as a white crystalline powder, which is 
slightly soluble in water. 

Comment — The average dose is o.io Gm. {i^^ grains), 
best administered in powder or in tablet (to be crushed before 
swallowing) and taken with plenty of water. 

ACETPHENETIDINUM— Phcnacetin 

Acetphenetidin occurs as a white crystalline powder, is 
insoluble in water, and the average dose is 0.30 Gm. (5 grains). 

Comment — It is best administered in powder or tablet (to be 
crushed before swallowing) and taken with plenty of water. 

46 



DRUGS AKD PREPARATIONS OF U. S, P. 

ACmUM ACETICUM GLACIALE 

Comment — Glacial acetic acid is a colorless liquid used 
only as an escharotic. 

ACEDUM BORICUM— Boracic Acid 

Boric add occurs as transparent scales or white powder, and 
is soluble in 4 or 5 per cent, of water. 

Preparations, — Glyccritum Boroglycerini; Unguenium Acidi 
Barici, 

Comment— Boric add should not be used internally. It is 
very valuable locally in inflammations of mucous membranes, 
on wounds and local infections, best in saturated solutions, 
which IS about 4 per cent* in cold waten It is used as a dusting 
powder and for dressings. The ointment contains 10 per cent. 
of boric add. 
^K ACIDUM CITRICUM 

W Citric add is obtained from the juice of limes or lemons, 

I and occurs as colorless prisms or as a white powder, is very 

^^ soluble in water, and the average dose is 0.50 Gm. (j}^ grains)* 

^^P Preparatioii. — Syrupts Acidi Ciirici, 

^^ Comment* — The syrup of dtric acid contains i per cent, of 

I dtric add and i per cent of tincture of lemon peel^ and is a 

I very useful addition to prescriptions that need a little sweeten- 

I ing» but not the sweet furnished by a thick nauseating syrup. 



ACIDUM HYDROCHLORICUM DILUTUM— Diluted MtirUUc 

Acid 



Diluted hydrochloric acid is a colorless liquid representing 
10 per cent, of hydrochloric add. 

Comment— It aids gastric digestion, stimulates intestinal 
secretions, and increases the acidity of the urine. It is useful 
in all cases of insufficient hydrochloric acid in the stomach, is 
often useful in anorexia, and is of benefit when there is a 
flabby, coated tongue. The average dose is 0.5 mil (7 minims), 
which should be taken wxU dilutedj after meals. More water 
should be taken afterwards to thoroughly cleanse the mouth. 





48 THE PRINCIPLES OF THERAPEUTICS 

ACmUM NITRICUM 

Nitric add is a fuming liquid, which is used only as an 
escharotic. 

ACIDUM PHENYLCINCHONINICUM— Atophan— Clnchophcn 

Phenyldnchoninic add occurs as small needles or as a 
yellowish-white powder, has a bitter taste, and is soluble in 
water. 

Comment. — It is best given in powder or capsule, and the 
average dose is 0.30 Gm. ('5 grains). Large doses are likely 
to cause a large output of uric add in the urine. 

ACIDUM PHOSPHORICUM DILUTUM 

Diluted phosphoric add is a clear, colorless liquid represent- 
ing 10 per cent, of phosphoric acid. 

Comment — This preparation has no other action than that 
of a pleasant add. The dose is i mil (15 minims), given well 
diluted. 

ACIDUM SALICYLICUM 

Salicylic add occurs in fine needles or as a crystaUine powder, 
has a disagreeable, sweet taste, and is slightly soluble in water. 
The average dose is 0.75 Gm. (12 grains). 

Comment — Salicylic add is used externally as an antiseptic 
and as a mild escharotic. To remove warts^ corns and callous 
skin it may be used in 10 to 20 per cent, ointment, or in a 
solution of collodion, i Gm. to 30 mils. When administered 
internally it should be ordered in powder to be taken with a 
large amount of water, but, as it is likely to cause nausea and 
vomiting, it is much better to use the salt, sodium salicylate, 
rather than this preparation. 

ACIDUM TANNICUM— Tannin 

Tannic add occurs as a yellowish-white powder, is dis- 
agreeably astringent in taste, and is soluble in water and glycerin. 
The average dose is 0.50 Gm. {y}^^ grains). 

Preparations. — Glyceriium Acidi Tannici; Trockisci Acidi 
Tannici; Unguentum Acidi Tannici. 



DRUGS AND PREPARATIONS OF U. S. P. 



49 



r 



Coimiient.^Tannic add is disagreeable and Batiseating, and 
for action on the bowels is best administered in capsule. It is 
not much used internaUvj as pleasanter preparations of tannic 
acid can be obtained, i or 2 per cent, solutions of tannic add, 
or a 5 per cent, solution of glycerite of tannin may be used as 
mouth washes or gargles, and tannic acid troches may be dis- 
solved in the mouth for local astringent effect. Each troche 
contains i grain of tannin. The ointment contains 20 per 
cent, of tanm*e. 

ACIDUM TARTARICITM 

Tartaric acid occiirs as a white powder, has an add taste, 
and is very soluble in water. The average dose is 0.50 Gm, 
(iH grains). 

Comments — Tartaric add is rarely given internally, except 
in effer\'escing combinations. It is contained in the white 
paper of the offidal Compound EfFerv-esdng Powder (Seidlitz 
Powder). 

ACIDUM TRIOiLORACETICUM 

Trichloracetic add occurs in crystals, which are very soluble 
in water. 

Coimnent.^ — This acid is used only externally, in saturated 
solution, as an escharotic, and is said to be a specific for Vincent's 
angina. After a thorough application it should be neutralized 
with a saturated solution of sodium bicarbonate. 

AGONITUM— Mo nks hood 

Aconite is used only in its preparations, the best of which is 
Tinctura Aconiii, 

Comineiit,^The tincture of aconite contains 10 per cent of 
aconite, and the average dose of an active preparation is one 
drop every half hour until there is evidence of its physiologic 
action. The official alkaloid Aconitina is too strong a prepar- 
ation to be used in medicine; a ver>' small dose has no value 
and a larger dose may cause toxic s>'Tnptoms^ 

ADEPS BENZOINATUS 

Comment—Beazoinated lard contains i per cent, of benzoin. 




50 THE PRINCIPLES OF THERAPEUTICS 

ADEPS LANJE— Wool Fat 

Commeiit — Anhydrous lanolin is used externally only, and 

will take up twice its weight in water, with which it readily 

mixes. 

ADEPS LANJE HYDROSUS— Lanolin 

Comment — Hydrous wool fat contains 25 to 30 per cent, of 
water. It is very soothing to the skin. 

£THER— Ether 

Comment. — There is no use for ether or its official preparation, 
Spiriius Miheris^ internally. 

JETHYLIS CHLORIDUM 

Ethyl chloride occurs as a white volatile liquid in hermeti- 
cally sealed containers. It is sprayed upon a part to cause 
freezing and local anesthesia. 

ALOE 

Aloes occurs as a yellowish or brownish powder. 

Preparations.— Pi/ute Aloes; PUuUb Rhei ComposiUg, Aloi- 
num, which occurs as a fine, crystalline yellow powder, of an 
intensely bitter taste, and represents the activities of aloes. 

Comment — ^Aloes is a stimulant to the muscular coat of the 
intestine, especially the large intestine, and may congest and 
irritate the rectum and pelvic organs; hence it is generally best 
not to administer aloes, except in small doses, during pregnancy, 
when there are hemorrhoids, or when there is rectal or pelvic in- 
flammation. Large doses cause colicky pains, and hence it is not 
a good purgative, but aloes, best in the form of aloin or in one 
of the pills, is a good laxative, generally best given in combi- 
nation. It should be given in pill, in capsule, or in tablet, either 
at bedtime or directly after the evening meal. Aloes should 
not be given to nursing mothers, as it is excreted in the milk. 
Each official pill of aloes contains 2 grains. The dose is one or 
two pills. Each of the compound rhubarb pills contains ij^ 
grains of aloes and 2 grains of rhubarb. The dose is one or two 
pills. The average dose of aloin is 0.015 Gm. ( J:i grain). This 



DRUGS AND PREPARATIONS OF U* S. P. 



5t 



dose is rather small, and the following combination for a pill or 
tablet is suggested. 

Strychnine sulphate 0.0015 Gin» 

A]om. 0.0? Gtn. 

Powdered ipecac o ,03 Gin. 

Extract of belladonna. , . . . , o . 01 Gm. 

In place of the belladomia, atropine sulphate could be used, 
0.0003 Gm, (J200 grain) to each pill or tablet. Many other 
combinations of so-called **A.B.S.'' pills or tablets are offered. 






ALUMEN— Alttffl 

Alum occurs as colorless crystals or white powder. It has a 
sweetish, astringent taste. 

Conunent — Alum is an astringent and an emetic. There is 
no use for this preparation internally. Alum pendls or cakes 
are used as an astringent in cankers, on the face after shaving, 
or to harden any part of the skin; they are^ also, used on granu- 
lar eye-lids and on herpes zoster (cold sores). Alum curds 
have been used for inflammations of the eye (2 Gm. of alum to 
the white of one egg). Alum should not be used as a mouth 
wash or as a gargle, as it is not go^d for the teeth. It may be 
used in i or 2 per cent, solution as a vaginal douche for leucor- 
rhea, and in stronger solutions for pruritus ani and vulvae. 
It should probably be used more frequently as a sedative as- 
tringent in skin diseases. The official Alumini Hydroxidum is 
an efficient dusting and drying powder. The official Alutnen 
Exsiccaium (Dried Alum — Burnt Alum) is a mild escharotic. 

AMMONII CARBONAS 

Ammonium carbonate occurs in hard white masses, having a 
strong odor of ammonia. It is soluble in water. 

Commoit^This preparation is irritating and nauseating, of 
doubtful value as a stimulant, and as an expectorant ammonium 
chloride is better. The official preparation (Spiriius Ammonia 
Aromatkus) so long used as a cardiac stimulant, is of doubtful 
value, except for the action of the alcohol that it contains. 




52 , THE PRINCIPLES OF THERAPEUTICS 

AMMONII CHLORIDUM 

Ammonium chloride occurs in white crystals or granular 
powder, has a disagreeable saline taste, and is very soluble in 
water. The average dose is 0.30 Gm. (5 grains). 

Preparation. — Trockisci Ammonii Chloridi. Each troche 
contains i3^ grains of ammonium chloride. 

Comment — This salt is generally given combined, and should 
be taken well diluted. As an expectorant it may be given in 
the above dose every two or three hours. As it is disagreeable, 
it is best given in a sour preparation, as: 

Ammonium chloride 5 Gm. 

Syrup of dtric acid 25 mils 

Water up to 100 mils 

Mix and sign: A teaspoonful, in plenty of water, every two or three hours. 

If it is desired, codeine sulphate may be added to this mixture 

for sedative purposes. 

AMYLIS NITRIS 

Amyl nitrite is a dear or yeUowish liquid, has a pungent, 
fruity odor, and is very volatile. 

Comment — ^This preparation is best obtained in glass am- 
pules, to be crushed and the contents inhaled. 

ANTIMONII ET POTASSII TARTR AS— Tartar Emetic 

Antimony and potassium tartrate occurs as colorless crystals 
or a white powder and has a sweet but disagreeable taste. 

Comment. — It is an emetic, is depressant to the circulation 
and nervous system, and increases the secretions. Small doses 
long continued may cause serious chronic poisoning, simulating 
that of arsenic and phosphorus. Acute poisoning causes 
collapse. The treatment of such poisoning is to wash out the 
stomach, give tannic add, and cardiac supporting treatment. 
There is no use for this drug. The oflSdal preparation which 
contains it, Misiura Glycyrrhiz<B Composiia (Brown Mixture), 
is not needed. 

ANTIPYRINA— Phenaxone 

Antipyrine occurs as a white crystalline powder, has a slightly 
bitter, disagreeable taste, and is very soluble in water. 



aUGS AND PREPARATIONS OF U. S. P. 



S3 



Ccmmeiit. — The average dose is 0.50 Gm. (7J>^ grains), best 
administered in a capsule. The capsule may be imcapf>ed 
before taking with plenty of water, 

APOMOItPHIN^ H^>ROCHLORIDUM 

Apomorphine hydrochloride is the salt of an alkaloid prepared 

from morphine, and occurs in minute whitish prisms. It is not 
very soluble in water. 

Comment — This preparation should be used only as an 
emetic, and best hypoderraatically, in the dose of 0,006 Gm, 
dio grain). 

AQUA HAMAMELEDIS^DistHIecl Extract of Witchhuel 

Witchhazel water is a colorless liquid, is mildly astringent, 
and is very popular for use on the skin and mucous membranes. 

ARGENTI NITRAS 

Silver nitrate occurs as colorless crystals, which are very 
soluble in water. Both crystals and solutions soon turn black 
on exposure to light. 

Cominent— There is no excuse for using silver nitrate inter- 

nally. It may be used externally in solutions of various 

strength for its stimulating and escharotic action. The 

official preparation, Argenti Nitras Fusus (Lunar Caustic), 

occurs as white soluble pendls, which are used for escharotic 

purposes. 

ARSENI lODIDUM 

Arsenous iodide occurs as orange-red crystals or powder, 
which are soluble in water. The average dose is 0.005 Gm. 
(H2 g'^ain). 

Conaineiit-^The action of this salt is that of arsenic. Its 
only preparation, Liquor Arsent ei Eydrargyri lodidi (Donovan's 
Solution), is superfluous and unnecessary. 

ARSENI TRIOXIDUM^Arsciious Acid— White Arsenic 

Arsenic trioxide occurs as an opaque white powder or in 
masses. It is soluble in water, and the average dose is 0*002 
Gm. (?^o grain). 




54 THE PRINCIPLES OF THERAPEUTICS 

Preparation. — Liquor PotasHi Arsenitis (Fowler's Solution). 
This is a I per cent, solution of trioxide of arsenic, the average 
dose of which is 0.2 mil (3 minims). 

ASAFETIDA 

Asafetida occurs as a gum-resin. 

Preparation.— Pi/fJ^ Asaftetida. 

Comment — Asafetida is a carminative like onions and garh'c, 
and is of no use in medicine, except in flatulence and intestinal 
inertia. It has been thought to be of special value for tympa- 
nites after laparotomy, but hypodermatic injections of ergot 
and pituitary extracts are much more efficient. Intestinal 
paresis will not as frequently occur when strong purgation is 
not caused before operation. The best method of administering 
asafetida is by means of the official pill. Each pill contains 3 
grains of asafetida and the dose is one or two pills. 

ASPmiUM— Male Fern 

Aspidiimi occurs as the rhizome and stipes of the plant. 

Preparation. — Oleoresina Aspidii. 

Comment — This drug is used only for the eradication of 
tapeworms, and generally in the form of the oleoresin. An over- 
dose may cause vomiting, diarrhea, tremors, and convulsions. 

In the treatment of tapeworm the method is to starve, purge, 
give the dose of the oleoresin of aspidium, then to purge again, 
as the drug must not be allowed to remain long in the bowels 
lest a poisonous amount be absorbed. Oil should not be 
administered before, with, or directly after the oleoresin. 
The oleoresin is well given in capsules, each capsule containing 
0.50 Gm. {^}4 grains). Two of these capsules, representing 
I Gm., should be taken at the time directed, with plenty of 
water, and just before swallowing the capsules should be 
uncapped. The same dose should be repeated in two hours, 
namely, two capsules (i Gm.). In two more hoiurs a purgative 
should be administered. 

ASPIDOSPERMA— Qtfebracho 

Comment — This drug has been recommended for use in 
asthma. It is of doubtful efficiency, and is used only as the 



DRUGS AND PREPARATIONS OF U. S. P. 



55 



official fluid -extract, Fluidexiracium Aspidospermalis, in doses 
of about a teaspoonfuL It has also been used in the form of 
the alkaloid^ aspidospermine. 

ATEOPINA 

Atropine is an alkaloid of belladonna. 

Comment — Atropine Is used mostly in the form of the 
sulphate, Airopin<B Sulphas, which occurs as a white crystal- 
line powder, very soluble in water. The average dose is 
cooos Gm, {K20 grain). 

BALSAMUM PERUVIANtJM 

Balsam of Peru is a visdd liquid of a dark brown color, and 
has a pleasant odor. 

Comment — It is used externally as a mild antiseptic and 
stimulant to indolent ulcerated surfaces. It is an efficient 
parasiticide in scabies. 

BALSAMUM TOLUTANUM 

Preparation. — Syrupus Tolut^nus, 

Comment^Balsam of Tolu is used principally in the form of 
the syrup as a pleasant menstruum in cough mixtures. 

BELLADONNA FOLIA— BELL ADONNJE RADIX— Deadly 

Nightshade 

The leaves and root of Airopa Belladonna. 

PTepSiTSitioim,~Emplastrum Belladonna; Unguentum Bella- 
dotmct. 

Comment.'— There are other preparations of belladonna, 
but as atropine represents the whole acti\ity of belladonna, 
there is no necessity for the use of any preparations except 
those above named. The ointment of belladonna contains 
10 per cent, of the drug and is slightly sedative to the part to 
which it is applied. The plaster of belladonna is sedative. 
Too large a plaster should not be used at once, as the atropine 
in the plaster can be absorbed and cause belladonna and atro- 
pine poisoning. The official liniment of belladonna is an inexcus- 
able preparation. It is too dangerous for use. 



56 THE PRINCIPLES OF THERAPEUTICS 

BENZOlNUM — Gfsm Benjamin 

Benzoin occurs as a balsamic resin. 

Preparati(m. — Tinctura Benzoini. 

Comment. — Benzoin is never used as such. The compound 
tincture has often been used to add to mixtures for inhalation^ 
but the plain tincture of benzoin is as valuable. 

BENZOSULPHINIDUM— Saccharin— Glffsldmn 

Saccharin occurs as white crystals or powder, has an intensely 
sweet taste, and is not very soluble in water. 

Comment — Saccharin has no medicinal properties. It is 
used in very small doses, as 0.006 Gm. (Ko grain) to 0.015 Gm» 
(}i grain) as a sweetener for foods and drinks for diabetics. 
There is really no necessity for such use, as a diabetic patient 
soon learns to go without the sweet taste to his foods. Long 
continued use of saccharin or larger doses may cause consider- 
able gastrointestinal indigestion. A more soluble preparation 
of saccharin is the official Sodii BenzostUpkinidum. 

BETAEUCAINJE HYDROCHLORIDUM— Eticaine Chloride 

Betaeucaine Hydrochloride occurs as a white crystalline 
powder, soluble in water (i Gm. in 30 mils). 

Conmient. — Betaeucaine is used as a local anesthetic in o.x 
per cent solutions. Novocaine and procaine are the same as 
betaeucaine. 

BETANAPHTHOL— Naphthol 

Betanaphthol occurs as a colorless or yellowish crystalline 
powder, practically insoluble in water, soluble in alcohol. 

The average dose is 0.25 Gm. (4 grains). 

Comment — Betanaphthol is a mild germicide both externally 
and internally, and is used as an intestinal antiseptic. On the 
skin it is irritant in strong preparations, and is used in oint- 
ments in 5 to 10 per cent, strength for some skin diseases. It 
is almost insoluble in the stomach. It breaks up in the intes- 
tines causing some antiseptic action, and may cause symptoms 
similar to mild phenol poisoning. It is not as much used as an 
intestinal antiseptic as is salol, as it is much more likely to cause; 



DRUGS AND PREPARATIONS OF U. S, P. 



5? 



poisoning, and is no more efficient. It is used largely in un- 
cinariasis, though thymol and oil of chenopodium are better. 
It should be administered in capsules. 

BISMUTHI BETANAPHTHOLAS— Orpfiol 

Bismuth betanaphthol is a compound of bismuth and beta- 
naphthol. It is insoluble in water, and the dose is 0.50 Gm. 
(7^2^ grains). 

Camment —This preparation has been used for diarrhea, 
(best administered in capsules), but a prescription for bismuth 
subcarbonate and phenyl salicylate (salol) is better for this 
condition, 

BISMUTHI SUBCARBONAS 

Bismuth Subcarbonate occurs as a yellowish-white powder, 
which is insoluble in water. 

Comment — This is a better preparation to use iBternaUy, 
ordinarily, than is bisrautli subnitrate, although the latter is 
the most frequently prescribed. The average dose is i Gm. 
(15 grains). 

BISMUTHI SUBGALL AS— Dermatol 

Bismuth SubgaUate occurs as a bright yellow powder, which 
is insoluble in water. The average dose is 0.50 Gm, (yj^ 
grains). 

Comm^it* — ^This preparation is more frequently used as a 
mild astringent drying powder for irritations of the skin. It 
has no advantage over other preparations of bismuth when 
used internally. 

BISMUTHI SUBNTTRAS 

Bismuth subnitrate occurs as a white powder, which is 
insoluble in water. 

Preparation. — Magma Bismuiki (Milk of Bismuth), the 
dose of which is a teaspoonfuL 

Comment — The Milk of Bismuth preparation is a compound 
mixture that does not keep well, and it is much better to admin- 
ister bismuth subcarbonate or bismuth subnitrate as a powder 
dropped into some effervescing water, as vichy, for an adult, 




58 THE PRINCDPLES OF THERAPEUTICS 

or in barley water or milk for a child. The average dose of 
bismuth subnitrate is i Gm. (15 grains). 

BUCHU 

Buchu occurs as the dried leaves of the plant. 

Prepaiati(m. — Fluidexiractum Buchu, the dose of which is 
2 niiU (30 minims) taken well diluted, four times a day. 

Comment — Buchu is a mild stimulating diuretic, and hence 
should not be used when there is inflammation of the kidneys. 
It has been given as a decoction made with 30 Gm. (i ounce) 
of the leaves to 500 mils (i pint) of water. The whole pint 
should be taken during the twenty-four hours. 

CAFFEINA— Caffeine— Thelne 

This substance is obtained from the leaves of tea (theine) 
and the seeds of coffee (caffeine), and occurs as white silky 
needles of very bitter taste, and not very soluble in water. 

Preparations. — Caffeina Citrata; Caffeine Citrata Efferves- 

CCflSm 

Comment — Caffeine is principally used in the form of the 
citrated caffeine, and the average dose is 0.30 Gm. (5 grains) ; 
or in the form of the effervescing citrated caffeine, which 
contains 4 per cent, of citrated caffeine, the average dose of 
which is 4 Gms. (i drachm). 

CAFFEIN£ SODIO-BENZOAS 

This substance is a mixture of caffeine and sodium benzoate, 
and occurs as a white powder, ias a slightly bitter taste, and is 
very soluble in water. 

Comment — This preparation is used mostly hypodermatic- 
ally, and the hypodermic dose is 0.20 Gm. (3 grains). 

CALCII CARBONAS PRJECIPITATUS— Precipitated Chalk 

Precipitated calcium carbonate occurs as a fine white crystal- 
line powder, is tasteless, and is insoluble in water. 

Comment — This preparation is mostly used as a dusting 
powder to dry moist surfaces. Sometimes it is used as an ant- 



DRUGS AND PREPARATIONS OF IT. S. P. §0 

add, and to aUay stomach and intestinal irritation. The average 
dose for this purpose is i Gm. (15 grains), 

CALCII CHLORIDUM 

Caldum chloride occurs in white, hard fragments, is very 
^delequescent, and very soluble in water. 

Comment. — ^Caldum chloride is used to increase the calcium 
content of the blood when there is bleeding, but it is irritant 
and nauseating, and hence the preparations of caldum lactate 
and caldum glycerophosphate are better. If this drug is used, 
the dose should be 0,30 Gm. (5 grains). It is best prescribed 
with some syrup, as syrup of acada, and water, and should be 
taken well diluted. 

CALCII GLYCEROPHOSPHAS 

Caldum Glycerophosphate occurs as a fine white powder, 

has a slightly sweetish taste, and is not very soluble in water. 

Cominent. — This is a very useful preparation and a pleasant 

method of administering calcium, and represents the most 
important ingredient of the various glycerophosphate prepara- 
tions. It acts as a nervous sedative. The dose to satisfy the 
caldum need of the body is about 0.50 Gm. (7H grains) given 
in powder, or in capsule, three times a day. 

CALCII LACTAS 

Caldum Lactate occurs as white masses or powder, is nearly 
tasteless, and not very soluble in water. 

Comment — Calcium is a specific for tetany and for any 
irritation or insufiidency of the parathyroid glands. Most 
caldum preparations are nerv^ous sedatives, and they may also 
be used when there are frequent hemorrhages. The average 
dose is 0,30 Gm. (5 grains), best given in powder. 

CALCII SULPHIDUM CRUDUM— Sulphurated Lim« 

Crude Calcium Sulphide occurs as a grayish or yellowish 
powder, has a faint odor of hydrogen sulphide, a disagreeable 
taste, and is insoluble in water. 




6o THE PRINCIPLES OF THERAPEUTICS 

Commeiit — Sulphurated lime lias been used for boils and 
carbuncles, and for pustular inflammations of the skin. What- 
ever value it has is probably due to its sulphur content, and 
other preparations of sulphur will doubtless act as well. In all 
such pustular conditions it should be remembered that focal 
infection must be sought and eradicated. An average dose is 
0.03 Gm. (3^ grain), every three hours, best administered as a 
tablet, which should be crushed before swallowing and taken 
with plenty of water. 

CALX— Calcitfm Oxide— Lime— Quicklime 

Comment — This drug is administered internally only in the 
form of its preparation. Liquor Calcis, the dose of which is a 
tablespoonful, administered from two to four times a day, 
either in milk or water. Lime water is a mild antacid which is 
often added to milk in the preparation of artificial food for 
children, as the alkali tends to prevent the formation of large 
curds in the stomach, hence thought to allow the milk to be 
more easily digested. A small amount of calcium is doubtless 
absorbed from this preparation. 

CALX CHLORIN AT A— "Chloride of Lime" 

Chlorinated lime occurs as a white or grayish granular 
powder giving off the odor of chlorin, of which it should contain 
not less than 30 per cent. It is partially soluble in water. 

Comment — ^This is used as a disinfectant in the strength of 
60 Gm. to 1,000 mils (2 ounces to a quart) for disinfecting 
stools and urine. The official Liquor Soda ChhrinakB (Labar- 
raque's Solution) is largely used as an antiseptic wash. 

CAMPHORA 

Camphor occurs as white masses, has a characteristic pungent 
odor, is slightly soluble in water, and very soluble in alcohol. 
The average dose by the mouth is 0.20 Gm. (3 grains). Hypo- 
dermatically the dose is o.io Gm. (ij^ grains). 

Preparations. — Aqua Camphors is a very weak preparation 
of camphor, the average dose of which is 2 teaspoonfuls. 



DRUGS AND PREPAHATIONS OF U^ S. P. 

Sfnritus Camphorm contains lo per cent, of camphor, and tbe 
dose is I mil (15 minims). 

CANNABIS— Cannabis IndlcA—lndUn Hemp— Hashish 

Comment — Cannabis Indica is a cerebral stimulant and 
sexual excitant. Later it causes soothing, pleasurable sen- 
sations and sleep. It is a habit-forniing drug^ and its medicinal 
value is doubtfuL If used for medicinal purposes the best 
preparation is the official fluidextract, the average dose of 
which is o.io mil (1*2 minims). Preparations of cannabis 
vary greatly in strength, 

CANTHARIS— Cant harides— Spa nfsti Files 

The preparations of Ceralum Canlharidis, Collodium Canthari' 
datum, and Tinciura CanUmridis are made from the dried 
bodies of Spanish beetles. Cantharis is used externally to 
cause blisters in the form of the cerate, as plasters made from 
the cerate» or as the cantharidated collodion. If much of this 
drug is absorbed, or if it is administered internally in good 
sized doses, it causes vesical irritation, strangurj% and sexual 
'excitement. The irritation of the kidneys may be sufficient to 
cause suppression. If taken in concentrated solution it is 
an irritant to the alimentarj^ tract. There is no good reason 
for using cantharides internally. 

CARBO LIGNI— Wood Ctarcoaf 

This substance is prepared from soft wood and occurs as 
3 black, tasteless powder. 

Conmieiit — It has been used externally as an absorbent on 
ulcerating surfaces, but is now rarely used for such purposes. 
Internally it has been used in gastric flatulence, and it may 
absorb some gas, if taken dr>' or nearly dry. Also, in its 
interstices it may carrj' enough oxygen into the stomach to be 
nuldly antiseptic, but its action is mostly mechanical in brushing 
along mucus that sticks to the gastric mucous membrane. In 
other words, there is ver>^ little use for charcoal, and most of 
the preparations offered containing it carry also sodium bicar- 
bonate and carminatives, and a small tablet containing a 




62 THE PRINCIPLES 09 THERAPEUTICS 

little chaxcoal to blacken it can carry no value of charcoal. 
If administered, an average comfortable dose would be 0.50 Gm. 
(7^ grains). 

CASCARA SAGRADA 

Preparations. — Extractum Cascara Sagrada; Fluidextracium 
Cascara Sagrada; Fluidextracium Cascara SagradtB Arama^ 
ticutn. 

Commeiit — Cascara Sagrada is not used as such; it is used 
only as one of its preparations. It is one of the best laxative 
drugs. It contains a bitter element, and may promote the 
appetite. Large doses are cathartic, but its best use is in 
small doses as a laxative. It is not irritant to the bowels, and 
if regularly administered with a prop>er diet and plenty of water 
drunk and exercise taken, smaller and smaller doses may be 
given, until the constipation is cured. Sometimes it is well to 
give a small dose three times a day, but, generally, it is better 
to give a dose of it after the evening meal or at bedtime, depend- 
ing upon the length of time it takes to act in the individual 
patient. The pleasantest form in which to administer it is in 
the form of the extract, which occurs in powder, and the average 
dose of which is 0.20 Gm. (about 3 grains) administered either 
in tablet or in capsule. The dose of the fluidextract, which 
is very bitter and very disagreeable to take, is i mil (15 minims), 
and the dose of the aromatic fluidextract, which is a pleasant 
preparation but contains many more ingredients than is 
needed, is 2 mils (30 minims). 

CERATUM 

Simple cerate contains 30 per cent, of white wax, 70 per cent, 
of benzoinated lard, and has a higher melting point than 
Unguenlum. 

CHLORALUM HYDRATUM— CWoral 

Chloral hydrate occurs in colorless crystals, has a caustic, 
nauseating taste, and is very soluble in water. The average 
dose is 0.50 Gm. (73^^ grains). 

Comment — Chloral hydrate is one of the most efficient 
hypnotics we possess, but it is very disagreeable to take, and 



^^^ DRUGS AND PREPARATIONS OF U. S. P* 63 

hence is best ordered in plain water to be administered in 
carbonated water, and followed by a piece of orange, or any 
other taste the patient desires. 

CHLOROFORMXJM 

^e^arution*~Spintm Chloroformi. 

Comment— This anesthetic preparation should be used 
internally only in the form of the spirit, which is a 6 per cent, 
preparation, and the dose is 0,50 mil (733 minims). Much 
larger doses may be administered, but it is likely to cause 
nausea. Its only action is as a carminative, although it has 
been used in large doses for intestinal worms. 

CHROMII TRIO XmUM— Chromic Acid 

Chromium trioxide occurs as shining purplish-red crystals, 
which are very soluble in water. It is used externally only, 
best in saturated solution as an escharotic. 

CHRYSAROBINUM 

Chrysarobin is prepared from Goa powder. The official 
preparation is Unguenlum Chrysarobini^ a 6 per cent, ointment, 
which should generally be diluted. 

Comment — This preparation is used only in ointments as a 
stimulant and irritant in certain diseases of the skin 

CINCHONA— Callsay^ B^rk— Yellow Pcrtfviafi E&rk 

Preparation. — Tinctura CincfwfUE. 

Comment — Cinchona in small doses is a bitter tonic, and is 
best administered as such in the form of the tincture, the dose of 
which is a teaspoonfuL Various elixirs of calisaya are on the 
market, and are effective appetizers, 

CINCHONA RUBRA— Red Peruvian Bark 

Comment — A preparation of this drug, namely, Tinctura 
Cinchona Compositay is very much used as a tonic, but as it 
contains serpen taria, which is a useless drug, the mixture seems 
unnecessary. The plain Tincture of Cinchona or an Elixir 
of Calisaya will act as well. 




64 THE PRINCtPLES OF THERAPEUTICS 

CINCHONIDIN£ SULPHAS 

Cinchonidine Sulphate (Cinchonidia) occurs as white needles 
or prisms, has a very bitter taste, and is slightly soluble in water. 
The dose is 0.15 Gm. (2H grains). 

Comment — ^This alkaloid of cinchona apparently has no 
advantage over the more efficient alkaloid, quinine. 

COCAINA— Cocaine 
COCAINiE HYDROCHLORIDUM 

Cocaine is an alkaloid of Erythraxyhm Coca. The hydro- 
chloride of cocaine, the preparation most used, occurs as 
colorless or white prisms or powder, and is very soluble in water. 

Comment — It is exceedingly rare that cocaine should be 
administered internally; it should only be used for local anes- 
thetic purposes, as the danger of forming a habit is very great. 

CODEINA 

Codeine is an alkaloid of opium. 

Comment — Codeine is principally used in the form of the 
official CodeifUB Phosphas or Codeina Sulphas. These salts 
occur as white crystalline powders, both soluble in water, but 
the phosphate the more soluble. For this reason the phosphate 
is the preparation that is best for hypodermic use. The dose of 
each of these salts is 0.03 Gm. ()^ grain). 

COLCHICI SEMEN 

Comment — Colchicum seed is best used internally in the 
form of the official Tinciura Colchici Seminis, which represents 
10 per cent, of colchicum, and the dose of which is 2 mils 
(30 minims). The official alkaloid of colchicum is Colchicina^ 
which occurs as pale yellow scales or powder. It is soluble in 
water, and the average dose is 0.0005 Gm. (H20 grain). 

COLLODIUM 

Comment — Collodion is a solution of gun cotton in ether, 
and is used as a protective. The official Collodium Caniharida- 
turn contains cantharides, and is used to cause blistering, and 



DRUGS AND PREPARATIONS OF U. S. I*." 



65 



I 



the official CoUodium Flexible contains castor oil to prevent it 
contracting the tissues to which it is applied. 

COT ARNIN^ H YDROCHLORmUM^S ty p tici n 

Cotamine hydrochloride is prepared from the narcotine of 
opium, and occurs as a yellow crystalline powder, very soluble 
in water. The average dose is 0.06 Gm. (i grain). 

Conunent — Cotarmne Hydrochloride acts like hydrastinine 
as a contractor of the uterus. 

CREOSOTUM 

Creosote is a mixture of phenols and phenol derivatives, and 
acts like phenol. 

Comment* — ^Creosote has been used internally for pulmonary 
tuberculosiSj for laryngeal tuberculosis by inhalation^ and was 
an ingredient of many mixtures used for influenza. However, 
it is of doubtful value when administered internally, though by 
inhalation it is of local value. WTien the doses are increased 
and the drug is pushed it causes indigestion and disturbance of 
the pancreas. The average dose is o.io mils fi3^2 minims). 

CRESOL 

Cresol is a mixture obtained from coal-tar. 
Preparation. —Liquor Cresalis Composilus. 
Conmient — Cresol and its oflicial preparation are used for 
antiseptic purposes. There is no use for cresol internally. 

GRETA PR^PAR AT A— Prepared Chalk 

Prepared chalk occurs as a grayish-white powder, insoluble in 
water. 

Preparations-^ AfiV/wra Crekt (Chalk Mixture), the dose of 
which is 2 teaspoonfuls. 

Comment— Prepared chalk is a mild antacid used in tooth 
pastes and as a dusting powder. Chalk Mixture has largely 
been used for children with add indigestion and with diarrhea, 
but Milk of Magnesia is better for this purpose. Internally 
the dose of prepared chalk is too large for comfort. 



66 THE PRINCIPLES OF THERAPEUTICS 

CUBEBA— Ctfbcbs 

Comment — There is no use for cubebs except in the fonn of 
the official Trockisci Cubeba which is made from the official 
Oleoresina Cubeba. The dose is one troche as needed to cause 
increased secretions of the membranes of the mouth, throat and 
larynx. 

CUPRI SULPHAS— Blue Vitriol— Bltsestone 

Copper Sulphate occurs as deep blue crystals, very soluble in 
water. 

Commeiit — Copper sulphate is not used internally except as 
an emetic. The dose as an emetic should be 0.50 Gm. (yj^^ 
grains) dissolved in water. This dose should not be repeated. 
Externally it is used in the form of the solid stick (bluestone) 
as an escharotic, esp>ecially on granular eye-lids. 

DIACETYLMORPHINiB HYDROCHLORIDUM— Heroin 

Diacetylmorphine is prepared from morphine by acetyliza- 
tion. The hydrochloride, heroin, occurs as a white crystalline 
powder, very soluble in water. The average dose is 0.003 Gm. 
0^0 grain). 

Comment — Heroin has no advantage over codeine in quieting 
cough, although it is cheaper. It is a very subtle habit-forming 
drug, hence should not be used. 

DIASTASUM 

Diastase is a mixture containing amylolytic enzjrmes obtained 
from an infusion of malt, and occurs as a yellowish-white 
powder, soluble in water. The average dose is 0.50 Gm. (yj^ 
grains). 

Comment. — ^Diastase will not have amylolytic action in the 
stomach after acid peptones have been formed, or after free 
hydrochloric add is present. Various malt diastatic prepara- 
tions can be obtained, and are used in preparing milk for feed- 
ing infants. 

DIGITALIS— Fozglove 

Digitalis occurs as dried leaves, and the average dose is 
0.06 Gm. (i grain). 



DRUGS AND PREPARATIONS OF U. S. P. 



67 



PreparatioiiS. — Fluidexlractum Digitalis ^ average dose 2 drops 
(about 1 minim), Injusum Digitalis , average dose a teaspoon- 
fill. Tinctura Digitalis^ represents 10 per cent, of the drug, 
average dose 0.50 mil (yj^ minims). 

CpTnTngnt. — Soluble tablets made of digitalis each represent- 
ing I grain axe very efficient. The infusion of digitalis must be 
freshly prepared, and a tpaspoonful of this preparation represents 
a little more than i grain, namely 0.075 Gm, This preparation, 
long thought to have better action than other preparations of 
digitalis, has such acti\rtty probably because a larger dose is 
generally given. Also, an old tincture will lose its strength, 
and therefore cannot be compared with a freshly made infusion. 
All preparations of digitalis deteriorate, except the properly 
prepared and properly cared for leaves. 0.50 mil of the 
tincture represents 0.05 Gm. of the drug, a little less than i 
grain. 

ELATERINUM 

Elalerin is a principle obtained from elaterium, and occurs 
as small white crystals* 

Preparatioru^ — Trituraii^} Elakrini. This preparation repre- 
sents 10 per cent* of elaterin, and the average dose is 0.05 Gm. 
(H grain). 

Comnieot — ^Elaterin is best used in the form of the tritarate. 
It is a very active purgative, producing watery stools, follow^ed 
by more or less prostration. The excuse for using this drug is 
uremia, and occasionally drops> due to insufficiency of the kid- 
neys. A weak circulation would contraindicate the use of this 
drug. 

ELIXIR AROMATICUM 

Comment — This is a very pleasant aromatic menstruum 
containing orange, lemon, coriander, anise, syrup and alcohol. 

ELIXIR GLYCYRRHIEiE 

Comment. — ^This preparation of licorice is used as a menstru um 
for administering disagreeable drugs, but it should be urged that 
sweets and syrups tend to aggravate a bad taste by prolonging 
it. Also, sweets destroy the appetite. 



, 68 THE PRINCIPLES OF THERAPEUTICS 

> EMETINiE HYDROCHLORIDUM 

The hydrochloride of the alkaloid emetine obtained from 
ipecac occurs as a white or yeUowish crystalline powder, soluble 
in water. It is used mostly hypodermatically. The average 
dose is 0.02 *Gm. {}i grain). 

Comment — This drug is used as a specific in amebic dysen- 
tery. 

ERGOTA— Ergot of Rye 

Ergot is a fungus, and occurs as a brownish-black substance, 
having a disagreeable taste. 

Preparations. — Exiractum ErgoUE, the average dose of which 
is 0.25 Gm. (4 grains); Fluidextractum ErgoUz, the average 
dose of which is 2 mils (30 minims). 

Comment — Ergot is used only in the form of its preparations. 
Ergotine is a name for a pure extract of ergot. 

EUCALYPTOL 

Eucalyptol is obtained from the volatile oil of Eucalyptus 
GlobuluSy and occurs as a colorless liquid having an aromatic 
camphoraceous odor. 

Comment — Eucalyptol is mildly antiseptic, and is added to 
many sprays and gargles for mild antiseptic and stimulant 
action. 

PEL BOVIS 

Oxgall is prepared from the fresh bile of the ox. 

Preparation. — Exiractum Fellis Bavis. This occurs as a 
powdered extract. The average dose is o.io Gm. (i^ grains). 

Comment — Oxgall is used as a mild laxative, and for this 
purj>ose is often added to laxative drugs. 

FERRUM 
Valuable preparations of iron are: 

FERRI CARBONAS SACCHARATUS 

The average dose of saccharated ferrous carbonate is 0.25 
Gm. (4 grains). 



^^^^^^ DRUGS AND PREPARATIONS OF V, S* P* 69 

f FERRI HYBROXIDUM CUM MAGNESII OXIDO 

This is the arsenic antidote, and is kept ready for immedi- 
ate preparation in the case of arsenic poisoning. The dose is 
100 mils (about $}4 fluid ounces). 

FERRI PHOSPHAS 

This preparation is soluble in water. The average dose is 
0.25 Gm. (4 grains). 

FERRI SULPHAS 

This astringent salt and its preparations are used externally 
only, 

Conmieiit- — A long used mixture of ferrous carbonate, 
oflicialJy Massa Ferri Carbmiaiis (Vallet's Mass), prepared 
from ferrous sulphate, and with honey, sugar, and syrup, is not 
needed in medicine. 

FERRUM REDUGTUM— Reduced Iron— Quevenne's Iron 

Reduced iron occurs as a fine grayish-black powder, slightly 
astringent, and the average dose is 0.06 Gm. (i grain). 

m GLUGOSUM 

Glucose occurs as a thick, syrupy liquid, and is obtained 
by the incomplete hydrolysis of starch, and consists chiefly of 
dextrose and dextrins» 

GLYCERINUM 

Glycerin occurs as a clear colorless liquid, of a thick, syrupy 
consistence. The average dose is a teaspoonful 

Preparatioii* — Suppositoria Glycerini. Each suppository con- 
tains 3 Cms. of glycerin. 

Comment — Glycerin is a mild antiseptic, and in full strength 
is irritant to many skins, and to some skins is irritant even if 
well diluted. A 25 per cent, solution in w^ater, or in perfumed 
water, is the strength of preparation generally advisable for 
external use. Internally glycerin is sometimes used as a 
laxative. 





70 THE PRINCIPLES OF THERAPEUTICS 

GLYCTRRHIZA 

Preparations.— £x/rac/Mm Glycyrrhiza occurs in the form of 
stick licorice used for solution in the mouth to soothe irritation 
and cough. It is used in the preparation of the official ammon- 
ium chloride and cubeb troches. Mistura Glyjcyrrkiza Com- 
posita (Brown Mixture). This is a multiple mixture containing 
licorice, syrup, acacia, tartar emetic, paregoric, and sweet 
spirits of nitre. It represents pharmacal nonsense, and though 
ancient and honorable should be relegated to the past and 
shelved as an exhibit of the tolerance of the himian stomach. 
Pulvis Glycyrrkiza CamposiluSy Compound Licorice Powder. 
This much used laxative mixture contains 23 per cent, of 
licorice, 18 per cent, of senna, and 8 per cent, of washed sulphur. 
The average dose as a laxative is 4 Gm. (i drachm). 

Commeiit — Licorice is a soothing, demulcent laxative, is 
sickish sweet in the form of the syrups, is likely to upset the 
stomach, and has no great activity except that it is pleasant to 
take. It is doubtful if the licorice adds any efficiency to the 
Compound Licorice Powder; it would be better named if it 
were called compound senna, or compound sulphur, powder. 

GRANATUM— Po mesrana tc 

Preparation. — Fluidexiractum Granati, the average dose of 
which is 2 mils (30 minims). 

Comment — Pomegranate is used only as an anthelmintic 
against tapeworms. The best preparation is the fluidextract. 

HEXAMETHYL ENAMINA— Hexamethylene-tctramine 

Hexamethylenamine is a condensation product of ammonia 
and formaldehyde, and occurs as colorless crystals or as a white 
powder. It is very soluble in water. 

Comment — Urotropin is used as a urinary antiseptic. It 
has not been shown that it has any antiseptic value except in 
acid media, therefore it cannot have germicidal activity in the 
alkaline fluids of the body. The average dose is 0.50 Gm. 
(73^ grains). It should be taken dissolved in from one-half 
to a glass of water. The frequency of the dose should be three 
or four times in twenty-four hours. 



DRUGS AND PREPARATIONS OF IT. S. P. 



7^ 



HOMATROPIN£ HYDROBROMIDUM 

The hydrobiomide of homatropine, an alkaloid obtained by 
the condensation of tropine and mandelic acid, occurs as a 
white cr^'stalline powder , soluble in water. 

Commeiit— This is used externally only, to dilate the pupils. 

HYDRARGYRUM— Mcfcury— Quicksilver 

Mercury is used in some preparation, as Massa Hydrargyri 
(Blue Mass, Blue Pill), the average dose of which is 0.25 Gm. 
(4 grains). Other preparations are, Ungti^tiium Hydrargyri, 
and Ungu^nium Hydrargyri Dilutum (Blue Ointment), 

Comment — Blue Mass (Blue Pill) is another ancient and 
honorable, and at times dishonorable, preparation. It should be 
relegated to the scrap heap. It has no advantage over calomeL 

HYDRARGYRI CHLORIDUM CORROSIVUM— Corrosive 
Sybil m^te^ — Mercuric Chloride 

The bichloride of mercury occurs in crystalline masses or as 
a white powder, soluble in water. The average dose is 0.003 
firn- (^20 grain). 

Preparation, — T^xiiabellm Hydrargyri Cfdoridi Corrosivi, 
poison tablets of corrosive sublimate, for use in solutions as an 
external antiseptic, 

HYDRARGYRI CHLORIDUM MITE— Merc urous Ctloride.- 
Subchtorfde of Mercury^ — ^Calomel 

Calomel occurs as a white impalpable powder. The average 
dose for systemic action is 0.015 ^^- (J i grain). 

Comment. — Calomel is mostly used as a purgative, generally 
best combined with bicarbonate of sodium. The average dose 
is o.io Gm, (1^2 grains), A larger dose may be given ^ if desired. 
It is rarely ad\dsable to give minute doses, as }io of a grain, 
every half hour or hour. Calomel occurs in that medieval 
preparation termed the Compound Cathartic Pill, 

HYDRARGYRI lODIDUM FLAVUM—Protoiodtde of Mercury-- 
Yellow Iodide of Mercury 

Yellow mercurous iodide occurs as a bright yellow amorphous 
powder, insoluble in water. The average dose is 0,01 Gm. 
(H grain). 





72 THE PRINCIPLES OF THERAPEUTICS 

HYDRARGYRI lODIDUM RUBRUM— Blnlodlde of MercurT— 
Red Iodide of Mercury 

Red mercuric iodide occurs as a scariet red amorphous pow- 
der, insoluble in water. The average dose is 0.003 Gm. ()^o 

grain). 

HYDRARGYRI OXIDUM FLAVUM 

Yellow mercuric oxide occurs as a light orange-yellow amor- 
phous powder, insoluble in water. 

PreparatioiL — Unguentum Hydrargyri Oxidi Flavi. This is a 
10 per cent, ointment of yellow oxide of mercury. 

Comment — Yellow oxide of mercury is not used internally, 
It is sometimes used externally as a powder on syphilitic sores, 
diluted with an equal amount of some inert powder. The oint- 
ment is frequently used externally. 

HYDRARGYRI OXIDUM RUBRUM— Red Precipitate 

Red mercuric oxide occurs as a heavy orange-red crystalline 
powder, insoluble in water. 

Comment. — This preparation is not used internally. It may 
be used externally for syphilitic sores when diluted with an equal 
amount of some inert powder. 

HYDRARGYRI SALICYLAS 

Mercuric salicylate is a compound of mercury and salicylic 
add, and occurs as a yellowish or pinkish powder, practically 
insoluble in water. The average dose is 0.004 Gm. (J^5 grain). 

Comment — This preparation is principally used for intra- 
muscular injections, and is given in oil suspension. 

HYDRARGYRUM AMMONIATUM— White Precipitate 

Ammoniated mercury occurs as a white amorphous powder, 
insoluble in water, and is used mostly in the form of its prepara- 
tion, Unguentum Hydrargyri Ammaniati, which is a 10 per cent, 
preparation of this salt. 

HYDRASTIN-E HYDROCHLORIDUM 

Hydrastine hydrochloride is a preparation of the alkaloid 
hydrastine which is obtained from hydrastis or prepared syn- 



^^^^^ DRUGS AND PREPARATIONS OF U. S. P, 73 

thetically* It occurs as a white powder, very soluble in water. 
The average dose is 0.0 1 Gm. (ji grain). 

Comment — This preparation causes uterine contraction and 
is used for uterine hemorrhage. 

HYDRASTININJE HYDROCHLORIDUM 

The hydrochloride of hydrastinine is an alkaloid obtained by 
the oxidation of hydrastine, and occurs as light yellowish 
needles or crj^stalline powder, ver>^ soluble in water and alcohol. 
The average dose is 0-03 Gm. {J^ grain). 

Comment— Tins preparation is active as a contractor of the 
uterus, and raises the general blood-pressure, but it may cause 
serious depression. 

HYPOPHYSIS SICCA— Desiccated Pituftary Body 

Desiccated hj^pophysis is prepared from the posterior lobe of 

the pituitary body of cattle, and occurs as a yellowish powder, 

only partially soluble in water. The average dose is 0.03 Gm. 

m grain). 

lODOFORMUM 

Iodoform occurs as a lemon-yellow powder. 

Comment— It has no use internally. It is only a mild 
antiseptic externally, and it is inexcusable to use it externally or 
in any orihce of the body on account of its odor. In oil emul- 
sion it has been used with some success as an injection into 
tuberculous joints and tendons. It can cause poisoning when 
used over large absorbing surfaces or in the caxdties of the body, 
and the poisoning is similar to that of phenol. Its antiseptic 
value is supposed to be due to its liberation of iodine. 

lODUM 

Iodine occurs in bluish-black plates, has a distinctive odor, 
and is practically insoluble in water, soluble in alcohol, 

^epaiB-HGns.— Liquor lodi Coffiposiius (LugoFs Solution), 
which is used as a mild antiseptic astringent and stimulant to 
mucous membranes. It is generally combined vAth a small 
amount of glycerin, and swabbed on the part to be treated. 
Tinciura lodi is a 7 per cent, alcoholic preparation of iodine. 





74 THE PRINCIPLES OF THERAPEUTICS 

It is largely used as an antiseptic and germicide and also as a 
counterirritant. It may be used internally in the dose of i 
drop. Unguentum lodi contains 4 p>er cent, of iodine. It is 
used as a mild counterirritant. 

IPECACUANHA 

Ipecac occurs as the dried root. 

Preparations. — Fluidexiractum IpecacuanluB, the average 
expectorant dose of which is about i drop. Pulvis IpecacuanfuB 
et Opii (Dover's Powder) contains 10 per cent, of ipecac. 
Syrupus IpecacuanfuB contains 7 per cent, of the fluidextract. 
The expectorant dose is 0.50 mil (y}4 minims), given every two 
hours. The emetic dose is a tablespoonful. 

Comment. — Powdered ipecac root is rarely used internally 
except as an emetic, and the emetic dose is 2 Gm. (30 grains). 

JALAPA 

PrepaiatioiL — Pulvis Jalapa Compositus contains 35 per 
cent, of jalap and 65 per cent, of potassium bitartrate. The 
average dose is 2 Gm. (30 grains). 

Comment. — ^Jalap is an active purgative, causing watery 
movements in three to four hours. It is best not used as such, 
but preferably as the compound jalap powder. The resin of 
jalap has been used in the compK)und cathartic pill, but neither 
this preparation nor the compound cathartic pill is needed 
in medicine. 

LINIMENTUM CALCIS— Carron Oil 

Comment. — This preparation contains equal parts of lime 
water and linseed oil, which should be freshly combined. It 
has long been used for bums. It was named carron oil from 
the Carron Iron Works of England where bums frequently 
occurred. This lim'ment is non-irritant and soothing. 

LINIMENTUM CAMPHOR£— Camphorated Oil 

Comment. — This preparation contains 20 per cent, of cam- 
phor in cottonseed oil. It is a mild stimulant to the skin. 



DRUGS AND PREPARATIONS OF tJ. S. P. 



n 



LmiMENTUM CHLOROFORM! 

Conunent. — This preparation contains 30 per cent, of chJoro- 
form in 70 per cent, of soap liniment, and is mildly counter- 
irritant. 

LMIMENTUM SAPONIS 

Soap liniment contains camphor and alcohol, and is mildly 
counterirritant. 

LmiMENTUM SAPONIS MOLLIS 

Comment — Soft soap linixnent contains 65 per cent, of soft 
soap (cottonseed oil soap) and is used for cleansing purposes 
and for shampoos. It is strongly alkaline. 

LINIMENTUM TEREBmTHIN£— Kenttsh'fl Oiatmeiit 
This is an irritant ointment. 

LIQUOR FORMALDEHYDI 

Solution of formaldehyde occurs as a clear colorless liquid. 
and is used as a disinfectant and antiseptic. It is very irritant, 
and its vapor is irritant to mucous membranes. 

LIQUOR HYDROGENII DIOXIDI 

This solution of peroxide of hydrogen contains not less 
than 3 per cent, of H2O2. It should be kept in a cool place and 
protected from light; it should be colorless. 

Comment — When this solution deteriorates it becomes 
irritant and should not be used either externally or internally. 
It is rarely used internally, but may be used in certain conditions 
of the stomach in teaspoonful doses, well dilute, 

LYCOPODIUM 

Lycopodium is a yellow dusting powder, used for protective 
purposes on the skin, 

MAGMA MAGNESIiE 

Milk of magnesia occurs as a white liquid containing magne- 
sium hydroxide in suspension. The average dose is 2 teaspoon- 
fuls. 



1 




76 THE PRINCIPLES OP THERAPEUTICS 

Commeiit — This is a very bland antacid, soothing to mucous 
membranes and is mildly laxative. It is used as a laxative 
for infants and children, and is often added to the artificial 
foods of infants. It is of value in ulcer of the stomach and as an 
alkaline mouth wash. 

MAGNESII CARBONAS 

Magnesiimi carbonate occurs as a light, white powder, insolu- 
ble in water. 

Comment — Magnesium carbonate is an antacid, but is not 
as useful as magnesium oxide, as it causes more gas, and the 
dose is too large for comfort. 

MAGNESII OXIDUM— Magnesia— Calcined Magnesia— Light 

Magnesia 

Magnesium oxide occurs as a white, fine powder, insoluble 
in water. 

Comment — This preparation is an antacid and a mild 
laxative. It must be given in powder, and the average dose is 
I Gm. (15 grains). 

MAGNESII SULPHAS— Epsom Salt 

Magnesium sulphate occurs as small needles or prisms, has a 
bitter taste, and is very soluble in water. The average dose 
is 15 Gm. (about 4 drachms). 

Comment — Epsom salt is a bland, effective, and rapidly 
acting saline purgative. It is usually administered before 
breakfast and in hot water. To cause depletion and to cause 
absorption of extravasated fluids it should be given in concen- 
trated solution. 

MANGANI DIOXIDUM PRECIPITATUM 

Precipitated manganese dioxide occurs as a heavy black 
powder, insoluble in water. The average dose is 0.25 Gm. 
(4 grains). 

Comment — This drug is used only as a stimulant to the 
menstrual flow in delayed or scanty menstruation. For this 
purpose it should be given a few days before the time for men- 
struation to begin. It should not be used when pregnancy is 



DRUGS AND PREPARATIONS OF U, S. P. 



n 



suspected, as it may cause abortion. It is best given in capsules 
or in soluble tablets. 

MENTHOL 

Menthol occurs as white crystals, only slightly soluble in 
water, very soluble in alcohoL 

Comment— Menthol is mildly stimulant if robbed on the 
skin, and causes a cooling sensation if It is allowed to evaporate. 
Menthol pencils are often used on the skin also menthol lini- 
ments and ointments. Menthol is added to sprays, mouth 
washes and gargles for its stimulating effect on mucous mem- 
branes, but it is irritant if used in too strong solutions* The 
vapor from menthol pencils is often inhaled in coryza. 

There is no use for menthol internally; other preparations 
of peppermint are better. 

METHYLIS SALiCYLAS— ^il of Wintergreeti— Oil of BetuI— 
OH of Sweet Birch 

Methyl salicylate is made synthetically or is distilled from 
wintergreen or birch , and the label should indicate by which 
method the preparation is made. It occurs as a yellowish 
liquid, with the smell an ' taste of wintergreen. 

Comment ^The action of methyl salicylate is similar to 
salicylic acid. It is used mostly externally as a liniment. If 

Iministered internally the average dose is about 0.5 mil 
Vl\2 minims). It should be given in emulsion or in ready 
prepared oO of wintergreen capsules, and should be taken well 
diluted and not on an empty stomach. 

METHYL THIONm^ CHLORIDUM— Methylene Blue 

Methylene Blue occurs as a dark green crystalline powder, 
soluble in water. 

Comment — This preparation is of value in malarial fever 
when quinine is not tolerated. The average dose is 0,10 Gm. 
dH grains) in capsules, taken with plenty of water, and 
administered every three hours. This drug has also been 
used in gonorrhea, and in infections of the bladder and pelvis 
of the kidney. The dose in this case is 0.10 Gm. {i\4 grains), 
in capsules, every six hours. The urine will become green or 




A 



78 THE PRINCIPLES OF THERAPEUTICS 

bluish-green after the administration of methylene blue. The 
over-action of this drug is shown by nausea, vomiting, backache, 
frequent urination, perhaps strangury, and general depression. 

MORPHINA 

This alkaloid of opium is mostly used in the form of one of 
its salts. 

MORPHIN£ HTDROCHLORIDUM AND MORPHINJE SULPHAS 

These salts are soluble in water. The average dose is 

0.008 Gm. (H grain). 

NUX VOMICA 

Comment — The best preparation is Tinctura Nuds Vomica^ 
which contains 10 per cent, of the drug. As the alkaloid 
strychnine represents all the activity desired of nux vomica, 
when strychnine action is needed salts of the alkaloid shotild 
be used. Therefore the only use for the tincture of nux vomica 
is as a stimulating bitter tonic, and the average dose is from 
I to s drops, in water, before meals. 

OLEUM CADINUM 

Oil of cade occurs as a dark, brown, thick, tarry liquid, in- 
soluble in water. 

Comment — This oil is used externally as a stimulant to 
the skin, best diluted with an oil or ointment to 25 to 50 per 
cent, strength. 

OLEUM CARYOPHYLLI— Oil of Cloves 

Conunent — Oil of cloves is very valuable as a local sedative 

in tooth cavities or in cavities in the jaw made after extraction 

of teeth. 

OLEUM CASSLE— Oil of Cinnamon 

Preparation. — Aqim Cinnamomi. 

Comment — The water of cinnamon is a very pleasant 
menstruum. 

OLEUM CHENOPODII— American Wormseed Oil 

This preparation is a volatile oil distilled from wormseed^ 
occurs as a yeUowish liquid, and has a disagreeable odor and 
taste. 



H DRUGS AND PREPARATIONS OF U. S, P. 79 

Coimneatp^Wonnseed oil is a very valuable anthelmintic 

both for roundworms and for hookworms. The proper dose 
and the method of administration depends on the age of the 
patient and the parasite to be removed. 

OLEUM EUCALYPTI 

Comment — Eucalyptus oil has no si>ecial internal use. It is 
used in gargles and sprays. 

OLEUM GOSSYPII SEMINIS— Cottonseed Oil 

Comment — This is a fixed oil, and is as valuable for external 

use as the more expensive olive oil. 

OLEUM JUNIPERI— Oil of Juniper Berries 

Oil of juniper is a volatile oil distilled from the juniper fruit- 
The average dose is 0.2 mil (3 minims). 

PreparEtions* — Spiritus Juniperi^ the average dose of which 
is 2 mils (30 minims), and Spiritus Juniperi Composiius^ the 
average dose of which is 2 teaspoonfuls. 

Comment' — Juniper is a mild diuretic, and the compound 
spirit which contains besides juniper, caraway and fennel, 
acts not unlike gin. 

OLEUM LAVANDULA— Oil of Lavender 

Comment — ^Lavender has no medicinal value. The offidal 
tincture, Tinctura Lavrntdulm Compositus, which contains 
besides lavender, rosemar>% cinnamon, clove, nutmeg, and 
red saunders, is a carminative, and, on account of its alcohol, 
at times has a pleasant, soothing effect. 

OLEUM LINI^Linaeed Oil— Oil of Flaxseed 

Comment^This is a fixed oil which is principally used 
externally. 




OLEUM BffirrrH^ PIPERIT^^-OII of Peppermint 

This is a volatile oil used principally in one of its preparations 
as a pleasant menstruum or as a carminative. 




8o THE PRINCIPLES OF THERAPEUTICS 

Preparations. — Aqua Mentha PiperikE; SpiHtus Mentha 
Piperita. The average dose of the spirit is 2 mils (30 minims). 

OLEUM MORRHU£— Cod Lhrer Oil 

Comxneiit — This preparation is a fixed, pale yeUow, thin oil, 

and has a fishy taste. It is one of the most easily digestable of 

oils, and contains a valuable vitamine, and hence is a food. 

Emulsions of cod liver oil are reaUy not needed, as they furnish 

less of the oil and are often not better tolerated than a small 

dose of the pure oil. It may be taken in ready prepared flexible 

capsules, or it may be given on salt and water, or on coffee. An 

average dose is from one-half to one teaspoonful, three times a 

day, after meals. In the summer it should be kept cold, 

as it deteriorates. Cod liver oil may also be rubbed into the 

skin. 

OLEUM OLIVJE— Sweet Oil 

This is a fixed oil obtained from ripe olives. 

Comiiieiit. — Olive oil is used mostly externally, but may be 
given as a laxative both to children and adtilts. The adult 
dose as a laxative would be about 2 tablespoonfuls. As a food, 
butter, cream, and cod liver oil are better. 

OLEUM PICIS LIQUIDJE RECTIFICATUM— RecUfied Oil of Tar 

Comment — This is used as a stimulant added to ointments 
in the treatment of skin diseases. 

OLEUM PINI PUMILIONIS-Oil of Pine Needles 

Comment. — This volatile oil is added to solutions for inhala- 
tion or for sprays. 

OLEUM RICINI— Castor Oil 

This b a fixed oil of pale yellow color, and has a nauseating 
taste. The average dose is a tablespoonful. 

Comment — Castor oil is one of the best of the purgatives. 
It is non-irritant » and acts in four or five hours. It & excreted 
in the milk, hence should not ordinarily be administered to 
nursing women. It should not be used as a laxatix-e, as consti- 
pation follows its action. It may be administered in flexible 



V DRUGS AND PREPARATIONS OF U, S. P* 8l 

capsules^ or on salt and water, on coffee, or in flavored effervesc- 
ing mixtures. 

OLEUM SANTALI— Oil of Sandafwooa 

This is a volatile oil distilled from sandalwood, and occurs 
as a pale yellow, somewhat thick liquid, with the odor and taste 
of sandalwood. 

Comment. — Oil of santal is a most useful stimulant antiseptic 
to the urinary organs. It gives its odor to the urine and to the 
breath. In large doses it may cause backache in the lumbar 
region and uretal pains. It has also been used as an expecto- 
rant in bronchitis. It is best administered in the form of 
flexible capsules, and the dose is 0,30 to 0.60 mils (5 to 10 minims) 
taken with plenty of water three or four times a day, best after 

meals. 

OLEUM SBSAMl—Te^i Oil— Ben nc Oil 

Comment— This is a fixed bland oil for external use. 

OLEUM TEREBINTHIN-M— '-Spirits of Ttirpentine** 

Comment — This volatile oil occurs as a colorless liquid, 
and is used externally for its rubefacient action on the skin, 
mostly for stupes, 

OLEUM TEREBINTHm^ RECTIFICATUM 

Comment. — -This colorless liquid is used externally for 
stimulating liniments, and on stupes, for its counterirritant 
effect. It has been used internally as a carminative, but such 
_treatment is not often ad\isable. Like volatile oils, it is a 
bt cardiac and cerebral stimulant, but if much is given it 
will irritate the kidneys and bladder, and may cause strangury 
and suppression. If used internally, the average dose is 0,30 
mil (5 minims) » given in emulsion* 

OLEUM THEOBROMATIS— Cacao Batter 
Comment — This is a bland, non-irritating, solid fixed oil, 
used for making suppositories and for massage, 

OLEUM TIGLII— Croton Oil 

This is a fixed oil of a yellowish-brown color. The average 
dose is one or two drops* 




82 THE PRINCIPLES OF THERAPEUTICS 

Ckmunent — This is an active irritant purgative, and has no 
other use. It acts in from one to two hours. Overactionis 
evidenced by severe purging, colic, enteritis and prostration. 
Formerly it was much used as a counterirritant painted over 
the skin, especially of the chest, to cause pustulation. It is 
best administered on the tongue, one or two drops on a tea- 
spoonful of granulated sugar. 

OPII PULVIS 

Powdered opium is light brown in color. The average dose is 
0.06 Gm. (i grain). 

Preparations. — Opium Deodaratum, the average dose of which 
is 0.06 Gm. (i grain). This preparation is opium with its 
narcotine removed, hence is thought to have less active effect 
on the brain in children. Pulvis Ipecacuanhcd et Opii (Dover's 
Powder). This preparation contains 10 per cent, each of 
ipecac and powdered opium. The average dose is 0.50 Gm. 
^7H grains). Tinciura Opii Camphorata (Paregoric). This 
preparation contains 0.4 per cent, each of powdered opium, 
benzoic add and camphor. The average dose is a teaspoonful. 

OPIUM 

Opium is the milky exudate of Papaver samniferum. 
Preparations. — Extracium Opii is a powdered extract of 
opium, and the average dose is 0.03 Gm. {^^ grain). 

OPIUM GRANULATUM— GrantfUted Opitsm 

Preparations. — Tinciura Opii (Laudanum). This prepara- 
tion represents 10 per cent, of the drug, and the average dose is 
0.50 mil (7J^ mim'ms). Tinctura Opii DeodoraH. This 
preparation represents 10 per cent, of the drug, and the average 
dose is 0.50 mil (y}r^ minims). 

PANCREATINUM 

Pancreatin contains enzymes, principally amylopsin^ trypsin 
and steapsin, and is prepared from the fresh pancreas of the hog 
or ox. It occurs as a cream colored amorphous powder. The 
average dose is 0.50 Gm. (7)^ grains). 



* 



V DRUGS AND PREPAHATIONS OF U. S. P. 83 

Conunent — Pancreatin is a digestant, but it does not well act 
in the stomach except before add peptones in any amoant have 
been formed and before free hydrochloric acid appears* It has 
been thought that it was rendered inert by the acid of the stom- 
ach. It has^ however, lately been shown that it may become 
again active when it reaches the alkaline intestines. Pancreatin 
acts only in alkaline media, consequently it is generaDy com- 
bined with sodium bicarbonate. The best use for pancreatin 
is as a predigestant of milk or other food before it is taken* It 
is best administered as a powder. 

PARAFORMALDEHyDlfM--Paraf©rm 

Paraformaldehyde occurs in white masses or powder, and has 
a slight odor of formaldehyde. 

Comment — This preparation has strong antiseptic properties 
and also b somewhat escharotic, and is used for warts and 
callons skin. When heated it liberates formaldehyde gas. It 
should not be used internally. 

PARALDEHYDtJH 

Paraldehyde occurs as a colorless liquid, and has a pungent 
odor and a burning taste. The average dose is }4 a teaspoonful. 

Comment, — This pungent preparation is best administered 
on cracked ice and water. 

PELLETIERIN^ TANNAS 

Peiletierine Tannate occurs as a yellowish powder^ practically 
insoluble in water, and the average dose is 0.25 Gm. (4 grains). 

Comment — THs drug is used as an anthelmintic especially 
against tenia. 

PEPSmUM 

Pepsin is a mixture containing a proteolytic ferment or en- 
zyme obtained from the fresh stomach of the hog. It occurs 
as yeUowish scales or powder. The average dose is 0.50 Gm. 
llH grains). 

Comment— Pepsin is an aid to stomach digestion. It should 
be given after meals, and is most active when combined with 




84 THE PRINCIPLES OF THERAPEUTICS 

dilute hydrochloric acid. Pepsin is not often needed in the 
stomach. Dilute hydrochloric add generally is sulficient. 

PETROLATUM 

Petroleum jeUy is a purified mixture of semisolid hydro- 
carbons and is obtain^ from petroleum. It occurs in the form 
of a yellowish ointment. 

Preparations. — Petrolatum Album (White Petroleimi JeUy); 
Petrolatum Liquidum (Mineral Oil). 

Comment — Petroleum does not mix with water, thus differ- 
ing from wool fat. It does not become rancid, and while not 
germiddal, still will not promote, but rather inhibits, bacterial 
growth. The above preparations are bland and protective, 
but are not absorbed by the skin or mucous membranes. 
Mineral oil is much used as a laxative. A tablespoonfid is a 
small dose. 

PHENOL— Carbolic Acid 

Phenol is obtained from coal-tar or made synthetically, and 
occurs in colorless crystals or as a white crystalline mass, and is 
soluble in water. 

Preparations. — Glyceritum Pkenolis is a preparation containing 
20 parts of liquefied phenol and 80 parts of glycerin. Phenol 
Liquefactum is a colorless liquid containing not less than 87 
per cent, of phenol. Unguentum Phenolis is an ointment con- 
taining 23^^ per cent, of phenol. 

Comment. — There is no internal use for phenol. 

PHENOLPHTHALEINUM 

Phenolphthalein occurs as a yellowish-white crystalline 
powder, is tasteless, and is soluble in water. The average dose 
is 0.15 Gm. (2j^ grains). 

Comment — Solutions of this salt are injected hypodermati- 
cally as a test of kidney efiidency. It is also largely used as a 
laxative, generally given at bedtime, and is pleasant for children 
to take, as it is tasteless, and, when combined with sugar of 
milk in a tablet, is similar to candy. The tablet should be well 
chewed or crushed. This preparation should not be used too 
long, as it tends to irritate the lower bowel. 



DRUGS AND PREPARATIONS OF U. S, P. 85 

PHENYLIS SALICYLATE— Salol 

Phenyl salicylate occurs as a white crystalline powdeFj has an 
aromatic odor, a characteristic taste, and is insoluble in water. 
The average dose is 0.30 Gm, (5 grains)* 

Comment. — Salol is a valuable bowel antiseptic and causes 
constipation. It is also a valuable urinarj^ antiseptic. Over- 
doses cause phenol poisoning. It is best administered in 
powder or capsule. 

PHYSOSTIGMM^ SALIC YL AS— EBcrine Salicylate 

Physostigmine is an alkaloid of calabar bean, and the salicy- 
late occurs as yellowish crystals, not ver>' soluble in water. 

Conuaentp-^Physostigniine salicylate is mostly used locally 
in ophthalmology to cause contraction of the pupiL It has 
been used hypodermatically to increase peristalsis in paresis of 
the intestines after laparotomy or from other cause. It is some- 
times successful, but ergot^ atropine and pituitary extracts are 
better. Poisoning from this drug is that of depression of the 
nervous and circulatory systems. There is no internal use for 
physostigmine. If used for action on the intestines it should 
be given hypodermatically. 

PILOCARPUS-- Jaborandf 

Commeot^ — Pilocarpus is not used as such. It may be used 

in the form of its fiuidex tract, Fluidexiractum Pilocarpi, the 
dose of which is 2 mils (30 minims). Pilocarpus is most used 
in the form of its alkaloid. 

PILOCARPINE HYDROCHLORmtJM 

Pilocarpine is an alkaloid obtained from pilocarpus, and the 
hydrochloride occurs as colorless crystals, very soluble in water 
and alcohol. 

Comineiit. — ^THs preparation is used to cause perspiration, 
and for this purpose is generally given hypodermatically* The 
average dose is 0.005 Gm. (}i2 grain). There is no good use for 
pilocarpine internally. 

PLUMBI ACETAS— SuRar of Lead 

Lead acetate occurs as crystalline masses or granular crystals, 
has a sweetish, astringent taste, and is very soluble in water. 





86 THE PRINCIPLES OF THERAPEUTICS 

^epaitLiiQiXL— Liquor Plutnbi SubacekUis (Goulard's Extract). 
This preparation also contains lead oxide, and should be used 
only externally and in very dilute solutions, not more than 4 or 5 
per cent. 

Cknmnent — There is no internal use for lead acetate. 

PODOPHYLLUM— Mandrake— May Apple 

PodophyUum occurs as the dried rhizome and roots, and is 
used best in its preparation, Resina PodophyUi, the dose of 
which is o.oi Gm. {^i grain). 

Comment — Podophyllum is used as a 'laxative, and best 
combined with some other laxatives. Large doses cause severe 
purging. 

POTASSII BIT ARTR AS— Cream of Tartar 

Potassium bitartrate occurs as crystals or as a white powder, 
and has an acidulous taste. The average dose is 2 Gm. 
(30 grains). 

Cknmnent — Potassium bitartrate is somewhat diuretic. In 
large doses it is a laxative. It rather tends to increase the 
acidity of the urine, and has been often used for its diuretic 
effect in cardiac dropsy and sometimes in kidney dropsy. 
A pleasant diuretic drink may be made as follows: 

Potassium bitartrate 10 Gm. (Siiss) 

Tartaric acid S Gm. (gr. Ixxv) 

The juice of one lemon. 

Water 1000 mils (i quart) 

This should be sweetened to the taste, and the whole taken 
during twenty-four hours. 

POTASSII BROMIDUM 

Potassium bromide occurs as crystals or powder, has a dis- 
agreeable taste, and is very soluble in water. 

Comment — Potassium bromide is a hypnotic which has no 
advantage over sodium bromide, and the latter is pleasanter to 
take and less of a muscle depressant. However, in epilepsy 
potassium bromide may be the better drug to use, because it 



DRUGS ANT> PREPARATIONS OF U. S. P. 



87 



* 



is more depressant. The average dose to produce sleep is 2 Gm. 
(30 grains), given with plenty of water, and administered three 
hours before bedtime, 

POTASSII CHLORAS 

Potassium chlorate occurs in crystals or granular powder, 
has a disagreeable saline taste, and is soluble to about 5 per 
cent, in water. 

Comment^Potassium chlorate is a very valuable local treat- 
ment for inflammation of the mucous membrane of the mouth 
and throat. Tablets of potassium chlorate should not be 
sucked and the saturated saUva swallowed. Also there is 
absolutely no excuse for adrainisterixig potassium chlorate 
internally. It is irritant, and can cause nephritis and inflam- 
mation of the Uver, It may also destroy red corpuscles. As 
a gargle it may be given in 5 per cent, solution in water or in 
peppermint water. It may be combined with boric acid for 
this purpose, 

POTASSII CITRAS 

Potassium citrate occurs as crystals or powder, and is very 
soluble in water. 

Comment — This is not an antacid in the stomach. It is a 
mild diuretic and tends to alkalize the urine, if give in sufficient 
amount. It is rapidly absorbed, and increases the alkalinity of 
the blood, and for its best action it should be given directly after 
meals. It may somewhat lower blood-pressure, and it increases 
nitrogenous metabolism as do all the alkaline salts. It may 
quiet nervous irritability. It is pleasanter to take, and has 
all the value of potassium acetate and potassium bicarbonate, 
both of which are more disagreeable drugs. There is no need 
for the historic **A B C mixture,'* i.e., potassium acetate, 
potassium bicarbonate, and potassium citrate. The average 
dose to alkalize the urine is 2 Gm. (30 grains) in 10 mils of 
peppermint or wintergreen water, given four times a day. 
A pleasant method of administering it is in the form of the 
official Potassii Citra^ Effervescetis, the average dose of which is 
a teaspoonful dissolved in a glass of water. 





88 THE PRINCIPLES OF THERAPEUTICS 

POTASSII ET SODII TARTRAS— Rochelle Salt 

Potassium and sodium tartrate occurs mostly as a white 
powder, very soluble in water. The average dose is lo Gm. 
(2>^ drachms). 

Comment — Potassium and sodium tartrate is efficient and 
less disagreeable than magnesium sulphate or sodium sulphate. 
It is pleasantly administered in the form of the official prepara- 
tion, Pidvis Effervescens Composiius (Seidlitz Powder). This 
preparation occurs as two papers. In the blue paper is wrapped 
sodium bicarbonate and potassium and sodium tartrate. In 
the white paper is wrapped tartaric add. The contents of the 
white paper should be dissolved in J^ of a glass of water, and 
the contents of the blue paper dissolved in 3^ of another glass 
of water; they should then be poured together and the whole 
drunk slowly as it is finishing effervescing. It should not be 
taken while it is in active ebullition. 

POTASSII HYDRO XIDUM—Caos tic Potash 

Potassium hydroxide occurs as dry white masses or in fused 
pencils, and is very soluble in water. 

Comment — This preparation is very active as an escharotic^ 
but it is difficult to limit its action. It may be used in 5 to lo 
per cent, solutions to remove thickened epidermis. 

POTASSII lODIDUM 

Potassium iodide occurs as crystals or powder, very soluble 
in water, and has a disagreeable, saline taste. The average 
dose is 0.30 Gm. (5 grains). 

Comment — As the therapeutic value of an iodide, or iodine, 
is generally obtained only after long administration, it is well 
to consider the extra depressant action from the potassium salt 
as compared with the sodium salt. Therefore generally sodium 
iodide is better than potassium iodide. Also it is less dis- 
agreeable to take. 

POTASSn NITRAS— Saltpetre 

Potassium nitrate occurs as a crystalline powder. 

Comment — There is no use for this preparation internally. 
Papers dipped in solutions of this salt are dried, then burned 



I 




DRUGS AND PREPARATIONS OP V. S 



and the vapor inhaled for the relief of asthma. The effect is 
that of a nitrite, namely, to relax spasm. In most combinations 
of asthmatic powders, pastilles, or cigarettes potassium nitrate 
is one of the ingredients, as it not only has its medidnaJ nitrite 
properties, but also causes the whole powder to bum quickly. 

POTASSn PERMANGANAS 

Potassium permanganate occurs as purplish prisms and is 
soluble in water. 

Commeiil- — It has no good internal use. Externally it is 
used in various strength solutions from i to i,ooo parts of 
water to 8 to i,ooo parts of water. It has been much used for 
injections into the bladder, vagina and rectumj. It has also been 
used to inject into the tissues surrounding the region bitten 
by a poisonous snake, and has been used in weak solution to 
wash out the stomach in morphine poisoning. 

PRUNUS VIRGINIAN A— Wild Chmrtj 

Comment. — This is used only in the form of the official 
Syrupus Pruni Virginianm^ which is a pleasant menstruum, 
In teaspoonful doses. It has no medicinal value. 

PYROGALLOL— Pyrogalllc Acid 

Pyrogallol occurs as white needles which are soluble in water. 
Comment — This preparation is an irritant to the skin 
which it stains brown, and is germicidal to vegetable parasites 
that infect the skin. If used on too large a surface it may be 
absorbed in sufficient amount to cause poisoning, the symptoms 
of which are somewhat similar to those of phenol poisoning. It 
is used in the treatment of ringworm, favus, psoriasis, etc. in 
water>^ solution of J 2 P^^ cent., painted daily on the parts 
affected, or it may be used in a 10 per cent, ointment It is 
sometimes used in the place of chrysarobin. 

QUASSIA—BitUr Wood 

Quassia occurs as chips or shapings from the wood. 
ConuneBt — Quassia is rarely used internally in the form of 
the tinctiu-e, which represents 20 per cent of the drug. The 



90 THE PRINCIPLES OF THERAPEUTICS 

dose is half a teaspoon! ul, in water, before mealsl It is intensely 
bitter, and its only action is that of a bitter tonic. As an anthel- 
mintic, decoctions are made of the wood; 50 Gm. (about 2 
ounces) of the chips to 750 mils (i^ pints) of water is boiled 
down to 500 mils (a pint). This solution may be injected 
into the rectum (which has previously been cleansed by injec- 
tions of water) for pinworms. 

QUININA 

Comment — Quinine is the most active alkaloid of cinchona, 

and is administered in the form of one of it3 salts, all of which 

are bitter. QuinituB Bisulphas is very soluble in water; QuinituB 

Dihydrochlaridum is also very soluble in water. QuinituB ei 

Urea Hydrochloridum (a compound of the hydrochlorides of 

quinine and urea) is very soluble in water and is used hypoder- 

maticaUy in an average daily dose of i Gm. (15 grains). QuinituB 

Hydrobromidum is not very soluble in water. QuinituB 

Hydrochloridum is soluble in water. QuinituB Sulphas^ the most 

used salt, is practically insoluble in water, but is readily absorbed 

when taken internally. This salt should not be given except 

in pill or capsule. If a solution is desired, one of the more 

soluble salts should be selected. The average dose of any one 

of these salts as a tonic is o.io Gm. (i^ grains), taken three 

times a day, after meals. The anti-malarial dose is much 

larger. 

RESORCINOI^-Resorcln 

Resordnol occurs in colorless crystals or as a powder, very 
soluble in water. 

CommeiKL — There is no excuse for using resordnol internally. 
Externally it has a mild antiseptic action, and is of value in 
solutions in hair tonics and in soaps for shampoo purposes. 

RHEUM^Rhtfbarb 

Rhubarb occurs as the rhizome and roots of the plant, and 
powdered rhubarb is of a yellowish-orange color. The taste is 
bitter and astringent, as it contains tannic add. 

Preparations. — Extractum Rhei is a powdered extract of rhu- 
barb, and the average dose is 0.25 Gm. (4 grains). Fluidex- 



DRUGS AND PREPAItATIONS OF TT, S. P, QS 

tracium Rkei, is given in the average dose of i mil (15 minims). 
Pilulm Rhei Compositm^ each pill containing 2 grains of rhubarb 
and 1)2 grains of aloes, are given in doses of one or two pills. 
Pidvis Rhei CotnpasUus (Gregory's Powder) is a powder con- 
taining 25 per cent, of rhubarb, 65 per cent of magnesium 
oxide, and 10 per cent, of Jamaica ginger, and the average 
dose is 2 Gm. (30 grains). Tinctura Rhei Aromalica contains 
20 per cent, of rhubarb , besides cinnamon, clove and nutmeg. 
The average dose is J- 2 ^ teaspoonfuL From this preparation 
is made the Syrupus RJwi Aromaiicus^ and this aromatic 
syrup is a pleasant purgative for children, the average dose of 
which is 2 teaspoonfuls, 

Comment^Rhubarb is rarely used as such, but sometimes 
the root is chewed, though it is bitter and disagreeable. Oiling 
to its tannic add it is more or less of a tonic to the intestines, 
and when it is used as a purgative causes a later constipation. 
It is excreted in the milk, and hence should ordinarily not be 
taken by nursing mothers, especially as it causes the milk to 
taste bitter, 

SANTOirmuH 

Santonin occurs as colorless prisms or crystaUine powder, is 
insoluble in water, and the average dose is 0,06 Gm. (i grain). 

Comment — This preparation is used as an anthelimintic 
specially in the treatment of roundworms. It easily causes 
poisoning, and the symptoms are tremors and even con\'ulsions, 
and sometimes disturbances of the eye sight Consequently 
this drug should never be administered without the supervision 
and orders of a physician. The following combination is a 
good method of administration. 

Sanlomn * , o . 03 Gm. 

CaJomd. . ..,..., 0.0a Gm. 

Sugar or milk * o , 30 Gm, 

Make i pKtwder. 

Give such a powder every hour for three doses. One hour after 
the last dose it is well to give a saline purgatrvcjin the proper 
dose for the age of the child, and very agreeable for this purpose 
is the Liquor Magnesii Ciiratis, 




ga THE PRINCIPLES OF THERAPEUTICS 

SAPO MOLLIS 

The soft soap of the Pharmacopoeia is made from cottonseed 
oil. 
Preparation. — Linimentum Saponis Mollis. 

SCTLLA—Squill 

The powder of this drug is of a yellow color and is bitter and 
acrid. The average dose is o.io Gm. (i3^^ grains). 

Preparations. — Acetum ScUUb (Vinegar of Squill) the average 
dose of which is i mil (15 minims); Fluidextractum ScUUb, the 
average dose of which is o.i mil (iH minims). Tinctura 
ScUUb is a 10 per cent, preparation of squill, and the average 
dose is I mil (15 minims). 

Comment — Squill is a stimulant diuretic and has some slight 
tonic action on the heart. Poisonous doses cause vomiting, 
irritation and congestion of the kidneys, muscle and heart de- 
pression, and finally collapse. There is no excuse for using this 
drug as an expectorant or as an emetic. It is often combined 
with digitalis in cardiac dropsy. It should be used with care 
in renal disease. 

SCOPOLAMINE HTDROBROMIDUM— Hyoscinc Hydrobromldc 

Scopolamine hydrobromide occurs as colorless crystals, very 
soluble in water. The average dose is 0.0003 Gm. (1/200 
grain). 

Comment — Scopolamine hydrobromide is a hypnotic, but 
like other atropines it may cause cerebral excitement in patients 
who have an idiosyncrasy against it. This drug is mostly 
given hypodermatically. The dose above suggested should be 
the beginning dose, although twice that amount may be given, 
if a patient is found tolerant to it. 

SENNA 

Senna occurs as dried leaflets. The average dose is 4 Gm,. 
(i drachm). 

Preparations. — Fluidextrdctum Senna, the average dose of 
which is 2 mils (30 minims) ; Pulvis GlycyrrlriztB Composiius 



DRUGS AND PREPARATIONS OT U. S. P. 



93 



(Compound Licorice Powder) contains, besides senaa. sulphur 
and glycyrrhiza. The average dose is 4 Gm,. (i drachm). 

Comment — Senna is a valuable, non-irritant laxative. The 
leaves may be chewed , or they may be chopped up with figs and 
taken as a laxative confection. 

SODII BENZOAS 

Comment* — Sodium benzoate is a weak antiseptic and pre- 
servative. It has no use internally- It has been used as a 
preservative for food, but its use was prohibited on account of 
its insidious irritant action on the kidneys. 

SODII BICARBONAS 

Sodium bicarbonate occurs as a white opaque powder, soluble 
in water. The average dose is i Gm,. (15 grains). 

SODII BORAS— Bor*x 

Sodium borate occurs as colorless prisms or as a white powder. 

It is soluble in water. 

Comment-^ Sodium borate should not be used internally. 
Externally it is a mild soothing antiseptic to mucous mem- 
branes, and is used for the same purposes as is boric acid and in 
solutions of the same strength. 

SODII BROMmUM 

Sodium bromide occurs as white crystals or granular powder, 
and is very soluble in water. 

Comment- — Sodium bromide is the best of the bromides to 
use for hypnotic or other purposes. The average hypnotic 
dose is 2 Gm. (30 grains). 

SODII CACODITLAS 

Sodium cacodylate occurs as white prisms or granular pK>wder, 
and is very soluble in water. The average dose is 0.06 Gm, 
(i grain). 

SODII CITRAS 

Sodium citrate occurs in small crystals or white granular 
powder, and is ver>" soluble in water. 



94 THE PRINCIPLES OF THERAPEUTICS 

Comment — This preparation may be used for the same 
purposes as is potassium citrate and in the same doses. 

SODII HTDROXIDUM— Caostic Soda 

Sodium hydroxide occurs as white masses or fused pencils, 
and is very soluble in water. It is used as an escharodc. 

SODII lODIDUM 

Sodium iodide occurs as colorless crystalsor white crystaUine 
powder, is very soluble in water, and the average dose is 0.30 
Gm. (5 grains). 

Comment — This preparation is more valuable than potas- 
sium iodide because it has the same therapeutic effect and is 
less depressant to the system than is the potassium salt. 

SODII NITRIS 

Sodium nitrite occurs as white masses or granular powder, 
is very soluble in water, and the average dose is 0.06 Gm. (i 
grain). 

Comment — This drug is sometimes used as a vasodilator, as 
it acts longer than does nitroglycerin. It is irritant, and should 
be taken after meals, with plenty of water. 

SODII PHOSPHAS 

Sodium phosphate occurs as prisms or as a granular salt, is 
soluble in water, and tastes like table salt. The average dose 
is 4 Gm. (i drachm). 

Preparation. — Sodii Phosphas ExsiccaiuSy from which is 
prepared the official Sodii Phosphas EffervescenSj which offers 
a very pleasant method of taking sodium phosphate, the 
average dose of which is 10 Gm. {2}^ drachms). 

Comment — Sodium phosphate is a gentle laxative and 
seems to especially relieve congestion of the liver. 

SODII SALICTLAS 

Sodium salicylate occurs as a white crystalline or amorphous 
powder, and is very soluble in water. The average dose is 
I Gm. (15 grains). 



Drugs and preparations of u* s, p. 



9S 



Comment— Sodium salicylate is one of the most useful 
preparations of salicylic acid. 

SODII SULPHAS— Gla liber's Salt 

Sodium sulphate occurs as large prisms or granular crystals, 
is very soluble in water, and has a bitter, saline, ver>' dis- 
agreeable taste. The average dose is 15 Gm, (4 drachms). 

SPARTEIHiE SULPHAS 

Sparteine sulphate is prepared from sparteine, a liquid 
alkaloid obtained from scoparius, and occurs as a crystalline 
powder^ very soluble in water. The average dose is o.oi Gm. 
(Ji grain). 

Comment — This preparation has been used as a diuretic and 
as a heart stimulant in certain conditions. In too large doses 
it acts as a nervous and circulatory depressant. It is not a 
very useful drug. . 

SPIGELlA^Pi nkroo t 

Prepafation. — Fluidextracium Spigelm, The average dose 
is 1 teaspoonfuL 

Comment — Pinkroot is used as an anthelmintic in the 
treatment of roundworms. It is best given in the form of the 
fluidextract combined with fluidextract of senna in equal parts, 
a teaspoonful of the combined drugs being given, in water, 
everj' two hours for three doses, to be subsequently repeated, 
if needed. 

ST APHIS AGRIA-^Stavesacre 

Comment.— Staphisagria should be used externally only. 
It is used as a wash or ointment to destroy Hce. 

STRAMONIUM— Jamestown Weed 

Comment^There is no need for this drug or its preparations 
as its action is similar to that of belladonna, and atropine 
represents the action of both stramonium and belladonna. 
However, the leaves of stramonium are sometimes burned and 
the vapor inhaled for asthma. The action is doubtless an 
atropine action. 




96 THE PRINCIPLES OF THERAPEUTICS 

STROPHANTHUS 

Comment — Strophanthus is used only in the form of its 
tincture, Tinctura StrophatUki, which represents lo per cent, 
of the drug. The average dose should ordinarily not be more 
than 0.30 mil (5 minims), as it is often irritant to the gastro- 
intestinal tract. This tincture should generally be ordered 
alone, as it does not weU combine, and also it quickly deterior- 
ates. Digitalis action should not be expected from tincture of 
strophanthus when administered by the mouth. 

The active principle of strophanthus, Strophantkinum (stro- 
phanthin), which is a mixture of glucosides obtained from 
strophanthus, is used hypodermaticaUy or intravenously as a 
very strong cardiac tonic. The intravenous dose is about 
Koo of a grain. 

STRYCHNINA 

Comment — Strychnine is rarely used except in the form of 
one of its salts, Sirychninm Nitras or Strychnitue Sulphas. 
These occur as crystalline powders, which are soluble in con- 
siderable water. The average dose is 0.0015 Gm. (J^o grain). 

SULPHONETHYLMETHANUM— Trlonal 

Sulphonethylmethane occurs as colorless crystals, has a 
bitter taste, and is practicaDy insoluble in water. The average 
dose is 0.75 Gm. (12 grains). 

Comment — Trional is a hypnotic that is slow to act, and 
has been largely superseded by veronal. 

SULPHONMETHANUM— Stflphonal 

Sulphonmethane is a crystalline powder, is practically in- 
soluble in water, and the average dose is 0.75 Gm. (12 grains) 

Comment. — This hypnotic acts very slowly, and has been 
superseded more or less by veronal. 

SULPHUR LOTUM. Washed Stslphor 

Washed sulphur occurs as a fine yellow powder without odor 
or taste, is insoluble in water, and the average dose is 4 Gm. (i 
drachm). 



DRUGS AND PREPARATIONS OP TJ, S. P. 



97 



Comment — Washed sulphur is the best preparation for in- 
ternal use. It may be used for laxative purposes, or as a so- 
called bowel antiseptic. Sometimes sulphur is given internally 
for its supposed effect on boils or on eruptions of the skin. The 
stools caused by sulphur are soft but not watery, and give off 
a strong odor of hydrogen sulphide. At the same time the 
breath and the perspiration smell of hydrogen sulphide, and 
this gas is also excreted in the milk, 

SULPHUR PRJECIPITATUM— Milk of Salphttr 

Precipitated sulphur occurs as an amorphous powder, has a 
pale yellow color, is T^dthout odor or taste, and is insoluble in 
water. The average dose is 4 Gm, (i drachm). 

Comment — If it is desired to give a sulphur preparation in- 
ternally, as the dose is large and disagreeable to take, it may be 
administered in a syrup or in a soft jam or thin cereal. 

SULPHUR SUBLIMATUM— Flowers of Siitphur 

SubHmed sulphur occurs as a fine yellow powder, has a 
characteristic ordor, and is insoluble in water* 

Preparation.^ 6'iigw^n/wm Sulphuris is a 15 per cent, ointment 
of sulphur, which is often too strong for most skins* It is used 
principally in scabies. 

Comment — The flowers of sulphur may be used as a powder 
externally for scabies. 

SUPRARENALUM SICCUM— Desiccated Stiprarenat Glands 

This preparation is made from the suprarenal glands of ani- 
mals used for food, and should contain fron 0.4 to 0.6 per cent» 
of epinephrine. It occurs as a yellowish-brown powder. 

TALCUM PURIFICATUM 

Purified talc occurs as a fine grayish-white powder^ and is 
used as a dusting powder and in tooth pastes. 

TERFINI HYDRAS 

Terpin hydrate occurs as colorless prisms which are practically 
insoluble in water, 

7 



d 



98 THE PRINCIPLES OF THERAPEUTICS 

CQHunent — This preparation is used to inhibit secretion of 
the air passages. Solutions in alcohol are unsatisfactory, be- 
cause the dose represented is not of sufficient size. It is best 
administered in powder, capsules, or tablets, the tablet to be 
crushed before swallowing and taken with plenty of water, 
although it is non-irritant. The average dose is 0.30 Gm. (5 
grains) and should be taken four times a day. 

THEOBROMINE SODIO-SALICYLAS— DItsretin 

Theobromine sodio-salicylate occurs as a white powder, and 
is very soluble in water. 

Comment — This preparation, first offered imder the name of 
diuretin, is a much over-lauded diuretic drug. It is not irritant, 
is a slight cardiac stimulant, and slightly stimulant to the kidney 
epithelium. It is contraindicated whenever caflFeine is con- 
traindicated. It may be used in cardiac dropsy. It is not 
pleasant tasted, and is best given in 0.50 Gm. (j}^ grains) cap- 
sules, which should be imcapped before swallowing and taken 
with plenty of water. Larger doses are often administered. 

THYMOL 

Thymol is a phenol, and occurs as colorless prisms, has an 
aromatic odor and a pungent taste, is practically insoluble in 
water, but very soluble in alcohol. 

Comment. — This drug is somewhat antiseptic, and for this 
purpose it is added to gargles and sprays, in weak solutions. 
It should not be used internally for any purpose except as an 
anthelmintic in the treatment of hookworm, as it is likely to 
cause poisoning. The method of administration and the dose 
for that purpose will be found under the detailed treatment of 
that disease. 

THYMOLIS lODIDUM— Arlstol 

Thymol iodide occurs as a reddish-brown powder, has a 
characteristic aromatic odor, and is insoluble in water. 

Comment. — Aristol is used as a drying, mildly antiseptic 
dressing for wounds and ulcers. 



DRUGS AND PKEPAILATIONS OF U* S. P, 99 

THYROIDEUM SICCUM—DfUd Thyroids 

This preparation is made from the thyroid glands of animals 
used for food, and should contain from 0,17 to 0.23 per cent, of 
iodine. It occurs as a yellomsh, amorphous powder, 

Ccmiiiient.^Dried thjToid is a very potent substance. The 

dose should be entirely regulated by the condition for which it 

is used* An average dose is 0.06 Gm. (i grain). This drug 

should not be sold by druggists except on the prescription of a 

physician. 

TRmiTROPHENOL— Picric Acid 

Trinitrophenol occurs as pale yellow scales, is not very solu- 
ble in water, but more soluble in alcohol. 

Com^^iit. — Picric acid is used externally for burns. It has 
no internal use. 

VERATRUM VIRIDE— -Green Hellebore— American Hellebore 

Veratrum viride is the dried rhizome and roots of the plant* 

Preparations, — Fluidextr actum Veratri ViridiSj the average 

dose of which is 0,1 mil (1^0 minims); Tincium Veratri Viridis 

represents lo per cent, of the drug, and the average dose is 0.50 

mil (7}-^ minims). 

ZINCI CARBONAS PR^CIPITATUS 

Precipitated zinc carbonate occurs as a white, impalpable 
powder. 

Comment ^ — This preparation is used as a drying and dusting 
powder. The impure zinc carbonate is termed calamine, 

ZINCI oxmuM 

Zinc oxide occurs as a fine white or yellowish-white powder. 
PreparatioiL — Unguentum Zinci Oxidi. 

Comment — This preparation is slightly astringent, and is 
used as a protective powder. 

ZlNCI STEARAS 

Zinc stearate occurs as a fine white powder. It has a greasy 
feel, is adherent to the skin, and therefore is used as a protective 
powder* 




lOO THE PRINCIPLES OF THERAPEUTICS 

ZINCI SULPHAS 

Zinc sulphate occurs as crystals or a crystalline powder, is 
very soluble in water, and is strongly astringent. 

Comment — This preparation has no use internally except as 
an emetic. The dose for that purpose is 2 Gm. (30 grains), 
given in solution at once and not repeated. Externally it has 
been used as an astringent, especially for injections in gonorrhea. 
Silver salts are now more frequently used for this purpose. 
The strength of solutions used is from J-^ to 2 per cent. 



SYNONYMS 



The following alphabetical list of more or less used syiionyros 

will be found of value for quick reference. 



Acetaimin — ^Tannigen 

Adrenaliii — Suprarenalin ; Epinephrine 

Albu tannin — TannaJbin 

AJcresta Ipecac — Emetinized Fuller*s 

Earth 
Antif ebrin — Ace tanilid 
Aqua Fortis — Nitric Acid 
Aqua Regia — Nitrohydrochloric Acid 
Aristol — ^Thymol Iodide 
Arsenous Acid — Arsenic Triosdde 
Atophan^ — Phenylcincboiiinic Add 



B 



Barbital— Veronal 

Barbital - Sodium — Sodium Diethyl- 
Barbiturate 

Basham's Mixture — Liquor Ferri ct 
Ammonii Acetatis 

Basilicon Ointment — Rodn Cerate 

Benne Oil — Oil of Sesame 

Benzocaine — ^Ancsthesine 

Bichloride — ^Mcrcuric Chloride 

Bitter Wood^Juassia 

Black Draught — Compound Lofuslon 
of Senna 

Black Wash— Lotio Nigra, N. F. 

Blaud Pill— Pill of Ferrous Carbonate 

Bleaching Powder— Calx Chlorinata 

Blue Mass — Massa Hydrargyri 

Blue Ointment — 'Unguentum Hydrar- 
gyri Dilutum 

Blue Pill — Massa Hydrargyri 

Blue Stoned-Copper Sulphate 

Blue Vitriol— Copper Sulphate 

B^ack Acid^ — Boric Add 

Bonx — Sodium Borate 

Boroglyccria — Glyccritc of Boroglyc- 
eria 



Brown Mixture — Compound Mixture 
of Glycyrrhh&a. 



Cacao Butter — Oleum Theobromata 

Calamine — Zinc Carbonate 

Calcined Magnesia — Magnesium QaC' 

ide 
Caldum Oxide — Cak 
CaHsaya Bark^ — Cinchona 
Calomel — IlydmrgjTi Chloridum Mite 
Camphorated Oil — ^Llnimentum Cam- 
phor© 
Carbolic Add — Phenol 
Carron Oil — Linimentum Calda 
Casda Oil — Oil of Cinnamon 
Castor Oil — Oleum Ricini 
Caustic Potash^Potassium Hydroxide 
Caustic Soda — Sodium Hydroxide 
Cayenne Pepper — Capsicum 
Chloride of Lime— Calx Chlorinata 
Chlorinated Lime— Calx Chlorinata 
Chromic Add — Chromium Trioxide 
Cinchophcn^Phenyldnchoninic Add 
Cod Liver Oil — (Xeum Morrhua; 
Compound Licorice Powder — Pulvia 

Glycyrrhiza; Compositus 
Corrosive Sublimate — Mercuric Chlor- 
ide 
Cotton Seed^Gossj'pii Semen 
Cream of Tartar — Potassium Bitar* 

trate 
Croton Oil— Oleum Tiglii 

D 

Deadly Nightshade— BeUadomia 
Dermatol — ^Bismuth Subgallate 
Digitan^ — Digipuratum 
Dionia — Aethylmorphinic HydiocMor- 
idum 



lOX 




I02 



THE PRINCIPLES OF THERAPEUTICS 



Diuretin — ^Theobromine Sodio-Salicy- 

late 
Dobell's Solution— Liquor Sodii Bor- 

atis Compositus, N.F. 
Donovan's Solution — Liquor Arseni et 

Hydrargyri lodidi 
Dover's Powder — Pulvis Ipecacuanha 

et Opii 

£ 

"Elixir Pro"— Tincture of Aloes and 

Myrrh. 
Epinephrine — Suprarenalin 
Epsom Salt — ^Magnesium Sulphate 
Ergot of Rye — Ergot 
Ergotine — Extract of Ergot 
Eserine — Physostigmine 
Eucaine — Betseucaine 
Eucatropine — Euphthalmine 



Hive Syrup — Syrupus Sdlls Composi- 
tus 
Hoffmann's Anodyne — Spirit of Ether 
Hoffmann's Drops — Spirit of Ether 
Huxham's Tincture — Compound Tinc- 
ture of Cinchona 
Hyosdne — Scopolamine 



Jaborandi — Pilocarpus 

James' Powder — Pulvis Antimonialis 

Jamestown Weed — Stramonium 



Kaolin — Aluminum Silicate 
Kentish's Ointment — Linimentum 
Terebinthinse 



Flaxseed — ^Linum 

Flowers of Sulphur— Sulphur Sublima- 

tum 
Fowler's Solution— Liquor Potassii 

Arsenitis 
Foxglove — Digitalis 
Fuller's Earth — Magnesium Silicate 



Gallotannic Add — ^Tannic Acid 
Glauber's Salt — Sodium Sulphate 
Glusidum — Benzosulphinidum; Sac- 
charin 
Goulard's Extract — ^Liquor Plumbi 

, Subacetatis 
Gray Powder — Hydrargyrum cum 

Creta 
Green Helebore — ^Veratrum Viride 
Gregory's Powder — Pulvis Rhei Com- 
positus 
Griffith's Mixture — Mistura Ferri 

Composita 
Gum Benjamin — Benzoin 

H 

Hashish — Cannabis Indica 
Heroin — D i a c e t y 1 morphine Hydro- 
chloride 



Labarraque's Solution — Liquor Sods 
Chlorinatse 

Lanolin — Adeps Lanse Hydrosus 

Laudanum — ^Tincture of Opium 

Licorice — Glycyrrhiza 

Light Magnesia — Magnesium Oxide 

Lime — Calx 

Lime Water — ^Liquor Calds 

Linseed — ^Linum 

Lugol's Solution — Liquor lodi Com- 
positus 

Luminal — Phenylbarbital 

Lunar Caustic — Silver Nitrate 

M 

Magendie's Solution — ^Liquor Mor- 
phinae H3rpodermicus, N.F. 

Magnesia — ^Magnesium Oxide 

Male Fern — Aspidium 

Mandrake — Podophyllum 

May Apple — Podophyllum 

Medinal — Veronal Sodium 

Methylene Blue — Methylthionine 
Chloride 

Milk of Sulphur — Sulphur Praedpita- 
tum 

Mineral Oil — Petrolatum Liquidum 



^^^^^ 


^j^^^W 


^^^^V DRTTGS.AND PREPARATIONS OF U. S. P. 103 ^^H 


^^^r Monkshood — Aconite 


^H 


^^H MonsePs Solution— Liquor Ferri Sub- 


^^H 


^^H sulpiiatjs 


Saccharin — Benzosulphinidum ^^^^| 


^^H Muriatic Add — llydrochlonc Add 


Salol— Phenyl Salicylate ^^H 


^^^L^ 


Saltpetr<f — Potassium Nitrate ^^^H 


^^^H 


Salvarsan— Arsphenamlne ^^^^| 


^^^^^f 


Sandalwood Oil — Oleum Snntali ^^^| 


^^^^^ Naphthol — Betamiphlhol 


Sddiitz Powder — Pulvis Eflfervescens ^| 


^^^^^^ Novocaine — Bcticiicaiae 


Compositus ^^^H 


^^^v 


Soap Liniment — Linimentum Saponis ^^^^| 


Spanish Flies — Canthans ^^^H 


^H Oil of Betul— Methyl SaHcylate 


Spirit of Turpentine — Oleum Terebin- ^^^^ 


^^M Oil of Cade— Oteum Cadini 


^H Oa of Sweet Birch— Methyl Salicylate 


Squill — Scilla ^^^H 


^^M Oil of Wintergrcen— Methyl Salicylate 
^^^H Orphol — Bismuth Betanaphthol 


Stavesacre— Staphisagria ^^^H 
St>T>ticin — Cotarmne Hydrochloride ^^^| 
Sugar of Lead — Plumbi Acetas ^^^^| 


^H 


Sulphonal — Sulphonmetbane ^^^H 


^^m 


Sulphurated Lime — Caldi Sulphidum ^^^| 


^^^M Paraform — Paraformaldehyde 


Crudum ^^^^t 


^^H Pafcgoric — ^Tinctura Opii Camphoiata 


Suprarenin— Suprarenalin ^^^H 


^^H Phenacaine — Holocaine 


Sweet Oil— Olive Oil ^^H 


^^H Phcnacetin— Acetphenetidinum 


^^H 


^^^H Phenazonc — Antipyrtne 


^^M 


^^H Picric Add — Trinitrophenol 


^^^H 


^H Pine Needle Oil— Okym Pini PumiU- 


Tannin^'Taniiic Add ^^^| 


^^1 


Tartar Emetic— Antimonii et Potassii ^^H 


^^m Pinkroot— Spigelia 


Tartras ^^H 


^^H Plummer's Pills^Pilula! Antimonii 


Tecl Oil— Oleum Sesami ^^H 


^^H Compofiits 


Theinc— Like Ca0eine ^^H 


^^H Pomegiunate — ^Granatum 


Trional^Sulphonethylmethane ^^^H 


^^M Piedpitated Chalk— Caldi Carbonas 


Tull/s Powder— Pulvis MorphioJB ^^H 


^^H Pnedpitatus 


Compositus, U. S. P., iqcx). ^^^| 


^^B Prepared Chalk — Creta Prsepazata 


^^^1 


^^H Procaine — Novocaine 


^ ^m 


^^^^ PyrogaUic Add— Pyrogailol 


s 


^^^^K 


Urethane— Aethylis Carbamaa 


^^^ 


Urotropin — Hexamethylcnamine 


^^H Quebracho — Aspidospcrma 


V 


^^m Qucvcnne'a Iron— Femim Reductum 




^^H Quick Lime— Calx 


Vallet's Mass— Masaa Ferri Carbon- 


^^H 


atis 


^^m 


Veronal— Barbital 


^^M Red Predpitate— Hydrargyri Oxidum 


VeronaUSodium — Barbital-Sodium 


^^m RubruDi 


w 


^^H Reaordo— Resordnol 


w 


^H RocheUe Salt— Potassii et SodH Tar- 


WarbuTg*s Pills^PUulffi AnUperiodicffi, 


^H 


N.F. 



I04 



THE PRINCIPLES OF THERAPEUTICS 



Warburg's Tincture — ^Tinctura Anti- 

periodica, N.F. 
White Arsenic — ^Arseni Triozidum 
White Precipitate — ^Hydrargyrum Am- 

moniatum 
Wild Cherry — ^Prunus Viiginiana 
Witch Hazel — Hamamelis 



Wood Charcoal— Carbo ligni 
Wormseed — Chenopodium 



Yellow Peruvian Bark — Cinchona 
Yellow Wash— Lotio Plava, N.F. 



PART m. 
THERAPEUTIC CLASSIFICATION OF DRUGS 

This classification is based on the use of dmgs to meet thera- 
peutic indications. The order of the classes is arranged on the 
plan of progression from the class that lists the dmgs used for 
external action to the class that lists drugs used for action on 
the most vital parts of the body. Under each class the drugs 
are named in alphabetical order^ as an order of preference is 
impossible, one drug being more therapeutically efficient in one 
condition and another drug more therapeutically efficient in 
another condition. Later under each class is discussed the 
whole subject for which the class stands and briefly the action 
and use of the most important drugs. The drugs later de- 
scribed in detail appear in italics in this classification. 

FIRST DIVISION 
For Local Use 

Class L — Drugs Used to Destroy Microorganisms. 

(a) To disinfect,^ — For huHdings; formaldehyde; steam; sul- 
phur fumes. For clothing: formaldehyde; heat. For dejecta: 
bichloride of mercury solutions; chlorinated lime solutions; 
formaldehyde solutions; heat. 

(b) To inhibit the growth of bacteria upon the body (anti- 
septics, germicides), — Bichloride of mercury solutions; boric 
add solutions; chlorine solutions; cresol solutions; formaldehyde 
solutions; hydrogen dioxide solutions; potassium permanganate 
solutions; phenol solutions; salicylic acid preparations. 

(c) To destroy skin parasites (parasiticides). — Balsam of 
Peru; betanaphthol; chrysarobin preparations; ichthyol; iodine 
preparations; mercury preparations; pyrogallol preparations; 
resordn; sulphur preparations; any of the drugs named under 
'V of this class. 




Io6 THE PRINCIPLES OF THERAPEUTICS 

Class n. — Drugs Used Externally for Action on the 
Skin. 

(a) To allay irritation. — Bland oils (almond oil, cocoa 
butter, olive oil, petroleum oils, wool fat); boroglycerin; gly- 
cerin; dry powders (bismuth preparations, boric add, lyco- 
podiuin, starch, talami, zinc oxide, zinc stearate). 

(b) To cause hyperemia (counterirritation). — ^Alcohol; 
ammonia; capsicimi preparations; tincture of iodine; liniments; 
mustard preparations; turpentine; volatile oils (especially oil 
of wintergreen (natural or artificial, methyl salicylate), oil of 
peppermint, etc.). 

(c) To blister. — Cantharides preparations. 

(d) To destroy tissue (escharotics). — Carbon dioxide snow; 
chromiimi trioxide; glacial acetic add; nitric add; potassium 
hydroxide; salicylic add; silver nitrate; trichloracetic add. 

Class m. — Drugs Used for Action on Mucous Membranes. 

(a) To allay irritation. — ^Barley water; egg albumin; flax- 
seed infusion; milk; starch water; slippery elm infusion; sodium 
chloride (.9 per cent.) solution. 

(b) To inhibit secretion (astringents). — ^Bismuth salts; 
silver (weak) solutions; tannic add. 

(c) To stimulate. — Copper salts; silver salts; zinc salts. 
Class IV. — Drugs Used for Local Action in the Stomach. 

(a) To increase the appetite. — Cinchona, gentian, and nux 
vomica, liquid preparations. 

(b) To aid digestion. — Diastase; hydrochloric add (dilute); 
pancreatin (under certain conditions) ; pepsin. 

(c) To reduce addity (antadds). — ^Ammonia preparations; 
chalk; lime water; magnesia preparations; sodiimi bicarbonate. 

(d) To relieve irritation. — Bismuth preparations; milk of 
magnesia; demulcents. 

(e) To cause vomiting (emetics). — Apomorpkine (acting on 
the vomiting center); copper sulphate; ipecac; mustard; zinc 
sulphate. 

Class V. — Drugs Used for Local Action in the Intestinal 
Canal. 

(a) To increase peristalsis (carminatives). — Asafetida; cap- 
sicum; ginger; peppermint; all spices. 



THERAPEUTIC CLASSFFICATION OF DRUGS 107 

(6) To cause evacuation of the bowels (cathartics), — These 
may be well sub-classed as: 

Laxatives; agar: aloes (aloin); cascara sagrada; Jel bavis; 
licence (compound powder); magnesia; petroleum oil; podo- 
phyllum; rhubarb; piienolphthnlein; senna; sidphur. 

Purgatives: calomel; castor oil; large doses of any laxative. 

Saline purgatives; magnesium citrate; magnesium sulphate; 
potassium and sodium tartrate; SeidUtz powder (compound 
effervescing powder); sodium phosphate; sodium sulphate. 

Irritant purgatives: colocytith; croion oil; elaterium; jalap 

(c) To diminish intestinal putrefaction, — Betanaphthol; lac- 
tie acid bacilli (Bulgarian baciUi) ; salol; sugar of milk; was/, 

{d) To remove parasites (anthelmintics), — Aspidium; be^ 
ianaphihol: cfnetin^; pelletierine iannaie; pumpkin seed; quassia; 
santonin; spigelia, thymol; wormseed oil, 

SECOND DIVISION 
For Systemic Action 

Class i,— Drugs Administered Internally for Their Action on 
the Skin, 

(a) To stimulate the activity of the skin, ^Arsenic; 
thyroid* 

(6) To increase perspiration (diaphoretics), — Alcohol; anti- 
pyrine; pilocarpine, 

{c) To decrease perspiration. — Atropine. 

Class II. — Drugs Used for Their Action on the Genitouri- 
nary System. 

(a) To increase the amount of urine. — Buchu; caffeine; digi- 
talis; scoparius; squill; theobromine sodio-salicylate. 

(J) To render the urine alkaline. — Potassium ciirate; sodium 
bicarbonate; sodium citrate, 

(c) To render the urine acid. — Hydrochloric (dilute) acid; 
acid sodium phosphate, 

(d) To prevent the growth of bacteria in the kidneys and 
bladder. — Hexam^thylettamine; methylene blue; salol. 

(e) To stimulate the mucous inembranes,^-Oj7 of santal. 

if) To increase menstruation (emmenagogues),^ — Corpus 



I08 THE PRINCIPLES OF THERAPEUTICS 

luteum; iron, manganese dioxide (precipitated); ovarian ex- 
tract, thyroid extract. 

(g) To contract the uterus (oxytocics). — Ergot; hydrastinine; 
mammary extract; quinine; pituitary extract. 

Class m. — Drugs Used for Action on the Respiratory 
Tract. 

(a) To increase the secretion of the mucous membranes 
(expectorants). — Ammonium chloride (small doses); ipecac; 
iodides. 

(b) To decrease the secretion of mucous membranes. — 
Ammoniimi chloride (large doses) ; atropine; codeine; morphine; 
terpin hydrate; various balsam and aromatic oil inhalants. 

(c) To relax spasm. — ^Atropine; bromides; chloral; morphine; 
nitroglycerin; stramoniimi; suprarenal preparations (In some 
conditions). 

Class IV. — Drugs Used for Action on the Circulation. 

(a) To accelerate the heart. — Atropine; camphor; caffeine; 
strychnine. 

(b) To depress the heart. — Aconite; coal-tar drugs veratrum 
viride. 

{c) To strengthen the heart. — Caffeine; digitalis; strophan- 
thin; strychnine; pituitary extracts. 

(d) To contract the blood-vessels (vaso-constrictors). — 
Atropine; caffeine; ergot; pituitary extracts; suprarenal 
extracts. 

(e) To dilate the blood-vessels (vaso-dilators). — Alcohol; 
nitrites. 

Class V. — Drugs Used for Action on the Central Nervous 
System. 

(a) To stimulate the brain and spinal cord. — Atropine; 
caffeine; camphor; strychnine; thyroid. 

(ft) To depress the brain and spinal cord. — Acetanilid; anti- 
pyrine; aspirin; bromides; chloral; gelsemium; opium and its 
alkaloids; phenacetin. 

(c) To stop acute pain (analgesics). — Opium and its alkaloids; 
chloroform; ether. 

(d) To cause sleep (hypnotics). — Bromides; chloral; paralde- 
hyde; scopolamine; sulphonal; veronal (barbital). 



THERAPEUTIC CLASStPlCATION OF DRUGS 109 

(e) To cause general anesthesia. — CHoroform; ether; nitrous 
Qxide gas. 

(f) To cause local anesthesia.— Cocaiwe; ethyl chloride; ice; 
menthol; phenol; procaine (novocaine)* 

Class VI. — Drugs Used to Lower the Temperature of the Body 
(antipyretics). — Aceianilid; anlipyrine; cold; pJwnacelin. 
Class \1I. — Drugs and Preparations that are Specific. 

Antidiphtheritic serum in diphtheria. 

Antitetanic serum in tetanus. 

Antimeningococcic serum in meningococcic meningitis. 

Arsphenamine and mercury in syphilis. 

Calcium in tetany. 

Oranges and lemons in scurvy. 

Quinine in malarial fevers. 

Serum in bleeding. 

Thyroid extract in cretinism and myxedema. 
Class VIII. — Drugs Used as Specifics. 

Calchicum in acute gout. 

Salicylic acid in acute rheumatism. 
Class IX. — Drugs Used to Modify Metabolism. 

Arsenic to stimulate metabolism. 

Alkalies to combat hyperacidity. 

Caldum to promote bone nutrition. 

Iodides to modify sclerosis. 

Iron to combat anemia. 

Phenylcinchoninic acid (cinchophen, atophan) to increase 
the excretion of uric add. 

ACTION AND USES OF VALUABLE DRUGS 

Under this section only the most important drugs are briefly 
described. All other drugs named in the classification and 
many not named will be found tersely mentioned and com- 
mented upon in Part II, the section on the United States Phar- 
macopoeial drugs and preparations. 

In describing the important drugs in this section it is aimed to 
give briefly the positive acti\ity of each useful drug; to describe 
its over-action; to suggest the treatment of poisomng from it; to 
recommend its use in certain conditions; and to state how it is 



no THE PRINCIPLES OF THERAPEUTICS ^ 

best administered. Detailed phannacology of, and long essays 
on, these drugs and on those not here described may be found 
in all good textbooks on materia medica and pharmacology. 

FIRST DIVISION 
CLASS I 

Drugs Used to Destroy Micro6rganisms 
disinfection 

The relation to each other of the terms "disinfectants'* and 
''antiseptics" has been much discussed. A disinfectant to be 
such must .be able to kill germs, i.e., be a germicide. An 
antiseptic may prevent germs from growing, and still not be a 
germicide. 

Fumigation is terminal disinfection, f.«., disinfection of 
buildings, rooms, household furnishings, beds, and clothing. 
Fumigation to be efficient must kill all live creatures, including 
rats, mice, flies, mosquitoes, fleas, lice, bed-bugs, and bacteria. 

The value of and the method of using a given disinfectant 
depend on the object for which it is to be used. In other words, 
it is obvious that an efficient disinfectant for a room or for 
clothing may not be a suitable disinfectant for the hands or for 
excreta. 

If disinf ective measures are properly carried out at the bed- 
side of a patient who has a contagious disease, infection of others 
will rarely occur, and the necessity for terminal disinfection be- 
comes more or less unnecessary, depending, of course, upon the 
disease. 

The first object of a physician who is called to care for a con- 
tagious disease is to circumscribe the contagium. Toward this 
end he sends the patient to a contagious disease hospital, if pos- 
sible. If this is not feasible, or the disease does not require that 
sort of isolation, he selects for the patient the most suitable room 
in the house, or tenement, one that is light, airy, remote, and 
as closely associated with a bathroom as possible. He removes 
unnecessary furniture and furnishings, and selects a trained 
nurse, or instructs the mother or some other member of the 
family, as to the care for the patient. He then endeavors to 



DISINFECTION 



III 



confine the germs of contagion to the sick-room by hanging at 
the door a sheet, wet with a chlorinated lime or a phenol solution. 

Present knowledge shows that most contagion is direct,even 
the contagium of smaM-pox not being able to travel more than a 
few feet. However, "direct contagion" can occur at any dis- 
tance, when dothing or other articles have become infected 
by contact with the secretions of the patient, and such con- 
tagium being swallowed, Inhaled, or otherwise absorbed by an 
individual who is not immune may cause infection. It has 
been proved that most contagiums are transmitted by ^*car- 
riers/^ who may harbor disease with immunity and impunity, 
and by * 'missed" cases, patients who have the disease but who 
are so slightly sick that their illness is not recognized. Also 
many diseases are acquired only by infection from an inter- 
mediate host, such as lice, fleas, mosquitoes, etc* 

Some pathologic bacteria die very quickly when exposed to 
the air, and especially when exposed to the sun. The patho- 
genic bacteria that seem to be the shortest lived are the germs of 
influenza, cerebrospinal fever, gonorrhea, and probably the 
germ of anterior poliomyelitis. The contagium of whooping 
cough survives during a short period only, though the disease 
still progresses. Diphtheria bacilli, typhoid bacilli, and tubercle 
badUi may survive in dust or other material for a considerable 
length of time; however, diphtheria and tuberculosis are prob- 
ably rarely thus acquired, but generally by the more direct 
**droplet" method of transmission. 

The germs of typhoid and paratyphoid fevers, of dysentery, 
of cholera, and perhaps other germs that cause diarrhea, are 
not air-borne, but are acquired by the contamination of some 
food or liquid that is taken into the stomach unsterilized. 
Typhus fever has been shown to be caused by the bites of in- 
fected lice, and bubonic plague by the bites of infected fleas. 

Because ordinary colds, tonsillitis and influenza so rapidly 
spread, it was thought they were disseminated by the air, but 
it is now known that they are only spread by contact, although 
the air near the patient may become contaminated by coughing, 
sneezing, laughing, and even by loud talking, unless a handker- 
chief or other protection is used. Some inflammations of the 




112 THE PRINCIPLES OF THERAPEUTICS 

eye, and some contagious diseases of the skin are spread only by 
contact. Measles and scarlet fever are spread by secretions 
from the upper air passages, or perhaps from a suppurating ear, 
but not by the eruptions on the skin. Pneumonia also is acquired 
by dose contact with the secretions of those who are ill with 
pneumonia or are carriers of pneumonia germs. 

One of the aids to direct contact is the fly, which can carry 
in its mouth and on its feet the germs of contagion and deposit 
them on food or liquid, or on handkerchiefs, or in some way 
that direct contact may be caused, or it may deposit germs on 
the lips or face of the individual. In other words, the fly is a 
menace, especially where there is contagion; therefore the sick- 
room must be screened absolutely against flies. 

Infected mosquitoes are the cause of malarial fever and of 
yellow fever. Certain types only of mosquitoes become in- 
fected by biting individuals who have these diesases, but after 
such infection they are ready to transmit it by their bites to 
individuals of the human race. Hence patients with malarial 
fever or with yellow fever must be screened against the possi- 
bility of mosquitoes becoming infected and thus transmitting 
the disease to others. 

As just stated, terminal disinfection is now rarely necessary 
although fumigation may still be done in certain conditions. 
Fumigation of schoolrooms, however, and of school buildings, 
is an unnecessary expense. Spraying the floor and washing the 
region in which a child has been, when he developed an infec- 
tious disease, with antiseptics such as corrosive sublimate solu- 
tions and strong formaldehyde solutions, is the proper course 
to pursue. Books, pencils, etc. should generally be destroyed. 
If a book is valuable, it may be subjected to dry heat or placed 
in a formaldehyde cabinet. 

With the object that the infecting agent must be confined to 
the patient's room and not be allowed to get out of it, and with 
the knowledge that the contagium is carried by some of the ex- 
cretions or secretions of the body, the instructions of the phy- 
sician to the nurse are for her to so dress that she cannot readily 
carry the germs; for her to properly cleanse her hands before 
eating or drinking; and for her to be sure that the patient's eat- 



DISINFECTION 



113 



ing utensils are placed in boiling water or otherwise thoroughly 
cleansed before they are allowed to be taken to other parts 
of the house. All secretions of the nose and throat and all spu- 
tum from coughing should be received on gauze or paper napkins, 
which should be immediately deposited in a paper bag, and the 
bag and contents be later burned. If the disease is one which 
is transmitted by coughing and sprajong, when the nurse is near 
the patient she should wear a rather thick mask protection for 
the nose and mouth. 

For the disinfection of the hands of the nurse, or others in 
attendance, a 1-1,000 solution of bichloride of mercury, or a 2.5 
per cent, solution of phenol, or a 1,5 per cent, solution of chlori- 
nated lime are efficient. WTten adv'isable, especially while the 
nurse is caring for the stools in cholera, dysenter^-^, typhoid 
fever, and paratyphoid fever, it is well for her to wear 
rubber gloves, which she can cleanse and keep in sterile 
solutions* 

The patient's urine should be passed into a receptacle con- 
taining a S P^r cent, chlorinated lime solution, or a 1-500 
mercuric chloride solution. The urine should then be allowed 
to stand, covered, in this vessel for an hour or more before it 
is poured down the closet. The feces should be passed into the 
same solutions, but an equal quantity of a 25 per cent, chlori- 
nated lime mixture should be added after the fecal matters have 
been broken up. The receptacle should then be covered and 
allowed to stand two hours or more before the contents are 
poured down the closet. The patient's buttocks may be 
cleansed w^ith gauze wet with a 1-1,000 bichloride of mercury 
solution or a 2.5 per cent, phenol solution, unless the parts are 
irritated and sore. In this case, saturated solutions of boric 
add may be used. 

The strength of other solutions used to disinfect the excreta 
are: 5 per cent, phenol solutions; 3 per cent, cresol solutions; 
5 per cent, copper sulphate solutions; and 5 per cent, solutions of 
the official Liquor Formaldehydi. 

The clothing of the patient and the bed clothing should be 

placed in a 5 per cent, formaldehyde solution or in a 1-2,000 

bichloride of mercury solution, and should remain in the 





114 THE PRINCIPLES OF THERAPEUTICS 

solution some hours before they are sent to the laundry, where 
they can be subsequently boiled. 

With the understanding that the skin does not carry infec- 
tion in the majority of contagious diseases, although it may be 
contaminated at some part by some secretion which carries 
infection being deposited upon it, general antiseptic baths are 
usually inadvisable until possibly just before the patient is to 
leave the contagious ward or the sick-room. At that time he 
may be bathed in a weak (1-10,000) solution of bichloride of 
mercury, if it seems advisable, afterwards bathed with boric 
acid solutions, and wrapped in an absolutely dean sheet before 
he goes into another room and puts on dean clothing. His 
hair should have been properly shampooed and deansed before 
his bath. It should be remembered that the long tedious 
desquamation of scarlet fever does not carry the contagium of 
that disease. 

The blankets, comfortables, and many equipments of the 
room, rugs, etc., may be steamed or dry heated to sterilization; 
or the whole room may be fumigated with formaldehyde or with 
sulphur. All doors, windows and other openings of the room 
must be sealed before fumigation. Five poimds of sulphur, 
best in so-called candles, for every thousand cubic feet of space 
are suffident. When sulphur is burned, proper care should be 
taken to prevent fire; the burning sulphur should be placed in 
pans on islands surroimded by water, so that spitting of the 
•burning sulphur cannot start a fire. There should also be 
steam from boiling water, ox from a radiator, in the room for 
the best results of sulphur fumigation. Sulphur is the best 
disinfectant when lice, flies, or other insects may be the carry- 
ing source of the contagium. When there are no animal 
carriers of the particular disease, formaldehyde is the better 
fumigator. 

One of the best methods for causing formaldehyde fmnigation 
is to dissolve 75 grams of permanganate of potash in 90 mils of 
hot water; then 30 grams of paraformaldehyde is added. This 
causes continuous liberation of formaldehyde gas until the 
formaldehyde has been exhausted, and this amount is suffident 
for disinfection of a thousand cubic feet. Dixon has suggested 



DISINFECTION 



IIS 



substituting the following for the above, namely: pour together 
a pint of a saturated solution of forinaldehyde gas and one and 
a half ounces of strong sulphuric acid. When this mLxture 
has become cooled the solution is poured over lo ounces of 
sodium dichromate crystals which is spread out in a thin layer 
in a large container. 

No matter how thoroughly the fumigation is done, scrubbing 
and sunlight, if possible, should follow. 

Formaldehyde,^ — Liquor Formaldehydi. — ^Solution of Form- 
aldehyde (Formalin) is best procured in sealed bottles. The 
strength of the oflScial preparation is 37 per cent. Formalde- 
hyde solutions should never be used internally. 

Action, — The local action of a strong formaldehyde solution 
is irritant and painful, and if it is applied to the skin in full 
oflScial strength, it must be quickly washed off or it mW. cause 
blistering. Even if weak solutions, as 2 or 3 per cent., are used 
repeatedly on the skin it will cause irritation, eczema, and per- 
haps dermatitis. It has been considered that i and 2 per cent. 
solutions were actively germicidal if the germs were subjected 
to the action of such solutions for an hour or more, but Hatcher 
and Wilbert state that it requires forty- five minutes for de- 
struction of tubercle bacilli in a 5 per cent, solution* If the 
solution is hot, it acts more rapidly. 

Toxic Action, — If formaldehyde gas is inhaled it is so irritant 
that it may cause swelling of the larynx, edema of the glottis, 
and suffocation. The gas, even in small amounts, will seriously 
irritate the nose, throat, and larynx, and cause reddening of the 
eyes. If a solution of formaldehyde (unless it is very weak) is 
taken into the stomach, it will act as an irritant poison and 
cause the usual symptoms of such a posion. If a very 
weak non-irritant solution is taken into the stomach it mil 
retard digestion. If much of this substance is absorbed into 
the blood it may break up the hemoglobin and cause hemoglo- 
binuria, and if very much is absorbed, nephritis may be caused, 

Trealmeni of Poisoning. — WTien strong solutions are taken 
into the stomach the treatment is that of an irritant poison (see 
page 757). If there are signs of edema of the glottis from in- 
halation of the gas, intubation or tracheotomy must be done. 




Il6 THE PRINCIPLES OF THERAPEUTICS 

Uses. — The use of formaldehyde as a disinfectant has abeady 
been described (see page 114). In a tightly closed room, and 
kept closed for twenty-four hours, sheets wet with 150 mils 
of the official solution of formaldehyde is sufficient for disinfecting 
one thousand cubic feet of space. Hatcher and Wilbert cau- 
tion that for this kind of formaldehyde disinfection to be effi- 
cient and successful, the temperature of the room must not be 
below 60° F. 

Solutions of formaldehyde may be used in full strength to 
destroy a wart, and to destroy such a skin infection as ringworm, 
especially ringworm of the legs. As soon as it begins to cause 
pain and burning, the part should be quickly washed with water, 
else a dermatitis will be caused. Weaker solutions may be 
applied to the skin every two or three days in various parasitic 
diseases. It is sometimes efficient in a 2 per cent, solution 
when applied every night for a short time to disagreeably 
smelling feet and axillae. It tends to inhibit the sweat glands, 
and also destroys the disagreeable odor. Clothing and in- 
struments may be disinfected by formaldehyde fumes, but for- 
maldehyde solutions corrode instruments. 

Ten per cent, solutions of formaldehyde are efficient in dis- 
infecting such excreta as sputum, urine and feces, provided they 
are subjected to these solutions for at least an hour. 

Paraformaldehyde {Paraformaldehydutn) — Paraform occurs 
as a white solid or powder, which on heating liberates form- 
aldehyde gas. It is antiseptic and irritant, and may be used 
as an escharotic to remove warts or other tissue. It should 
not be used internally. 

ANTISEPTICS 

One of the strongest antiseptics is the bichloride of mercury ^ 
and it is germicidal even in a solution of 1-25,000 or even weak- 
er, but the strength of solution most frequently used for 
external antisepsis is from 1-2,000 to 1-1,000. Corrosive subli- 
mate should not be used on instruments, and if used frequently 
on the hands it causes a dermatitis. When it is added to sub- 
stances containing albumin, as the feces, it forms an albuminate 
which interferes with its germicidal efficiency. Tartaric acid 



ANTISEPTICS 



117 



prevents this reaction, and this acid is added to bicUoride anti- 
septic tablets. The number of tablets required to make the 
various strengths of mercuric chloride solutions is indicated on 
the bottles containing them. 

On account of the frequency with which bichloride of mercury 
poisoning has occurred accidentally, the tablets are now colored 
blue or red and labelled ** poison;'* or they are made in triangu- 
lar or diamond shape. Therefore there seems no excuse but the 
grossest kind of carelessness for mistaking these tablets for any 
other kind of tablets* The official tablets termed Toxitabellm 
Eydrargyri Chloridi Carrosin contain about one-half a grain 
each of mercuric chloride and sodium chloride. 

Mercuric Oxycyanide is a strong antiseptic and does not act 
on albumin as much as does mercuric chloride. It may also 
be used to sterilize instruments without corroding them. As 
an external antiseptic it is used in the strength of 1-5,000 to 
1-3,000. 

Schamberg, Kolmer and Raiziss^ have shown that Mercuro- 
phen (sodium oxymercuryorthonitro phenolate) is fifty times as 
active as mercuric chloride against the staphylococcus aureus, 
and it destroyed these bacteria on prolonged exposure in bouillon 
in a dilution of i part to 10 million. It was found to show many 
thousand times greater germicidal power against the typhoid 
bacillus, and to disinfect the hands in i part to 10,000 to i part 
to 40,000 in one minute, as compared with mercuric chloride, 
which required five minutes to disinfect the hands in the 
strength of i part to 5,000, and fifteen minutes in a dilution of i 
part to 10,000. This preparation was found to sterilize rubber 
tubing in thirty minutes in a dilution of i part to 100,000. It 
was found to sterilize the feces in thirty minutes in i part to 
5,000. Nickle-plated instruments after twenty-four hours* 
exposure in i part to 5,000 of this mercurial salt showed no 
tarnishing. 

Macfarlan^ finds that potassium mercuric iodide is a distinct 
chemical entity, is a salt that is delequescent, and upon taking 
up water readily deposits red mercuric iodide. This salt is 

^Journal A. M. A.| May 19, 1917, p* 1458, 
^AiDcr. Joum. Med. ScL, April, 1920, p, 5&6, 




H8 THE PRINCIPLES OF THERAPEUTICS 

most conveniently used in tablet form for antiseptic purposes. 
it is soluble in both water and alcohol. It is much less toxic 
than mercuric chloride, and therefore is safer for germicidal use 
in parts from which it could be absorbed. Macfarlan finds 
that H to I per cent, solutions are slightly irritating to mucous 
membranes, but solutions of such a strength have no irritating 
effect on the skin. Potassium mercuric iodide is a powerful 
germicide even in high dilutions, and he found that it kills 
many organisms after prolonged exposure, even in dilutions of 
I part to 80,000. 

This double iodide has been found efficient as a disinfectant 
for the skin in the strength of i per cent, in 70 per cent, alcohol. 

Phenol solutions are expensive, require for thorough germi- 
cidal purposes to be 5 per cent, in strength, are benumbing to 
the hands, more or less irritant, and are now rarely used. 

Labarraque^s Solution {Liquor SocUb Chlorinated) is effici- 
ently germicidal and is especially valuable in removing bad 
odors. Dakin's solution is a chlorinated lime solution. Both 
it and the Daufresne's modification of it are difficult of prepara- 
tion. Consequently, except in hospital service, a chlorinated 
solution is more readily made with the so-called "Dichloramine- 
T" tablets. The number of tablets to be dissolved in 100 
mils, or in 500 mils (a pint) of water is designated on the bottle; 
the strength of solution for injection is generally i or 2 per cent. 

Chloramine-T (Sodium Paratoluenesulphochloramide) is a 
stable chlorinated soda antiseptic, and is used in i to 2 per cent, 
solutions in the s?.me' manner that Dakin's solution is used. 
Dichloramine-T (Paratoluenesulphodichloramide) is a little 
more irritant than the chloramine-T, but it is more soluble. 
Various chloramine-T and dichloramine-T preparations are on 
the market. 

For disinfection of small quantities of water Dakin found 
most efficient and satisfactory parasulphondichloraminohenzoic 
acid. This substance can be obtained in tablet form ready for 
use under the name of "Halazone." 

The official Liquor Formaldehydij diluted one part to one or 
two thousand, may be used as an antiseptic wash, but even such 
weak solutions are irritant and soon cause irritation of the skin. 



STERILIZATION 



119 



The tincture of iodine painted thoroughly over the skin, 
provided the skin is dry and has not been recently moistened, 
is one of the best germicides that we possess. It seems to 
positively render sterile the region to which it is applied, and it 
is now used to sterilize the skin for surgical incisions. This is 
the age of using too much iodine, especially in the mouth, and 
the laity with a little knowledge of first aid to the injured 
use iodine too frequently. Many times it injures the tissues 
and prevents healing. 

Peroxide of hydrogen solutions in full strength or diluted 
depending entirely upon the part to be treated, are efficient 
antiseptics, but they should never be used in cav'ities or sinuses 
where there is any possibility of the bubbles of gas causing 
dissection or tearing of the tissues. 

The oflScial Cresol is a mixture of cresols, and is a valuable 
antiseptic in 3 to 5 per cent, solutions. Iodoform is not 
an antiseptic and never should be considered such, although it 
may at times prevent germs from growing* 

Churchman/ after repeatedly urging the antiseptic value of 
genlian violet since 1912, again states that, even in high dilutions, 
this drug has great antiseptic value in long continued suppura- 
tions in old wounds, and, where the bacillus diphtheria w*as the 
infection, gentian vnolet properly applied killed the infection 
and caused healing. He also* shows its effective antiseptic 
action, combined with lavage, in purulent arthritis, 

STERILIZATION 

Not to enter into the discussion of sterilization of instru- 
ments and dressings, it should be emphasized that intense dry 
heat, boiling water, and steam, applied for one-half hour or 
more, are the most efficient sterilizing means knowTi, and make 
possible our present day aseptic surgery. 

PhenoL — Carbolic Acid, — Phenol crystals are used only for 
escharotic purposes. The official preparations of phenol are 
Glyceriium Phenolis SindP/ienol Liquef actum which occurs either 
as a colorless or slightly reddish liquid and should contain not 

« JouinAi A. M. A., Jan. 17, 1920, p. 145. 
» Journal A. M. A., Aug. 28, 1920, p. 583. 




I20 THE PRINCIPLES OF THERAPEUTICS 

less than 87 per cent, of phenol. The official Unguenlum Phe- 
nolis contains 2>i per cent, of liquefied phenol. Phenol, carbol- 
ic acid, is obtained from coal-tar by fractional distillation, but 
it may also be made synthetically. Neither phenol nor any 
of its preparations should be used internally. 

Action, — When liquefied phenol is used in full strength, or 
nearly full strength, it blanches the skin and mucous membranes, 
causes a sharp, burning pain, soon followed by dulling of sensa- 
tion. In other words, it causes localized anesthesia. It may 
or may not blister with one application, but the part to which 
it is applied turns white, and if the application is longer than 
momentary, the part becomes necrotic, and continued appli- 
cations of even weak solutions will cause gangrene. Hence it 
is inexcusable to keep a part wet with phenol solutions. 

Except in weak solutions it is irritant to the skin and mucous 
membranes. In 10 per cent, solutions, applied to a part for a 
short period, it causes considerable anesthesia, and incision 
may be made through the skin in this region without pain; but 
other methods of producing local anesthesia for operative pur- 
poses are better. Frequent applications of even weak solutions 
to the skin will cause eczema, and perhaps dermatitis. On the 
other hand, solutions as weak as 2 per cent, may soothe an 
irritated and inflamed region, but if the surface is denuded of 
skin, dangerous absorption may occur. Other preparations 
for soothing the skin and stopping itching are better. 

Toxic Action. — When this drug is absorbed in a small amount, 
it is irritant to the central nervous system, causing headaches, 
irritability, restlessness, and muscle twitchings. The digestion 
is slowed, and vomiting and purging may occur. The urine 
becomes dark, if much of the drug has been absorbed; there is 
irritability of the bladder, urination becomes more frequent, 
and albumin may appear in the urine. Soon, if more phenol 
has been absorbed, the circulation and respiration are depressed. 

If a considerable amount has been rapidly absorbed the 
symptoms are those of collapse and drowsiness. The pulse be- 
comes weak and thready, the face pale, the skin covered with 
clammy perspiration, and muscular twitchings occur. If the 
patient long survives the poisoning, there may be suppression of 



STERILIZATION 



Jtt 



urine. If a very large dose has been taken and there has been 
rapid absorption, coma sometimes occurs within a few minutes, 
and death soon follows. When death is not immediate, there 
may be convulsionSj or at least muscular twitchings, generally 
nausea and vomiting, lowered temperature, and weak heart 
action. If the preparation was strong, there is erosion of the 
esophagus, and perhaps of the stomach, if enough of the fluid 
was taken to reach the stomach. 

The brown or black urine is caused by the formation of 
hydroquinone and pyrocatechin. When this urine is first 
passed it may not be very darkj owing to incomplete oxidation, 
but when it is exposed to the atmosphere for a time oxidation 
becomes more complete, and the urine becomes dark brov^-n or 
black. Albuminuria is often present, and acute nephritis may 
occur. 

When small amounts of phenol are frequently absorbed, or 
coal-tar products are long taken, chronic poisoning occurs, evi- 
denced by anemia and cardiac depression. 

Treatment of Paisoning. — Whether or not the stomach tube 
should be passed depends upon the amount of the poison that 
has been taken. When much concentrated phenol has been 
swallowed, as in any other irritant poisoning, a stomach tube 
should not be used on account of the injury that would 
be caused. 

The treatment of phenol poisoning is not very satisfactory. 
The best method seems to be, as recommended by Hatcher, 
to immediately give raw white of egg in considerable amount, 
diluted sufficiently for swallowing. Then if the stomach tube 
can be passed, the stomach should be washed out immediately 
with water containing lo per cenL of alcohol. If the stomach 
tube cannot be passed, and the patient can swallow, this alco- 
holic water should be given him as a drink. Magnesium sul- 
phate and sodium sulphate have both been recommended, as 
tending, when given in solution, to form harmless phenosul- 
phonates, but their usefulness is doubtful 

Emetics are not indicated and would do harm, as the cardiac 
prostration is serious. Oils should not be given, as they may 
promote more absorption. 



122 THE PRINCIPLES OF THERAPEUTICS 

Later, if the patient survives, all the soothing applications 
that are recommended imder irritant poisoning should be 
utilized. Cardiac failure should be treated as usual, and 
adrenalin and pituitary vasopressor solutions, injected hypoder- 
matically , are perhaps most indicated. Atropine is also valuable. 
The patient should be surrounded by hot water bags, on account 
of the lowered temperature. 

Uses. — ^As above stated, there is no good reason to use phenol, 
as such, internally. Externally it may be used as an antiseptic 
and as a parasiticide. It is occasionally valuable as a local 
anesthetic and as an escharotic, and it is used not infrequently 
to abort boils and carbuncles. Two or three drops of Phenol 
Liquefactum injected into the base of a furuncle or boil will 
often abort it. 

Its use as an antiseptic has already been discussed under the 
general heading of "Antiseptics." While bacterial growth is 
inhibited by a i per cent, solution, it requires stronger solutions 
and some length of time of emersion to destroy all bacteria. 
In other words, most infective germs are probably destroyed 
by emersion for an hour in a 5 per cent, solution. 

As a parasiticide, in strong solutions, it is efficient, but 
the surface to which it is applied should be small, as dangerous 
absorption may occur. 

Preparations containing phenol, so-called coal-tar prepara- 
tions, should not be used when there is cardiac weakness, 
insufficiency of the kidneys, or cerebral irritation. 

Cresol. — The official preparation is a mixture of cresols. It is 
less poisonous than phenol, although its action is similar. It 
is about four times as active a germicide as is phenol, and is 
efficient in solutions of i per cent. The official preparation. 
Liquor Cresolis Compositus, is efficient as a wash for wounds, 
or for douches, in the strength of i to 5 per cent, solution in 
water. 

Hydrogen Dioxide. — Liquor Hydrogenii Dioxidi, — Solution 
of hydrogen dioxide contains 3 per cent, of hydrogen dioxide. 
This preparation rapidly deteriorates on exposure to light 
and heat, and from opening the bottle or container, the 
liquid becoming more or less irritant. Consequently, it is 



STERILIZATION 



X33 



generally best to order an original small bottle, to be diluted, 
just before using, to such strength as desired. Solution of 
peroxide of hydrogen is not much used internally, although it 
has been recommended in certain conditions of the stomach for 
its antiseptic properties, to prevent hyperacidity, and some- 
times to stop oozing of blood from the esophagus or stomach* 

The chief uses for this preparation are in certain conditions in 
the mouth and throat, and externally. 

Actian^ — The solution of hydrogen dioxide should be colorless 
and odorless; it generally has a slightly acid taste, and causes 
frothing of mucus, blood, and pus. This solution is destructive 
to microorganisms and spores, and in sufficient amount will 
purify drinking water. It tends to coagulate albumins, and 
hence has a slight hemostatic power on bleeding surfaces. Its 
antiseptic action is rapid; as soon as it has lost its extra atom of 
oxygen its action ceases. 

It is more or less irritant to both mucous membranes and raw 
surfaces, hence within a few minutes after the peroxide solution 
has been used, the part should be washed with plain warm water 
or with some alkaline water. On account of its irritant effect it 
should not be used on acutely inflamed mucous membranes or 
on raw surfaces except when its antiseptic action is desired. 
It should never be injected into a closed cavity or into a sinus, 
as the gas produced causes dissection of tissue and pre- 
vents healing. It should not be used as a disinfectant for 
instruments. 

WTien taken into the stomach it has no action except to give 
up its oxygen. If the solution is strong, it may cause distress 
and nausea, but it cannot cause poisoning. 

Uses. — Although there may be occasions, especially in 
gastric cancer, when peroxide of hydrogen solutions may be 
administered internally, there is no good reason for using 
this preparation in any way except externally. 

As an antiseptic mouth wash, in diphtheria, scarlet fever, 
follicular tonsillitis, and other mouth infections, it is one of 
the most valuable of preparations. It may be used in full 
strength as a spray on localized regions, but it is better used as 
a mouth wash or gargle diluted one to three, four, or five parts 





124 THE PRINCIPLES OF THERAPEUTICS 

of warm water, depending upon the age of the patient and the 
purpose for which it is used. In follicular tonsillitis, in diph- 
theria, and in the tonsillar inflammation of scarlet fever it 
should be used as a swash {i.e., not to vibrate the soft palate too 
frequently or too long) every one and a half to three hours, 
depending upon the severity of the condition, generally, every 
two hours during the daytime and every three or four hours 
during the night. Such gargling or washing should be followed 
within two or three minutes with such an alkaline wash as J^ of 
a teaspoonful of salt and yi of a teaspoonful of bicarbonate of 
sodium in J^ a glass of warm water, or by a saturated solution 
of boric acid, or by any of the simple alkaline mouth washes. 
As above stated, the object of this second sedative wash is to 
dear the membrane of froth and of the acid irritation which the 
peroxide of hydrogen causes. 

Peroxide of hydrogen solutions should not be used as a gargle 
every time the throat feels irritated, as it tends to continue such 
irritation. In purulent conditions of the gums it may be used 
for a time until surgical cleanliness has been accomplished, but 
it should not be used in the pockets dipping down to the roots 
of teeth, as it tends to dissect the tissues. Other antiseptic 
washes for these conditions, especially saturated boric acid 
solutions, are better. 

Sprays and douches with peroxide of hydrogen solutions in 
the nose are of questionable value. They are likely to do as 
much harm as good. 

It is a valuable germicidal wash in various conditions of the 
skin, although other preparations are generally better. It may 
be used to disinfect fresh wounds, but the tincture of iodine is 
the more popular remedy, although perhaps not more efficient. 
It should not be frequently used on ulcers or ulcerated surfaces, 
as it tends to prevent healing. 

It has been used to wash out the bladder, urethra, and vagina, 
but other solutions are better for these purposes. It has also 
been injected into the rectum and into the descending colon in 
parastic or ulcerated conditions, sometimes with considerable 
apparent success. Wherever it is used as an injection it must 
be followed by other soothing injections. 



EXTERNAL ACTION ON SKIN 12$ 

PARASITICIDES 

To show how large a choice of these preparations the United 
States Pharmacopoeia offers, besides the stronger antiseptics 
and escharoticSy the following list is given in their alphabetical 
order: 

Balsamum Peruvianum 

Betanaphthol 

Glyceritmn Phenolis 

Hydrargyrum preparations 

Linimentum Saponis Mollis 

Phenol Liquefactum 

Pyrogallol 

Sulphur 

Tinctura lodi 

Resordnol 

Trinitrophenol (Picric Acid) 

Unguentum Chrysarobini 

Unguentum Picis Liquidae 

Unguentum Sulphuris 

With this list of preparations that may be used as para- 
siticides it would seem entirely unnecessary to resort to 
proprietaries. 

CLASS n 

Drugs Used Externally for Action on the Skin 

Before local treatment of an abnormal condition of the skin 
is instituted, the cause should be sought, which may be a drug, 
a food, or some protein poison (see list of drugs that cause erup- 
tions, page 43; and see article on protein poisoning, page 553). 
Or the cause may be some disturbance of metabolism, typically 
of the digestion of proteins. Hence the primary treatment of 
irritations of the skin is to limit the intake of drugs and foods; 
purge with salines, castor oil, or calomel; give large amounts of 
water; and often administer alkalies. The secondary treat- 
ment should be directed toward the skin. 

If local or external irritants have caused the inflammation 



126 THE PRINCIPLES OF THERAPEUTICS 

of the skin, the local treatment is primary; but a modification of 
the diet and free bowel movements, even in such a condition, 
are valuable secondary treatments. 

When the skin is acutely inflamed, it should not be bathed 
with water, but should be cleansed with some bland, thin oil, as 
almond oil. All skin irritations are made worse by cold water, 
but are soothed by warm water, especially if to the warm water 
is added sodium bicarbonate, boric acid, or borate of soda. 
Water is made irritating and stimulating by the addition of sea 
salt. 

The amount of surface to be treated by external applications 
must always be considered, for a large area would permit ab- 
sorption of an absorbable drug to an extent which a small area . 
could not. The situation of the lesion must also be taken into 
consideration, for this not infrequently decides whether (if the 
cause be inherent to the skin itself) we shall use a strongly acting 
preparation for a short time, or a milder one for a long time. 

DUSTING POWDERS 

Dusting or protective powders are used to meet the following 
conditions: 

1. Erythema ta in general, and particularly in erythema 
intertrigo (chafing) and erythema solare (sunburn). 

2. Hyperidrosis and bromidrosis (excessive and foul smelling 
perspiration). 

3. Herpes. 

4. Miliaria. 

5. In certain forms of eczema which are acute and free from 
discharge. 

The oflScial powders that prevent irritation of the skin, soothe 
irritated surfaces, and prevent excessive secretion of the skin 
are: 

Acidum Boricum (boracic add) 
Acidum Tannicum 
Alumini Hydroxidimi 

(Alumnol, not oflSdal) 
Amylum (corn starch) 



DUSTING POWDERS I27 

Bismuth preparations 

Calcii Carbonas Praedpitatus (precipitated chalk) 

Creta Pra^parata (prepared chalk) 

Iodine preparations 

Lycopodium 

Magnesii Oxidum (magnesia) 

Sodii Boras (borax) 

Zinc preparations 

Starchj fuller's earth and kaolin are good simple dusting 
powders. 

Bismuth Preparations, — The best preparation of bismuth for 
external use is the subgalate (derma tol). This is a yellow 
insoluble powder, which is more astringent than the other bis- 
muth salts. Bismuth subnitrate should not be used on moist 
external surfaces, especially not on blistered surfaces, as bismuth 
poisoning can occur from such applications. It is less likely to 
occur when the subcarbonate is used. 

Boric Acid, — Boric acid is not as drying as other powders, 
adheres to surfaces, and is mildly antiseptic. On moist sur- 
faces it tends to promote rather than diminish secretions. 
Borax acts similarly to boric acid. Both preparations are very 
valuable, in saturated solutions ^ as mild antiseptic washes for 
any mucous membrane, and they tend to promote healing of all 
ulcerated surfaces and to promote the healing of wounds. 
Most talcum powders have boric acid as a base. 

When boric acid or borax is taken internally poisoning may 
occur. There is no excuse or justification, or any good indica- 
tion for administering internally either boric acid or its sodium 
salt. 

Iodine Preparations. — Iodine powders are more or less germi- 
cidal and more or less protective. Large numbers of proprie- 
tary preparations are offered, and the official Thymolis lodidum 
when well made, is a valuable drying, mildly antiseptic powder 
and often is an aid in the healing of wounds. This preparation 
contains 43 per cent, of iodine. 

Iodoform, — Iodoform is a bad smelling, yellow powder, mildly 
antiseptic but not germicidal. There is no excuse for using 



128 THE PRINCIPLES OF THERAPEUTICS 

this drug internally, and it is absolutely unjustifible to use it 
externally on account of its obnoxious odor. It may be used in 
emulsion in oil as an injection into a tuberculous joint or tendon. 

Lycopodium, — This light, yellow, odorless powder is soothing, 
and is much used as a dusting powder on excoriated surfaces. 

Zinc Preparations. — The most used are the precipitated car- 
bonate, the oxide, and the stearate. The impure zinc carbonate 
is termed calamine. The precipitated carbonate and the oxide 
are excellent protective dusting powders. The zinc oxide is 
slightly astringent, and is most frequently used as the oxide of 
zinc ointment. The stearate of zinc has a soapy feel, is more 
adherent to the skin, and, therefore, gives protection against 
watery secretions or excretions passing over the part. 

AlumnoL — Aluminum betanaphtholsulphonate is a white 
powder, soluble in water. It is astringent and an antiseptic 
even in i per cent, solutions. When used as a powder it is 
generally diluted with some bland substance, as starch or 
chalk. 

Fuller^ s Earth. — Hess^ has shown that there is a distinct 
difference between kaolin and fuller's earth, kaolin having a 
greater amoimt of hydrous aluminum silicate, and fuller's earth 
having considerable more calcium. Fuller's earth has greater 
drying properties than kaolin, and therefore is efficient as a dry- 
ing powder for external use, and also has been found of value for 
internal use in intestinal disturbances of children. Hess recom- 
mends for diarrhea of infants the administration of a teaspoonful 
of the powder, either in milk or in some other food, every hour or 
two. Sometimes to facilitate administration he adds a very 
small dose of saccharin. He thinks the powder of more value 
in inhibiting diarrhea than bismuth or chalk mixture. The 
powder may also absorb bacteria. Fuller's earth may be found 
more valuable than kaolin for insufflation in the throat in 
diphtheria carriers. 

EMOLLIENTS 

Emollients are bland oily or fatty substances which, though 
generally devoid of medicinal properties, are more or less 
mechanically sedative when applied to the skin. The method 

^Journal A. M. A., Jan. 8, 1916, p. 106. 



EMOLLIENTS 



129 



of application varies with the conditions for which they are used. 
The indications for the use of emollients are: 

1. To aid massage. 

2. To soften a dr)^ skin. 

5. To soothe chafed or excoriated surfaces. 

4. To protect the skin from irritating discharges. 

5. To soothe and protect burned areas. 

6. To soothe in acute eczema and dermatitis. 



The large number of oily substances offered as soothing appli- 
cations to the skin are entirely unnecessary; a few well selected 
preparations are sufficient* Organic (animal and vegetable) 
fat substances will become rancid and harbor microorganisms 
unless they contain a sufficient amount of an antiseptic. The 
mineral oils do not become rancid, and although not germicidal 
do not promote the growth of bacteria* Which kind of fat is 
best for a given condition or for an individual skin must be 
decided by the physician, namely : whether a mineral, vegetable, 
or animal fat shall be used. It does not seem logical to com- 
bine mineral and organic fats in the same ointment or 
preparation. 

The Pharmacopoeia prepares cerates and ointments. The 
former are harder preparations with a melting point higher than 
the temperature of the body, while the ointments are softer and 
generally melt at the temperature of the body. 

Some of the various fatty soothing preparations of the Phar- 
macopoeia are: 

Adeps Benzoinatus (benzoinated lard) 

Adcps Lanse Hydrosus (lanolin) 

Oleum Gossypii Seminis (cottonseed oil) 

Oleum Lini (linseed oil) 

Oleum Olivae (sweet oO) 

Oleum Theobromatis (cacao butter) 

Petrolatum (vaseline) 

Petrolatum Album (white vaseline) 

Petrolatum Liquidum 

Unguentum Acidi Borid 




I30 THE PRINCIPLES OF THERAPEUTICS 

Unguentum Addi Tannid 
Unguentum Aquae Rosae (cold cream) 
Unguentum Belladonnae 
Unguentimi Zind Oxidi 

Some of the Pharmacopceial liquid preparations that are 
soothing to the skin are: 

Aqua Hamamelidis (extract of witch hazd) 

Glycerinum 

Glyceritum Addi Tannid 

Glyceritum Boroglycerini 

Linimentum Calds (carron oil) 

Liquor Ferri Subsulphatis is sometimes used as a strong 
astringent on external surfaces. 

Liquor Plumbi Subacetatis, diluted to 5 per cent, in water, 
may be used as a sedative on the skin when absorption cannot 
take place. 

Simple collodion and flexible collodion will protect apart, but 
it should be emphasized that broken skin lesions should never 
be sealed with collodion or in any other manner, even if surgi- 
cally clean, as such sealing prevents normal respiration of the 
skin, sweats and softens the tissues, delays healing, and promotes 
infection. 

Picric Acid (Trinitrophenol) is used in saturated solution in 
water, or in ointments, as a dressing for burns. 

Ichthyol is used as a mild stimulant in certain conditions of the 
skin. 

IchthyoL — Ichthyol is a thick brown oily liquid obtained by 
the distillation of bituminous shales which contain fossil fish. 
The name "ichthyol" signifies fish oil. Ichthyol occurs 
mostly as ammonium ichthyo-sulphonate, which has a 
distinct fishy odor and taste. A sodiimi compoimd, sodiimi 
ichthyo-sulphonate, is more solid than the anmionium prepara- 
tion and has been more used in the preparation of pills or 
capsules for internal administration. Both preparations con- 
tain about 10 per cent, of sulphur, 

Ichthyol, in various forms, has been reconmiended for 



EMOLLIENTS 



131 



internal administration as a bowel antiseptic, and as such has 
been much used in disturbances supposed to be caused by 
intestinal fermentation and putrefaction. For this reason it 
has been recommended and used in acne. It is doubtful if 
for this condition it is of any more benefit than other sulphur 
preparations, combined with a proper arrangement of the diet, 
Ichthyol has also been recommended for internal use in tuber- 
culosis. Any advantage that it might have in this disease 
is probably due to the action of the sulphur on the bowels and, 
after its absorption, on the skin and possibly by such 
exhalations of sulphur as may occur through the lungs, /*e., 
the action is probably nothing but that of sulphur. 

When ichthyol is administered internally generally the 
sodium salt is preferred, and the dose is from 0.25 to 0.50 Gm 
(4 to 7V2 grains), in capsule, three times a day, after meals. 
When used for tuberculosis ichthyol has been diluted with 
water, and the dose has gradually been increased up to the 
point of causing indigestion. 

Externally ichthyol is used as an ointment, or in combination 
with an oil or glycerin, and the strength of the preparations 
vary from 10 to 50 per cent. 

Wlien ichthyol is applied undiluted to the skin it is an irntant, 
When it is combined with an oil, or a fat, it can be rubbed into 
the skin, and some of the sulphur may be absorbed. It may 
have a mOd antiseptic action. 

Though ichthyol is not as much used as it was some few years 
ago, it is stiU considered a valuable application in erysipelas, 
for sprains and swollen joints, for frost bites, chilblains, and 
for burns. It is well used in 25 per cent, ointment, or solution 
in either water or oil. In subacute swellings of the lymphatic 
glands applications of ichthyol ointment, 10 to 20 per cent*, 
or in the same strength in glycerin or oU, have seemed to hasten 
the reduction of the swelling. This preparation has also been 
used in many skin diseases, especially in acute and chronic 
eczema. It has been used as suppositories for hemorrhoids and 
fissures of the anus, and has been much used as suppositories, 
or applications on tampons, in the vagina for chronic conditions 
of the pelvis and neck of the womb. 




132 THE PRINCIPLES OF THERAPEUTICS 

IcfUhalbiny N.N.R^ — Ichthyol albiuninate is a compound of 
ichthyosulphonic acid and albumin. This solid preparation is 
used in place of ichthyol for internal purp>oseSy and is less likely 
to disturb the stomach than the latter. The dose is 0.30 Gm. 
(5 grains). 

Inunctions. — By inimction is imderstood rubbing into and 
through the skin some drug that is dissolved or contained in an 
oil or fat. Systemic eflFects may be produced by such a method 
of administration with a few drugs only, notably mercury and 
belladonna. The parts of the body best adapted for this 
method of administration are where the skin is soft and flexible, 
as the inner surfaces of the thighs and the inner surfaces of the 
arms. This method is rarely utilized except for the adminis- 
tration of mercury in syphilis. 

Antiseptic Ointments. — For local stimulation of a chronically 
diseased portion of the skin, the following Pharmacopoeial 
preparations may be used: 

Balsamum Peruvianimi 
Oleum Cadinum 
Pyrogallol 

Unguentum Chrysarobini 
Unguentum lodi 
Unguentum Pids Liquidae 

One of the most important non-offidal preparations for 
stimulation of a chronic ulceration is Scarlet Red, (N.N.R.,) as 
it is termed. This preparation is a compound of betanaphthol 
and toluol, and occurs as a red ointment, which promotes the 
healing of ulcers, wounds, and burns. 

COUNTERIRRITATION 

Coimterirritation means to so irritate a part of the surface 
of the body as to cause reflexly a modification of a condition in 
another part of the body, generally at some distance from the 
part irritated. The term is often used to indicate local irrita- 
tion for local results. 

^ New and Nonoffidal Remedies, a book of drugs issued by the American 
Medical Association. 



COUNTERIILRITATION 



233 



Various ointments may be used for local stimulation or for 
their reflex or irritant action. Some are used only to increase 
the value of massage. The least irritant of the liniments is 
Linimenium Camphar{B (camphorated oil). Linimenium Sapo- 
nis Mollis {soft soap) is used for cleansing purposes and for 
shampooing; it is strongly alkaline. 

The oflScial stimulating liniments ares 

Linimentum Ammoniae 
Linimentum Camphorae 
Linimentum Chloroformi 
Linimentum Saponis 
Linimentum Terebinthinae (a cerate) 
Menthol (in solutions) 

Methylis Salicylas (synthetic oil of wintergreen) 
Oleum Terebinthinse Rectificatum (used as an addition 
to liniments). 

If the irritation from liniments goes a step farther, blistering 
may be caused, and if still farther, destruction of tissue occurs. 
Blistering for a reflex effect on some other part of the body is 
often practised. Destruction of tissue (causing a slough) to 
cause reflex action on some distant part is now rarely or never 
caused. For local effect, or at least for effect on tiie tissues 
closely associated with the part treated, the stimulating (rube- 
facient) liniments are frequentiy used. At the present time the 
benefits caused by counterirritation are probably not suffi- 
ciently utOized* 

Two effects arc combined when a liniment is properly used: 
first, the massage, and second, the local irritation and hyperemia 
of the skin that is caused. The massage improves the circula- 
tion and nutrition of the part, and often is the factor of greatest 
advantage in the use of liniments; but the hyperemia of the 
skin may change for the better the circulation of the parts imme- 
diately beneath the skin or the parts closely associated with the 
part treated. Chloroform and menthol preparations may cause 
the part treated to feel cool, imless the skin is quickly covered 
and evaporation prevented after they are used. 

Blistering with liniments is inadvisable, as the blisters do 




134 THE PRINCIPLES OF THERAPEUTICS 

not readfly heal, and the process is more painful than when the 
Spanish fly blister is used. 

The value of dry heai applied to a part, whether by hot water, 
sand, salt, or bran bags, or by various hand stoves or electric 
pads, is very great, and many a surface nerve pain, or more 
deeply seated inflammation, is helped by such treatment. 
Moist applications of heat by hot water or hot water and alcohol 
are also valuable in certain conditions. The old-fashioned 
poultice is now rarely used, but may have its place. A sub- 
stitute is hot water and alcohol. — a towel wet with one part of 
alcohol and three or four parts of hot water, then ahot water bag 
placed over it, and the combination applied closely to the body. 

Mustard is a very efficient coimterirritant. It may be applied 
as a mustard paper, which is moistened and applied directly 
to the skin or with a thin piece of gauze between it and the skin. 
Or a mustard plaster may be made with equal parts of mustard 
and flour (or perhaps better with flaxseed meal instead of flour) 
which is efficient. This mixture of mustard and flour, or flax- 
seed meal, should be stirred to a paste with warm (not hot) 
water, then the paste is spread on a piece of doth and 
applied to the skin; or it may be placed in a cheesecloth bag. 
This paste should be left on the skin from fifteen to thirty 
minutes, but not long enough to blister. For a thin-skinned 
individual and for a child the proportional strength of the mus- 
tard to the flour should be greatly diminished. Some stiff 
backgroimd for this improvised poultice, as a piece of stiff 
paper, facilitates the handling of the plaster. It should be 
emphasized that blistering from mustard is inadvisable and 
should be avoided if possible, as the blister is painful and hard 
to heal as compared with blisters causes by cantharides. 

A plaster that will not blister, but at the same time will have 
some of the stimulating effects of mustard, hence best for a 
child, is made of spice, and may be compounded with equal parts 
of groimd cloves, cinnamon, allspice, and a small portion of 
black pepper. This mixture having been stirred up with warm 
water is spread on a doth, then the side to be applied to the 
body should be wet with hot water. If the child is young and the 
skin is very tender, the pepper should be omitted from the plaster. 



COUNTERIRRITATION 



^35 



A turpentine stupe is prepared by wringing out a piece of 
flanDcl from hot water, folding it several times, and sprinkling 
over it about half a teaspoonfiil of turpentine. This stupe 
should be applied closely to the part to be treated, generally the 
abdomen. 

AU hot water fomefttaiions and fomentations with alcohol and 
with turpentine should be applied as hot as can be borne, and 
be changed frequently, until the skin is well reddened. Then 
they should be removed and a dry, hot flannel should be applied. 
Blistering should not be allowed. If a blister inadvertently 
occurs from any of these treatments it should be treated like 
an ordinary burn, 

A milder treatment to cause reddening of the skin is furnished 
by capsicum aintnwntSy which should be rubbed on the surface 
until slight irritation is caused. Various menthol preparations 
are also used. A menthol stick rubbed over the forehead, if 
there is headache, or over the region of some painful nerve is 
often beneficiaL 

Iodine as an irritant to the skin is used too frequently. This 
is the iodine age. While all wounds with any possibility of 
infection may be treated with iodine, it should be remembered 
that it does not promote healing, and that frequent applications 
of it to a part that is trying to heal is a mistake. The skin over 
swollen glands, or the skin around a joint, may be painted, 
daily, with the tincture of iodine, if it is deemed advisable. Its 
use should be stopped before the skin becomes thick and leath- 
ery, and it should never be used to the point of causing a blister. 
Various iodine ointments may be used, and iodine may be 
rubbed through the skin and be absorbed. 

If a blister is desired, it is best produced by a plaster of can* 
tharides, which can be obtained at any drug store in the size 
desired. The skin to which the plaster is to be applied should 
be cleansed, and, if the part is hairy, it should be shaved. The 
active plasters that can now be obtained should not be kept on 
more than three or four hours; they should then be removed 
and a portion of the cerate from which the plaster is made will 
remain on the skin and cause blistering after some length of 
time, anywhere from five to six hours. li the object of the 




136 THE PRINCIPLES OF THERAPEUTICS 

blister is to remove considerable serum from the body, the blis- 
ter must be of fair size; if it is used for counterirritant 
action only, the blister may be small, or a series of small blisters 
a short distance apart may be applied. It is often well to drain 
oflF the fluid from the blister by a puncture at the lowest, de- 
pendent part, letting the fluid slowly exude. This allows the 
pellicle of skin to cover the raw surface and tends to promote 
healing. The cuticle should not be broken, if it is possible to 
prevent it, and it may be protected by linen, or thin cotton, well 
saturated with a sterile, thin oil, which should be removed before 
it becomes dry and adherent to the loose skin. If the skin is 
broken, the part is then treated as any other bum. Blisters 
should not be caused on yoimg children, on old people, on any 
part where the nutrition and circulation is unpaired, or on a 
paralyzed part. 

The blister is not now used as much for counterirritation as 
is the cautery, and the most used cauteries are the Paquelin or 
the electrocautery. The Paquelin is an apparatus which by 
burning benzine vapor causes a red or white heat of the terminal 
points, which may be of several different shapes. The white 
heat causes less pain than the red heat, but the red heat is better 
if a part is to be destroyed or cauterized, as it is less likely to 
allow hemorrhage. Light strokes of this cautery, or of the 
electrocautery, along the course of a nerve or around a painful 
joint is often of great benefit in neuritis and in inflammation of 
joints. 

Counterirritant treatment is based on the distribution of 
nerve filaments from different segments in the spinal cord, the 
different organs having reflex spots, or regions, on the 
surface of the body. When these organs are in trouble these 
particular external regions are generally painful and at times 
sore. Knowing the region that is a surface depot of information 
of the condition of a deeply seated organ gives the clue as to 
where the counterirritant should be applied to obtain a deep 
seated benefit. In other words, the circulation and nervous 
energy of an organ cannot be changed directly by what is done 
on a small part of the surface of the body, but both may be 
modified indirectly when the surface nerves transmit the irrita- 



COUNTERIRRITATION 



137 



tion to its particular segment of the spinal cord, and reflexly 
that segment of the cord sends nervous stimuli to the organ in 
trouble. 

Many of our counterirritant eflfects need not have this ex- 
planation, if the part so treated is directly over or at the region 
of trouble; the local hyperemia and the nervous irritation caused 
may directly affect the part underneath, but typically through 
these spinal segments come the referred pains from these inter- 
nal organs, and sometimes counterirritation applied at these 
points acts reflexly to advantage. 

A blister should not be placed directly over an inflamed region, 
if that region is near the surface. In other words, a blister, 
in pericarditis should be placed at one side of the peri- 
cardium; in a pleurisy a short distance away from the region of 
acute pain and with a painful joint generally above or below 
that joint. 

It is common knowledge that vomiting may be stopped by a 
mustard plaster, or other irritant, placed over the epigastric 
region; that headaches, and even meningitis, may be beneficially 
affected by stimulant applications to the back of the neck; and 
that the kidneys may be influenced by heat in various forms 
applied to the lumbar region. 

In intercostal neuralgia the irritation, blistering, cautery, 
heat, diathermy, or whatever other application is advisable, 
should be applied at the side of the spine, at the point of exit 
of the nerve. The following combination may be used over 
painful joints and nerves: 

Chloral. , 5 Gm. 

Methyl salicylate , jo mils 

This should be rubbed over the painful part and the part then 
covered with w^axed paper, rubber tissue or flanneL 

The nervous reflexes, especially the messages sent to the skin 
from disturbed inner organs of the body, should be more care- 
fully studied, and counterirritation should probably be more 
frequently used in medicine- 

The above discussion is only a brief outline of what the sub- 
ject means; but counterirritation, as well as other physical 



138 THE PRINCIPLES OF THERAPEUTICS 

therapeutic measures, should not be neglected by the physician, 
and fewer patients will be treated by irregular practitioners. 

ESCHAROTICS 

An escharotic means a destruction of tissue; hence the drugs 
of this class are used for this activity. The destructive action 
is chemical, and consequently the tissue destroyed is limited by 
the amount of the drug used; namely, the destructive action 
ceases when a chemical union has taken place between the drug 
or preparation and the tissue. 

It is not now deemed good treatment to use strong caustics on 
hard chancres, in fresh wounds which may have been infected by 
the tetanus germ, or in dog or rat bites. Such cauterizations 
are likely to seal toxins and germs of infection within the wound 
and allow them to be absorbed and cause systemic poisoning. 
The best method is to constrict the circulation, if possible, 
above the bite, and to treat the lesion with a pure phenol 
solution. In snakebite the circulation above should be shut 
oflf, if possible, the woimd sucked, and then perhaps best, 
freely incised to promote bleeding, and the wound filled 
with permanganate of potassiimi solution and the tissues 
above the wound perfused with strong permanganate solu- 
tions. Antivenine may be injected and ammonia given by the 
mouth. 

Escharotics are best used where small amounts of tissue are to 
be destroyed, as superabundant granulation tissue, and the 
semi-necrotic tissue of indolent ulcers; but modem surgery to- 
day rarely finds need for escharotics. 

The escharotics most used are the following: 

Chromium Trioxide, — Chromic acid occurs as small, purplish- 
red, brilliant crystals, which are soluble in water. This drug 
is used only as an escharotic, and in approximately a saturated 
. solution. 

Glacial Acetic Acid, — This acid is a clear colorless liquid used 
in full strength as an escharotic. 

Trichloracetic Acid, — ^This acid occurs as colorless crystals, 
very soluble in water, it is used only as an escharotic. 

Nitric Acid, — This acid occurs as a clear liquid, the fumes of 



ESCHAR ones 



^39 



which are irritating and should not be inhaled. It is used 
undiluted as an escharotic. 

Salicylic Xc«i,— This add occurs as fine white crystals or 
powder, has a sweetish ^ rather burning, acrid taste, and is not 
very soluble in water. Externally it is an antiseptic, and in 
strong preparations escharotic. As an escharotic it is used to 
remove corns, warts, and callous skin. Its action is slow and 
painless. It may be applied as an ointment in lo to 20 per cent, 
strength in petrolatum; or it may be used in collodion, i or a 
Gm* to 30 mils, 

SUver Nitrate. — Nitrate of silver occurs as colorless crystals 
and IS very soluble in water. Solutions turn black on exposure 
to Ught. A few drops of a 25 per cent, solution is especially 
useful in stimulating the healing process in ulcers^ cankers, etc, 

Argenti Nitras Fusm, — Molded Silver Nitrate, (Lunar 
Caustic) is a hard white solid, generally prepared in pencils, 
and used as an escharotic. The pendl is passed over the 
surface to be acted upon, generally exuberant granulations. 
Better than this molded stick is a bead of fused silver nitrate 
on a wooden applicator or probe. This insures the use of the 
same applicator but once. 

Copper Sulphate. — Sulphate of copper (Blue Vitriol) occurs 
as blue transparent crystals or powder. It has a metallic, 
nauseating, astringent taste, and is soluble in water. It is 
largely used as a emetic in a dose of 0.25 to 0.50 Gm. (4 to 
7H grains). The dose should not be repeated, and if vomiting 
is not quickly caused, the stomach should be washed out, lest it 
cause cauterization. 

As a caustic, copper sulphate is generally used in fused 
crystals as the blue stick, which is rubbed over the part to be 
treated. It is most frequently used on granular eye-lids. 

Potassium Hydroxide, ~Cdi\is\ic potash occurs in dr>^ white 
masses, or as molded pencils, and is very soluble in water. It 
should not be handled with the bare fingers, as its escharotic 
action is very rapid. It is not much used as an escharotic, as 
its action is more difficult to limit than that of other escharotics. 
It may, however, be used to remove superfluous epidermis, for 
which purpose a 5 to lo per cent, solution is employed. 



I40 THE PRINCIPLES OF THERAPEUTICS 

Sodium Hydroxide (Caustic Soda) acts similarly to potassium 
hydroxide, but caustic potash is preferable. 

Zinc Chloride. — Chloride of zinc occurs as a white granular 
powder or in molded pencils, and is very soluble in water. It 
has been used to destroy growths. As its action in concentrated 
preparations is very painful and protracted, its use is rarely 
justifiable. 

Carbon Dioxide Snow. — Liquid carbon dioxide comes in 
steel cylinders, and when the stop-cock is opened the spray 
developes a snow of —85° F. A mold of this carbon dioxide snow 
may be made, as Hare suggests, by holding a piece of thick 
chamois skin over the nozzle of the cock, and the snow forming 
in the pocket may be molded to any size desired. The chamois 
protects the hand from the intense eflfect of the cold. Hare 
states that when this molded snow is held on the tissues for 
ten to thirty seconds it acts as a stimulant, and from thirty 
seconds to a minute acts as an escharotic. The tissue to 
which it has been applied is frozen white. In a minute or two 
after the carbon dioxide snow has been removed the area 
becomes red and swollen and vesicles or blebs occur, similar to 
blistering. Several days later exfoliation takes place, a scab 
may form, and there may be a slight scar. 

This freezing substance has been used by dermatologists to 
destroy different kinds of growths or blemmishes on the skin. 
Too large an area should not be treated at once. 

CLASS m 
Drugs Used for Action on Mucous Membranes 

The drugs and preparations of this class coat and soothe 
inflamed mucous membranes, and also mechanically prevent 
harm from irritant substances which pass over them. Some 
drugs of this class are astringent and retard the normal secretion 
of the membranes and diminish excessive secretion. On 
account of the mechanical and astringent activities, when 
these preparations are swallowed, the digestive fluids of the 
stomach and intestines are more or less retarded in their output 
and digestion is slowed. 



ASTRINGENTS 



141 



Inflamed mucous membranes require soothing treatment. 
Abo to prevent irritation of the mucous membranes of the 
gastrointestinal tracts irritant drugs are generally administered 
combined with some protective preparation. On the other 
hand, too long use of even an inert mineral oil for laxative 
purposes can so continuously coat the intestinal waUs as to 
inhibit normal secretion. Too much washing, scrubbing, 
garglingj hot water drinking before meals^ constant taking of 
slushy, mushy J non-stimulating foods, and long repeated rectal 
injections and vaginal douching can but make the mucous 
membrane of the part abnormal and inhibit its normal secre- 
tion. Consequently, however useful and beneficial for an acute 
inflammation of a mucous membrane a local application or 
treatment may be, such treatment long continued is inadvisable, 
as it is likely to do harm, perhaps permanently, 

DEMULCENTS 

The drugs and preparations used to soothe mucous mem- 
branes are called demulcents. Besides those named under the 
classification of drugs, the foUowing are also useful: Acacia 
(Gum Arabic) ; Althca (Marshmallow) ; Chondrus (Irish Moss) ; 
Glycyrrhiza (Licorice) ; and Tragacanth. 

ASTRINGENTS 

Drugs used to inhibit secretion are termed astringents be- 
cause they dry up secretions and are sufficiently irritant to 
cause a contraction of the tissue to which they are applied. 
This action of astringenc>^ can occur only on moist surfaces, 
whether external or internal, but these drugs are mostly used 
for action on mucous membranes. Astringents vary in the 
intensity of their action, from the mildest soothing astringency, 
which will hardly irritate sufficiently for an outpouring of white 
corpuscles, to a greater astringency that wOl cause irritation of 
a part, to a still greater astringency' that will cause such chemi- 
cal reaction as will produce inflammation and local eschars, to 
such severe action as will cause actual corrosive ulceration and 
destruction of tissue. Many of the metallic poisonous drugs 
come under this class of irritant astringent drugs. 





142 THE PRINCIPLES OF THERAPEUTICS 

The most astringent metak in the order of their astringency 
are: lead, iron, aluminum, copper, zinc, and silver. Nitrates 
and chlorides of metals are more irritant and corrosive than are 
the acetates, citrates, and tartrates. The sulphates are less 
irritant than the last named salts. Most of these metallic 
preparations are primarily styptic, namely, causing sufficient 
coagulation of albumin to stop hemorrhage from small vessels. 
The more poisonous of these preparations, i.e., the more irritant 
ones, soon cause further destruction of the albuminate formed, 
corrosion and more hemorrhage. 

The symptoms of corrosive poisoning are described imder the 
section on poisoning, Part XI, and therefore need not be describ- 
ed here. 

The indications for the use of astringents are local, namely, 
for some disturbance of the skin or mucous membrane. Conse- 
quently they are used to treat some part of the gastrointestinal 
tract, the upper air passages, the conjunctivae, the urethra, 
bladder, vagina, and rectum; or they are used for some localized 
or general disturbance on the surface of the body, as in certain 
inflammations, or ulcerations, of the skin. 

Before deciding that an astringent is needed, it should be 
remembered that a mucous membrane is relieved of its conges- 
tion by free secretion; hence many times anything that promotes 
free secretion or excretion relieves this congestion. As a dry 
mucous membrane is generally an irritated one, it may require 
soothing, moist applications, as frequently best offered by a 
physiologic saline solution. In other words, astringents are 
often misused. On the other hand, a mucous membrane may 
have become flabby and relaxed and have its circulation im- 
paired, and may need a slight local irritation as offered by some 
mild astringent. However, in such conditions circulatory 
stimulation and improved general nutrition will often correct 
the local mucous membrane mistake. 

The main objects of astringent action are to diminish secre- 
tion; to stimulate a membrane to a more healthy secretion; and 
to stimulate healing of some part of the skin or mucous mem- 
brane. Mild astringents and weak preparations of strong as- 
tringents are used for the first indication, and strong astringents 



ASTRmOENTS 



X43 



or stronger preparations are used to meet the last mdication, this 
pro\dded the application can be locally applied and its action 
tenninates with the cessation of the application* Bismuth 
preparations and some preparations of tannic acid are generally 
the only astringents that should be used for the treatment of 
the stomach and intestines. The best preparation of bismuth 
for action in the intestinal canal is the subcarbonate. Some 
protein combination of tannic acid may also be used, especially 
for astringent action in the intestine. No other so-called as- 
tringent drug should be taken internally. There is absolutely 
no justification for taking nitrate of silver, or any other form 
of silver for that matter, into the stomach. Solutions of organic 
silver salts have strong germicidal activity, and are used for 
stimulant action in weak solutions on various external parts of 
the body, but though weak silver solutions may lessen secre- 
tions, they do not soothe the membrane, 

A valuable astringent wash is Liquor Alumini Subatetaiis 
(Burow's Solution). It is soothingly astringent to the skin in 
the strength of from i part to 8 of water to i part to 15 of water 
This preparation is distinct from the Liquor Alumini Acetatis 
N. F., and is an improvement on that preparation. 

Some drugs are strongly astringent and yet not irritant, 
hence are used to stop local capillary bleeding. Such drugs are 
termed sly plies. As styptics, tannic acid, the persalts of iron, 
peroxide of hydrogen solutions, and suprarenal solutions may 
be used. 

Preparations of copper, silver, and zinc salts are always 
stimulating, more or less germicidal, and in strong preparations, 
escharoUc, The object of stimulating a mucous membrane is 
to cause a healthy reaction so that the tendency' to return to 
health will be promoted. The object of stimulating a sluggish 
ulcer or sinus is to cause such a reaction as to promote the nor- 
mal tendency to heal. 

Tarmic Acid, — Administration, — Tannic acid is obtained from 
BUtgaEs, and occurs as a yellowish amorphous powder or as 
spong>' masses, its taste is astringent and disagreeable, and it is 
soluble in water, glycerin and alcohol. Tannic add is often 
used as an antidote in poisoning by metals and alkaloids, with 




144 THE PRINCIPLES OF THERAPEUTICS 

which it forms tannates. These tannates are more or less in- 
soluble, but if they remain long in the intestine they may, in 
part at least, re-dissolve and allow poisoning to occur. Con- 
sequently, when tannic add is used as an antidote, the stomach 
and intestines should later be thoroughly emptied. 

There is little use for tannic add as such internally. If the 
astringent action of tannin is desired, it is better oflfered by one 
of the several protein combinations. Tannic add is a mild 
irritant to the stomach and readily causes vomiting. When 
administered for action in the intestine, it should be given in 
capsules or one of the protein preparations may be used. The 
dose is 0.30 to 0.50 Gm. (5 to j^i grains), given three, four, or 
more times a day, as desired. 

Tannic add is frequently used as a wash or gargle to cause an 
astringent action in the mouth and throat. It should be ordered 
in a 1 3^^ to 2 per cent, solution in 5 per cent glycerin in water, 
or as a glycerite dissolved in water. Or it may be well to disguise 
the taste with peppermint or wintergreen water. The follow- 
ing prescription is a suggestion : 

■^ Tannic add 4 Gm. 

Glycerin 10 mils 

Peppermint water up to 200 mils 

Mix. 
Sign: Dilute with an equal part of warm water and use as a gargle three times 
a day. 

Tannic add is not a good treatment for an acute sore throat; 
it is better for relaxed and flabby conditions of the throat. 

Externally solutions of tannic add in water are sometimes 
applied to harden the skin, as to the nipples before nursing, and 
to dry up secretion, as sweating axillae, but other preparations 
are better. It is, however, harmless. 

The official preparations are: 

Glyceritum Acidi Tannici is a preparation of glycerin contain- 
ing 20 per cent, of tannin. It may be used in making tannic 
add solutions, or it may be applied by cotton applicators to 
inflamed parts of the mouth and throat. 

Trochisci Acidi Tannici are troches (each of which contains 
0.06 Gm. of tannin) used for solution in the mouth. 



ASTRINGENTS 



US 



Unguentum Acidi Tannici is an ointment containing 20 per 
cent, of tannin. 

Action.— Tho^ only action of tannic acid externally on the 
skin is to cause a drying of normal secretions and a coagulation 
of albuminous abnormal secretionSj and hence to inhibit exu- 
dation. On mucous membranes it coagulates the albumin and 
causes sufficient irritation to more or less constrict the tissues 
and dry the surface. Tannic acid will more or less constrict 
the small vessels of the membrane to which it is applied, 
and it is sufficiently styptic to stop oozing from small blood- 
vessels. It will not ordinarily stop hemorrhage from the 
larger vessels unless other methods are first used. 

Tannic acid slows digestion and more or less forms tannates 
with the proteins of the food. It generally causes constipa- 
tion, but if large amounts of tannic acid are taken it may cause 
diarrhea* If there is iron in the food, or iron has been ad- 
ministered as a medicine, tannic acid will cause the formation 
of black tannates as an ink. A small portion of tannic acid is 
absorbed as sodium gaUate, but there is no systemic action of 
any importance from tannic acid or its preparations, although 
both tannic acid and gallic acid have been given in albuminuria, 
and in bleeding from the kidneys. At times gallic acid has 
seemed to be of benefit in bleeding from the kidneys. 

There is no over-action or toxic action from tannic acid, al- 
though as stated, it may cause vomiting, and in larger doses 
an increased activity of the bowels. 

Uses,— The principal uses of tannic add have already been 
described. Combinations of tarmic acid in powders, ointments, 
or solutions are sometimes used in the mouth, nose, and rectum/ 
and on irritated regions of the skin, and for some skin diseases. 
Other preparations, at the present time, are more used for these 
purposes. 

Prolan^ N.N.R, is a combination of tannic acid and casein 
containing about 50 per cent, of tannic acid. 

Aceiannin, NuWR. is an acetic add ester of tannin. Tanni- 
gen is a similar preparation. 

Both of these preparations are used at times with advantage 

in persistent diarrhea, and for treatment of ulcerations of the 
10 




146 THE PRINCIPLES OF THERAPEUTICS 

intestines. They are not much dissolved in the stomach, are 
non-irritant to the stomach, and, therefore, are satisfactory 
methods of administering tannic add for intestinal conditions. 

The dose of the Protan is about 0.50 Gm., best in capsule, 
every three or four hours. The dose of the Tannigen is about 
0.25 Gm. best in capsule, every three or four hours. 

Silver Nitrate.— -4dmi»w/ra/«w. — Silver nitrate occurs as 
colorless, transparent crystals, which are very soluble in water. 
Solutions should always be made with distilled water, as any 
organic matter changes the color of the solution to gray, or even 
black, and exposure to light does the same; hence solutions are 
best kept in colored bottles with glass stoppers. 

There is no excuse for using silver nitrate internally for 
systemic treatment. It may be used in weak solutions in the 
treatment of chronic inflammations of the bladder, rectum, and 
lower colon. These silver solutions must be immediately passed 
out of the body, or, if they are not expelled, a sodiimi chloride 
solution should be injected to cause an insoluble chloride of 
silver to be formed. 

Silver nitrate has been used in the treatment of gastric ulcer, 
but on accoimt of the danger of too much absorption it is hardly 
justifiable, also it is problematical whether the solution, or a 
dissolving capsule, will hit the spot to which it is directed. 
Acute metallic poisoning, with nephritis, may occur, and chronic 
metallic poisoning has not infrequently occurred, from the use of 
silver nitrate internally. Therefore, the only justifiable use for 
nitrate of silver is locaUy, i.e., externally, or in cavities of the 
body that can be quickly evacuated. 

• Action. — Silver nitrate is a powerful germicide, forming a 
silver albimiinate with protein matter and setting free a small 
amount of nitric acid. On account of the formation of the 
albuminate the destructive action is not deep. Metallic silver 
inhibits germ growth and silver foil is often used as a germicide 
and a protective to healing surfaces. 

The eschar produced by the action of silver nitrate is white, 
later turning black. When solutions stain the skin it may be 
removed, if treated soon, with a saturated solution of potassium 
iodide, but, if it is not soon treated, the stain will remain imtil 



ASTRINGENTS 



147 



exfoliation of the epidermis occurs. Nitrate of silver stimulates 
the healing of a sluggish ulcer, provided it is not used too fre- 
quently or too many times. It has been thought that it could 
over-stimulate a part and cause tumor growth. When nitrate 
of silver is absorbed it may cause, after two or three weeks' 
treatment, deposits of organic silver in the skin and mucous 
membranes, and perhaps in the organs* The mucous mem- 
branes show brown spots, and the skin shows blue patches, or 
even a generaEzation of bluish pigmeGtation. Such pigmenta- 
tion will always remain, and can never be removed. This con- 
dition has been termed arg>'rism or argyria. As stated, such 
chronic poisoning should never occur, as there is no excuse for 
admiaistering nitrate of silver internally. 

Toxic Action. — Acute poisoning is similar to that of other 
gas tro- intestinal irritants, with lowering of the blood-pressure, 
weakening of the heart, and irritation of the nervous system, as 
shown by convulsions, and later coma and collapse, 

TreatmcfU of Acute Poisoning,— The antidote is a strong 
solution of sodium chloride administered immediately. If 
vomiting does not soon occur the stomach should be washed 
out. The later treatment is that of the local inflammation that 
has been caused. 

Uses, — ^Silver foil is often used as a surgical dressing, both for 
protective and antiseptic purposes; it also tends to prevent ex- 
uberant granulations. The stick nitrate of silver (Lunar Caustic, 
Argenti Nitras Fusus,) is often used as an escharotic, as well as 
is a fused bead of nitrate of silver on a wooden applicator. The 
latter is better, because it can be destroyed after it is once used. 
Twenty-five per cent nitrate of silver solutions are generally as 
valuable, applied by means of a swab. Weak solutions have 
been used on the mucous membrane of the nose, nasopharynx, 
bladder, urethra, vagina, and rectum. Nitrate of silver appli- 
cations are very curative treatment for cankers in the mouth* 
However, for most purposes organic silver salts are now more 
used than is the nitrate of silver. 

Except in the prevention of ophthalmia neonatorum, by in- 
stillation into each eye of the newly born child of two drops 
of a I per cent, watery solution of nitrate of silver, known as 




148 THE PRINCIPLES OF THERAPEUTICS 

Cred6's method, organic preparations of silver are now the ones 
used in all inflammations of the eyes. 

Nitrate of silver is now rarely used in preventing gonorrhea. 
Other silver solutions or weak corrosive sublimate solutions are 
more used. To destroy tissue, except to remove exuberant 
granulations or to stimulate the base of an ulcer, other escha- 
rotics are used more than nitrate of silver. To destroy warts, 
callous skin, etc., nitrate of silver is now rarely used. 

The book New and NonoflGicial Remedies, edition of 1920 
recognizes the following silver preparations: 

Cargentos, a colloidal silver oxide, containing about 25 per 
cent, of silver. 

CoUargol, an allotropic form of metallic silver, containing a 
small percentage of albumin and about 78 per cent, of silver. 

Argyrolj a compoimd of a derived protein and silver oxide, 
containing from 20 to 25 per cent, of silver. 

SolargetUumSquibbf a compoimd of silver and gelatine, con- 
taining about 20 per cent of silver. 

Sopholj 2l compound of silver and methylenenucleinic add. 

Protargolj a compoimd of albumin and silver, containing 
about 8 per cent, of silver. 

Proganoly a compound of albumose and silver, containing a 
little more than 8 per cent, of silver. 

Of these preparations the most used are Cargentos, Collargol, 
Argyrol and Protargol. Argyrol is the one generally preferred, 
and is used in solutions of various strength, from 10 to 25 per 
cent. The value of these solutions in the prevention of and in 
curing many localized infections is very great. 



CLASS IV 

Drugs Used for Local Action in the Stomach 

drugs used to increase the appetite 

Drugs administered to increase the appetite are generally 
bitter, but it is a mistake to believe that every loss of appetite 
should be combated by one of these drugs, as many times the 



TO INCREASE THE APPETITE 



149 



b 



anorexia is due to inflammation of the gastric mucous mem- 
brane. If there is much inflammation, i.e., if gastritis is 
present, even in a mild form, bitter tonics are not indicated to 
increase the appetite and will often defeat the object for which 
they are administered, even producing nausea. Bitters should 
also not be used when there is hyperacidity of the stomach, as 
fiiey tend to increase that condition. If gastritk is present it 
should be treated with bismuth and soda, or with some other 
sedative, and by such an arrangement of the diet as will dimin- 
ish or prevent indigestion. When gastritis or simple indigestion 
improves, the appetite will return. 

If the loss of appetite is due to an anemic condition of the 
stomach and gastritis is not present, any mild irritant to 
the mucous membrane of the stomach will often increase the 
appetite, and the best stimulant is a weak bitter. The bitter 
should not be too strong, and many times it is well to have it 
combined with aromatics, as aromatics and aromatic oik also 
stimulate the stomach and hence the appetite. 

Many drugs increase the appetite by improving the systemic 
condition, but the best bitter appetizers are cimhona, gentian , 
and nux vomica. If a capsule or pill of quinine is taken some 
hours before a meal (and quinine is generally given as a tonic 
three times a day, after meals) it causes an increase of appetite 
by giving a bitter taste, owing to a slight excretion of the 
quinine with the saliva, and the patient desires more food. 
However, the official Tincture of Cinchona in teaspoonful doses 
in a wineglass of water before meals, or an Elixir of Calisaya in 
dessertspoonful doses before meals are eflBcient methods of 
increasing the appetite. If a simple clean bitter is desired, the 
Tincture of Nujc Vomica in from one to five drop doses in a 
wineglass of water before meals is also very efficient. The 
official Compound Tincture of Gentian in teaspoonful doses, 
in water, before meals is also a valuable stomachic. 
If the digestion seems to be impaired, as evidenced by 
H gastric flatulence and a coated tongue, 5 to 10 drops of Acidum 
^B Hydrocfdoricum Dilulum, taken in a wineglass of water directly 
■ after meals, not only aids digestion, but seems to promote the 




150 THE PRINCIPLES OF THERAPEUTICS 

If the patient is anemic, iron in most any form will increase 
the appetite. It is best given in some simple form directly- 
after meals. 

There are various other bitter, non-poisonous drugs that are 
official, but they are superfluous, as the above preparations are 
sufficient. 

DIGESTANTS 

Indigestion is a very frequetrt condition, especially in the 
United States, largely due to rapid eating, eating too rich 
foods, drinking too many sweet, so-called "soft drinks," drink- 
ing too much ice water, eating between meals, and to the 
over-use of coflfee, tea and tobacco, to say nothing of the fre- 
quency of indigestion due to some general systemic disturbance. 
Indigestion is frequently due to constipation, and also, many 
times, to the bad habit of taking too strong laxatives. Con- 
siderable stomach indigestion is caused reflexly by disturbances 
of the nervous system, the most frequent of which is eye- 
strain. 

The larger part of indigestion is gastric in origin, and the 
principal symptoms are distress, gastric flatulence, pyrosis, and 
heartburn. Pain, nausea and vomiting are rare symptoms in 
simple dyspepsia. When these symptoms occur, there is an 
acute indigestion or gastritis, or there is some more serious 
cause. 

The treatment of gastric indigestion is suggested by the above 
list of causes. A correction of the diet and the method of 
eating will often cure the condition. To treat dyspepsia by 
the administration of digestants, one must bear in mind the 
physiology of digestion. The diastase from the saliva, or a 
diastase that may be given a patient, will act on the carbo- 
hydrates in the stomach until free hydrochloric add or a 
considerable amount of add peptones from the peptic digestion 
have developed, which ordinarily will be from one to one and a 
half hours after the food has been taken. The add peptic 
digestion then proceeds from three to four hours, imtil the 
stomach is emptied, gradually, into the duodenum, where 
the digestion again proceeds in medium rendered alkaline by the 




DIGESTANTS 



15^ 



bile. Obviously, then, it would be a mistake to administer 
hydrochloric acid or pepsin before the meal, and it would also 
be a mistake to give an alkali two hours after a meal. As a 
matter of fact, the pepsin of the stomach is rarely deficient, 
except in certain cases of pathologic conditions of the mucous 
membrane. The hydrochloric acid is often deficient. There- 
fore, many times indigestion will be quickly corrected by a 
proper arrangement of the diet and the administration of 5 or 
10 drops of dilute hydrochloric acid, in water, after meals. 
Also an aid to digestion is a moderate amount of water, taken, 
not too cold, in the latter part of a meal or after a meal. 

Unless the starchy food has been greatly diminished, sodium 
bicarbonate in 0*50 to i gram dose, combined with 0.50 to i 
gram of bismuth subcarbonate, taken three times a day, before 
meals, will also often aid digestion. The bismuth soothes 
a possibly irritated mucous membrane, and the bicarbonate of 
sodium prolongs the starch digestion. 

Some of the so-called "hyperacidity'* and pyrosis occurs be- 
cause food remains too long in the stomach, from lack of motil- 
ity of the stomach or from some other reason, and is due to the 
formation of lactic acid and is not due to an excess of hydro- 
chloric acid. The administration of dilute hydrochloric add 
in these cases corrects the condition by hastening the comple- 
tion of normal digestion and apparently hastens the passage of 
the food into the duodenum. In these cases a glass or two of 
water drunk three or four hours after a meal is of benefit. If 
the hydrochloric acid increases the sensation of burning and 
acidity, it should, of course, be stopped. 

As stated^ unless there is some serious disease of the stomach, 
as atrophy of the gastric mucous membrane or cancer, pepsin 
is rarely needed, but in these conditions pepsin, in good sized 
doses, may be given in any pleasant manner. 

\^Tiile pancreatin will digest protein in neutral, as well as 
partially, perhaps, in faintly acid, medium its greatest activity 
is in alkaline medium. It has lately been disputed whether or 
not it is destroyed by passing through the stomach, namely, 
through the add digestion, before it reaches the duodenum 
where it is normally active. It seems entirely unnecessarTr" to 




152 THE PRINCIPLES OF THERAPEUTICS 

spend any time discussing this subject, as it is not necessary to 

give pancreatin as a digestant. To pre-digest food pancreatin 

is very valuable, and for this activity it is combined with a small 

amount of sodium bicarbonate. 

A brief description of the drugs of this class will be found 

under their titles in Part 11, the section of the United States 

Pharmacopoeia. 

ANTACIDS 

Treatment by drugs for this purpose is purely symptomatic 
treatment. Alkalies should not be used too long or too fre- 
quently, as they not only antagonize hyperacidity, but may 
cause irritation of the stomach by constantly stimulating the 
antagonistic action of the acid-secreting glands. As stated 
above, an alkali before meals may prolong the diastatic action 
of the saliva on starches, but if given some time after meals, 
will interfere with gastric protein digestion. 

It is better, by diet and proper management, to prevent 
hyperacidity rather than to treat it, and the treatment 
of heartburn, pyrosis, and distress from hyperacidity is 
symptomatic, and many of the symptoms of hyperacidity are 
due to lactic add. Too much hydrochloric acid may be secreted 
in nervous irritability and in mental tire and reflexly from some 
abdominal disturbance, or it may be due to. some increased irri- 
tability of the stomach mucous membrane. Butter, bland oils, 
and arrangement of the diet may control the condition. 
Atropine so much used for hjrperacidity generally fails to help 
' this condition. 

The drug most frequently used to combat gastric acidity is 
sodium bicarbonat€j given either alone or combined with bis- 
muth, or with peppermint, charcoal, or pepsin, and at times with 
ginger. The value of all of these so-called digestive tablets or 
powders lies principally in the bicarbonate of sodium. An 
effective dose of sodium bicarbonate is 0.50 to i Gm., repeated 
in fifteen minutes or half an hour, if needed, taken with plenty 
of water, and most eflBicacious in hot water. If there is much 
gas, causing distress, the official Spiritus Ammonia Aromaticus 
in half a teaspoonful dose, taken well diluted, is an efficient rem- 
edy. This may be repeated in half an hour, if needed. 



TO RELIEVE IRRITATION IN STOMACH 



I S3 



A more sedative antacid for the stomach is mapiesiaf and the 
best preparation is a milk of magnesia, given in warm water in 
I, 2, or 3 teaspoonfut doses. It may be repeated in an hour, if 
needed. Magnesia has slight laxative properites. 

Magnesium oxide may also be used as a mild antacid. Cal- 
cium is also used as prepared chalk (Creta Praparald)^ as the 
precipitated calcium carbonate (CakiiCarbonas Prmcipitalus), 
or as the official lime water (Liquor Cakis), These drugs and 
preparations are described in Part II, under the section on the 
United States Pharmacopoeia. 

DRUGS USED TO RELIEVE IRRITATION IN THE STOMACH 

Irritation or inflammation of the stomach mucous membrane 
is the same as irritation or inflammation of any mucous mem- 
brane, and requires to be soothed in the same way. The food 
must be bland, if it is not temporarily prohibited, plenty of 
water must be taken, and many times demulcent drinks, as 
albumin water, flaxseed or sUppery elm tea, or some other 
bland drink. When properly prepared and in good condition, 
milk of magnesia given with warm water is one of the most 
soothing preparations. 

The drugs most frequently used to relieve gastric irritation 
are the bismuth preparations, and of these the best is the sub- 
carbonate. Sometimes the subgallate with its slightly greater 
astringency is the salt of preference. The subnitrate of 
bismuth is the salt that has been and is still used the most. 
In certain conditions of the stomach and intestines, such as a 
fresh ulcerated absorbing surface, this salt may cause poisoning. 
The subcarbonatc cannot cause such poisoning. 

There is no good reason why silver nitrate should ever be 
given internally, although it has been used frequently in chronic 
inflammation and ulceration of the stomach. It may do harm. 

Suprarenal preparations have been used to prevent or inhibit 
hemorrhage from the stomach. Tannic add has been used for 
stomach conditions, but it is more or less nauseating and slightly 
irritant. The non-irritant protein combinations of tannic acid 
do not develop tannic acid action until thej^ have reached tbe 
intestines. 



154 THE PRINCIPLES OF THERAPEUTICS 

Bismutii SnlKaihonate.— Administration. — The subcarbonate 
of bismuth occurs as a yellowish white powder, insoluble in 
alcohol and water. For action in the stomach it is best admin- 
istered in powder in a dose of 0.50 to 2 Gm. It may, pr may 
not, be combined with bicarbonate of sodium, but many times 
the sedative action in the stomach is better when so combined, as 
I Gm. of subcarbonate of bismuth and 0.50 Gm. of bicarbonate 
of sodium, taken three times a day, just before meals. If it is 
very disagreeable for the patient to take a powder as such, the 
bismuth salt may be given in a small glass of vichy or other 
sparkling water; the bubbles suspend the heavy salt and the 
whole may be drunk as a liquid. 

If it is desired that the stomach should be well coated with 
bismuth for sedative and astringent purposes, as perhaps in 
ulcer, the best method is to give a large dose, at least 2 Gm. 
(30 grains) at one dose, before breakfast, preceded half an 
hour by a cup of hot water. 

For action on the intestines, as for acute diarrhea, a gram of 
the subcarbonate of bismuth may be given every two hours for 
ten doses, best combined with phenyl salicylate (salol) in 0.30 
. Gm. (5 grain) doses. For astringent action for a chronic 
condition in the bowels, bismuth subcarbonate may be given in 
capsules of 0.30 to 0.50 Gm., or in 5 or 10 grain tablets every 
three or four hours for some days. Bismuth should not be 
given too long, as it tends to cause constipation and the forma- 
tion of hardened masses of feces in the intestines. 

Action, — Bismuth subcarbonate has no action on the skin 
except that of a dry protective powder; on ulcerated surfaces it 
has a slightly astringent action. Bismuth powder should not 
be used on a fresh raw surface, whether an acute bum, a blister, 
or a denuded surface from an injury, as absorption and metallic 
poisoning may occur. 

The action of bismuth throughout the alimentary tract is a 
local one. It is soothing and mildly astringent. In the large 
Intestine sulphide of bismuth is formed which causes the stool to 
become black and the feces to have more or less of a sulphurous 
odor. 

It is doubtful if bismuth subcarbonate can cause poisoning. 



TO RELIEVE IRRITATION IN STOMACH 



1 55 



The subnitrate has, rarely, caused poisoning, sometimes smous, 
(possibly sometimes contaminated with arsenic) due to the 
formation of nitric acid and nitrites. The symptoms have been 
inflammation of the duodenum, liver, and kidneys. When 
bismuth salts have been absorbed from fresh wounds the 
symptoms are those of a metallic poison, not dissimilar to 
mercurial poisoning; the treatment is the same as that for 
other metallic poisons. 

Uses, — ^The principal use of subcarbonate of bismuth is in 
gastric and intestinal irritations and inflammations. It is of 
little value in inflammation of the lower part of the small 
intestine or of the large intestine* It is of value in ulceration of 
the large intestine when given by colon injections* 

Bismuthi 5 w6««7ra^.— Subnitrate of bismuth occurs as a 
heavy white powder insoluble in alcohol and water. It has been 
used much more frequently than the subcarbonate of bismuth 
and for the same purposes, and in the same doses. The action 
is the same, with the exception, as above stated, that the sub- 
carbonate is a safer preparation to use, 

Bismuthi Subgallas.—Th^ subgallate of bismuth (**Derma- 
tol'O occurs as a bright yeUow powder, and is insoluble in water 
and alcohol. This preparation has been used externally as a 
drying powder more frequently than the other forms of bismuth, 
especially on moist eczemas, and for sweating axillae and feet. 
It is a finer, lighter powder than the other salts of bismuth. Its 
best action internally is in chronic intestinal disturbances, and 
is best given in capsules containing 0.30 to 0.50 Gm. (5 to 7^ 
grains), three or four times a day. The action is similar to that 
of the subcarbonate. 

Bisfnuihi Beianafhiholas . — Bismuth betanaph thol (' * Or- 
phol'*) is a compotmd of bismuth and bctanaphthol, containing 
not less than 15 per cent, of betanaphthol. This preparation 
occurs as a yellowish or grayish-bro^vn powder which is insolu- 
ble in water and alcohoL In the intestines the naphthol is re- 
leased from this salt and causes more or less antiseptic action. 
It has been used as an astringent antiseptic in diarrhea, best 
given in capsules, in doses of from 0.50 to 0,50 Gm. (5 to ^^i 
grains); but the combination of bismuth subcarbonate and 




156 THE PRINCIPLES OF THERAPEUTICS 

phenyl salicylate, as above suggested, is better in diarrheal 
conditions. 

Bismuthi Trtbromphenas, N.N.R. — Bismuth Tribromphe- 
nate (Xeroform) is an amorphous, yellow, tasteless powder, 
which is very slightly soluble in water. It is recommended for 
use externally in the place of iodoform, as being non-irritant and 
having mild antiseptic properties. 

Other official preparations of bismuth are not needed. 

Barium Sulphate , N.N JR.. — This preparation has largely 
superceded bismuth subnitrate and bismuth subcarbonate in 
roentgen-ray examinations of the stomach and intestines. 
About 2 ounces of barium sulphate are administered, mixed with 
some cereal gruel. There is no medicinal use for barium. The 
preparation in this dose seems non-poisonous. 

EMETICS 

The irritant emetic drugs in the order of their activity are: 
mustard, ipecac, zinc sulphate, copper sulphate. The sim- 
plest of these, namely, mustard^ may be given in a dose of a 
tablespoonful or more, stirred in a glass of warm water. The 
emetic dose of powered ipecac is 2 Gm. (30 grains), also given 
stirred in a glass of water; or the syrup of ipecac may be 
given in I, 2, or 3 teaspoonful doses, and repeated in ten or 
fifteen minutes, if vomiting has not been caused. The emetic 
dose of zinc sulphate is 2 Gm. dissolved in half a glass of water, 
not to be repeated. If vomiting does not occur within ten or 
fifteen minutes, the stomach should be washed out. 

A good combination to be carried in the emergency bag is: i 
Gm. of zinc sulphate and 2 Gm. of powdered ipecac, a powder 
to be administered at once, and repeated in fifteen minutes, 
if vomiting has not been caused. 

Copper sulphate is the most active of these irritant emetics, 
and the dose should be 0.50 Gm. (yj^^ grains) dissolved in warm 
water, given at once. If vomiting does not occur in five or ten 
minutes, the stomach should be washed out. 

The emetic drug that acts on the vomiting center, when 
administered hjrpodermatically is apomorphine. 



CARMINATIVES 



IS7 



Apomotphine Hydrochloride* — A dminisiration . — Apomor- 
phine is an alkaloid prepared from morphiee by the abstraction 
of one molecule of water; the hydrochloride is the official pre- 
paration. This salt occurs as nunute white or greenish-white 
prisms J which soon become green, and the solutions become green, 
on exposure to light and air. It is not very soluble in water. 

There is no good use for this drug except as an emetic, and 
as such it should always be given hypodermatically. The 
hypodermatic dose is 0.005 ^^ o.oo6 Gm. (J {2 to Jiq grain). 

Adian.— When given hypodermatically vomiting occurs 
within a few minutes, unless some narcotic poison has been 
taken, when it may take longer for its action- The vomiting is 
caused by direct action on the vomiting center in the medulla. 
The emetic dose rarely requires to be repeated, but if nausea 
persists or vomiting is frequent, prostration is caused and some- 
times collapse. For this reason, as soon as the stomach has 
been thoroughly emptied, stimulantSj best atropine and caffeine, 
should be given. Of course in poisoning that necessitated the 
use of apomorphine^ the particular poisoning must be treated, 
but if the poison was a depressant, apomorphine must be used 
with care* 

t/5e5.— Although apomorphine has been recommended as an 
expectorant, to be used to promote secretion of the air passages, 
it is not good treatment, as it is too depressant. There is no 
real good reason for administering apomorphine for any purpose 
except to cause vomiting, and then it should be given hypoder- 
matically or intramuscularly. It may be used to produce 
vomiting in such conditions as when there is intense gastric 
pain from contractions of the stomach with the cardia and 
pylorus closed. Apomorphine will almost instantly relax the 
spasm of these sphincters, especially of the cardia. 



CLASS V 

Drugs Used for Local Action in the Intestinal Canal 

carminatives 

All spices, preparations of spices and aromatic oils increase 
peristalsis and hence have carminative action. Of the spices, 
capsicum, ginger,and peppermint are the best, while asafetida 



158 THE PRINCIPLES OF THERAPEUTICS 

(a garlic) is also a promotor of peristalsis. Onions act as car- 
minatives, hence onion broth is as efficient as asafetida pills. 
Anise is often given to babies for intestinal flatulence. 

Turpentine enemas are given to relieve intestinal distention, 
and cold to the abdomen promotes peristalsis. Heat applica- 
tions to the abdomen in the form of stupes relieve localized 
abdominal congestion and may thus relieve spasm of some part 
of the intestines and promote peristalsis. . Dry heat applications 
to the abdomen also relieve local congestion and spasm and 
hence promote normal peristalsis. 

Intramuscular injections of ergot are of value in intestinal 
paresis, and atropine, in large doses, is of benefit in intestinal 
spasm and colic by relieving a spastic condition of some part of 
the intestine and thus allowing normal peristalsis to occur. 
Pituitary extracts, given h)rpodermatically, also increase 
peristalsis. 

CATHARTICS 

These drugs are well sub-classed, for therapeutic purposes, 
into laxatives, purgatives, saline purgatives, and irritant 
purgatives. 

A laxative drug is one that may be used ordinarily for a long 
time without causing inflammation of the gastrointestinal tract 
or a tendency to a worse condition of constipation. 

A purgative is a drug that is used once (repeated if needed) 
to more or less rapidly evacuate the bowels. These drugs 
should not be used continuously, or be taken repeatedly, as 
they are likely to irritate the intestine; cause inflammation; 
cause too much depletion; and increase a tendency to consti- 
pation. 

The saline purgatives are mineral salts, which are very useful 
in causing rapid evacuation of the bowels. In certain condi- 
tions a small dose of one of these saline drugs, given before 
breakfast, may be good medication, as in over-weight, in pleth- 
ora, at times in insufficiency of the kidneys, and in high 
blood-pressure; but simply for the treatment of constipation 
saline purgatives should not be used. 

The irritant purgatives are those that cause very active, more 



CATHARTICS 



159 



or less rapid movements of the bowels. If they are given in 
large or in repeated doses they are likely to cause inflanimation, 
and very prostrating, if not poisonous effects. In other words, 
the drugs classed as irritant purgatives should not be used unless 
there is a positive indication for their use, such as systemic 
poisoning, or when some poisonous drug has been taken and 
very rapid evaoiatJon of the bowels is necessary. 

Cathartic drugs and even the laxative drugs are used too 
much; the people of this country seem to be cathartic crazy* 
One has but to read the advertisements of nostrums in one of our 
second class daily papers to realize that the American world 
must think itself constipated. If these advertisements did not 
sell the nostrums they represent, the cost of the advertising 
could not be paid. 

Before discussing the indications for the use of cathartics, it 
is well to suggest when cathartics should not be used: (i) 
They should never be used habitually, even the laxatives, ex- 
cept by a small percentage of indi\dduals. (2) Unless there is 
some special indication they should not be given as routine 
practice before operations. (3) Unless there is some special 
reason they should not be given too soon after an operation, or 
too soon after parturition, (4) They should not be given after 
a profuse diarrhea, although they should be given if the diarrhea 
has just begun. (5) They should not be given when there is 
acute abdominal pain, except possibly after a careful considera- 
tion of the diagnosis, when castor oil may be administered. (6) 
They should not be given in acute heart weakness. (7) They 
should not often be given in cardiac dropsy. (8) They should not 
be given in too large doses even in systemic poisoning. 

In the beginning of most acute infections it is generally ad- 
visable to unload the bowels with some purgative, and to greatly 
modify the diet. It is also advisable during illness, when the 
heart is in good condition and the patient is taking food, to have 
the bowels move at least every other day. Under these conditions 
they may require the aid of some simple laxative or of an enema. 
The simplest and most effective enema is an ounce of glycerin 
and an ounce of water. It may be well to have the bowels 
move every day during illness, when the glycerin enema may 




l6o THE PRINCIPLES OF THERAPEUTICS 

be given on one day and some simple laxative on the alternate 
day, if the bowels do not move without such treatment. If 
much fruit can be given, the bowels may move without help. 

It has been a mistake to purge every patient before operation. 
It is also a mistake to give such a patient either divided doses 
of calomel or a saline too soon after an operation, and divided 
doses of calomel are almost always a mistake. A single proper 
dose is much better. 

It is a mistake to cause purging in cardiac failure, in cardiac 
dropsy, and in cardiovascular-renal disease, as many a time the 
severe purging is the last straw to cause the patient to succumb. 

It is not proposed to discuss here the whole treatment of 
constipation, but except for a short time it is a mistake for 
most individuals to take laxatives. Constipation is best 
treated: (i) by the regular habit of going to stool at the same 
time every day, best after breakfast; (2) by diet; (3) by exer- 
cise; (4) by massage and exercise of the abdominal muscles. 

Constipation is a very common symptom of most diseases, and 
when the diagnosis is made and the general condition corrected 
the patient may have normal movements of the bowels. The 
frequency with which chronic abdominal disturbances cause 
constipation should also be recognized — whether gall-bladder 
disturbances, chronic appendicitis, ovarian disturbance, or 
some ulceration. The constipation then is purely a symptom. 

The habit of the individual must be considered in deciding 
whether it is best for him to have one or two movements of the 
bowels a day; ordinarily one should be sufficient. If, however, 
he has hemorrhoids, or a tendency to hemorrhoids or conges- 
tion in the pelvic region, it is well to have a movement of the 
bowels before going to bed, thus relieving unnecessary pelvic 
pressure. On the other hand, some individuals, generally 
women, are perfectly well and perfectly healthy and have good 
digestion though they have a movement of the bowels only on 
every second, and sometimes on every third day. Movements 
of the bowels every third day does not seem to be normal; but 
if every second day is the habit, and the patient is well, he 
should not be disturbed by cathartics. 

Some patients, especially those who cannot take much exer- 



LAXATIVES 

dse, in spite oC regularity of habits, and a regulated diet and 
an increased ingestion of water, do not have normal movements 
of the bowels without some little help. With such patients a 
small dose of cascara, of aloin or aloes, or of senna, taken daily, 
is probably of no more harm than the daily dose of tea or coffee, 
or for that matter, of pepper and spice or some other condiment. 

It is always advisable in constipation to tell most patients to 
drink more water^ A glassful of w^ater on going to bed, and 
another before breakfast is an aid in curing constipation. 
Fruit before breakfast, and, for those who tolerate it well, at 
bedtime, is good treatment. The value of bran foods should 
be urged. 

It is inadvisable to allow a patient to use enemas for any 
length of time, either of water , of soap and water, or of otherwise 
medicated water. The injections rarely reach the colon, and 
generally distend the rectum and possibly the sigmoid flexure, 
and soon the bowel acquires the habit of needing this distention 
before it will perform its duty. There is no harder simple 
habit to cure than the habit of taking enemas. Veiy much 
worse is the enema habit than is the habit of a small dose of a 
simple laxative. On the other hand, an enena is frequently 
indicated to unload the bowel, and colon washing is very essen- 
tial in certain conditions of the large intestine; but this should 
be considered medication for specific purposes, and injections 
of solutions into the bowel should not be used as routine practice. 

LAXATIVES 

Agar.—Ag^T often acts efficiently as a laxative because it, 
acquiring w^ater, does not give it up, and causes the stool to be 
bulky and pultaceous, and gives the intestine moist matter 
upon which to contract. 

Ahes. — ^AJoes may be termed a tonic laxative, and is one of 
the best drugs for this purpose. It is slow to act, taking from 
eight to ten hours, or more, and therefore is best given directly 
after the evening meal or at bedtime. It should be taken with 
plenty of water, if the stomach is empty. Aloes may be admin- 
istered as the oflficial pill of aloes, each pill containing 2 grains 
of the drug, or in the form of the official compound rhubarb pill 
11 




l62 THE PRINCIPLES OF THERAPEUTICS 

which contains 2 grains of rhubarb and ij^ grains of aloes. 
Aloes, however, is most frequently administered in the form of 
its active principles, aloin. As aloes is a stimulant to the mus- 
cular coat of the intestine, especially of the large intestine and 
may irritate the rectum, it is generally best not to use it when 
there are hemorrhoids, pregnancy, or congestion of the pelvic 
organs. 

As large doses may cause colicky pains, aloes does not make 
a good cathartic, but it makes a most valuable laxative, and 
one of the best combinations is a pill or tablet made of: 

Aloin 0.02 Gm. 

Sulphate of strychnine 0.0015 Gm. 

Powdered ipecac 0.03 Gm. 

Extract of belladonna o .01 Gm. 

If this combination is administered daily for about two weeks, 
then two-thirds of the dose for another week, and half the dose 
for the following week, combined with proper diet and regularity 
in exercise, the constipation may be cured. At any rate, this, 
or some similar combination, has the advantage of not necessi- 
tating an increase of the dose. 

Ox-gall. — Bile is always more or less of a laxative, and when 
the secretion of the bile is insufficient or it is absent from the in- 
testines constipation occurs. As ox-gall contains excretives 
which are depressant and lower the blood-pressure, it should not 
be given for more than four or five days at a time. In other 
words, its use is limited, and its value is uncertain. 

The bile salts Sodium Glycocholate and Sodium Taurocholate 
are now sometimes used in insufficiency of the liver, but, like 
the preparations of the whole bile, they are depressant and 
should not be used for more than a week at one time. They 
may be somewhat stimulant to the secretion of the liver and 
may tend to lessen the formation of concretions in the gall- 
bladder. 

Glycyrrkiza. — Licorice is a mild laxative, and the official Com- 
pound Licorice Powder, in which senna plays the largest part 
with the sulphur a close second, is a very popular laxative. 
The combination contains 23 per cent of glycsrrrhiza, 18 per 



LAXATIVES 



1% 



cent, of senna, and 8 per cent, of washed sulphur. This prepa- 
ration should be more used as a purgative than as a laxative*, 
f\e., intermittently rather than regularly. 

Magnesium Oxide.— M^gn^siB, is a mild laxative, is harmless, 
and is well used in the form of milk of magnesia, 

Petroletim OIL — Mineral oil is now the fad. It was at first 
thought that the Russian mineral oil was better than our mineral 
oil, but our purified oils are as valuable as any imported oil. 
The finer classes of these oils are tasteless, odorless, and color- 
less. They act purely mechanically, and cause action of the 
bowels by softening the feces and tending to promote their pro- 
pulsion to their exit. Large doses are generally required; small 
doses are not very efficient. Too large doses, and with some 
individuals J small doses, cause a leakage of oil from the rectum, 
which is very unpleasant. For patients who have dry, hard 
feces, such treatment for a time is valuable, but to take mineral 
oil for a long time is not good treatment. Coating the stomach 
and intestines wnth continued doses of oil can but inhibit the 
digestive juices, and also must inhibit the absorption of nutri- 
ment. It may be a good treatment for those who eat too much, 
Ver>^ fine emulsions of mineral oil are now obtainable, but more 
bulk of the emulsion must be taken than of the oil itself. This 
mineral oil fad has probably reached its height* 

Podophyllum, — May apple has long been used in combination 
with other laxatives, and best in the form of the official resin, 
the dose of which Is o,oi Gm, (J ^ grain). This drug acts slowly, 
generally in about twelve hours, and, as it is more irritant than 
the other drugs of this class and is likely to cause griping, it is 
rarely given alone. The very fact that it is more active than 
the other laxatives should preclude its use for any length of time, 
as it tends to cause irritation and to prolong the need of the 
bowel for a stimulant drug. 

Cascara Sagrada, — Cascara is one of the best laxative drugs. 
The official extract is the preparation most frequently used, 
given in the form of pills or tablets in from 2 to 5 grain doses. 
This preparation, however, is often almost inert. More effi- 
cient is the official Fluidextract of Cascara Sagrada, but it is 
very bitter and disagreeable to take. An aromatic fluid extract 





164 THE PRINCIPLES OF THERAPEUTICS 

is official, which is a pleasant preparation and especially adapted 
for children. It contains, besides cascara, licorice, glycerin and 
several spices, and is sweetened with saccharin. The Pharma- 
copoeia states the average adult dose to be one-half a teaspoon- 
ful, but generally i or 2 teaspoonfuls are required. The dose 
of this very pleasant tasting laxative may be easily computed 
for children from the adult dose. As it is perfectly harm- 
less, the dose is always sufficient to act in the individual 
patient. 

Many patients who suffer from constipation may be cured by 
slowly diminishing the dose that has been at first found suffi- 
cient. This drug is often well administered three times a day, 
in small doses, but most patients prefer the single dose after the 
evening meal or at bedtime, as it takes from eight to twelve 
hours to act. The drug may be combined with other laxatives, 
but as it does not gripe, it is best administered in a sufficient 
dose, uncombined. 

Cascara may be given when there are hemorrhoids, in preg- 
nancy, and when there is pelvic irritation, as it does not cause 
pelvic congestion. 

Rhubarb. — Rhubarb is not only a laxative, but is also some- 
what of a bitter tonic. In large doses it is almost an irritant 
cathartic, hence rhubarb should not often be used when there is 
inflammation of the intestines. It is also doubtful if rhubarb 
uncombined is a good drug to be frequently used as a laxative, 
as its action often produces a subsequent constipation, or its 
continued action may cause irritation. As rhubarb contains 
chrysophanic acid, it may cause the urine to be yellow, and 
even present the appearance of bilious urine. This yellow 
urine will turn to purple or red if it is made alkaline. Rhubarb 
is excreted in the milk and may affect a nursing child, when 
taken by the mother. 

The most frequently used rhubarb preparation is the Com- 
pound Rhubarb Pill, each pill of which contains 2 grains of 
rhubarb and 1}^ grains of aloes. This pill is a stimulating 
laxative, but for the reasons above stated, rhubarb should not 
be given for any great length of time. A pleasant preparation 
of rhubarb for children is the aromatic syrup. The Pharma- 



1J\XATI\^S 



i6S 



* 



copoeia also recognizes an aromatic tincture, and the Compoimd 
Rhubarb Powder (Gregory *s Powder). This contains 25 per 
cent, of rhubarb, 65 per cent* of magnesium oxide, and 10 per 
cent, of Jamaica ginger. The dose of this mixture is 2 Gm. 
(30 grains). It is not pleasant to take, and is probably rarely 
needed, 

Phenolphifmkin.— This chemical drug, a much lauded laxa- 
tive, is best given in a tablet, which should be well chewed 
before swallowing. It is pleasant to take, as it is tasteless, and 
for children is generally given in a sweetened tablet. For a 
short time it is a well acting laxative, but it may soon cause 
irritation of the intestines, especially of the large bowel. 

This drug has been added surreptitiously to many laxative 
foods, such as biscuits, crackers, and even confections, and 
these preparations are urged as laxatives for children. Such 
a use of this drug is inexcusable, as it can do harm both to the 
bowel and, rarely, to the kidneys, especially when it is taken for 
a considerable length of time. 

Senna. — Senna is one of the simplest and one of the best of 
the laxatives. It can be taken for a long time without harm, 
does not leave an after effect of constipation, and is non- 
irritant. Frequently the leaves are chewed and swallowed be- 
fore bedtime; or they may be chopped up with figs and taken 
as a confection. The Compound Licorice Powder, as before 
stated, has a laxative effect largely due to its senna. The 
official Fluidextract of Senna is one of the best liquid prepara- 
tions of this drug, and the average dose is half a teaspoonful. 

Sulphur,— Sulphur is now rarely used as a laxative except in 
the combination of the Compound Licorice Powder. It 
produces a disagreeable gas in the lower intestine, and some- 
times gives the odor of sulphur to the breath and to the per- 
spiration; but as a simple laxative it is efficient, producing soft, 
pultaceous, and generally not water>', stools. The preparation 
of sulphur used as a laxative is the official Sulphur Lotum, 
washed sulphur. The dose is 4 Gm, (i drachm). 

Many of the laxative drugs slightly stimulate the uterus, 
probably not enough to cause abortion, but often enough to 
hasten menstruation, if it is due. This is especially true of 



l66 THE PRINCIPLES OF THERAPEUTICS 

podophyllum, aloes and rhubarb; even senna and cascara may- 
cause some slight stimulation of the uterus. Many of these 
drugs are excreted in the milk. 

PURGATIVES 

• 

Large doses of most of the above laxative drugs will cause a 
purgative action, but if such action is desired, it is better 
caused by calomel, castor oil, or a saline purge. 

Calomel. — ^The routine use of calomel or of any other form of 
mercury as a purgative in the beginning of every acute disease 
is, of course, a mistake. Not infrequently, however, a small 
dose of calomel combined with some other drug, as aloin, 
rhubarb, or senna, is good treatment in the beginning of many 
diseases. Such a dose of calomel may be advisable in the 
beginning of the treatment of constipation, of an acute indiges- 
tion, or of an acute diarrhea. The dose need not be large, but 
should be sufficient (from 0.05 to o.io Gm. (about i to 2 
grains), rarely more) and best given with an alkali, as the 
bicarbonate of sodium 0.50 to i Gm. (73^ to 15 grains), and not 
on an empty stomach. Calomel should be given with some 
simple food, as milk, or malted milk, or with crackers and 
water. Ordinarily it will take from five to eight hours for 
calomel to cause cathartic action; therefore it is the cathartic 
of choice when one must be given at bedtime. One grain or 
one and a half grains of calomel given at night with an aloin 
tablet, of the combination above suggested, will cause good 
catharsis in the morning. If for any reason the calomel action 
is delayed, or if it is given alone, some saline purgative may be 
given in the morning. 

As soon as calomel reaches the intestine it is decomposed by 
the alkaline secretions into mercury and the yellow oxide of 
mercury, and therefore there is developed some antiseptic action 
in the intestine. But unless such antiseptic action of calomel 
in the intestine is intended, as may be desirable at times in 
intestinal disturbances of young children, calomel should not 
be given in divided doses. In other words, the fad of 3^{o of a 
grain of calomel every half hour or hour until a grain or more 
has been taken is bad medication. The first doses of the calomel 



PXmGATIVES 



167 



are causing irritation before the last dose has begun to act. 
The result is duodenal irritation, often nausea and vomiting, 
and perhaps loss of appetite, without efficient movement of the 
bowels. Salivation may even be caused by such medication. 
It is much better to select the dose of calomel deemed best and 
give it all at once. The 3 10 grain calomel treatment to cause 
movement of the bowels after an operation is very prevalent, 
but deplorable. 

Castor Oil. — This cathartic oil is still the old stand -by for 
purgative action from childhood to old age. Although it 
develops in the intestine a slight irritant which causes catharsis, 
it never causes inflammation, and may even soothe an inflamed 
membrane. It causes catharsis that is not active, so that little 
harm can be done in intestinal obstnictioe or in appendicitis. 
If castor oil does not act on account of intestinal obstruction, 
other cathartics should generally not be given. Castor oil acts 
in from three to six hours, and therefore should not be given at 
bedtime. 

Almost tasteless castor oil can now be obtained, but it is 
never pleasant to take, although young children do not mind it. 
It is well given in an efifervescing w^ater, or added to some soda 
fountain drink, especially to the preparations flavored mth oil 
of wintergreen. At home it may be taken on black coffee, or 
may be given in a wineglass as follows: salt at the bottom of the 
glass, then cold water, then the oil is placed in the center of the 
glass, and the whole is swallowed at once, and the taste left is 
that of the salt. Or it may be administered on lemon juice and 
cracked ice. The dose is from a teaspoonful to two tablespoon- 
fuls, the usual dose for an adult being one tablespoonful, or half 
an ounce. Large flexible capsules of castor oil may be swallow^ed 
after the capsule is moistened. Many individuals can swallow 
capsules better with a warm liquid, as milk, coffee, tea, or 
malted milk, than they can with plain water. In swallowing 
all pills and capsules the head should be thrown forward, not up 
and back, and the difficulty of swallowing them will be very 
much lessened. 

The National Formulary offers an aromatic preparation of 
castor oil that is not unpleasant. 




l68 THE PRINCIPLES OF THERAPEUTICS 

SALINE PURGATIVES 

The saline purgatives act mostly as such by causing an in- 
creased amount of water to remain in the intestine or to be 
passed into the intestine by osmosis, so that the weight of the 
increased liquid in the intestine is what really causes the purga- 
tive action. For this very reason a saline purge will act better, 
more rapidly and more eflBdently, if the patient is up and about. 
The salts that are the slowest to be absorbed from the intestine 
are those that act the best as purgatives. Those that are the 
most readily absorbed are those that act the least eflSciently as 
purgatives. 

Salines interfere with the absorption of water that reaches 
the intestines, and, if in concentrated solutions, they may, by 
osmosis, cause water to pass from the blood into the intestine. 
Hence when they act, all this water is evacuated, and the patient 
often feels faint and thirsty. Magnesium sulphate seems to be 
converted in the intestine into magnesium bicarbonate and 
sodium sulphate, and this combination makes a more active 
watery purge than is caused by some of the other salines. Un- 
less there is some special reason why salines should be given 
concentrated, they should be administered well diluted. If given 
in strong solutions they are likely to remain in the stomach 
until enough water has been acquired to render the solutions 
isotonic, and during this process irritation of the stomach 
mucous membrane is caused and the passage into the intestine 
is delayed. When the saline solutions enter the intestine, if 
there is no obstruction to peristalsis, they are rapidly passed 
along and evacuated in anywhere from one to four hours. If 
anything prevents peristalsis or slows peristalsis, catharsis may 
not occur, or there may be several small troublesome movements 
instead of the complete evacuation. If the patient lies in bed, 
or is under the influence of some narcotic drug, or if the dose is 
not large and he goes to sleep, peristalsis is delayed and the 
evacuation of the bowels is delayed, and eflBcient action of the 
saline does not occur. Also, for the reasons above stated, if a 
saline is taken at night it may not cause catharsis, as the night 
rest may allow time for the water that the salt has retained to 



SALINE PURGATIVES 



169 



be re-absorbed with some of the dissolved salt, and the absorbed 
salt may have slight diuretic action. 

It has been shown that magnesium sulphate, Epsom salt, 
tends to increase acidity of the urine, and the reverse is true of 
sodium sulphate, Glauber's salt. This is one more reason that 
in serious toxic conditions magnesium sulphate, the most used 
saline cathartic, is not the safest drug to administer, in fact, 
other salines should preferably be used. Also, if for any reason 
the magnesium ion is absorbed, an added nervous depression 
will occur. It is doubtful if salines really expell many toxins or 
pathogenic germs from the intestines. The salines have their 
value in causing quick evacuation of the bowels, but they are 
used too freely and too much in serious conditions without tangi- 
ble therapeutic results, and often to the patient's harm. 

Theoretically, the more concentrated the salt solution that 
is taken the more water will be drawn from the body to the 
intestines; therefore to deplete the system or to aid in causing 
absorption of exudates the saline cathartics are given in con- 
centrated solution. 

Most salines will act in from two to four hours, if the dose 
given is sufficient, and when they act with this rapidity most of 
the salt is excreted in the stools. 

A not bad tasting saline purgative is the official Puhis 
Effervescens Compositus, know^n as the Seidlitz powder. This 
official preparation is put up in two papers, the blue paper 
containing sodium bicarbonate and potassium and sodium tar- 
trate (Rochelle salt), the white paper containing tartaric acid. 
The contents of one paper should be dissolved in one-third of 
a glass of water, and the contents of the other paper in one- 
third of another glass of water; they should then be poured 
together slowly so that the effervescence will not be too turbu- 
lent and a part of the solution be lost. It should then be slowly 
drunk while it is finishing effervescing, not while it is in 
violent ebullition, lest too much distention of the stomach be 
caused. 

A pleasant saline solution is the official Liquor Magncsii 
CiiraHSy which is an effervescing preparation of magnesium 
citrate. It is prepared in twelve-ounce bottles, and the whole 



lyo THE PRINCIPLES OF THERAPEUTICS 

of it is not a large dose, although two-thirds of it is often 
sufficient. It is a palatable sour drink. 

Sodium Phosphate tastes like table salt, and is rather nau- 
seating unless it is taken well diluted or in lemonade; or it may 
be taken in an effervescing mixture. It is a mild purgative in 
the dose of 4 Gm. (i drachm). An effervescing preparation is 
official. 

Potassium and Sodium Tartrate (Rochelle salt) is an efficient, 
not bad tasting preparation, and the dose is 15 Gm. (about 4 
drachms) taken well diluted. 

Magnesium Sulphate (Epsom salt) is the most efficient of the 
saline purgatives, it is bitter and salt at the same time, and very 
disagreeable unless taken in an effervescing mixture. The dose 
is 15 Gm. (about 4 drachms). If the saline is likely not to act 
quickly and hence may be absorbed, some salt other than magne- 
sium sulphate should be selected, as magnesium may be seriously 
depressant. 

Sodium Sulphate (Glauber's salt) is the most disagreeable of 
the salines and is nauseating to most individuals, but it is effi- 
cient and useful, and is preferred by some physicians. The 
dose is 15 Gm. (about 4 drachms). 

Carlsbad Salt varies slightly in its composition, but generally 
it is composed of sodium sulphate 4 parts, sodium bicarbonate 
2 parts, and sodium chloride i part. Therefore it will be seen 
that any combination of a saline laxative with an alkali will 
be as efficient as this much used and much advertised saline. 

The saline purgatives may be given at any time, except late 
in the evening. They are best given before breakfast, and act 
most efficiently when given in hot water. 

The indications for the use of the saline cathartics are when 
rapid evacuation of the bowels is desired, and when castor oil 
is not preferred. They are also used in regular daily morning 
doses to cause depletion in plethora, in high blood-pressure, and 
when it is deemed advisable in kidney insufficiency. It should 
be emphasized that it is not always well to use salts that may be 
more or less absorbed and cause more or less difficult excretion by 
insufficient kidneys. The saline purgatives have been used too 
much, and the value of the salines in causing excretion of sys- 



mitlTANT PURGATIVES 



171 



temic toxms through the bowels has been over estimated. The 
salines, when given in concentrated solutions and when the 
amount of water ingested is diminished, may cause absorption 
of exudates and effusions. 



IRRITANT PURGATIVES 

The drastic or irritant purgatives that are most used are 
colocynth, croton oil, elaterium, and jalap. Colocynth is 
never used alone, but always in combination with some other 
cathartic. It is doubtful if the drug is needed, 

Croton oil is a very rapidly acting cathartic, and in some 
comatose conditions, when there is no obstruction of the bowels 
it has therapeutic value. 

Elaterium has been much used to cause watery purging, with 
the object of eliminating toxins, by the bowels, that cannot be 
excreted by deficient kidneys. It is doubtful if nitrogenous 
poisons can be much eliminated by this method. Elaterium has 
also been much used in dropsies, with the object of eliminating 
large amounts of water by way of the intestines, thus promoting 
absorption and aiding the removal of effusions. It is thought 
to be especially valuable when the kidneys do not work and diu- 
retics are not satisfactory. Catharsis from this drug is very 
weakening, and unless the heart is strong, the drug should not be 
used. 

Jalap is generally given in combination with some other 
cathartic, also with the object of causing watery stools, and 
therefore depletion. Its action is not so depressant to the 
circulation as is elaterium. 

To sum up the discussion of irritant purgatives, it may be 
stated that croton oil is rarely needed, but is a most efficient, 
quickly acting cathartic; that elaterium is vGvy rarely indicated; 
and that jalap may be occasionally used. These drugs have 
come into disrepute because it has been found that large 
depletion by the bowels is very depressant to the circulation, 
and that in most dropsies there is cardiac insufficiency, and 
anything that increases that insufficiency is serious for the 
patient. Many a patient with cardiac dropsy has had his 
death hastened by profuse catharsis. Another reason that 



172 THE PRINCIPLES OF THERAPEUTICS 

these drugs have come into disrepute is because it has been 
learned, as above stated, that in insufficiency of the kidneys the 
irritants that are retained in the blood and act as toxic poisons 
cannot be eliminated in any great amounts by profuse purging. 

Colocynth (Bitter Apple) when used at all is given in combi- 
nation with other drugs. It is an active irritant cathartic, 
and would not be mentioned here if the official Compound 
Extract of Colocynth (which contains, besides colocynth, aloes 
and resin of scammony) was not, unnecessarily, frequently 
added to cathartic combinations. It is also mentioned because 
it enters into the combination of the Compound Cathartic 
Pill, which is used so largely in all hospitals. 

Cfoton Oil\s2L yellow fixed oil, irritant to the skin and mucous 
membranes. When rubbed on the skin it will cause a pustular 
eruption, and has been used as a counterirritant, but is now 
rarely used externally. Internally it is an irritant, imless well 
diluted. When absorbed from any part of the alimentary canal 
it will soon cause purging. Over-action of this drug, as of any 
of the other irritant cathartics, will cause an inflammation of 
the intestine. The dose is one or two drops, well diluted. If 
the patient is comatose, it may be given on granulated sugar for 
absorption in the mouth. Catharsis generally occurs in from 
one to two hours. 

Jalap is used only in some preparations. It is an active, 
mildly irritant cathartic, causing watery movements in three 
or four hours. It enters into the combination of the Compound 
Cathartic Pill in the form of the official resin. The best 
preparation of jalap, if watery movements of the bowels are 
desired without danger of much irritation or much depression, 
is the official Pulvis JalapcB Compositus. This powder contains 
35 parts of jalap and 65 parts of potassium bitartrate, and the 
dose is 2 Gm. (30 grains), which may be repeated in four to 
six hours, if it has not satisfactorily acted. 

Compound Cathartic Pills are ancient and fairly honorable, 
but are certainly not up to date. Few prescribers recognize 
that this pill represents a combination of eight ingredients, 
namely, colocynth, aloes, scammony, calomel, jalap, gamboge,* 
cardamom seed and soap. This shotgun prescription may 



TO DIMINISH INTESTINAL PUTREFACTION 



J 73 



produce the desired results, but its use is simply a matter of 
habit. Other more simple purgatives will succeed as well, and 
in this age of simplicity in the medicinal treatment of disease the 
compound cathartic pill should be eliminated, 

DRUGS USED TO DIMINISH INTKTINAL PUTREFACTION 

It has long been a question of doubt as to the efficiency of the 
so-called bowel antiseptics. Certain specific germs can be 
killed in the intestine with special germicides, but, of course, 
it is impossible to render the intestines aseptic. On the other 
hand, the different flora of the intestines can be changed, not 
only by diet, but by drugs* A change from an animal protein 
diet to a vegetable diet will change the intestinal flora. A 
change from a mixed diet to a pure milk diet, or the reverse, 
will also change the intestinal flora. Probably many drugs act 
as antiseptics in the upper part of the intestine; most of the 
salicj^lic acid preparations and some of the phenol combinations 
have such action* Perhaps some of the synthetic drugs, es- 
pecially the antipyretics, and some of the metallic drugs, 
especially calomel, will have some antiseptic action in the upper 
part of the intestines; but the drugs that are most successful in 
causing some sort of antiseptic action in this region are beta- 
naph thol and salol . Beianaphihol can act as a depressant poison, 
and consequently, except when intestinal parasites are to be 
eradicated, the drug should not often be used in intestinal 
putrefaction. Salol (phenyl salicylate) is the best of the bowel 
antiseptics, as it is changed in the upper intestine (in alkaline 
solutions) into salic^'lic acid and phenol. In ordinary doses 
for a short length of time it is non-poisonous, and the only 
symptoms of poisoning are those of a weak phenol. 

The most successful method of diminishing intestinal putre- 
faction IS by a radical change in the diet in which all protein is 
temporarily removed, especially all meat proteins. Various 
forms of lactic acid bacilli and various forms of fermented milk 
are used to check putrefaction. 

It has long been considered that the B, bidgaricus was the best 
of the lactic add bacilli for the purpose of changing the bacterial 
flora in the intestine and for preventing putrefaction. Lately, 



1 




174 THE PRINCIPLES OF THERAPEUTICS 

however, Rettger^ has shown that this bacillus cannot be trans- 
planted into the intestine, but that it allows to develop the B, 
acidophilus, a normal constituent of the intestine, and it is this 
bacillus which is capable of changing the intestinal flora. Con- 
sequently, theoretically it would seem more logical to administer 
directly the B. acidopkilus, perhaps preferably as milk soured 
by this germ. Besides the various forms of badllary milk 
offered, liquid cultures may be obtained and taken with watet 
or the tablets of Bulgarian bacilli may be chewed up and swal- 
lowed after meals. If the food previously taken has not 
contained starch and sugar, a small amount of sugar, best 
sugar of milk, should be eaten or taken with the tablets or 
culture. 

Yeast, both brewers' yeast and the ordinary compressed 
yeast, is valuable in changing the intestinal flora. The organism 
this yeast contains is the saccharomyces cerevisue. Yeast con- 
tains a large amount of nuclein. It may liberate lactic acid, 
and not only yeast preparations, but also the Bulgarian bacilli 
preparations, should not be given for any great length of time, 
as they tend to cause hyperacidity and joint pains. It is best 
to give lactic bacilli preparations intermittently, thus changing 
the intestinal flora for a time, then allowing the reverse change 
by stopping the treatment, and then to again give the bacilli. 
Lactic bacilli treatment combined with the proper diet will 
many times completely eliminate intestinal putrefaction. 

Yeast has long been administered in infections, and is fre- 
quently a very valuable treatment. It cleans the tongue, 
causes movements of the bowels, stimulates the production of 
white corpuscles, and seems at times to combat streptococcic 
infections. It has also been used locally for various purulent 
conditions in douches and washes. Brewers' yeast can be 
used in full strength or diluted for such purposes. Internally, 
the dose is a tablespoonful of liquid brewers' yeast,^ well diluted, 
or from 3^ to 3^ of a compressed yeast cake, dissolved in a glass 
of water. . This dose may be taken once, twice, or three times 
a day, as deemed advisable, the dose to be reduced, if it causes 

1 Proceedings of the Nadonal Academy of Sciences. Vol. 6, No. 7, p. 423 
July, 1920. 



ANTHELMINTICS 



I7S 



purging or nausea. This soured drink is not disagreeable to 
most peoplcj and may be agreeable to those who have fever* 

Dried preparations of brewers' yeast may be obtained j but 
they are not quite as satisfactory^ as are the fresh preparations. 
The dried brewers* yeast is quite efficient as a carrier of vita- 
mines that are activators of nutrition and stimulants to the 
appetite. The dose for this purpose is one gram ( 1 5 grains) three 
times a day, taken with the meals* Unless special care is taken 
in the method of drying aad preserving this yeast, it readily 
becomes wormy. 

It has been learned that sugar of milk (lactose), dextrose 

(glucose) and dexiri-maltose (f.^., dextrine and maltose) act 

naore or less as preventives of intestinal putrefaction. They 

are therefore valuable additions to the foods of indi\idualswho 

are suflfering from that condition, and prevent such putrefaction 

when added to the milk and other artificial food of young 

children. 

ANTHELMINTICS 

The intestinal parasites that are coram on and must be medicin- 
ally eradicated are the tapeworms {tcftiajj of which there are 
three principal varieties, the pork, the beef, and the fish, the 
last being rare in this country; the round-worm {a^caris luwhri- 
caides); the pin-wonn {oxyuris vermkularu); and the hook- 
worm {necator Anwrkanus), Another chronic infection of the 
intestine is the atneba, the cause of amebic dysentery. Acute 
infections of the intestines, as occur in typhoid fever, and carriers 
of pathogenic germs in the intestines, are not cured by anthel- 
mintics. The stools of aU patients who have intestinal para- 
sites of any kind should be disinfected. 

Tape-worms.^ — The drugs used to eradicate tape-worms are, 
aspidium, pelletierine tannate, and pumpkin and squash seeds- 
Pomegranate has also been used for this purpose. Pumpkin and 
squash seeds are harmless and infusions (not boiled) of 
ground pumpkin or squash seeds are often very successful in 
eradicating the worm, A treatment is not successful unless the 
head of the tape-worm is eliminated. The most used drug 
is aspidium (male fern), but a drug much in vogue to-day is 
pelletierine tannate. 



176 THE PRINCIPLES OF THERAPEUTICS 

An anthelmintic should not be given until the patient has 
been previously more or less starved. Toward that end, free 
purging ^by some saline cathartic) is caused in the afternoon of 
the day before the treatment is to be begun, and the patient has 
only some light liquid food for supper that evening, as a cup of 
gruel or a bowl of soup. Early in the morning the patient 
should take the male fern as directed: 

Oleoresin aspidium 4 Gm, 

Make eight capsules. 

Take four capsules with half a glass of hot water, and the 
remaining four capsules in an hour with more hot water. The 
capsules should be uncapped before swallowing. 

In two more hours the patient should receive an ounce of 
Epsom or Rochelle salt, well diluted, thus to insure the rapid 
passage of the aspidium with the stupefied worm through the 
alimentary canal. 

Neither castor oil nor any other oil should be given a patient 
who has taken aspidium, as oils promote absorption of the drug 
and therefore poisoning. 

If during the time of the administration of these drugs the 
patient is faint, he may have clear tea, cofifee, or bouillon. Also 
he may be given a dose of strychnine. One hour after taking 
the Epsom or Rochelle salt he may have a cup of cereal gruel, or a 
poached egg, or some broth. The patient should lie down, 
except when it is necessary that he be up. He should not be 
left alone, and must have nearby conveniences for movements 
of the bowels, as he is likely to become faint from the severity 
of the treatment. Either a trained nurse or a physician should 
stay with him during the hours of the active treatment. If the 
head of the tape- worm is obtained, the patient's troubles are 
ended, unless he has more than one worm. 

Treatment with other vermifuges require the same privation 
of food and about the same method of procedure on the day 
of the administration of the active drug. Ifpelletierinetannate 
is used, the dose is about 0.30 Gm. (5 grains), given in water. 

Aspidium (Male Fern) is administered as the oleoresin, and 
is used only for the eradication of tape-worms. The method of 



ANTHELMINTICS 



177 



its administration is as above described. In overdoses, or 
when it is long contained in the intestine (t, ^., when cathartics 
do not act thoroughly after it has been ingested) it w411 cause 
vomiting, diarrhea, tremors and convulsions. The dose of the 
official oleoresin is 2 Gm. (30 grains). This dose may 
be repeated mthin an hour, if the patient is a strong 
adult, to insure its efficient action* If the patient is weak, or is 
a child, the dose of course should be diminished ; but the danger 
of poisoning lies not so much from the size of the dose as from 
the length of time it remains in the intestines. Purging must be 
caused in two or three hours after the final dose has been taken. 

Pelktkrine T annate is a mixture of the tannates of four al- 
kaloids, occurs as a yellowish powder, and has a slightly astrin- 
gent taste. It is used only for the eradication of tape-worms. 
The dose is about 0.30 Gm. (5 grains), taken with plenty of 
water, with the preparatory and after treatment as above 
described. 

Round-wonns* — The round-worm is not very frequent, as 
children do not now have the opportunity of, and are prevented 
from, eating infected food and drinking infpcted water. Unless 
worms have been found in the child 's stools, the symptoms as- 
cribed to them should not be considered as causing more than a 
possible diagnosis. A worm ha\nng been found in the stools, 
there are probably more, and the best drugs to eradicate them 
are santonin, thymol, spigelia, and wormseed oil. Santonin 
is perhaps the most used, and is well given in the following 
combination: 



Santomn 
Calomel 

Milk sufrar 

Make ten fwwders 



0.30 Gm. 
o . 20 Gm . 
3. Gm, 



Take a powder, with water, every hour, for three doses, A 
star\^ation period should precede the santonin, and some laxa- 
tive, such as the dtrate of magnesium or a Seidlitz powder (the 
amount depending upon the child^s age) should be given two 
hours after the last dose of the santonin has been taken. Neither 
castor oil nor other oils should be given in conjunction with 
santonin, as oils promote absorption and poisoning. 

12 



178 THE PRINCIPLES OF THERAPEUTICS 

It will likely be necessary to repeat this same treatment in a 
week, and perhaps again in two weeks, to be sure that all the 
worms are eliminated. 

Wormseed oil has often been given to eradicate round-worms 
in a dose of five drops, on sugar, repeated in an hour. The 
treatment should be preceded by a starvation period and a 
cathartic, and be followed by a cathartic. 

Santonin occurs as colorless, shining prisms or as a crystalline 
powder, insoluble in water, and is best given in combination 
with a cathartic, as above suggested. As it is very poisonous, 
and may aflfect the eye-sight, and may cause tremors and con- 
vulsions, it should not be given by druggists to mothers for their 
children without a physician's perscription; the promiscuous 
administration of santonin tablets is inexcusable. 

Betanaphthol (Naphthol) is a phenol, and occurs as a yellow- 
ish-white crystalline powder, practically insoluble in water, but 
very soluble in alcohol. It has been used as an external antisep- 
tic, and is an intestinal antiseptic and germicide. It may cause 
poisoning, with symptoms similar to phenol poisoning, or it may 
cause destruction of red blood cells, and, although frequently 
successful as an anthelmintic, other drugs are better and safer. 
The dose of betanaphthol is 0.25 Gm. (4 grains), best given in 
capsules. 

Spigelia (Pinkroot) has long been used as an anthelmintic, 
for round-worms especially, although it has also been used for 
pin-worms. It is a non-poisonous, mild anthelmintic, best 
administered as the official fluidextract, and best combined with 
a laxative. The most satisfactory combination is with the 
fluidextract of senna. These preparations may be combined 
in equal parts, and the child having been without food for a 
number of hours, a teaspoonful of this mixture may be given 
every hour for three doses. If in a few hours the bowels do 
not move, a more active purgative may be administered. 

Pm-wonns.— These small worms occur in the rectum and 
cause very troublesome irritation, and often eczema develops 
from the scratching. The most used preparation to eradicate 
these worms is a decoction of quassia. The decoction is made 
by placing 50 grams of quassia chips in 750 mils of water and 



ANTHELMINTICS 



179 



boiling it down to 500 mils. This strained solution is then in- 
jected into the rectum which has been previously washed with 
a w eak soap and water ene ma. This trcatmen t m ust be repeated 
for many days. Injections of glycerin and water have also 
been used, and also Lisulphate of quinine solutions, in about i 
per cent, strength, are often successful. The bow^els most move, 
daily, with some simple laxative, as senna, and it may be well to 
give a few doses of spigeUa, as above suggested for round-worms* 
The local eczema should be treated with a weak phenol oint- 
ment. Infants and young children should be so clothed that 
their fingers cannot become contaminated and make re-infection 
possible. 

Hook-worms. — This very common cause of general debility 
and anemia in the Southern States can be completely cured, and 
will probably gradually be eradicated. The treatment is with 
thymol or worm-seed oil. The preparatory treatment is much 
the same as has been described under the treatment of tape- 
worm* After the bowels have freely moved in the morning, 
one-hatf the dose decided upon is given, and the other half is 
given in two hours. The dose of thymoi^nust be large to be 
effective, and the adult dose should be 3 or 4 grams (45 to 60 
grains). The dose for children should be computed from this 
adult dose; a ten-year old child should receive half the dose; 
a five-year old child one-quarter of the dose, etc. Ferrell be- 
lieves that thymol acts better when combined with an equal part 
of sugar of mUk. It is best administered as a powder, in cap- 
sules, and the capsules should be uncapped at the time of 
swallowing. Two hours after the last dose of thymol, half an 
ounce to an ounce of Epsom salt, or Rochelle salt, should be 
taken, this to be repeated if the bowels have not moved in four 
hours. The danger from thymol Ees in its absorption, and the 
longer it remains in the intestine, the more likely is absorption to 
occur. When the patient is reclining he should lie on his right 
side to facilitate the passage of the thymol into the intestine. 

Wormseed oil has been shoiMi to be as effective as thymol in 
eradicating hook-worms, and it is not as poisonous a drug. 
While wormseed oil does not kill the hook-worms, it seems to 
stupefy them, and if, after a short action of the wormseed oil, 



l8o THE PRINCIPLES OF THERAPEUTICS 

a brisk cathartic is given, the worms are passed out of the 
bowels. While castor oil or any other kind of oil must not be 
used as a cathartic after thymol treatment, castor oil may be 
given as a cathartic after wormseed oil has been administered. 
The dose of wormseed oil suggested is one drop for every year 
of the age of the child up to fifteen years. It may be given on 
granulated sugar. This dose may be repeated every two hours 
for three doses, and two hours later the child receives a full dose 
of castor oil. The preparatory treatment is the same as when 
other anthelmintics are used; i.e., sl starvation period, then 
purging, and later sustaining treatment. 

As it is difficult to eradicate hook-worms at one treatment, 
the anthelmintic may have to be repeated several times at six- 
day intervals. Whenever depression occurs from these treat- 
ments, coffee, caffeine, atropine, and other cardiac stimulants 
may be needed. Throughout the treatment the patient should 
be under the careful observation of the physician. 

Thymol is a phenol, and occurs as colorless prisms, practically 
insoluble in water, very soluble in alcohol, and has a pungent, 
aromatic taste. It is often added to gargles and sprays, in 
weak solutions, for its antiseptic action, and has been used as a 
bowel antiseptic, but it should not be used internally except 
for the specific purpose of eradicating hook-worms, as it is a 
drug which may readily cause poisoning. The poisoning that it 
causes is typically of the phenol type; it may cause nausea, 
vomiting, sweating, dizziness, and collapse. It may cause the 
urine to become dark or greenish, and it is more or less irritant 
to the kidneys. The intestinal antiseptic dose is o.io Gm. 
(about 2 grains), best given in capsules. The Pharmacopoeia 
gives the anthelmintic dose as i gram (15 grains), but in the 
treatment of hook-worm disease much larger doses must be 
given, as above described. 

Carvacrol is produced from spruce turpentine, is similar to 
thymol, and costs much less. Before this drug is used inter- 
nally as a substitute for thymol in hook-worm disease it 
must be more thoroughly investigated. 

OU of Chenopodium (Wormseed Oil) is a pale yellowish 
liquid, having a disagreeable taste and odor. This oil has been 



ANTHELMTNTICS 



l8l 



used to expel roued-wormsj but more especially, as just stated, 
for the eradication of hook-worms. It has no other uses. The 
United States Phannacopoeia gives the dose as 0*2 mil (3 
minims). The dose may be considered, as above described in 
the treatment of hook-worm, about 15 drops for an adult for 
any one day. 

At times oil of chenopodium may show no serious symptoms 
on the day of its lirst administration, but when it is repeated 
several days later there may be found an increased hyper- 
susceptibility to it. This is especially true if the individual is 
under-nourished. A cacliectic child or older patient should 
probably not receive the second treatment from the oil of cheno- 
podium unless his nutrition has improved, and he has taken a 
goodly amount of food. Castor oil given before and after the 
administration of wormseed oil has seemed to prevent toxic action 
from the latter. Also, plenty of water should be taken with the 
oil to insure its rapid passage from the stomach to the intestine. 

Amebic Dysentery. — Fortunately, this disease is not frequent 
in all parts of this countrj% but it is common in the tropics. 

The specific treatment of amebic dysentery is the adminis- 
tration of ipecac and emetine. The ipecac is administered by 
the mouth, perhaps best in the form of emetine bismuth iodide, 
as the ipecac in the intestines better eradicates the ameba that 
aie on the surface of the intestinal w^alls than does the dose of 
emetine given hypodermatically. Emetine given hypoder- 
matically wiU kill the ameba that are deej>er in the tissues of 
the intestinal walls. WTien ipecac is administered by the 
mouth in a form that is insoluble in the stomach, it is not 
necessary to precede the dose with opium or morphine, but in a 
form that is irritant to the stomach, vomiting will be caused 
unless a hypodermic of l^ to 3^^ of a grain of morphine has 
been previously administered. The Pharmacopoeial hypoder- 
matic dose of this preparation is stated to be 0.02 Gm. (H 
grain), but when this is to be repeated, as in amebic dysentery, 
the dose should be smaller ^ perhaps about o.oi Gm. given once 
or twice a day, hypodermatically, for three or four days, and 
then once a day for a week, this combined with the administra- 
tion of some form of ipecac by the mouth. 



l82 THE PRINCIPLES OP THERAPEUTICS 

It should be noted that emetine in too large doses may cause 
some paralysis and heart weakness, and may cause death. 

The best preparation for administration by the mouth is 
perhaps emetine bismuth iodide, which may be administered 
in 0.05 Gm. (about i grain) doses three times a day, for two 
weeks. According to Sollmann^ this preparation is but slightly 
soluble in the stomach, and seems to be freely soluble in alkaline 
media. Therefore it is soluble in the intestine. 

Emetine Hydrochloride is the hydrochloride of the alkaloid 
emetine, which is obtained from ipecac. It is a yellowish 
crystalline powder, is soluble in water, and is used mostly 
hypodermatically as a specific in amebic djrsentery. Its value 
in pyorrhea alveolaris has not been proved. The single dose 
is 0.02 Gm. {}4 grain) hypodermatically. 

Emetine Bismuth Iodide, N .N.R. is a complex iodide of 
emetine and bismuth, containing not far from 20 per cent, of 
anhydrous emetine and about 20 per cent, of bismuth. It 
rarely causes vomiting, and is a good method of administering 
ipecac for intestinal action. The dose is 0.20 Gm. (3 grains), 
given either in a single or in divided doses for several days, well 
administered in capsules. 

Akresta Ipecac. — This is an emetinated fullers' earth. It has 
been shown by Sollmann that the alkaloids of alcresta ipecac 
are insoluble not only in the stomach but in alkaline media. 
Therefore they may not be dissolved in the intestines. 

Caution. — Emetine in any form should always be used with 
care, as it may cause poisoning. 

It should be emphasized that the ipecac and emetine treat- 
ment of amebic dysentery does not heal the ulcers in the intes- 
tines, and after the ameba have been eradicated, this surgi- 
cal condition requires further treatment. 

Leukemia. — Benzene (Benzol) has been recommended and 
used in leukemia, as by its administration the number of white 
corpuscles is reduced. This is especially true if the roentgen- 
ray treatment is used coinddently. Several preparations may 
be obtained, and the dose of "benzene, medicinal," according to 

* Journal A. M. A., Oct. 11, 1919, p. 1125. 



DIAPHORETICS 



183 



New and Nonofficial Remedies, is 0.5 to i mil (8 to 15 minims) 
given four times a day, best in emulsion. Treatment with this 
drug is not mthout danger, and the condition of the patient 
and the condition of the blood must be watched. Its perma- 
nent value in this disease has not been proved. 



SECOND DIVISION 



CLASS I 

Drugs ADMiNisTEEtED Ikterhally For Their Action On 

The Skin 

drugs used to stimulate the acrivlty of the skin 

The surface of the body is dry, scaly and harsh in various 
chronic diseases of the skin, and it is also dry in hjpothyroidism, 
in chronic nephritis, and in diseased conditions of the liver. 
Any treatment that improves the systemic condition will 
improve the condition of the skin. Many times a dry skin — a 
skin that does not normaDy perspire— will be unpro%^ed by the 
administration of thyroid extract, if such medication is not 
contraindicated. Arsenic is also a stimulant to the skin, but 
it should not be given if there is disease of the kidneys or 
liver. The majority of dry skins, not due to organic diseases, 
are due to sub-thyroid secretion. 

A description of the action of arsenic and of thjToid gland 
extracts will be found on pages 382 and 406 respectively. 

DIAPHORETICS 

It IS desirable to increase the perspiration in fever, after 
chilling, and in some toxemias* The so-called antipyretic drugs 
all promote perspiration^ and especially valuable for this ac- 
tivity is antipyrine. Alcohol^ by dilating the peripheral blood- 
vessels, is a promo tor of perspiration. 

Of all methods to promote perspiration, the best are body 
baking, electric light cabinet baths, Turkish baths, ordinary 
hot baths, and strenuous exercise. Turkish baths and exercise 
are especially valuable in reducing obesity by causing perspi- 



184 THE PRINCIPLES OF THERAPEUTICS 

ration. Most of these physical methods of causing perspiration 
are of value in aborting a cold after chilling. 

Profuse sweating has long been advocated in systemic 
conditions. Whether caused by pilocarpine, by dry hot air, 
or by moist hot air, the value of profuse perspiration in eliminat- 
ing toxins, particularly in uremic conditions, is very doubtful. 
The action of alcohol and of antipyrine are described on pages 
238 and 337 respectively. 

Pilocaipus. — Administration. — ^Jaborandi occurs as the dried 
leaves of a South American plant. The active part of this 
drug is represented by its alkaloid, pilocarpine. Pilocarpus 
is not used as such, but it may be used as the official fluidextract, 
the dose of which is 2 mils (30 minims). As the alkaloid 
represents the activities of the plant, the drug is best used in the 
form of the official Pilocarpine Hydrochloridum. This salt 
occurs in colorless crystals and is very soluble in water and 
alcohol. The dose by the mouth is o.oi Gm. (3^ grain), and 
the hypodermic dose is 0.005 Gm. (H2 grain). For quick 
action, the hypodermatic method is the better. 

Action. — Pilocarpus has no external action. It is rapidly 
absorbed, and stimulates the sympathetic nerves, sweat glands, 
and salivary glands. It also stimulates the bronchial glands, 
and may cause profuse bronchial secretion. Consequently, 
in prostration or in impaired circulation, and especially if there 
are signs of edema of the lungs, it should not be used, as it 
can literally cause drowning by the enormous watery secretion 
into the lungs that may occur. It may also lower the blood- 
pressure and weaken the heart, therefore, in any condition of 
depression pilocarpine should not be used. 

In about ten minutes after its administration by the stomach 
(unless something prevents its absorption), and in about five 
minutes when it is administered hypodermatically, flushing of 
the face and neck occurs, from dilatation of the peripheral 
blood-vessels; and in about fifteen minutes sweating begins, 
which may persist for one or two hours, or even longer. 

The slight stimulation of the endings of the vagi nerves will 
slow the heart, although the heart is not strengthened but is 
really weakened, and soon the least exertion may cause the 



DIAPHORETICS 



»85 



; 



heart to become rapid. This is especially in e\'idence if the drug 
causes nausea or vomiting. Salivation may be profuse, the 
nasal secretion increased, and the lachrymal glands stimulated. 

Pilocarpine has been thought to stimulate the uterus to con- 
traction, and it may increase labor pains, but it should not be 
used for this purpose. When applied to the eye, it produces 
contraction of the pupil and increases the ocular tension* 

Over-aUion, — When this drug acts excessively, it not only 
causes profuse and prolonged sweating but also vomiting and 
diarrhea. It increases the secretion of the intestinal glands, 
and may disturb the pancreas and the glands of internal secre- 
tion, perhaps the suprarenal glands. 

Toxic Acliatt, — ^PDocarpine may cause dizziness, disturbed 
vision, cold perspiration^ and collapse^ and death may occur 
from pulmonary edema j or from heart failure. 

Treatment of Poisofting, — Besides evacuating the stomach, if 
the drug has been administered by the mouth or taken by 
accident^ tannic acid should be given* The physiologic anti- 
dote to pilocarpine is atropine, which should be given hj^o- 
dermatically. Atropine is directly opposed to the action of 
pilocarpine, nameJy, it inhibits the secretion of the skin and 
most of the glands of the bodyj stimulates the respiratory 
center, stimulates the heart and raises the blood-pressure. 

A patient suffering from pilocarpine poisoning should be 
surrounded with dry heat, and, besides the atropine, caffeine 
and strychnine should be administered. 

Uses, — The most important use of pilocarpine has been in the 
anasarca of nephritis and in uremia. The object was to pro- 
mote profuse perspiration, and therefore to eliminate water from 
the body and as many toxins as could be excreted by the skin. 
In uremic poisoning without general edema, the large excretion 
of water by the skin which pilocarpine promotes could do 
nothing but concentrate the toxins in the blood, and the amount 
of nitrogenous excretives that can be eliminated through the 
skin, even with profuse perspiration, is not great. More 
sodium chloride may be thus removed, but little urea is elimi- 
nated. Therefore, theoretically, this is not good treatment 
in such a condition: venesection would be better. On the 



l86 THE PRINCIPLES OF THERAPEUTICS 

other hand, if profuse sweating is advisable in such a condition, 
it is best promoted by some method of applying heat which 
would cause the same physical results without the prostration. 

If there is general anasarca, or even large localized edemas 
in nephritis, pilocarpine, by promoting a large excretion of 
water by the skin, if the patient is not flowed to ingest water, 
may cause resorption of the exudate. But while this process is 
going on the patient is likely to become debilitated. Edema 
with a weakened circulation, and certainly cardiac edemas, 
should not be treated by pilocarpine. If the kidneys are so 
damaged that applications of heat (if perspiration is desired) 
will not relieve the serious condition, neither will pilocarpine. 
Therefore pilocarpine treatment of serious conditions is gener- 
ally inadvisable. 

Pilocarpine has been suggested to promote secretion in the 
beginning of colds and acute bronchitis. The dose for this con- 
dition is small, and it is generally given by the mouth; but other 
treatments are better. 

Pilocarpine has also been suggested to promote the mammary 
secretion in lactation, but its action for this purpose is doubt- 
ful, as when the dose is sufficient to stimulate the mammary 
glands it will also be sufficient to promote perspiration, which is 
likely to diminish the lacteal secretion. 

The hydrochloride of pilocarpine has been used in i per cent, 
solutions in the eye for the same purpose as physostigmine 
(eserine) is used. It is a little less irritant than eserine, and, as 
above stated, will contract the pupils. Two or three drops of a 
I per cent solution may be dropped into the eye, two or 
three times a day. 

Pilocarpine has also been used in certain skin diseases, as 
psoriasis and dry eczema, but in most of these chronic dry condi- 
tions of the skin thyroid extract acts better. It has also been 
used to promote the growth of hair in baldness, but it is doubt- 
ful if there is any good reason for such use. 

DRUGS USED TO DECREASE PERSPIRATION 

Profuse, weakening perspiration often occurs at the time of 
the crisis of a disease or at any time when there is a rapid fall of 



GENlTOtTRINARY SYSTEM 



187 



temperature in disease. It also occurs as a part of septic in- 
fectioDj is especially common in acute rheumatism, and is a 
serious symptom of tuberculosis. 

The treatment of profuse perspiration is the application of dr>" 
heat, and the administration of J'^qo to J^f 00 grain of atropine 
sulphate. Preventive treatments are massage, warm alcohol 
rubs, circuIator>' stimulants, and anything that improves the 
general condition of the patient. 



SECOND DIVISION 



CLASS n 



l DitUGS USED FOR TOEIR ACTION ON THE G^aTOUWNARY 

^B System 

^H All vegetable foods and drugs of strong taste and smell are 

^^ mildly diuretic, such as onions, ga-rlic, radishesj celer>^, aspara- 
I gus^ asafetidaj and valerian^ as they are mild stimulants to the 

kidneys. All of the spices are more or less stimulant to the 
genitourinary mucous membranes, and hence should be avoided 
in kidney, bladder and other genitourinary inflammations- 
Tea and coffee should also be avoided when these regions are 
inflamed or irritated. All of the turpentines are stimulant to 
the kidneys, and in any large amount are irritant. 

Anything that irritates the kidneys, or any poison that is 
ingested and irritates them during its excretion will cause the 
following symptoms, in the order named: increased frequency 
of urination with diminishing amounts of urine passed; back- 
ache; perhaps vesical tenesmus and urethral burning; later 
an increased amount of mucus in the urine; then albumin; then 
blood; and finally suppression ; and, after some drugs, stranguF>\ 
The treatment of such an acute inflammation is that of acute 
nephritis. 

So-called diuretic drugs, whose names were legion, have 
become of less and less importance, until only a certain few have 
stood the test of effidenc)' and are of value. It is by no means 
always possible to increase the amount of urine, and especially 
is success often lacking when diuresis is most needed* 





l88 THE PRINCIPLES OF THERAPEUTICS 

The amount of urine is increased: 

1. By increased blood-pressure. 

(a) Hypertension. 

(b) Increased heart action. 

(c) Cold to the surface of the body. 

(d) Nervous excitement (fear, hysteria). 

2. By drugs that raise the blood-pressure. 

3. By drugs or substances that stimulate the secreting epi- 
thelium of the kidneys. 

The amount of urine is diminished: 

1. By low blood-pressure. 

(a) Insufficiency of the heart. 

(b) Shock. 

(c) Hemorrhage. 

{d) Heat to the surface of the body. 

2. By drugs that lower blood-pressure. 

3. By fever. 

4. By kidney lesions. 

5. By pressure on the kidney blood-vessels. 

Therefore, to increase the output of urine, with the kidneys 
intact, we must raise the general blood-pressure by heart tonics 
or by vasocontractors; or we must increase the bulk of the 
blood (by water) ; or we must give drugs that actually stimulate 
the kidney epithelium. 

DRUGS USED TO INCREASE THE AMOUNT OF URINE 

The best drugs for this purpose are those listed in the classi- 
fication, but before administering such a drug, it is essential to 
note some general physiologic principles. 

The skin and the kidneys act and react upon each other; the 
more secretion or excretion by the skin, the less by the kidneys,, 
and the reverse. If the skin cannot act during fever and is hot 
and dry, the kidneys soon become congested, and frequently 
excrete albumin. On the other hand, a profuse sweat during a 
feverish process may not only cause the urine to become con- 
centrated, but it may also cause it to contain albumin. When 



DnmETics 



189 



a large amount of skin has been destroyed by bums, and the 

secretion and excretion of the skin is seriously interfered mth, 
the kidneys are likely to become irritated, and the urine to 
become albuminous. Any serious skin disease that attacks a 
large portion of the surface of the body, preventing its normal 
acti\ity, may also cause kidney disturbance. The obverse 
of this is also true, namely, in chronic nephritis the skin is 
called upon to do extra work, and it, sooner or later, becomes 
dr>% irritated, and perhaps eczematous. When this condition 
of the skin develops the prognosis of the kidney disturbance is 
grave. Acute inflammations that attack large surfaces of the 
body, as scarlet fever, erysipelas and small-pox, also tend to 
cause kidney irritation, congestion, and perhaps inflammation. 

In any of these conditions named treatment aimed at a modi- 
fication of the urinary secretion is advisable. If the urine is 
concentrated and diminished in amount, plenty of water should 
be ingested, with perhaps some non-irritating drug that 
would increase the output of the urine. Often, however, the 
kidneys should be relieved by causing the skin to become more 
active, by hot baths and hot drinks, or by other methods that 
cause perspiration. 

If albumin is found in the urine, the diet should be non-irrita* 
ting and bland ; often meat, tea, coffee, spices and condiments 
should be withheld, and no drugs should be aUowed that could 
irritate the kidneys. If congestion of the kidneys has occurred, 
the treatment should be such as would prevent acute nephritis, if 
possible, and it may be inadvisable to push the ingestion of 
water. This, however, is determined by the cause of the kidney 
irritation. In general infection it may be well to give extra 
amounts of water, even at times by high enemas. 

Local congestion of the kidneys may be relieved by heat, 
applied as in body baking or by electric light baths, or by moist 
hot applications to the lumbar region. This is not with the 
object of causing elimination of toxins in uremic conditions, 
but vtith the object of relie\dng the congestion in the kidneys 
by dilating the systemic blood-vessels, especially the surface 
vessels. It should be emphasized that if there are edemas, 
either from kidney insufficiency or from cardiac insufficiency, 




igo THE PRINCIPLES OF THERAPEUTICS 

the ingestion of water should not be pushed, in fact it may be 
well to diminish the intake of water. 

There is probably no such thing as a "sedative" diuretic; 
hence if the kidne3rs are inflamed, everything should be taken 
out of the diet and every drug omitted that carries or produces 
salts difficult for inflamed kidneys to excrete. In other words, 
so-called diuretic drugs should never be administered in acute 
and rarely in chronic nephritis. 

The amount of urine is increased by buchu, which is a mild 
stimulant to the kidney epithelium ; by caffeine, which raises the 
blood-pressure, stimulates the heart, and is also a mild stimulant 
to the kidney epithelium; by digitalis, which strengthens the 
heart and raises the blood-pressure; by scoparius, which stimu- 
lates the epithelimn of the kidneys; by squill, which may raise 
the blood-pressure, and stimulates the kidney epithelium; by 
theobromine sodio-salicylate (diuretin) which slightly raises 
the blood-pressure and is a stimulant to the kidney epithelium. 

DRUGS USED TO RENDER THE URINE ALKALINE 

If the urine is very acid and irritates the bladder and urethra, 
as evidenced by an increased desire to urinate, with more or less 
pain, all food that increases the acidity of the urine should be 
withheld, a diet of milk and cereals given, plenty of water 
should be drunk, and no mineral adds shoidd be taken. With 
this increased acidity of the urine there may be lumbar backache 
joint pains, and other signs of disturbances from uric add. 

In this condition potassium or sodimn dtrate, given in doses 
of 2 grams, three times a day, directly ^ter meals, combined 
with a modified diet, is effective treatment. The old "A. B. C." 
mixture, i,e.y potassium acetate, potassimn bicarbonate and 
potassimn dtrate, is a heritage used in the treatment of gonorrhea 
that may be buried without causing privation. The acetate 
and the bicarbonate are more disagreeable and no more effident 
than the more pleasant dtrate of potassium. 

If there is acute bladder or urethral inflammation, the potas- 
simn or sodium citrate should be pushed to the point of ren- 
dering the urine alkaline, ever though it is necessary to give a 
2-gram dose four or five times a day to accomplish this purpose. 



DRUGS TO RENDER THE URINE ALKALINE 



191 



The urine, however, should not be allowed to be too long alka- 
line, as an alkaline urine tends, sooner or later, to irritate the 
mucous membrane of the bladder and cause more secretion of 
mucus jWith a tendency to alkaline deposits, and later, perhaps, 
ammoniacal fermentation and actual infection. Alkalies too 
long continued also debilitate the system rather than strengthen 
it, as they promote destructive metabolism^ Consequently, 
alkalies are not tonics to weak, convalescent and neurasthenic 
patients. On the other hand, nervous patients are many times 
quieted with calcium salts, which, however, would rarely alka- 
lize the urine. 

Urine that is too acid or too long alkaline may allow deposits 
of salts and the formation of calculi; hence in either case the 
diet should be modified according to the condition. 

Potassium Cilraie. — Potassium citrate occurs as transparent 
crystals or as a w^hite powder, is very soluble in water,has rather 
of an unpleasant taste, and is well administered in peppermint, 
wintergreen, or cinnamon water. Although the Pharmacopoe- 
ial dose is i Gm. (15 grains), in order to alkalize the urine gener- 
ally 2 Gm. (30 grains) must be given three or four times a day. 
The dose of 2 grams may be dissolved in 10 mils of a flavored 
water, and should be taken well diluted, best after meals, and 
on going to bed, if it is decided to give the drug four times a day. 
The official efferv^escing citrate of potassium is a pleasant method 
of administering this drug. The dose of this preparation is 4 
Gm. (1 drachm). An alkali given directly after meals more 
readily alkalizes the urine than when given at other times. 

Potassium citrate is not an antacid as far as the stomach is 
concerned. It is rapidly absorbed, tends to increase the alka- 
linity of the blood like all alkalies, somew^hat lowers blood-pres- 
sure, and increases nitrogenous metabolism. 

As the potassium element is slightly depressant to the muscu- 
lar system, the sodium salts are sometimes preferable. Some 
indigestion may be caused by potassium citrate, but poisoning 
will not occur. 

Sodium Ciirale* — Sodium citrate occurs in crj^stals or as a 
granular powder, has a saline taste, and is very soluble in water. 
The dose is the same, and the method of administration is the 




192 THE PRINCIPLES OF THERAPEUTICS 

same, and it is used for the same purposes as potassium citrate. 
The only advantage of the sodium salt is because sodium causes 
less muscle depression than potassium. 

DRUGS USED TO RENDER THE URINE ACID 

When the urine is too add, meat, coffee and tea should be 
withheld, and the diet should be limited to carbohydrates and 
to vegetable proteins. On the other hand, when the urine is 
alkaline, meat should be allowed and dilute hydrochloric add 
may be administered. In either condition more water should 
be taken to dilute the urine and therefore prevent deposits. 

An alkalinity of the urine may be temporary, due to drinking 
alkaline waters, or to a vegetable diet; or it may be due to 
some nervous disturbance, as shock or anxiety, or to actual 
disease of the brain. An alkaline urine deposits the alkaline 
phosphates, and if this deposition long continues, phosphatic 
calculi may occur, and later fermentation. Except sometimes 
soon after meals the urine should not be alkaline, but should 
be acid. 

The diet should be modified to, if possible, render the urine 
acid. Nerve tire should be prevented, and, if necessary, a rest 
cure should be ordered. Although drugs cannot be guaranteed 
to render the urine acid, the most successful are dilute hydro- 
chloric acid and acid sodium phosphate. Salol, and all forms 
of salicylic add, by causing salicyluric add to appear in the 
urine, will more or less prevent fermentation in the bladder 
and may render the urine acid. Hexamethylenamina (uro- 
tropin), especially if given in conjunction with acid sodium 
phosphate, will generally succeed in rendering an alkaline 
urine acid. 

Sodium Biphosphate. — Add sodium phosphate occurs as 
colorless crystals or white crystalline powder, has an add taste, 
and is very soluble in water. The dose is i to 1.5 Gm. (15 to 
22 grains), given well diluted. It is well administered in syrup 
of citric add and water. 

It is often advised that this drug be given in conjunction with 
hexamethylenamina when the urine is alkaline and an antisep- 



BACTERIA IN KEDNEYS AND BLADDER 



193 



tic is desired, as hexamethylenamina will not act in alkaline 
media; but these two dnigs, namely, acid sodium phosphate 
and hexamethylenaminaj should not be combined in the same 
prescription, and should be adininistered at different times so 
that one drug is out of the stomach before the other enters it 
on account of chemical changes that may occur. 

This salt does not change in the stomach, but is converted in 
the intestine into disodium hydrogen phosphate. The acid 
phosphate in the intestine is neutralized by alkali drawn from 
the blood, and to offset this reduction of the alkalinity of the 
blood more acid is excreted in the urine. In large doses it has 
a laxative effect. 

DRUGS USED TO PREVENT THE GROWTH OF BACTERIA IN 
THE KIDNEYS AND BLADDER 

To meet this indication, namely, to destroy bacteria growing 
in some focus in the kidney, in the pelvis of the kidney, or in 
the bladder, no drug exeeds in value hexamethylenamina. This 
drug may not be tolerated in doses that are efficient, and salol 
or methylene blue may be substituted. Both are valuable. 
The oil of santal may also meet this indication, as, like many 
resins and aromatic oils and the turpentines, it is not only a 
stimulant to the genitourinar)' mucous membrane, but it is 
more or less of an antiseptic during its excretion, and germs do 
not well grow in urine carrying a considerable amount of santal. 

Alkaline urines tend to allow bacteria to grow, especially 
staphylococci; consequently, all alkaline urines must be made 
add if possible, although colon bacilli wUl grow in both acid and 
alkaline urine. A bacilluria necessitates careful investigation as 
to its cause; also as to where the trouble lies, in the peKis of 
the kidney, in the bladder, or in the urethra. Whatever treat- 
ment is needed, surgical or other, one of the urinary antiseptics 
is advisable. In acute conditions, with bacilluria, salol or 
hexamethylenamina are the best drugs, pro\ided there is no 
inflammation of the kidneys. Methylene blue may also be 
used, and is not irritant. In chronic bacilluria santal oil is 
also of benefit. But, as just intimated, it is essential in every 

13 




1^4 THE PRINCIPLES OF THERAPEUTICS 

such condition that the diagnosis be made, and that surgical 
treatment be not too long delayed. 

All inflammations of the pelvis of the kidney, of the bladder, 
and of the urethra are surgical conditions and require local 
treatment. 

Hexamethylenamine. — Hexamethylenamine (urotropin), a 
condensation product of anmionia and formaldehyde, occurs in 
colorless crystals or as a white powder, and is very soluble in 
water. The Pharmacopoeial dose is 0.25 Gm. (4 grains); an 
effective dose as a urinary antiseptic is two or three times this 
amount. It is best given as a tablet or powder, dissolved in 
half a glass or more of water. It has been lauded for antiseptic 
and germicidal action in various parts of the body, but it has 
been shown that it cannot act as an antiseptic except in add 
media (f.c., it cannot give up its formaldehyde except in the 
presence of add), therefore it cannot act internally as an 
antiseptic except in the urinary tract when the urine is acid. 
A 0.25-gram dose may be administered several times a day, 
double that amount three or four times a day, or a gram (15 
grains) may be administered twice a day. In acute or chronic 
nephritis urotropin should not be administered, and in some 
individuals with normal kidneys it causes irritation, and in large 
doses may cause hematuria. Hexamethylenamina is sold 
imder many proprietary names, and sometimes is combined 
with other drugs, but none apparently has any advantage over 
the official hexamethylenamina. This drug should not be 
given in any form for any great length of time, at least not 
without intermission. 

Methylthionine Chloride. — Methylene blue occurs as a dark 
green crystalline powder, is soluble in water and alcohol, and the 
dose is o.io Gm. {1}^ grains), in capsules, taken with plenty of 
water. It has been used as a genitourinary antiseptic in 
gonorrhea, in infections of the bladder and of the pelvis of the 
kidney. The drug may be administered every six hours, and, 
as just stated, should be always taken with plenty of water. 
Under its action the ui^ine becomes blue or blue-green. It has 
been used with some success in malarial fever when quinine 
cannot be given. 



EMMENAGOGUES 



195 



This drug may cause nausea and vomiting, unless each dose is 
taken well diluted. If large doses have been given, it may cause 
backache, kidney and bladder irritationj and may even cause 
strangury and general depression. 

DRUGS USED TO STIMULATE THE MUCOUS MEMBRANES 

In chronic inflammation of the pelvis of the kidney, of the 
bladder and of the urethra, no one drug is more successful, in 
proper cases, than is santal oil. The more disagreeable copaiba, 
cubebs, com sUk, pichi, and numerous other lauded stimulant 
diuretics are no more efficient and generally not as favorable in 
their action as is the oil santaL 

Most of the drugs called stimulant diuretics stimulate the 
membrane of the genitourinary tract. All aromatic oils act in 
this manner, and these, as well as the drugs above mentioned 
modify the character of the urine and prevent the growth of 
germs, but they more or less disturb the digestion. 

Oil of SantaL — Oil of sandalwood is a volatile oil distilled 
from sandalwood, and occurs as a pale yellow, somewhat thick 
liquid having a strong odor and taste of sandalwood. It is 
best administered in flejoble capsules containing 0.30 to 0.60 
mils (5 to 10 minims), given three or four times a day, best 
after meals; or, if taken on an empty stomach, plenty of water 
should be drunk at the same time. 

Santal oil gives its odor to the urine and to the breath. 
Large doses, and even smaU doses sometimes, cause backache in 
the lumbar region and pain doi^Ti the ureters sometimes into the 
testicles. It not only acts as an antseptic in the urinary pas- 
sages, but many times seems to stimulate a chronic inflammation 
to more rapid healing. It should not be used in acute inflam- 
matory conditions. 

Santal oil has also been used as an expectorant to promote 
more active secretion in bronchitis, when the exudate is thick 

and tenacious. 

EMMENAGOGUES 

Before giving so-called emmenagogiieSi the cause of the 
amenorrhea must be sought and pregnancy must be excluded. 
If the cause of the amenorrhea is systemic, the underlying con- 




196 THE PRINCIPLES OF THERAPEUTICS 

dition must be treated. If there is anemia, proper diet and 
iron is the treatment. Amenorrhea is often due to endocrine 
gland disturbances, and a frequent cause is insufficiency of the 
thjrroid. Thjrroid feeding, ovarian feeding, and the adminis- 
tration of corpus luteum are all often efficient treatments. If 
there is dysmenorrhea, a local cause should be sought and, if 
found, treated. 

In the many preparations, Pharmacopoeial, National For- 
mulary, proprietary mixtures, and nostrums recommended for 
dysmenorrhea, the efficient ingredient is generally alcohol. The 
dose of each of these alcoholic preparations recommended is 
generally sufficient to cause alcoholic relaxation, and therefore 
a diminution of the pain. 

In proper cases, the most efficient emmenagogues are]thyroid, 
ovarian, and corpus luteum extracts. The use of these pre- 
parations in amenorrhea will be described in Part IV. If 
the patient is anemic, iron is a most valuable emmenagogue. 
Many times precipitated manganese dioxide in doses of o.io to 
0.20 Gm, (about 2 or 3 grains), best given in capsule, is efficient 
in hastening menstruation or causing a scanty menstruation to 
become more profuse. It should be given for several days 
before the expected flow. 

OXYTOCICS 

Different terms have been applied to these drugs. The term 
"oxytocic" should be limited to those drugs that have the 
power to hasten parturition. The term "ecbolic" has been 
applied to drugs which not only increase the rapidity of natural 
parturition, but which may cause such contraction of the uterus 
as to cause abortion. Such drugs have also been termed 
"abortifacients.'' Some drugs that cause contraction of a 
dilated uterus cannot produce abortion. 

If the uterus is unduly dilated after parturition, ergot will 
generally cause contraction of the uterus, often, however, 
interfering with desirable after pains which are necessary for the 
uterus to evacuate clots, etc. If chloroform has been adminis- 
tered during the parturition, an oxytocic is generally indicated, 
unless an assistant can sit at the bedside and clasp the uterus 



OXYTOCICS 



197 



through the abdomen until it normally contracts. If there 
IS post-partum hemorrhage, besides the drug treatment (ergot 
and pituitary extract) local measures are needed, as the intro- 
duction of ice into the uterus; or the reverse, namely, very hot 
water introduced into the uterus. 

For a dilated uterus at other times than post-partum, and 
when there is profuse bleeding, hydrastinine is of value, as is 
also quinine. Ergot frequently acts well in stopping profuse 
menstruation. For too frequent and too profuse uterine flow, 
especiaUy in young girls, mammary extract is of value. It 
should be urged that drugs that contract the uterus are used 
symptomatically, and the cause of the increased uterine flow 
must be diagnosed and properly treated. 

Mammary extract, in the form of tablets, given two, three or 
four times a day, beginning with the fourth or fifth day of the 
menstruation will frequently stop the flow in a normal manner, 
while ergot will cause sudden stoppage, with pain, and often 
to the disadvantage of the patient. In too frequent menstrua- 
tion, if mammary extract, one or two tablets a day, is given for 
at least a week before the date at which the menstruation has 
been coming, it may postpone the menstruation to the normal 
period. 

There is no question that ergot will generally slow any uterine 
flow, but it has the disadvantage of stopping the flow too soon 
and producing nausea in many patients. It also often raises 
the general blood-pressure, but not always. It should not be 
used after parturition as a routine practice, as it may cause 
contraction of the lower part of the uterus and thus shut up in 
the uterus blood clots and membrane, and it should rarely be 
used before the third stage of labor has been completed. 

Quinine sulphate has often been used to cause a better tone of 
the uterus after parturition, and to expel blood clots. It will 
also, in good sized doses, cause contraction of the uterus in pro- 
fuse menstruation, unless there is some more serious condition 
than simple dilatation present. 

Pituitary extracts, namely, the blood-pressure-raising stuff 
from the posterior lobe of the hypophysis, best given hypo- 
derma ticaUy, is of value (when used with care) in certain 





198 THE PRINCIPLES OF THERAPEUTICS 

conditions during parturition as an oxytocic. This drug 
always, by the way, raises the blood-pressure and stimulates the 
heart. 

Eydrastinine Hydrochloride. — Hydrastinine is obtained by 
the oxidation of hydrastine, and the hydrochloride occurs as 
light yellowish needles or as a powder, and is very soluble in 
water and alcohol. This preparation is more active than 
HydrastifUB HydrocMoridum^ as a uterine contractor, hence the 
latter is not needed. This drug raises the blood-pressure, 
generally slows the heart, and sometimes causes depression. 
The dose by the mouth is 0.03 Gm. (3^ grain), but it is often 
given hypodermatically. It may be given in all conditions of 
bleeding from the uterus, but it is not sufficiently active for the 
treatment of post-partum hemorrhage. 

SECOND DIVISION 

CLASS in 

Drugs Used for Action on the Respiratory Tract 

As these drugs are generally used to prevent or treat colds 
and coughs, it is not amiss to briefly discuss the causes of colds 
to better understand their prevention, and to discuss the types 
of cough to better direct their treatment. Such a discussion is 
of special value, as too much faith has long been placed in the 
ability of the drugs of this class to prevent and cure disease of 
the air passages. 

Colds due to adenoids, tonsil disease, nasal obstruction, sinus 
disease, tooth infection, too much or too little clothing, too 
much or too little bathing, poorly ventilated bedrooms, the 
inhalation of dust especially irritant dust, carelessness in using 
germ contaminated telephones, carelessness in using handker- 
chiefs and towels that have been infected by others, and the in- 
halation of droplets of infection sneezed or coughed into the 
atmosphere by those who are infected, cannot often be pre- 
vented by drugs. 

Coughs due to reflex irritation, and coughs due to local irri- 
tation, such as congestion of the lingual tonsil, cannot be cured 



DRUOS FOR ACTION ON RESPIRATORY TRACT 



199 



by so-called expectorants any more than can coughs due to 
cardiac insufficiency be cured by this class of drugs. The t>'pe 
of cough must be noted and the probable cause must be found 
before success from medication can be expected. 

Cough may be caused by irritation in any part of the respira- 
tory tract, may be caused by a disturbance of the stomach act- 
ing reflexly through the pneumogastric nerve, and may be 
caused by reflexes from the nose and from the ear* Cough may 
also be caused by passive congestions, venous congestions, in 
some part of the air passages caused by an insufficient heart or 
by a valvular lesion. Any irritant in the bronchial tubes, tra- 
cheaj and larynx will cause a cough* A tuberculous or other 
abnormal process in the lungs may so irritate the nerves as to 
cause coughing, and congestions in any part of the lung and in 
the pleura will cause more or less coughing. 

Very frequently when there is no congestion of the bronchial 
tubes, trachea J or larj^nx, and therefore no abnormal exudate, 
the cough is dry and non-productive. Such coughing is of no 
advantage to the patient, is very tiresome and irritating to the 
mucous membranes, and may even cause erosions and bleeding 
from some part of the lar3mgeal region, or just below or just 
above it. Such slight hemorrhages are often diagnosed as an 
hemoptysis and as indicative of tuberculosis. 

The dry cough of incipient tuberculosis is a mild, hacking 
cough. The cough from cardiac dyspnea, or from anything 
that congests the venous vessels of the respiratory tract, is 
short and more or less gentle. The cough due to a laryngeal 
tickle, or to a lingual tonsil tickle, or to the rarer elongated 
uvoila tickle is a loud cough, generally coming in scries or in 
showers. If the lingual tonsil is the part at fault, the coughing 
continues until something soothing has quieted this region, or 
until the part has been actually scraped with the rush of air, 
similar to scratching until it bleeds some itching spot on the sur- 
face of the body. The first stage cough of a bronchitis is also 
dry and may be harsh, and in plethoric, strong individuals is very 
sturdy and strenuous. With bronchial exudate, and in the 
moist stages of tuberculosis, and in the second stage of pneu- 
monia, the cough is productive and less harsh, although if, in 




2CX> THE PRINCIPLES OF THERAPEUTICS 

bronchitis, only the larger tubes are affected, a series of coughs 
may be necessary to bring the secretion to the mouth for expec- 
toration. A dry trachea may give a troublesome cough, which 
is difficult to stop, as repair of the epithelium takes place but 
slowly in the trachea. The cough of pleurisy is a dry, non-pro- 
ductive, repressed cough, as every movement causes pain. The 
asthmatic cough is wheezy, and continues imtil frothy mucus 
is expectorated, and there is more or less difficulty of inspiration. 
The cough of pertussis occurs in spasms, with difficulty in in- 
spiration, hence the whoop. In whooping cough, and in patients 
with asthma, emphysema of the upper parts of the limgs may 
occur from the effort to cough and expire against a more or less 
closed glottis. The cough of a laryngitis is husky, and the 
voice is generally hoarse at the same time. Pain in the sides in 
the region of the diaphragm insertions, and epigastric pain, as 
well as pains in other parts of the chest, shoulders, and neck, 
may occur from hard coughing. 

It is obvious that before drugs are given to stop a cough, or 
for expectorant action, the diagnosis of the cause of the cough 
must be made. Cough mixtures are too frequently given, to 
the disturbance of the stomach, when the cause of the cough 
cannot be removed by such treatment. Inflamed, dry mucous 
membrane in the air passages requires treatment that will pro- 
mote secretion. The secretion of these membranes will be in- 
creased by ipecac, by small doses of ammonium chloride, by 
inhalation of steam and vaporized drugs, and, in subacute or 
chronic conditions, by iodides. 

Too profuse secretion requires treatment to diminish it, 
perhaps by atropine, or by large doses of ammonium chloride, 
or by terpin hydrate. Nauseating, sweet, syrupy mixtures 
that upset the stomach are not justifiable. Codeine, or other 
sedatives, may be needed to diminish the frequency of a 
cough, as it is evident that, even in bronchitis, with a cough 
that is very frequent and non-productive, coughing does harm 
and is not of benefit. If a cough is due to spasm, as in asthma, 
drugs that change the character of the circulation and relax 
muscle spasm are required. 

Inflammation in the nose, throat, larynx and trachea may be 



EXPECTORANTS 



20X 



treated by inbalationSi sprays, douches, and by gargling. Re- 
moval of obstructive adenoids and of diseased tonsils is fre- 
quently the only curative treatment of nose, tliroat and ear 
disturbances, 

DRUGS USED TO INCREASE THE SECRETION OF THE MUCOUS 
MEMBRANES •-^SO-CALLED EXPECTORANTS 

It should be noted that any drug that will act on the mucous 
membrane of the bronchial tubes will also act on the mucous 
membranes of aU the air passages, and also more or less on all 
the mucous membranes of the body. It should be recognized 
that general systemic treatment to modify the congestion and 
circulation in the lungs is of more importance than is a so- 
called expectorant. Various physical therapies can do more 
toward aborting and stopping a cold than can drugs* 

The best drug to promote secretion of the air passages in 
acute conditions is ipecac in frequent doses, not sufficient in 
amount to cause nausea; small doses of ammonium chloride 
are also efficient for this purpose. Inhalations of warm, moist 
air in dry conditions of the upper air passages are beneficial, 
and a sedative, as codeine, to allay the cough, is of value. 
There is no excuse for using the irritating and nauseating am- 
monium carbonate, or any ammonium preparation other than 
ammonium chloride. If a codeine, or other, preparation that 
tends to dry up secretion is used too long, the membrane be- 
comes dry and the cough is protracted* There is no activity 
of heroin (diacetylmorphine) that codeine does not have, and 
the tendency of heroin to cause a pernicious habit should pre- 
clude its use in medicine* It is not a respiratory stimulant. 

In chronic dry conditions of the air passages an iodide is 
almost a specific; the dose need not be large. 

Ammomum Chloride. — AdmimsiraMom---Aminomuin chlo- 
ride (muriate of ammonium) occurs as a white crystalline 
powder, has a disagreeable nauseating saline taste, and is 
soluble in water. The dose varies from 0.25 Gm. to i Gm. 
(4 to 15 grains). It should always be administered in solution, 
and best in a sour nuxture. Sweet syrups prolong the taste 
and increase its unpleasantness, although a small dose for a 
child may be disguised by a syrup, such as syrup of tolu or 





202 THE PRINCIPLES OF THERAPEUTICS 

syrup of wild cherry. Plenty of water should always be taken 
with, or after, a dose of this drug. 

Nascent ammonium chloride may be inhaled from various 
simple apparatus which will combine the fumes of strong am- 
monia water and hydrochloric add. Ammonium chloride is 
thus formed in white clouds which may be inhaled, and is 
apparently of benefit in acute colds and laryngitis. 

The official Trockisci Ammonii Chlaridi do not represent a 
good method of administering ammoniiun chloride. These 
troches are supposed to be dissolved in the mouth. Each 
troche contains i^^i grains of ammonium chloride. 

Action. — Large doses of ammonium chloride, or when it is 
given not well diluted on an empty stomach, may cause irrita- 
tion, as well as nausea from its taste. It is quickly absorbed, 
and seems to have a specific action on mucous membranes, 
increasing their secretion, and it is especially active in stimulat- 
ing secretion of the mucous membranes of the respiratory tract. 
It has no impK)rtant action on the nervous or circulatory systems. 
It is excreted by the kidneys, by the mucous membranes of the 
respiratory and digestive organs, and by the salivary glands. 
It is not poisonous, and therefore has no over-action except that 
it may cause sufficient nausea to interfere with digestion, but 
it rarely has this undesired action unless the dose is large. 

Uses. — ^Ammonium chloride is rarely used except as an 
expectorant, i.e., to promote the secretions of the air passages. 
Its most efficient action is in the treatment of acute and sub- 
acute bronchitis. If the cough is excessive and non-productive, 
ammonium chloride is well combined in small doses with code- 
ine. For this purpose it is repeated frequently: 

I* 

Codeine sulphate o . 20 Gm. 

Ammonium chloride 5 . Gm. 

Syrup of citric acid 25 . mils 

Water up to 100 . mils 

Mix. 

Sign: A teaspoonful, in water, every two or three hours. 

It is well to take a good drink of water after the medicine. 
If the cough is not troublesome, the codeine may be omitted. 



EXPECTOItANTS 



203 



Such a prescription may be used in the acute stages of colds 
and bronchitis when the secretion is not suflSdent for comfort. 

If the secretion is profuse and semi-purulent^ larger doses of 
ammonium chloride should be given, less frequently, as 0.40 or 
0*50 Gm. about (6 to j^i grains) three times a day* 

Ammonium chloride may be used in catarrhal jaundice, or in 
conditions of otter mucous membranes that require some stimu- 
lant that will cause the mucus secreted to be less tenacious, and 
therefore to be more easily passed along the tubes that are in- 
flamed. Large doses, as 0*50 to i Gm* (j}i to 15 grains) have 
been given with apparent success in hastening the reduction in 
size of a spleen enlarged by malarial poisoning. 

IpecSiC^Administraiion. — Ipecac is official as the dried root, 
and is used as such in powdered form for emetic action. The 
dose as an emetic is i to 2 Gm. of the powder. The official 
preparations are the Fluidextract, the Syrup which is made 
from the fluidextract in the strength of 7 per cent, of the 
fluidextractj and Pulvis I pecacuanhcB et Opii (Dover's powder). 
This preparation contains 10 per cent, of ipecac. The expecto- 
rant dose of the fluidextract is 0.05 mils (or i minim). The 
Pharmacopoeial expectorant dose of the syrup is i mil (15 
minims). If this dose is to be repeated, it is too large, as it mil 
cause nausea and vomiting; the best action of the s>Tup of 
ipecac as an expectorant is in very small doses frequently re- 
peated. The dose for this purpose, then, should not be more 
than from 0.25 to 0.50 mil (4 to yj^ minims), given every two 
hours* 

The alkaloid EmetincB Eydrochloridum^ (emetine hydrochlo- 
ride) occurs as a whitish crystalline powder, which is soluble 
in water. This preparation is principally used hj-podermat- 
ically in doses of 0.02 Gm. (^ grain). It is a specific treatment 
for amebic dysentery. 

Ipecac contains another alkaloid, cephselin. To this alkaloid 
the drug owes its emetic action, the alkaloid emetine not acting 
as an emetic. 

^c/ww.-*Ipecac causes vomiting mostly by its local irritant 
action in the stomach, although after absorption it acts on the 
vomiting center. Both ipecac and its alkaloid emetine are 



204 THE PRINCIPLES OF THERAPEUTICS 

irritant to the skin and mucous membranes, the merest whiff 
of ipecac causing some individuals to sneeze and have symptoms 
of hay fever and even asthma. Ipecac is rapidly absorbed, and 
promotes the secretion of the glands of the mucous membranes 
and of the salivary glands. The drug and its alkaloid emetine 
are eliminated to some extent through the intestinal walls, and 
during such elimination kill the amebas which may be harbored 
there in amebic dysentery. In combination with opium in the 
. Dover's powder it promotes perspiration, v 

Over-action. — The most frequent symptom of over-action of 
ipecac is, of course, nausea and vomiting, and it may also irri- 
tate the intestines and cause diarrhea. Large doses of emetine 
have caused paralysis, prostration, and even fatal cardiac fail- 
ure. Some individuals who are very susceptible to the action 
of ipecac when taken internally, have an eruption on the skin, 
erythematous or urticarial in type. 

Treatment of Poisoning. — The treatment of poisoning, if such 
should occur, is evacuation of the stomach and bowels, the hypo- 
dermatic administration of morphine to stop the vomiting, and 
atropine and strychnine, hypodermatically, to overcome any 
depression that may be present. 

Uses, — The principal use of ipecac is as an emetic, and the 
best dose of the powdered ipecac for this purpose is 2 Gm,. (30 
grains). If the syrup of ipecac is used, the dose for an adult is i 
or 2 tablespoonfuls. 

As above outlined, a valuable use of ipecac is to cause increased 
secretion of dry mucous membranes, thus diminishing their 
congestion. As soon as the mucous membranes of the air pas- 
sages secrete freely, distress is diminished, obstructive swelling is 
reduced, and if the bronchial tubes are affected, coughing be- 
comes easier and the secretion is more easily expectorated. 

The use of emetine in amebic dysentery has already been 
described; see page 181. It has also been stated that emetine 
bismuth iodide is perhaps the best preparation to give by the 
mouth for the treatment of that disease. This preparation is 
not official. 

Emetine, either used locally or given by injection, destroys 
the ameba which occurs in pyorrhea alveolaris, but as it does 



i DRUGS TO DECREASE SECRETION OF BfUCOUS MEMBRANES 20$ 

not destroy the more important pathologic germs always asso- 
ciated with the endameba, and as it has not been show^n that the 
cndameba has any pathogenic importance, the much lauded 
emetine treatment of pyorrhea alveolaris becomes of little 
importance, 

DRUGS USED TO DECREASE THE SECRETION OF THE MUCOUS 

MEMBRANES 

Ammonium chloride in medium sized doses is often successful 
in hurrying an inflammation of a mucous membrane back to 
health. Terpin hydrate is another very useful drug for this 
purpose- Morphine and codeine will not only act as sedatives 
in irritated conditions of the mucous membranes of the upper air 
passages, but they also tend to dry the mucous membranes, 
often more than is desired. Atropine dries the nose, throat, 
and bronchial tubes, much as it inhibits most other secretions. 
Atropine is rarely advisable except as an abortive treatment 
for colds, when it may be given in small doses, frequently 
repeated (as J^qq ^^ ^ grain of atropine sulphate every three 
hours for ten doses), and in such profuse bronchorrhea as 
would occur in the undesirable action of pilocarpine. 

Many of the balsams and aromatic oils, either inhaled or 
administered by the mouth, often tend to diminish the secretion 
of the air passages. 

The best treatment in continued colds and continued simple 
bronchitis is often by tonics, as represented by the following 
prescription: 

Quinme sulphate . , , , 2 . Gm. 

Reduced iron , .♦..,.,». , * 1 . Gm. 

Strychnine sulphate *,,..,. o .03 Gnu 

Mix, 

M&ke 20 capsules (dry). 

Tftke a capsule three times a day^ after meals. 

The above tonic capsule is a suggestion, but any tonic treat- 
ment is of value. The hypophosphites are absolutely of no 
value, and the only reason that a hypophosphite preparation 
does good is because it is combined with quinine, strjxhnine 
and iron. 




2o6 THE PRINCIPLES OF THERAPEUTICS 

Cod-liver oil may be a very valuable treatment in certain 
conditions of prolonged bronchitis; when the circulation is 
impaired, digitalis is of benefit. 

Change of climate to a drier air and especially to an atmos- 
phere of pine woods, is often advisable, even when no serious 
trouble with the lungs is suspected. Prolonged colds and 
coughs, and reciirrent colds and coughs, should be considered 
as possible precursors of tuberculosis and treated accordingly. 

There is absolutely no need for, and no value in, all of the 
many old so-called expectorants, cough syrups and cough 
mixtures. The drugs mentioned above are sufficient for the 
treatment of bronchitis. 

At times a prolonged cough with expectoration may be well 
treated by small doses of sodiimi iodide, which seems to promote 
healing. An iodide is especially indicated when there is an 
asthmatic condition with the bronchitis. 

Terpin Hydrate, — Terpin hydrate occurs as colorless prisms, 

which are slightly bitter in taste and practically insoluble in 

water. It is non-irritant and non-poisonous in all ordinary 

doses. It is best administered in powder, in capsules, or as 

tablets to be crushed with the teeth before swallowing. The 

dose is about 0.30 Gm. (5 grains), taken with plenty of water, 

three, four, or five times a day. This drug tends to dry up 

secretions of the air passages, and does not interfere with the 

appetite or irritate the stomach in any way. Tablets of terpin 

hydrate in combination with heroin are very frequently ordered, 

and have been extensively used, but it is best not to administer 

heroin. If a sedative is required, codeine is better; heroin is 

not needed. 

DRUGS USED TO RELAX SPASM 

Contractions of parts of the air passages occur in asthma 
and in croup. In spasmodic croup an emetic such as the syrup 
of ipecac is indicated, with inhalations of steam and hot moist 
applications to the neck. 

Asthma is a frequent and very troublesome condition, and 
an asthmatic attack requires treatment by one of the drugs 
suggested in this classification. An asthmatic condition may be 
due to a chronic disturbance as emphysema, and it may be due 



BHtJGS trSED FOR ACTION ON CIRCULATION 



207 



to an insufficient heart. The blood-pressure may be too high 
or may be too low^ and proper treatment, in the first instance to 
reduce the blood-pressurej and in the second instance to increase 
the strength of the heart > will tend to remove the asthmatic 
condition. 

Many times the best treatment of acute asthma is by nitro- 
glycerin in doses of Hoo ^^ ^ grain, dissolved on the tongue, 
and repeated in fifteen minutes, if relief is not obtained. When 
frontal headache is caused by this drug the spasm of the 
bronchial tubes will be relaxed. If there is considerable venous 
congestion and the heart is laboring and insufficient, suprarenal 
preparations given for absorption in the mouth, either as 5 to 10 
drops of adrenalin solution (i-iooo), or as a suprarenal tablet 
dissolved in the mouth, will be useful. 

Various substances to be burned and the fumes inhaled, or to 
be smoked, all containing atropine in some form, most fre- 
quently as stramonium leaves, and most of them containing a 
nitrite (generally the nitrate of potassium) tend to relax spasm 
and cause relief. It is probable that atropine sulphate in- 
jected hypodermatically will act as well as the inhaled fumes of 
stramonium leaves. The slower acting but often effective 
bromides and chloral may be administered, pro\dded the circu- 
lation is good. 

Morphine should be given only in exceptional cases and when 
the indication is urgent. Many an asthmatic patient has be- 
come addicted to the use of morphine, and the physician 
cannot be too careful lest he cause such a habit. 



CLASS IV 

Drugs Used For Action on the Circulation 

The care of the heart and circulation becomes of more im- 
portance every year, as we have developed a condition of 
nervous tension, and the circulation is easily thrown out of 
balance. The advance of civilization has weakened the circu- 
latory power as evidenced during the ages, first by patients 
surviving most terrible bleedings; then vomitings; then purg- 
ings; then the use of aconite; then the use of alcohol as a ** stimu- 





2o8 THE PRINCIPLES OF THERAPEUTICS 

lant;" then the use of coal-tar drugs to combat fever; and 
then the starvation era. Next came the recent strychnine 
age; and now we have reached the digitalis age, and each/ in 
its era, was considered the proper treatment of serious iUness. 
This chronological story shows that the reserve strength of the 
heart has grown less and less, and it is the reserve strength of 
the heart upon which the individual must depend in emergencies. 
The following are some of the reasons for the progressive 
circulatory insufficiency, and especially for the lack of reserve 
strength of the heart at the present time: 

1. Less sleep than is necessary for rest of the brain and heart. 

2. More excitement: rapid travel, constant dangers, more 
evening amusements, bright lights, more noise, more calls on 
one's attention, and the need for rapid execution of duties. 

3. A large assortment of rich foods that cause, sooner or later, 
substances to be produced and absorbed that are irritant to 
the brain or depressant to the heart, or that cause high tension. 

4. Too much tea and coffee. 

5. Too much tobacco. 

6. Strenuosity needed to keep up with the times. 

7. Strenuosity not needed, but assumed: too much com- 
petitive athletics, too much dancing, too much misdirected 
exercise by those who are not in condition for it. 

8. Business and household frets of the age. 

9. Impatience with, and unwillingness to stand, even a 
little pain, and the consequent taking of depressant analgesic 
drugs, especially the coal-tar and synthetic drugs. 

10. Mouth infection, and consequent endocrine gland dis- 
turbance. 

These are probably not all of the causes of the weakened 
hearts of this age, but be the causes what they may, the physi- 
cian's primary duty to-day, with every illness and with every 
operation, is to care for the heart. The blood-pressure must 
be watched; the anesthesia must be short; even nerves must 
be blocked to relieve shock; strychnine, atropine, caffeine, 
camphor, epinephrine and pituitary stimulation may have to be 
given; transfusion may be required; and, now, even purging 



DRUGS USED FOR ACTION ON THE OniCULATION 



2og 



before operations is being abolished* This all shows the weak- 
ened circulations, and the lack of reserve heart strength, that 
are being encountered. In other words, the cardiac reserve is 
not titere, and cannot be depended upon, therefore the im- 
portance of a good understanding of the drugs of this class, as 
they not only can save life, but also they are often misused. 

The nutrition of the heart muscle is derived from the blood 
supplied to it through the coronary arteries. The activity 
of the circulation of the blood through these vessels and con- 
sequently the amount of nutrition furnished to the heart 
muscle depends upon the blood -pressure in the aorta during 
the cardiac diastole, and also upon the complete relaxation of 
the cardiac muscle during diastole* Drugs which increase the 
strength of the cardiac systole or which increase arterial tension 
increase the blood-pressure in the aorta, and consequently 
increase the activity of the circulation in the coronary arteries, 
and therefore improve the nutrition of the heart. Only such 
drugs as meet these requirements can be cardiac tonics, and 
these drugs act slowly and cause the best results only after a 
more or less prolonged use. 

To meet the condition of shock or heart failure or any sudden 
cardiac weakness, drugs which are stimulant to the heart and 
vasomotor system are indicated. It is a question of momen- 
tary emergency and not a question of cardiac nutrition. 

It is impossible to ad\nse what drug or drugs should be used 
in a given case, but the following suggestions of the special circula- 
tory activities of the drugs named in the classification may indi- 
cate when they should be used: 

Atropine causes increased rapidity of the heart, raises the 
blood-pressure, and awakens the brain and nerve centers. Its 
activities last for some time; it is slow of excretion; and the 
average dose of the sulphate is 3 loo of a grain. Undesired 
effects from this drug are flushing of the face, nervous ex- 
citement, insomnia, dryness of the throat and skin, and 
tachycardia. 

Camphor causes an increased rapidity of the heart, dilates the 

peripheral blood-vessels, thus relieving internal congestions and 

giving a feeling of warmth and well-being, and slightly stimu- 
u 




2IO THE PRINCIPLES OF THERAPEUTICS 

lates the nervous centers. It acts quickly, and its action is soon 
over, hence it may be frequently repeated, every hour in small 
doses. Generally it is best given intramuscularly in a saturated 
solution in a sterile vegetable oil (tumors have been caused by 
injections of camphor and petroleum oil), in a dose of 0.20 Gm. 
(3 grains), which is the strength of camphor in the ampules 
which may be obtained for such medication. 

Caffeine causes the heart to become more rapid and its con- 
tractions stronger, raises the blood-pressure, stimulates the brain, 
and increases the output of urine. It may be administered 
as a cup of strong coffee, or as dtrated caffeine in the dose of 
0.30 Gm. (5 grains), or hypodermatically in the form of caf- 
feine sodio-benzoate in a 0.20 Gm. (3 grains) dose. It acts 
quickly, may be repeated in two or three hours, and is more or 
less rapidly excreted. It may cause prolonged insonmia and, 
rarely, tachycardia. 

Strychnine stimulates all the nerve centers, may slow the 
heart, often makes its contractions stronger, and at times 
raises the blood-pressure and increases the output of urine. It 
often prevents sleep, and if too frequently administered or given 
in too large doses, may cause the heart to become rapid and 
prevent complete diastole, due to over-stimulation. Strychnine 
is used too much in cardiac depression, although when the heart 
fails and the vital nerve centers are sluggish strychnine may 
greatly improve the condition and perhaps save life. In shock 
other drugs are better. The dose of strychnine sulphate in 
emergencies is 3^^o to 3^ of a grain, given hypodermatically. 

Digitalis J given intramuscularly, will help a weak heart in 
from four to twelve hours, but its full action will not take place 
until from eighteen to twenty-four hours. With a weak heart 
very large doses should not be given, as excretion is slow and 
poisoning readily occurs. Also large doses should not be given if 
the patient is already more or less saturated with the drug. It 
cannot act in a short time unless it is administered intravenously 
hence it is not a drug for emergencies. It should not be given 
when the heart is very slow, or in heart failure when the patient 
has for some time had a serious feverish disease. It should not 
be given when there is acute myocarditis or acute endocarditis, 



DRUGS TO ACCELERATE THE HEART 



211 



or if these conditions are suspected. It may be used, if indi- 
cated , early in acute disease or in broken compensation in chronic 
heart disease. It is not indicated in acute heart failure or 
shock. It slows the heart, strengthens its contractlonSj gener- 
ally raises the blood-pressure (it may lower a high pressure if 
there is cardiac dilatation), and increases the output of urine. 
If too large or too frequent doses are given, the heart may be- 
come fast, headache is present, a diminished amount of urine is 
passed, vomiting is frequent, and diarrhea may occur. It 
should not be administered too often, generally best twice in 
twenty-four hours. As stated, it is of no value in sudden 
emergencies, but in the slower emergency of auricular fibrillation 
it is the drug to use, and in good sized doses. 

Sirophanthin given intramuscularly or intravenously is of 
great value in heart failure in severe illness. It should be given 
in one sufficient dose, not ordinarily to be repeated, and should 
not be given after a patient is under the influence of digitalis. 
Ampules for intramuscular or intravenous administration may 
be obtained. It should be noted that the solution in these am- 
pules should be neutral or slightly acid; if it is alkaline the drug 
has deteriorated. 

Pituitary Exirads made from the posterior lobe of the 
hypophysis raise the blood-pressure and strengthen the heart; 
they are best given hypodermatically, and ampules may be 
obtained for this purpose. 

Suprarenal Extracts or epinephrine preparations raise the 
blood -pressure both when given on the tongue for absorption 
in the mouth, or when given hypodermatically. 

Ergoty when an assayed fluidextract is used and it is given 
intramuscularly, raises the blood-pressure. The dose is i or 2 
mils, injected deeply into the deltoid muscle, and it may be 
repeated two or three times in twenty-four hours, if needed. 

DRUGS USED TO ACCELERATE TI^ IffiART 

The drugs used for this purpose are atropine, camphoff 
caffeine, and strychnine. As all of these drugs act more or less 
on the nervous system, they are better described under that 
dass* 





212 THE PRINCIPLES OF THERAPEUTICS 

DRUGS USED TO DEPRESS THE HEART 

Most methods employed to depress the heart, once used so 
much in the first stage of acute disease, should be dropped, 
owing to the danger of precipitating cardiac weakness. Even 
the milder methods of causing slowing of the heart and lowering 
of the blood-pressure, in the beginning of an illness, by means 
of aconite or of veratrum viride are now but little used. Fortu- 
nately or unfortimately (because they are too much used) the 
coal-tar products, as acetanilid, phenacetin and antipyrin, and 
some synthetics as aspirin, not only lower the temperature 
and stop aches and pains, but also lower the blood-pressure 
and depress the heart. They are often used to accomplish all 
these results at once. 

Aconite. — Administraiion. — Aconite (monkshood) is not used 
as such, and is best administered in the form of the official 
tincture, which contains lo per cent, of the drug. The official 
dose of 0.3 mils (5 minims) is too large, if it is to be repeated. 
The best method of giving aconite to cause slowing of the pulse 
and lowering of the blood-pressure is to administer a drop 
every half hour until the eflfect desired is produced, and then to 
stop it. 

Aconitine, the alkaloid of aconite is very poisonous, and 
should not often be used. The dose is 0.00015 Gm. (Hoo of a 
gram). 

Action. — This drug acts rapidly to slow the heart and lower 
the blood-pressure, and it somewhat dilates the peripheral blood- 
vessels and lowers temperature. It is excreted in the urine. 

Over-action. — It may cause tingling of the tongue, tingling 
and nimibness of the extremities, and a feeling of faintness. 

Toxic Action. — It causes death by depression of the respira- 
tory center and the heart. 

Treatment of Poisoning. — Further absorption of the drug must 
be prevented by emetics; there must be absolute rest; dry heat 
applied; and respiratory and circulatory stimulants given. 

Uses. — I. To reduce fever. For this object one drop of the 
tincture may be given every half hour until the pulse shows a 
distinct slowing and softening; it should then be stopped. 



DRUGS TO DEPRESS THE HEART 



213 



Aconite is not now much used to meet this indication, as the 
coal-tar drugs are more efficient in reducing temperature and 
promoting sweating, and at the same time they depress the 
heart and circulation. 

2. To lower the pressure in hypertension. It is not often 
advisable to use aconite for this purpose, as hypertension is 
continuous, and the continuous use of aconite is inadvisable, 
on account of its weakening the heart muscle, 

3» To allay peripheral pain. It is rarely advisable to use 
aconite for this purpose, although m full doses it will benumb 
the peripheral nerves, but at the same time it causes depression. 
Any local application of aconite is inadvisable, 

Verafcrum Vmde* — Adminisiraiion, — Veratnim viride (green 
hellebore, American hellebore) is not used as such, but in the 
form of the official fluidextract, the dose of which is o.i mil 
(ij^ minims), or as the official tincture, which represents 10 
per cent, of the drug, in the dose of 0.5 mil (7}^ minims). 
When these preparations are used to lower the blood-pressure 
and slow the heart, they should be used as it is advised to use 
aconite, namely, about 2 or 3 drops of the tincture every half 
hour until the results desired are obtained. 

Action, — This drug is more or less of a cardiac depressant 
(not as depressant as aconite), slows the pulse, lowers the blood- 
pressure, and lowers the temperature. 

Over 'action. — It causes vomiting so soon that when adminis- 
tered by the mouth serious poisoning is not likely to occur. 
The treatment of its over-action is to wash out the stomach, 
administer atropine and digitalis, keep the patient quiet, and 
surround him with dry heat. 

Uses. — The only use for viratrum viride is to slow the heart 
and lower the blood-pressure. It is much less likely to cause 
cardiac depression than is aconite, but is less efficient, at least 
in the doses generally used* Perhaps this drug should be used 
more frequently and in larger doses (provided the stomach is not 
irritable, as it is likely to cause vomiting) ; however, as already 
stated in the case of aconite, this drug also has given place to 
the coal-tar drugs* 

Veratrum viride has been suggested for chronic hypertension. 




214 THE PRINCIPLES OP THERAPEUTICS 

It is doubtful, however, if it should be used for this purpose any- 
great length of time. It has also been highly recommended in 
puerperal eclampsia, administered in large doses, but profuse 
bleeding, from the uterus or by venesection, and the adminis- 
tration of thyroid extracts is better treatment. 

DRUGS USED TO STRENGTHEN THE HEART 

Caffeine. — Administraiion. — Caflfeine (theine) is a basic sub- 
stance obtained from the leaves of tea and from the seeds of 
coffee. It is also prepared synthetically. It occurs in white 
silky needles, has a very bitter taste, and is not very soluble in 
water. It is generally used in the form of the oflSdal Caffeina 
Ciirata, which is a white powder, has a bitter, add taste, is 
soluble in water, and the dose is 0.30 Gm. (5 grains). A 
pleasant method of administering dtrated caffeine is in the 
official Caffeina Citrata Effervescens. This preparation contains 
4 per cent, of the dtrated caffeine and effervesces when placed 
in water. The dose is 4 Gm. (i drachm). 

Caffeine and theobromine are purins. The former is tri- 
methylxanthin, and the latter is dimethylxanthin. Caffeine is 
quickly absorbed and acts quickly, and the dose may be re- 
peated in two or three hours, if needed. It is often well to 
administer caffeine hypodermatically, and the official Caffeinw 
SodiO'BenzoaSj a mixture of caffeine and sodium benzoate, is the 
salt that is most satisfactory for this purpose. It occurs as a 
white powder, is very soluble in water, and the hypodermic dose 
is 0.20 Gm. (3 grains). It should be remembered that caffeine 
is often as well administered in the form of strong coffee as in 
any other way. 

Action, — While caffeine is perhaps the best cerebral and men- 
tal stimulant we possess, and inhibits mental fatigue and allows 
longer continued work, it, of course, cannot take the place of the 
cerebral rest caused by sleep. Consequently, while it stimu- 
lates, it leaves the brain more fatigued after its action is over, 
and when it is used repeatedly as a cerebral stimulant and to 
prevent sleep, when it is necessary for a person to be awake, it 
can do nothing but cause general nerve and brain fatigue, 
unless adequate sleep is obtained. 



DRUGS TO STRENGTHEN THE HEART 



315 



r 



Caffeine raises the blood-pressure by stimulating the vaso- 
motor centers, may slow and steady a weak heart by stimulation 
of the vagus center, and thus may strengthen the heart. How- 
ever, if a heart has become irritated by nervous stimulation as 
by hyperthyroidism, or by cerebral irritationj or by a drug, as 
strychninej caffeine will add to the irritability of the heart and 
will do harm. In other words, in all rapid, irritable hearts 
caffeine in any form, including coffee and tea^ should be pro- 
hibited. A slow, weak heart may be made faster and stronger 
mth caffeine. 

It has been shown that caffeine will not protect a heart from 
the depressing effects of a coal-tar product, but its combination 
vnth such, as acetanilid or phenacetin, when these drugs are to 
be administered for headache, may make their action more 
effective. 

WTiile caffeine in most any form seems to prevent fatigue, and 
will allow a patient to go longer \^ithout food and without de- 
pression, still it has not been shown that caffeine is a 
valuable muscle stimulant. In muscular exertion it may in- 
crease the nervous irritability, and nervousness or increased 
tension or excitability is well known to interfere with the 
best muscular efforts. Therefore an athlete is better without 
coffee, tea, or caffeine stimulation before a trial of his strength 
is made. 

With most individuals caffeine acts as a diuretic, even if the 
blood-pressure is not much raised. Caffeine is excreted largely 
by the kidneys as dimethykanthin and uric acid. 

There is no question but that a caffeine habit can be acquired, 
whether as such (perhaps in the form of coca cola) or as a tea 
or coffee habit. Coca cola, tea, and coffee ** fiends" are of com- 
mon occurrence* 

Over-acUofi, — Over-action of caffeine is shown by great 
nervous irritability, rapid heart, insomnia, and, perhaps, by 
muscle twitchings. It may also cause both stomach and intes- 
tinal indigestion, as mostly evidenced by increased peristalsis. 
Perhaps some of the indigestion is caused by excessive neivojs 
irritability, and it is well known that cerebral irritation can 
cause hyperacidity of the stomach. 




2l6 ' THE PRINCIPLES OF THERAPEUTICS 

It is not necessary here to discuss the end e£fects of the 
coca cola habit; it is serious, and is especially harmful to 
children and youth. The cause of the habit is the caffeine in 
the mixture. It is not pertinent to discuss the small amount 
that one glass may contain, or that the civilized world drinks 
tea and coffee freely. The coca cola habit is pernicious. 

Very many individuals drink too much tea or too much coffee, 
and since prohibition was established, the sale and use of tea 
and coffee have been very greatly increased; probably a con- 
servative estimate would be a 25 per cent, increase. With the 
withdrawal of alcohol in all forms the use of substitute stimula- 
tion will necessarily increase, and if more dangerous drugs can- 
not be obtained, the accessible drugging by tea and coffee will 
increase, to the nervous harm of the race. In other words, 
more people will be harmed annually by the excessive use of 
tea and coffee, or by caffeine in some other form, than were 
harmed by alcohol in the year 191 8, for instance. 

Civilized man in this age is over-stimulated, and needs 
something to soothe and quiet him. He (and also she) is 
beginning to get that quieting from more tobacco than he (or 
she) ever before used. But if this does not satisfy him, he, also, 
as well as those who do not smoke, will drink more tea and 
coffee. The result is greater nervous tension, greater nervous 
irritability, less sleep, more indigestion, and finally a loss of 
mental balance and of physical strength. We are now menaced 
with the probable overuse of tea and coffee; hence this warning 
is issued. 

Acute poisoning with caffeine rarely occurs, and serious 
symptoms would rarely be caused by any ordinary amoimt of 
caffeine except in one who had an idiosyncrasy against it, 
generally evidenced by a more or less persistent tachycardia 
after even a single cup of coffee. In all cases of hyperthyroid- 
ism or of irritability of the thyroid gland, coffee, tea, and all 
forms of caffeine should be prohibited. 

Uses, — The principal use of caffeine is as a circulatory stimu- 
lant, and as such it is generally well administered as a cup of 
coffee, unless it is deemed best to administer it as the dtrated 
caffeine; or it may be given in emergencies hypodermatically, as 



DIGIT AUS 



217 



P 



the caffeine sodio-beEzoate. In collapsed conditions, and in 
all cases of low temperature with a weak or sluggishly acting 
heart, and in mental apathy, as many times occurs in typhoid 
fever, caffeine is a very valuable drug, and is of great benefit. 
In many acute diseases, and especially in typhoid fever, and 
often in pneumonia, a morning cup of coffee is advisable. Of 
course, if there is any cerebral irritation or a tendency to 
delirium, caffeine is contraindicated. In high blood-pressure all 
caffeine should be prohibited. 

As a cerebral stimulant caffeine may be used in emergencies, 
but should not be regularly taken for that purpose. Reporters, 
editors, and night clerks aM frequently take coffee to keep them- 
selves awake. Excessive use of coffee for this purpose can but 
be harmful, if taken for any length of time. 

Digitalis. — Admintstraiion,—I>ig\t3]is (foxglove) is official 
as the dried leaves of the plant. It contains several active 
glucosides, no one of which thoroughly represents the action of 
the drug. The most poisonous of these glucosides is digitoxin. 
Another active glucoside, digitalin, is either crystalline or 
amorphous, and some preparations contain also digitoxin. 
These glucosides, or active principles, are sometimes used 
hypodermaticaUy, but they are irritant, and the digitoxin, as 
stated, is more poisonous than is the drug itself. Consequently, 
for hypodermatic use a sterile, assayed preparation of the whole 
leaf is better. The dose of the leaves is 0.06 Gm, (i grain), 
and when good leaves are used it is a very efficient and pleasant 
method of administering digitalis. 

The official preparations arc the Fluidextract, the Infusion, 
and the Tincture. The dose of the fluidextract is 0.05 mil or 
I minim)- The dose of the infusion is 4 mils (i fluidrachm), 
and to be of value it must be freshly prepared. A teaspoonful 
(5 mils) equals a little more than i grain (0.075 Gm.) of the 
drug. The infusion has long been thought to be of more value 
therapeutically than the tincture, but it is more active only 
because it is made of fresh, active leaves, while the tincture may 
have become old and deteriorated; the action of the tincture 
and the infusion is about the same. The dose of the tincture of 
digitalis, which represents 10 per cent, of the drug, is 0.5 mil 




2X8 THE PRINCIPLES OF THERAPEUTICS 

(yj^ minims). 0.5 mil of this preparation equals 0.05 Gm. of 
the drugy a litde less than i grain. 

The proper dose of digitalis in different conditions is not 
agreed upon by clinicians. Small doses frequendy repeated, 
though advised by some, seem inexcusable, as the drug acts very 
slowly, and is also slow of excretion. On the other hand, very 
large doses, computed according to the weight of the patient, 
are given by some clinicians, who claim such doses do not cause 
poisoning. The rapid digitalization of a patient, watching 
for mental depression and dropped heart beats as signals to stop 
the drug before vomiting occurs, is the method of administration 
by these clinicians. Other clinicians obtain good effects from 
small doses of an active preparation, not frequentiy repeated. 
All agree that when the effect of digitalis is evident on the 
heart and circulation, that large doses should no longer be given, 
and that they should be given less frequentiy, at least not 
more than once or twice in twenty-four hours; and some 
clinicians believe the drug should be stopped, to be repeated 
later. There is a decided difference in patients as to their 
tolerance of large doses of digitalis, probably frequentiy depen- 
dent upon the individual rate of excretion. 

There are various imported glucosides and assayed digitalis 
preparations on the market, but there is no reason why Ameri- 
can assayed preparations of digitalis are not as active and as 
therapeutically useful as those that have travelled across the 
ocean. An assayed tincture or an assayed fluid preparation in 
ampules for hypodermatic or intramuscular injection, or assayed 
leaves in tablets, or a fresh infusion made efficientiy by a skilled 
pharmacist from active leaves, represent all the preparations 
needed for digitalis use. All liquid preparations of digitalis, 
even the tincture, more or less rapidly deteriorate, and the much 
used fat-free tinctures also deteriorate, although they may be a 
littie less likely to cause nausea. 

Whatever the preparation of digitalis used, the dose is always 
enough to do the work desired, and that dose will vary not only 
with similar preparations, but with preparations made at dif- 
ferent times by the same chemist. 

Action. — There is no external action of digitalis. On mucous 



DIGITALIS 



219 



membranes it is dightly irritant in strong preparations, and 
tends to cause nausea and vomiting when taken on an empty 
stomach. Large doses may cause diarrhea. Occasionally 
when digitalis is given hj'podermatically, unless the preparation 
is especially prepared for that purpose, it may cause an abscess. 
Digitalis is absorbed both from the stomach and intestines, the 
rate of absorption depending upon the preparation used, and 
upon when it is takenj whether on an empty or a full stomach. 
It should be recognized that in conditions of shock digitalis 
may be absorbed very slowly from the alimentary canal. 

The drug does not cause strong systemic effects until at least 
twelve hours after it has been taken, although its action may 
begin in about four hours. The vagus center in the medulla is 
stimulated, and the heart is slowed through the action of the 
vagi nerves. Larger doses may act on the endings of these 
nerves in the heart to more or less prevent the retarding action 
of vagus stimulation. Still larger doses, or excessive doses, will 
more or less paralyze the endings of the vagi nerves, and the 
heart becomes irregular and rapid. Ordinary doses of digitalis 
may retard the conductivity of the auriculo- ventricular bundle, 
and thus slow the heart. Larger doses may cause heart-block, 
and the auricular rhythm wiU be greater than the ventricular 
rhythm. 

Digitalis acts more on the ventricles than on the auricles, 
and causes more forceful contractions and more complete di- 
astoles* Slowing of the heart rests it, and by better contraction 
and better dilatation and an increased pressure in the aorta, 
there is a better coronarj' circulation, and therefore im- 
proved nutrition of the heart. It should not be aimed to 
slow a heart by digitalis below 65 or 70 beats a minute, and in 
aortic regurgitation it should not be slowed below 80 beats a 
minute. 

In an ordinary healthy individual and in depressed circula- 
tory conditions, digitalis will ordinarily increase the blood- 
pressure, and in many conditions of disease, with hypertension^ 
the blood-pressure will be lowered rather than increased by 
digitalis. In conditions of venous dilatation and venous con- 
g^tion, and with the diastolic pressure high, digitalis will often 




220 THE PRINCIPLES OF THERAPEUTICS 

lower the [diastolic and increase the pulse-pressure, to the 
benefit of the patient. 

Digitalis probably rarely causes such local irritation of the 
vasomotor system as to increase the blood-pressure from that 
cause. With healthy individuals it will generally increase the 
output of urine, largely by causing a better tone of the blood- 
vessels of the liver and splanchnic system. Digitalis probably 
does not act on the kidney structure as a stimulant; the increased 
diuresis is entirely due to the increased circulatory tone. 

Over-action. — Undesired action of digitalis is evidenced by 
nausea; perhaps diarrhea; a tight, bandlike feeling in the head; 
too great slowing of the ptdse; slight cardiac pains or cardiac 
ache, often of a different type than those which the patient may 
have had before the digitalis was given; dropped beats; the 
hands and feet may be cold, and there may be a continuous 
headache. 

If, when any of these symptoms occur, digitalis is immedi- 
ately stopped, in from twelve to twenty-four hours the above 
symptoms will generally entirely disappear. If, on the other 
hand, the drug is not stopped with the above symptoms present, 
the so-called cumulative effect will occur. Cumulative action 
is evidenced by a slowing of the excretion of urine, and perhaps 
almost suppression, with an exacerbation of all of the above 
symptoms. Cumulative effect will rarely occur with ordinary 
small dosage, even if the drug is given daily for a long period, 
provided nephritis is not present. 

When, during the administration of digitalis, the heart tends 
to beat in couplets, the drug should be stopped, as it is 
seriously affecting the heart. However, generally before this 
effect takes place, loss of appetite, nausea, and headache should 
have caused the drug to be withdrawn. 

Toxic Action. — ^A toxic dose of digitalis causes the heart to 
become rapid and irregular, with perhaps, on the other hand, 
heart-blocking.- The extremities become cold, there is numb- 
ness, occipital headache, disturbed vision, and cardiac death. 

Treatment of Poisoning, — In digitalis poisoning an emetic 
should be given and also tannic acid solutions; later a quick- 
acting cathartic is advisable. There is no physiologic anti- 



DIGITALIS 



321 



dote. Dry heat should be applied to the body to dilate the 
peripheral vessels, and hot fomentations to the kidney region 
to hasten elimination. Nitroglycerin is of some value. 

Uses. — There is no drug that equals digitalis in the treatment 
of dilatation of the heart and of broken compensation in vahnj- 
lar disease. It is also very beneficial in the treatment of heart 
strain (acute dilatation) from any cause, as from over-work, 
from athletics, from hard marching, etc. It also benefits a 
heart that has been weakened by tobacco. It is generally of 
benefit when there is edema or exudates in any part of the body, 
when there is poor drciilation and no serious kidney lesion^ 
It may or may not be of benefit in low blood-pressure. Some- 
times in this condition, without edema, and without dilatation 
of the heart, it utterly fails to raise a low pressure. It may be of 
benefit in many cases of myocardial degeneration, but it may 
not be tolerated in such a case, and may do harm. It is rarely 
indicated when there is fatty degeneration. It will not act well 
in irregular action of the heart when the pulse is slow and ^ith 
irregular blood-pressure readings. In this condition other 
heart drugs are indicated- 

A vahnalar lesion is not an indication for the use of digitalis 
unless there are signs of broken or impaired compensation. On 
the other hand, a heart may badly need the aid of digitalis when 
no valvular lesion can be demonstrated. Hence, before digitaUs 
is administered, it should be decided that such an active drug 
is needed. 

It is not purposed here to describe the treatment of heart 
disease, only to suggest the beneficial acti\'ity of this drug in . 
certain characteristic conditions. 

In mitral regurgilalion with broken compensation and a con- - 
sequent damming back of the blood in the lungSj then into the 
right auricle and right ventricle, thus causing a sluggish general 
venous circulation, especially in evidence by congestion of the 
portal system and a congestion, and often enlargement, of the 
liver, poor circulation in the stomach and intestines, and sooner 
or later passive congestion of the kidneys, with still later pen- 
dent edemas, digitalis, by increasing the activity of the ventricles 
and causing more contraction at the mitral valve and therefore 




222 THE PRINCIPLES OF THERAPEUTICS 

less leaking, and by slowing the heart, thus increasing its rest 
period and its nutrition, will generally bring about a re-establish- 
ment of compensation. 

In mitral stenosis and compensation beginning to fail, with 
a damming back of blood in the lungs and right ventricle strain, 
and often general venous congestion, 'digitalis is of especial 
value by slowing the action of the heart so that more blood may 
pass through the narrowed mitral valve into the left ventricle. 
The heart with this defect may be slowed with more benefit than 
in any other lesion; but when the heart has become slowed with 
digitalis, sudden rising from the bed, or from a chair, must be 
prohibited during the intense action of the drug, lest sudden 
death be caused, perhaps by anemia of the brain. 

In aortic itisufficiency with broken or breaking compensation, 
the already very large left ventricle is becoming dilated, with 
possibly a temporary mitral leak. All the systemic and bodily 
activities are below par, because of the low blood-pressure often 
found in this condition, the diastolic pressure at least being 
found excessively low. If there is not much hardening of the 
arteries, not too much sclerosis, and not too much myocarditis, 
digitalis will benefit such a patient by bringing back the left 
ventricle strength to its normal compensation, and by toning 
up the heart muscle will eradicate the mitral leak, if it was a 
relative insufficiency and not an insufficiency due to disease. 
By this extra activity the blood-pressure in the aorta is in- 
creased, and therefore proper coronary circulation occurs, and 
the nutrition of the heart is improved. Obviously, it would not 
be of advantage to slow a heart with aortic insufficiency much 
below 80 beats a minute, as the longer the diastole, the more 
blood must flow back through the insuffidnt aortic opening into 
the left ventricle. This lesion is the one that so frequently 
causes sudden death, either by some sudden rising causing 
anemia at the base of the brain, or causing a sudden dilatation 
and paralysis of the left ventricle. 

In broken compensation in aortic stenosis digitalis may or 
may not be of benefit. The heart in this condition, unless 
badly diseased, is generally slow in order to force the blood 
through this narrowed opening; consequently, for that purpose 



DIGITALIS 



223 



digitalis is not needed^ and to give more forceful propulsion 
of blood through a narrowed orifice by an extra activity of the 
strong left ventricle may not be of advantage. On the other 
hand, mth failing drculation in such a condition, digitalis may 
be of benefit, if it is given in small doses and its results carefully 
watched* If a mitral leak has occurred from strain due to the 
over-filled left ventricle endeavoring to overcome the resis- 
tance at the narrowed aortic valve (1,^., if the ventricle is 
dilated) digitalis may be of benefit up to a certain point of its 
activity^ but it should not be pushed. 

It is readily understood that as the circulation is improved 
in any case of broken compensation, the lungs are relieved of 
congestion, the portal drculation is relieved of passive conges- 
tion, the Uver becomes nearly normal in size, the output of urine 
by the kidneys is increased, the digestion becomes normal, the 
nutrition improves, the various disturbances of the head and 
brain caused by the sluggish circulation disappear, and the 
patient temporarily recovers. 

Whenever the heart fails from weakness, due to the misuse of 
drugs, such as the coal-tar and synthetic drugs; to the over-use 
of tobacco; to the misuse of coffee and tea; to hard coughing; to 
whooping cough; to asthma; to chronic infection; when the 
heart is pressed upon by a pleurisy or an empyema; and w^hen 
the right ventricle is severely taxed as in emphysema, in all such 
conditions, provided there is no special contraindication, digi- 
talis is of benefit* 

Digitalis may also be of benefit in chronic myocarditis with 
heart weakness, provided the drug is carefully used. Large 
doses should not be given, and the results should be carefully 
watched. In obesity with possibly fat deposits around the 
heart, digitalis may be of great benefit. If there is actual fatty 
degeneration of the heart muscle, digitalis may do serious harm. 

Digitalis should not be used in acute endocarditis or peri- 
carditis, unless, in the latter condition, the heart is laboring. It 
should not be used during acute fever processes, unless possibly 
in the beginning of such a condition, as with most infections the 
heart musde is more or less affected, and in any acute myocar- 
dial condition digitalis is contraindicated* 





224 ^^^ PRINCIPLES OF THERAPEUTICS 

Lately it has been advocated to administer digitalis in the 
beginning of pneumonia. Because a patient has pneumonia is 
not necessarily an indication to administer digitalis. In certain 
conditions of heart weakness, and when there is prune- juice ex- 
pectoration, or there is a tendency to venous congestions and 
the blood-pressure is low, digitalis may be indicated, pushed to 
the point, as advised, of digitalization, which means to the 
point of the heart showing complete action of digitalis and then 
the drug stopped. But it is believed that it is not good treat- 
ment to give digitalis in the first stage of every case of pneu- 
monia. Digitalis notably fails of good action in the failing 
heart of pneumonia in the later stages. 

In auricular fibrillation, digitalis has almost a specific action, 
and it is now recognized that auricular fibrillation is not infre- 
quent with hearts that are not seriously damaged. With the 
rapid, weak hearts of serious myocardial disease, it may not act 
to advantage, but in auricular fibrillation, which often occurs 
with yoimger individuals without arteriosclerosis, digitalis 
pushed to full activity will soon stop the paroxysm. Some clini- 
cians advise very large doses, rapidly repeated, to practically 
intoxicate the heart with the drug. It is not often necessary to 
take such a chance of a possible over-action of the drug. Small- 
er doses repeated at six-hour intervals, perhaps in gradually 
increasing doses, is often a safer method. 

It must be remembered in administering digitalis that it acts 
as a muscle trainer, and, except in auricular fibrillation, very 
large doses should rarely be given. The heart should be coaxed 
gradually to greater activity, much as a muscle is trained in 
athletics, rather than to start with excessive stimulation. As 
just stated, however, in auricular fibrillation it may be well to 
intoxicate or really paralyze the heart by inhibiting the con- 
ductivity of the auriculo- ventricular bundle; but many times 
ordinary dosage rather than excessive dosage is as successful 
and safer. A few hours more or less of rapid heart action is 
rarely fatal in these cases, but a too sudden excessive action of 
digitalis may be. Digitalis may also act well in auricular 
flutter. 

The tachycardia of hyperthyroidism is never well treated by 



DIGITALIS 



225 



r 



digitalis, and the heart will not become slow under the action of 
digitalis, unless the dose is too large for safety, if the cause 
is hj'perthyroidism. 

In delirium tremens, with failing heart, good treatment is 
digitalis and ergot, both giveh hypodermatically. 

Digitalis should not be used when there is internal hemor- 
rhage, unless there is venous oozing, as may occur in circulatory 
weakness. Occasionally in repeated hemoptysis, and especially 
when small amounts of blood are constantly expectorated in 
tuberculosis, digitalis may stop such repeated hemorrhages. 
In all acute hemorrhages from the lungs digitalis is contra- 
indicated; nitroglycerin, to dilate the peripheral vessels and to 
lower blood-pressure is generally good treatment. 

Digitalis, by increasing the blood-pressure and the general 
as well as local circulation, may cause normal menstruation ; on 
the other hand at times a menorrhagia is well treated by 
digitalis. It may also relieve impotence in the male by improv- 
ing the circulation. 

AU dropsical conditions due to weakening of the circu- 
lation are benefited more or less by digitalis, but if the 
edemas are of kidney origin, and if there is nephritis, digitalis 
should not be given. In combined diseased conditions of 
heart and kidneys the decision should be made aa to whether 
the insuffidenc)' of the heart causes the disturbance in the 
kidneys, or whether the chronic inflammation of the kidneys 
is the primary lesion. With a passive congestion of the kidneys 
caused by a defective heart, with albumin and casts appearing 
in the urine, digitalis mil be of benefit. If, however, the 
kidneys are so diseased that an hypertrophied heart has finally 
become insufficient, owing to the excessive work that it was 
asked to do, digitalis in small doses may be of benefit; but even 
in such doses it is likely to make the excretion of the kidneys 
less. This is especially true in high blood-pressure caused by 
kidney lesions, and with such blood-pressure and kidney lesions^ 
digitalis is generally contraindicated. 

Always in heart-block, and generally when coronary disease 
has been diagnosed, digitalis is contraindicated. Occasionally, 
coincident with coronary disease is a degenerated and dilated 

15 



226 THE PRINCIPLES OF THERAPEUTICS 

heart. If edema is caused in such a condition, and much 
dyspnea, digitalis in small doses sometimes is of benefit, but 
it should be used with care. 

Strqphanthus. — Administration. — Strophanthus (African ar- 
row-poison) occurs as dried seeds, but is never used as such. 
The only official preparation is the tincture, which represents 
ID per cent, strength of the crude drug, and the dose is 0.5 mil 
(73^ minims). 

The most active part of this drug is represented by a 
mixture of glucosides, which is official xmder the name of 
Strophanthinum. 

Strophanthin occurs as a white or yellowish powder, which is 
very soluble in water. This preparation is generally admin- 
istered intramuscularly or intravenously, and the Pharma- 
copoeial dose is 3^o of 2l grain. A crystallized preparation of 
strophanthin, a glucoside, is recognized by the N.N.R., 1920, 
imder the title of Ouabain, Crystallized. The intravenous or 
intramuscular dose of this preparation is 3^20 of a grain. 
Neither this preparation nor the strophanthin of the Pharma- 
copoeia should be administered intravenously, ordinarily, 
more than once in twenty-four hours, and rarely should it be 
given more than twice at the same period. Strophanthin 
should not be given if the patient has been taking digitalis, as 
there is danger of an excessive action on the heart xmder these 
conditions. Solutions of strophanthin and of ouab^b rapidly 
deteriorate. They should test neutral or faintly add. 

Action. — Strophanthus has no action on the unbroken skin. 
The seeds, which contain a volatile oil, are irritant to mucous 
membranes, and, consequently, in large doses all preparations 
cause nausea, vomiting, and diarrhea. In very small doses the 
tincture may act as a bitter tonic on accoimt of this slight 
irritant action, while larger doses cause more or less indigestion, 
and often diarrhea. 

It was long supposed that strophanthus acted on the heart 
somewhat similarly to digitalis, only much less powerfully. It 
has, however, been proved, that for the best strophanthus 
effect on the heart the glucoside preparation of strophanthin, or 
ouabain must be given intramuscularly, or better, intravenously. 



STROPHANTHTJS 



237 



at least for quick effect. When, so given it wiU frequently, at 
least for a time, save life by stimulating a failing heart* 

The heart muscle is stimulated by strophanthin, and a rapid 
heart is somewhat slowed; the blood-pressure is somewhat raised 
by the increased heart action, although the arterioles are not 
contracted by it. 

In ordinary dosage strophanthus, given by the mouth, in the 
form of the tincture may have a slight sedative effect on the cen- 
tral nervous system. It has no diuretic effect, except when 
the heart is stimulated by injections of strophanthin. 

Over-a^iioft, — When the tincture of strophanthus is given by 
the mouth, the only undesired effect evident is gastrointestinal 
irritation, and some patients cannot take even a small dose, 
without its causing such irritation. 

Toxic Action,— h^itgi^ doses of strophanthus, unless immedi- 
ately vomited, produce paralysis through its action on the nervous 
system, WTicn given intramuscularly or intravenously the 
drug, if given in large doses, may cause death by action on the 
heart* When the drug is given subcutaneously it may cause 
abscesses. 

If poisoning occurs by way of the stomach, an emetic should 
be given and later a saline cathartic. If poisoning occurred 
after injection of strophanthin, the treatment would be purely 
symptomatic, and caffeine, atropine, camphor, and dry heat 
to the body is the treatment indicated. 

Uses. — The tincture of strophanthus should hardly be con- 
sidered a useful preparation in cardiac disturbances. It has 
seemed, however, to be of value, at times, in the conditions for 
which digitalis was being used; but it is quite probable that the 
apparent good effect the strophanthus had in these cases was 
because the digitalis was stopped, as but little strophanthin actioa 
on the heart can be obtained from strophanthus by the month* 
However, in nervous, irritable hearts, or when there is general 
nervous irritability with associated cardiac irritability, the 
tincture of strophanthus may have a good effect. 

The most useful action from this drug is in sudden heart 
failure, when strophanthin, or ouabain, should be given intrave- 
nously. Its greatest value is when there is no real defect of the 




228 THE PRINCIPLES OF THERAPEUTICS 

heart muscle, but in such conditions as sudden failure in typhoid 
fever or in pneumonia, or in collapse from shock, or perhaps when 
there is great slowing of the heart from partial heart-block, or 
in the Stokes-Adams syndrome. Strophanthus does not tend 
to aggravate a heart-block as does digitalis. It should be 
again emphasized that it should not be given when the patient 
is under the influence of digitalis. In emergencies the dose 
should be 0.0005 Gm., (half a milligram, H20 grain) of a good 
crystallized ouabsdn. Sterile ampules can be obtained forintra- 
venous use. 

Strophanthus does not act well in decompensation with 
general edema and dropsy. Also, it is rare that such a condi- 
tion has developed without the patient being under the 
influence of digitalis. 

Nux Vomica. — Administration. — ^Nux vomica occurs as dried 
seeds, but is not used as such, and the only official preparation 
that is needed is the Tinctura Nucis Vomica, which represents 
10 per cent, of the crude drug, the Pharmacopoeial dose of which 
is 0.5 mil (73^ minims). The only real use for this preparation 
of nux vomica is as a bitter tonic, as it is stimulant to the diges- 
tion, and to the gastrointestinal activities. It woxild rarely be 
given in sufficient doses to cause strychnine activity. 

As the only real value of nux vomica is due to its alkaloid, 
strychnine, the activities of this drug will be described under 
that heading. 

Strychnine. — Administration. — This alkaloid of nux vomica is 
rarely used except in the form of one of its official salts, namely, 
the nitrate and the sulphate. As there is no advantage of the 
nitrate over the sulphate, the sulphate should be the preparation 
of choice. The sulphate of strychnine occurs as colorless white 
crystals or as a crystalline powder, is soluble in considerable 
water, and the dose is o.ooi to 0.002 Gm. {}io to ^io grain). 

Action. — Strychnine has no action on the external skin, and is 
used only for administration by the mouth, or hypodermatic- 
ally. Strychnine is rapidly absorbed and rapidly stimulates the 
central nervous system, especially the motor tract of the spinal 
cord. It stimulates all of the nerve centers; stimulates the 
vasomotor centers, therefore raises the blood-pressure; stimu- 



STRYCHNINE 



229 



lates all glands and muscles; aids digestion; and increases peri- 
stalsis. It is slightly diuretic and is excreted in the urine. It 
increases the activities of all the special senses, is^a respiratory 
stimulant, and is stimulant to the heart. 

Over-action, — Strychnine may greatly increase the nervous 
reflexes and cause nerv^ous irritability and sleeplessness, and it 
may cause a rapid heart to be more rapid, and a Wgh blood- 
pressure to be higher. Hence it may do harm by causing too 
much general stimulation. 

Toxic Action,-— Poisoning causes tetanic convulsions, during 
which the patient may die from asphyxia^ or, if the convulsions 
are frequently repeated, he may die from exhaustion. 

Treatment of Poisoning.— li the drug has been taken into the 
stomach, emesis should be immediately caused, then tannic 
acid and water should be given; if the patient does not 
vomit sufl&ciently, the stomach should be washed out. If 
con\ailsions have already occurred, chloroform inhalations 
should be giveBj in order to facilitate washing out the stomach. 
Then chloral 2 Gm. (30 grains), and sodium, or potassium, 
bromide 3 Gm, (45 grains), should be given by the rectum, 
the patient being under the influence of chloroform. The 
patient should also be catheterizcd. 

t/^e5,— Indications for the use of strychnine are: (1) to 
increase the appetite; (2) to increase intestinal peristalsis; (3) 
to promote general metabolism; (4) to stimulate the nervous 
system; (5) to stop profuse sweating; (6) to improve the 
circulation. 

To meet the first two indications it is best given in the form 
of the tincture of nux vomica, in a dose of i to 5 drops, three 
times a day, before meals. Or, if the bitter is objected to, 
strychnine sulphate may be given in a dose of o.oor to 0,002 
Gm. (3^0 to J^o grains) three times a day, after meals. In this 
dose the strychnine \^t11 also more or less meet the next two 
indications, namely, to promote metabolism, and to stimulate 
the general nervous system. Therefore, strychnine sulphate, in 
properly selected cases, increases the appetite, the digestion, 
the normal movements of the stomach and intestines, increases 
all secretions, and awakens a sluggish ner\'ous system. How- 



230 THE PRINCIPLES OF THERAPEUTICS 

ever, in nervous tire and debility it should be recognized that 
strychnine is a whip and can only develop the reserve eneigy 
and strength without causing much recuperation of nervous 
energy. What such a patient generally needs is rest, both 
physical and mentaL Strychnine will give neither, although 
it will give temporary increased strength. 

Strychnine is used more or less extensively in all kinds of 
paralysis, but it should always be associated with mwe <x less 
massage and electrical treatment. It should not be givm in 
irritable, inflamed, or acute conditions of the spinal cord or 
braiiu If pain is caused by such inflammation, strychnine will 
increase that pain and increase muscle irritability and musde 
spasms. In paralysis, at the stage when general stimtilation is 
desirable, strychnine has been frequently injected into the 
paralyzed muscles. There seems to be no good reason for such 
localization of treatment, as the strychnine must go to the 
motor tract of the cord to be of any benefit to the paralyzed 
nerves and muscles. By the mouth, however, in most paretic 
conditions, in which there is no acute central lesion, strychnine 
is of benefit, and in the paral3rtic stage of neuritis it is benefidal 
when associated with local stimulation of the paralyzed muscles. 

In prostrating sweats either of tuberculosis or of acute disease, 
and in convalescence, when all tissues are relaxed, there is no 
drug more beneficial than strychnine. In the sweating of 
tuberculosis it is well associated with atropine. 

Before discussing the indication for the use of strychnine to 
improve the circulation, it should be urged that the sooner we 
leave the "strychnine age" the better. Too much strychnine 
is administered to-day during all acute diseases, and especially 
in the first stages of acute disease, and in the later stages with 
circulatory failure too large doses of strychnine are given. 
In the first place, during acute disease it is much better for a 
patient to rest, mentally and physically, rather than to be 
stimulated by this or any drug. In the second place, in acute 
cardiac weakness in serious illness strychnine often fails. It 
rarely raises the blood-pressure in conditions of shock, and it 
rarely is of benefit in serious heart weakness. 

On the other hand, with low temperature, without delirium. 



VASO-CONSTRICTORS 



231 



Willi much drowsmess, and a general sluggish metabolism^ and 
with all the vital centers acting sluggishly, strychnine is the 
drug of choice, and may be given once in six hours by the 
mouth, in a dose of from o.ooi to 0.002 Gm, ()^o ^^ Ho grain), 
depending on its effect on the patient. If the drug causes the 
patient to be sleepless, restless, and irritable, or if the heart is 
made more rapid, it should be stopped, or at least it should be 
given in smaller doses. If the patient is very much depressed, 
the temperature low, and the skin moist and cool, or if there is 
a tendency to collapse, the strychnine should be given hypoder- 
matically once in six to twelvehoiirs,butnot in large doses, and 
not more frequently. This is not to state that it may not be 
advisable, if strychnine has not been given at all, to administer, 
in certain acute shocked or collapsed conditions, a large dose of 
strychnine, even as much as 3^20 ^^ ^ grain, h>podermatically, 
but strychnine should not be relied upon to save a patient from 
shock or collapse, and to give large doses frequently is inex- 
cusable. It mil not raise the blood*pressure in such conditions, 
it will not strengthen the heart, and many times prevents 
normal cardiac diastole. The heart becomes irritable, and 
does not have its normal complete rest cycles. Again it 
should be stated that strychnine, though one of our most useful 
drugs, is used too much at the present time. 

In sudden heart failure during chloroform or ether narcosis, 
one large dose of strychnine may be given h>T)odermatically, 
not to be repeated; but in all shocked conditions the value of 
atropine and caffeine associated with strychnine should not be 
forgotten. 

DRUGS USED TO CONTRACT THE BLOOD-VESSELS 
VASO -CONSTRICTORS 

All drugs that strengthen the heart more or less increase the 
blood-pressure, but in emergencies atropine and caffeine are the 
most valuable drugs for this purpose. The drugs that cause 
local contraction of the blood-vessels, i.e., styptics, are not nsed 
to raise the general blood-pressure. 

In hypertension neither atropine nor caffeine should be 
administered as a drug, and the caffeine beverages should not 
be aUow^. Both of these drugs are very valuable in depressed, 



232 THE PRINCIPLES OF THERAPEUTICS 

low blood-pressure states, especially when the temperature is 
low in serious illness. Pituitary and suprarenal extracts will 
immediately raise the blood-pressure when given on the tongue, 
or hypodermatically. The latter raises the blood-pressure 
more than the former, but its action does not last as long. 
Pituitary extracts raise the blood-pressure, sustain it for some 
time, and at the same time are stimulant to the heart and have 
a diuretic action. 

Ergot — Administration. — Ergot of Rye is a fimgus growing 
on rye, and occurs as a brownish-black substance which has an 
oily, nauseating, disagreeable taste. It is not used as such, but 
in the of&dal preparations of Extractum Ergota and Fluidex- 
tractum Ergot^B. The extract of ergot in pure form, sometimes 
termed ergotin, occurs as a black pillular mass, the dose of 
which is 0.25 Gm. (4 grains). When this preparation is prop- 
erly made from good ergot, it is efficient, but generally the 
fluidextract is the preparation of choice, the dose of which is 2 
mils (30 minims). Ergot varies greatly in strength, and there- 
fore in activity. The ordinary fluidextract is irritant when 
administered hypodermatically or intramuscularly, but assayed 
fluid preparations are obtainable (both in sealed small bottles 
or in ampules) which are not irritant and are actively efficient. 

Ergot contains several active principles, ergotinine, ergo- 
toxine, tyramine, and histamine. Ergotoxine is a hydrate of 
ergotinine, and has a somewhat similar action to epinephrine. 
Tyramine is chemically similar to epinephrine and acts like 
epinephrine. It is formed from tyrosin by putrefactive pro- 
cesses, and is apparently the active ingredient of watery prepa- 
rations of ergot, which probably do not contain ergotoxine. 
Histamine is an active principle of ergot, but occurs in the 
drug in very minute amounts. 

Action. — Ergot is irritant to the stomach, sometimes even 
in small doses, and with some patients it always causes nausea 
and vomiting, even when given on a full stomach. When given 
hypodermatically it may cause nausea and vomiting by acting 
on the vomiting center. It is absorbed more or less rapidly, 
and is stimulant to all imstriped muscle fiber. It increases 
peristalsis, and therefore promotes activity of the bowels. It 



ERGOT 



^3i 



tends to raise the blood-pressure by causing contraction of the 
arterioles, but at times it lowers blood-pressure. 

It strongly stimulates contraction of the uterus when it is 
dilated, and more especially during and after parturition. 
Even small doses may cause tonic contractions of the utems 
during parturition, which would be dangerous to both the 
mother and child. Consequently, ergot should never be given 
until the child has been bore, and rarely until after the placenta 
has been expelled. 

Ergot acts as a sedative to the central nerv^ous system^ per- 
haps by controlling the circulation in the nerv^ous tissues* It 
certainly is many times beneficial in acute cerebrospinal inflam- 
mations, and is especially of benefit when there is edema of the 
brain, as occurs in delirium tremens and in low tj^hoid states. 

Oier'a€lioti. — Ergot may raise the blood-pressure too high, 
and therefore cause over-exertion of the heart, and heart pains* 
It may cause cold hands and feet, from too great a contraction 
of the blood-vessels, and it may cause severe uterine pain, 
when it is used to stop menorrhagia. 

Toxic Acliofi.—Acute poisoning from ergot is rare, although 
if vomiting and purging is not caused, and much of the drug is 
absorbed, there may be severe headache, ringing of the ears, 
dilatation of the pupils, a sense of chilliness, coldness, and 
perhaps tingling and numbness of the extremities. It is 
likely to cause abortion in pregnancy. 

Chronic ergot poisoning is rarely seen, although it can occur 
from eating diseased rye and flour, and has occurred in epidemics. 
Two forms of ergotism occur, the nervous t>T>e, in which there 
are all kinds of nervous sensations from itching, numbness and 
anesthesia to actual gangrenous conditions; the other type 
causes gastrointestinal symptoms. There may also be cerebral 
types. 

Treaiment of Poisoning. — Acute poisoning should be treated 
by evacuation of the stomach and intestines^ and by all means 
possible to dilate the peripheral blood-vessels, as hot baths, 
dry heat, nitrites and alcohol. 

Uses, — Ergot has been most used to cause contractions of the 
uterus in all bleeding from this organ. It is purely symptomatic 




2J4 ^^2 PRINCIPLES OF THERAPEUTICS 

treatment, and wliik it may stop bleeding at the time, the 
cause of the hemorrhage must be sou^t and properly treated; 
during its action it may cause severe uterine pains. It is 
used after parturition much less frequently than f ot m e i ly. 
It is perhaps always of value after chlOTofonn has been 
used as an anesthetic during parturition. Its disad- 
vantage b in sometimes preventing the normal after-pains, 
which are necessary to evacuate dots and shreds of membrane. 
Pituitary extracts are much more frequently used to-day than 
is ergot. 

The value of ergot in promoting intestinal peristalsis in 
semi-paretic conditions, as often occurs after abdominal opera- 
tions, is not generally recognized. For this purpose an aseptic 
preparation, given intramuscularly, is often efficient in promot- 
ing normal peristalsis. Ergot should not be given when there 
is intestinal obstruction, nor should it be given if there is high 
systolic blood-pressure. 

The value of ergot in acute cerebrospinal meningitis is not 
recognized. Intramuscular injections will many times quiet the 
patient and prevent the necessity of administering morphine 
for pain. If morphine is needed, ergot will prolong the sedative 
action from a single dose, and will also cause a smaller dose to 
be effective. Ergot is of great value in delirium tremens, in 
wet-brain, and in overcoming a narcotic habit, more especially 
when these conditions are associated with a failing heart and 
low blood-pressure. 

Perhaps one of the most efficient uses of ergot is in failing 
heart and circulation in serious conditions, and in all kinds of 
shock and collapse. For these purposes it must be given in 
aseptic solution intramuscularly, best into the deltoid muscle. 
The slight swelling that occurs should be covered with some 
simple wet dressing, and the swelling will soon disappear. 
With proper care (the preparation must be first class and 
aseptic) an abscess from injections of ergot need never occur. 
In these emergencies the ergot injection should be repeated 
once in three hours for two or three times, and then once in six 
or twelve hours for a series of doses, depending on the effect. 
Delirium can be quieted, a stupid brain may be cleared, low 



VASODILATORS 



^35 



blood -pressure may be raised, and a failing heart may be 
braced by ergot thus adimnistered. 

In serious acute collapse from broken compensation in 
valvular lesionsj with cold, clammy skin, blue lips, and acute 
edema of the lungs, ergot intramuscularly, associated mth 
venesection to relieve the laboring, dilated heart, may save life. 
In the heart failure of pneumonia it will at times save life. 

Ergot is of value in some forms of asthma associated with 
nervous irritability, and it may be of benefit in hyperthyroidism ^ 
and in hysterical conditions. In diabetes insipidus, the cause 
being cerebral, probably pituitary, ergot is of benefit, and may 
even aid in curing the condition. FuU doses should be given 
by the mouth. 

Ergot should not be given when there is internal hemorrhage, 
and it is a mistake to raise the blood-pressure in hemoptysis, for 
instance. In such conditions the opposite effect is desired and 
nitrites should be administered. 

In depressed conditions, and in vasomotor ataxic conditions 
in which there is an instability of the blood-pressure with head- 
ache and insomnia, ergot is often of benefit, improving the 
circulation, stopping the headache, and causing normal sleep. 

Tyramine Hydfi>chloride, N.N.R. — This preparation is pro- 
duced synthetically, but it also may be prepared from ergot. 
It occurs as a white crystalline powder, soluble in water, and is 
used mostly h>TX>dermaticaIIy in doses of 0.02 to 0,04 Gm. 
(H ^^ % grain). It may also be administered by the mouth. 

Its action resembles that of epinephrine. It contracts the 
uterus (but not as actively as does pituitary extract) and raises 
the blood-pressure quite rapidly when given hypodermatically, 
but in about half an hour t]n blood-pressure has returned to 
normal. It may increase extra-systoles, and is not a reliable 
drug in heart failure. Other drugs are better. 



DRUGS USED TO DItATE THE BLOOD-VESSELS 
VASO-DILATORS 

These drugs are used to lower blood-pressure, consequently, 
to discuss the indications for them we must briefly refer to the 
cause of high blood-pressure or hypertension. 



236 THE PRINCIPLES OF THERAPEUTICS 

The causes of systolic hypertension may be briefly enumer- 
ated as follows: 

The rapid, nervous tension of our lives. 

Too much coffee and tea. 

Too much tobacco. 

Hyperthyroidism, which either stimulates to extra secretion 
the posterior lobe of the pituitary, or the adrenals, or both; or 
hyperthyroidism allows substances to circulate in the blood 
which irritate the blood-vessel walls to cause vaso-contraction 
or which stimulate the vasomotor center. 

Substances absorbed from the intestinal canal in intestinal 
indigestion which cause vaso-constriction. 

Strenuous athletics which cause cardiac hyj>ertrophy. 

Hard labor which causes cardiac hypertrophy. 

Serious acute infection of years before, which has caused 
glandular disturbances which tend toward hypertension. 

Some forms of chronic infection may cause hypertension by 
disturbing glandular secretions. 

Syphilis. 

Glandular disturbances of the menopause often cause hyper- 
tension. 

Kidney disease. 

These may not be all of the causes of hypertension, but in- 
creased arterial pressure is the forerunner of disease in some part 
of the body, and hypertension soon causes symptoms of its own 
which may require treatment. 

The most frequent symptoms are headache, nervousness, 
restlessness, insomnia, increased frequency of urination espe- 
cially at night, dizziness, flushing, hypertrophy of the left ven- 
tricle, and symptoms of cardiac tire. Such symptoms occurring, 
means must be taken to lower the pressure. However, without 
symptoms, a pressure that is not very high does not require 
treatment. 

It is not purposed here to outline the treatment of hyperten- 
sion, but the list of causes that produce this condition should 
lead to the elimination of all removable etiologic factors, and 
especially should warn against such conditions as may cause 



VASODILATORS 



237 



hypertension in the futare. In other wordSj prevention of 
h>T>ertension should be the watchword of this age. 

It is not often wise to lower chronic high blood-pressure by 
drugs that weaken the heart, although occasionally small doses 
of aconite, or a coal-tar drug, or chloral, may be used for this 
purpose. 

Anything that produces watery purging will always lower the 
blood-pressure^ but such treatment would be for an emergency, 
and should not be carried out daily. On the other hand, daily 
free movements of the bowels are essentia! in hypertension, as 
constipation and intestinal putrefaction will always tend to 
increase the blood-pressure. 

In hypertension caused by th>Toid disturbance, by intestinal 
putrefaction, and by kidney disease, it is essential to either 
deprive the patient entirely of meat and all purins, or at least 
to greatly curtail their intake. 

In the hypertension of the menopause, corpus luteum prep- 
arations are of benefit in some instances, and thyroid extracts 
in other instances. In subsecretion of the thyroid with hyper- 
tension, and espedally if there is a history of syphilis, the 
iodides are indicated, and will lower pressure. 

The various methods of applying heat to the body will lower 
pressure, such as body baking, electric light baths, Turkish baths, 
and the ordinary hot bath, provided cold applications are not 
given immediately after the he^t treatment. Warm weather 
and hot dimates lower blood-pressure; cold weather and cold 
climates raise the pressure. 

In emergencies venesection may be done and considerable 
amounts of blood removed, but the lowered pressure from vene- 
section is not likely to last more than a few days; consequently, 
this treatment is rarely indicated. 

The drugs that are most used to dilate the blood-vessels and 
therefore lower pressure are the nitrites. Alcohol will always 
low^er the blood-pressure by dilating the peripheral blood- 
vessels, but it should not be used in hypertension. It is of value 
in dilating the peripheral vessels after chilling, and in certain 
conditions in severe illness. Properly administered, wath high 
fever, it will increase evaporation and sweating and be of 




238 THE PRINCIPLES OF THERAPEUTICS 

benefit. It is not a cardiac stimulant, and should not be used 
in shock. 

It should be noted that many a patient with high pressure 
tolerates, and thrives on, this pressure for years with no serious 
consequences. Also, when some patients with high pressure 
have that pressure lowered, they become dizzy, weak, and in- 
capacitated. Consequently, the actual lowering of the pressure 
by drugs should be considered a matter for as careful decision 
and care as is the decision to give digitalis in disturbances of the 
heart. 

AlcohoL — Administration. — This prepai'ation must contain 
not less than 92.3 per cent, by weight of alcohol, while the official 
Alcohol Dehydratum^ absolute alcohol, must contain 99 per cent, 
by weight, and the official Alcohol Dilutum contains from 41 to 
42 per cent, by weight. The so-called denatured alcohol is 
alcohol to which has been added about 10 per cent, of wood 
alcohol and about 0.5 per cent, of benzene. Denatured alcohol 
should never be used extemaUy or internally. 

The alcohol of the Pharmacopoeia and the alcohol of whiskey 
and brandy is ethyl alcohol. Wood alcohol is methyl alcohol. 
Ethyl alcohol is largely produced by fermentation of grape sugar 
with yeast. A sweet wine is one in which some of its sugar is 
unfennented, while a dry wine is one where the sugar has all 
been fermented. Whiskey and brandy contain from 40 to 50 
per cent, of alcohol; sherry and port about 20 per cent.; gin and 
rum 40 to 50 per cent.; the clarets about 10 to 12 per cent.; 
champagne about 10 to 12 per cent.; ales S to 7 per cent.; the 
beer that used to be about 4 per cent., to what it now is, about 
0.5 per cent. 

If alcohol is used therapeutically, the dose is about 30 mils 
(i fluidounce) for an emergency, and about 5 to 10 mils (i to 2 
fluidrachms) given every two hours as long as the patient re- 
quires such treatment. It should be more or less diluted, de- 
pending upon the object for which it is used. Quick absorption 
and slight primary stimulation will be best obtained when the 
solution is strong. When such rapid action is not desired, and 
it is used only to cause general vasodilatation, or when it is 
administered as a food, it should be well diluted. 



ALCOHOL 



239 



Action, — Externally, alcohol in strong solution, especially 
when rubbed on is slightly irritant, and causes flushing and con- 
gestion of the skin. If strong alcohol is allowed to evaporate 
from the surface the skin is cooled ; rapid cooling, as by fanning, 
will cause slight benumbing of the skin. Alcohol or cologne 
is sometimes used in this manner to relieve headache- Strong 
preparations of alcohol are astringent to the skin, mUdly hemo- 
static, and more or less antiseptic* Alcohol rubs tone up the 
skin and muscles, while sponging with it, in more or less con- 
centration, will reduce temperature. In low temperature the 
alcohol should be warm. A dash of alcohol in a basin of water 
does not constitute a solution for an alcohol bath or for alcohol 
sponging, although it may be pleasing to the sense of smell. 
Repeated use of alcohol on the skintends to dry it; therefore a 
dry, scaly, eczematous skin should not receive such treatment. 
An oily, over-secreting skin is well treated by alcohol, and if 
it is desired to harden any part of the skin alcohol is efficient. 

On the mucous membranes, alcohol is irritant and slightly 
astringent J unless very much diluted. 

Alcohol is rapidly absorbed from the gastrointestinal tract, 
and when taken before meals tends to stimulate the desire for 
food, but irritates the stomach, and when repeatedly taken in 
that manner may cause chronic gastritis and indigestion, A 
large amount of alcohol taken with a meal will inhibit the diges- 
tion. Alcohol on an empty stomach is rapidly carried to the 
liver, and sooner or later inhibits its activities, unless the doses 
taken are small, Wann alcohol in any form is more or less 
stimulant to the intestines, causing increased peristalsis, acting, 
like all aromatics, as a carminative. Concentrated solutions 
will not ordy inflame the stomach, but may cause a duodenitis. 

There is no question that alcohol may be used as a substitute 
for food in the place of starch and sugar. In emergencies it may 
thus sustain life, but it cannot be long used as a food without 
its undesirable activities becoming evident. About i H ounces 
of alcohol, or 3 ounces of whiskey, will sustain the body without 
loss for twenty-four hours. Much less than this amount may 
be advisable in certain conditions in acute illness when only a 
small amount of other food is allowed. 



240 THE PRINCIPLES OF THERAPEUTICS 

Alcohol may work harmfully in several ways. It may 
cause indigestion and disturbance of the liver. This may cause, 
later, congestions of the liver, insufficiency of the bile, and in- 
testinal indigestion; consequently more irrtiants reach the 
kidneys, and kidney irritation develops. Or, alcohol may in- 
crease the blood-pressure by allowing irritants to circulate in 
the blood. These irritants, or the alcohol itself, may disturb 
the brain by actual irritation or by chemical reaction with sub- 
stances in the brain. On the other hand, if a man is otherwise 
well, alcohol may increase his appetite, cause him to eat more 
than he needs, and, it being more readily burned than are the 
fats, cause him to deposit extra amounts of fat and to increase 
his weight, largely on his abdomen. 

Strenuous exercise and hard labor will allow a man to use 
more alcohol without harm than can be used by a man of seden- 
tary habits; however, alcohol will not increase his ability to 
work, but on the contrary will diminish his strength. Also, one 
cannot do as good mental work under the influence of alcohol as 
without it. 

Alcohol was long used as a stimulant to the circulatory 
system. During previous sturdy ages it may have had the 
effect desired, by lowering the blood-pressure, dilating the peri- 
pheral blood-vessels, and weakening a too strenuous heart; but 
in the present age it is never a cardiac stimulant. It is abso- 
lutely contraindicated in shock, although in sudden chilling and 
sudden syncope it may cause the stimulating effect desired. 
Repeated taking of alcohol is likely to cause peripheral dila- 
tation of the surface vessels, especially on the face and around 
the nose, although not every such condition of dilated capillaries 
of the face and nose is due to alcohol. 

Small doses of alcohol are stimulant to the nervous systems 
of those who are not used to its effect, and sedative to the 
nervous systems of those who are used to it. It may cause 
sleep in sufficient doses, by dilating the peripheral circulation 
and lowering blood-pressure. Very large doses may cause 
much cerebral excitement, or may cause stupor, and later coma. 

Over-action. — The over-action of alcohol is evidenced by 
cerebral excitement; a rapid, bounding pulse; flushing of the 



ALCOHOL 



241 



£ace, and a strong odor of alcohol on the breath. If alcohol is 
used medicinally these s^Tuptoms occurring show that the dose 
is too large or is being too frequently repeated. However, it is 
almost inexcusable to give a sufficient amount to cause such 
symptoms. 

Toxic Action. ~A\lcohol in toxic doses may cause serious 
cerebral excitement and, later, heart weakness and stupor. 
Delirium tremens is likely to be caused by privation of alcohol in 
those who have been hard drinkers, or who have been having a 
period of excessive drinking. The body temperature is very 
much lowered after excessive doses, and individuals who are 
suffering from such a condition readily become chiUed and 
develop internal congestions, typically pneumonia. Under 
present conditions it may become very rare for a physician to 
be called to treat a man in alcoholic coma, but it may be worth 
while to still remember that a patient may be suffering from 
narcotic poisoning, uremic or diabetic coma, apoplexy, or cere- 
bral injury and yet have the odor of alcohol on liis breath. 

Trealnwnt of Poisaning.~ThG patient should be vomited; if 
the heart is in good condition, best with apomorphine hypo- 
derma tically. If there is cerebral excitement, scopolamine 
hydrobromide should be given hypodermatically, an ice cap 
placed on the head, and perhaps a dose of bromide or chloral, 
or both, given. If the heart is weak, ergot intramuscularly 
should be given, and if there is no delirium, coffee by the mouth. 
Digitalis may be needed. This is best administered hj'poderma- 
tically or intramuscularly. Morphine is generally inadvisable, 
as these patients require a large dose to quiet them, a small dose 
only increasing their excitement. 

Death from alcohol is caused by paralysis of the respiratory 
center, although the heart may fail and the death may be 
largely from exhaustion. In comatose conditions the bladder 
Lriiould be catheterized more or less frequently. 

Uses. — The external use of alcohol has already been referred to 
under the heading of '* administration.'* Besides the uses 
there suggested wet dressings with alcohol are often of value in 
sprains and acute inffammations of a part, especially of the 
joints, A small towel or napkin wet with one part of alcohd 



242 THE PRINCIPLES OF THERAPEUTICS 

and three parts of cold water is wrapped around the jomt, cov- 
ered with oil silk or rubber tissue, and the whole bound firmly, 
but not too tightly, with a bandage. This alcohol pack tends 
to relieve inflammation. 

Gushing^ describes the value of injections of alcohol in 
trigeminal neuralgia and states that, though not without some 
danger, these injections into the maxillary and mandibular 
nerve trunks are preferable to peripheral neurectomies. If the 
neuralgia is refractory the injections should not be pushed, but 
the more radical surgical operation should be done. 

The internal therapeutic use of alcohol should be entirely 
separated from a consideration of alcohol as a beverage or from 
the prohibition standpoint. Alcohol is a drug, and as such has 
many valuable uses. It is absolutely inexcusable to order 
alcohol for any chronic condition, or as an appetizer, or as a 
sleep producer, except under very unusual conditions. There 
are times, for individuals who are very weak, and in old age, 
when a little bitter tonic which contains alcohol, taken before 
meals, is perfectly legitimate treatment. In the age when 
alcohol could be obtained, it was a perfectly harmless proposi- 
tion, in old age, with sleeplessness, to order a small amount of 
alcohol in the form best suited to the individual, to be taken 
before bedtime. It is in such cases much less likely to do harm 
than is a stronger hypnotic drug. 

In sudden syncope, when whiskey or brandy is available, a 
dose of it may quickly relieve the condition and revive the 
heart and circulation. It never does any harm in such a case, 
and always some good. 

In acute illness when but little food can be taken, and when 
the skin is dry and hot, small doses of alcohol, as a teaspoonful 
of whiskey once in three or four hours, taken well diluted, will 
often slow the pulse, lower the temperature, and make the 
patient much more comfortable. Large doses of alcohol are 
never needed in illness, and if they ever saved life in the pneu- 
monias of years ago, as once strongly advocated, they cannot 
save life now. In all depressed conditions in acute illness 
alcohol is contraindicated. 

^ Journal A. M. A., Aug. 14, 1920, p. 441. 



ALCOHOL 



243 



When a vaso-dilator is needed in high fever, a small dose of 
nitroglycerin, 3^*200 of a grain once in three or four hours, may 
act on the circulation as does alcohol Generally any serious 
ilhiess to-day may be treated satisfactorily from start to finish 
OTthout a single dose of alcohol, while twenty-five years ago 
perhaps but few patients went through an illness without alco- 
hol, and fifty years ago perhaps no one was treated throughout 
an illness without alcohol. But this does not signify that it was 
a mistake to give alcohol to these patients, although unquestion- 
ably many received more alcohol than they needed. It 
simply means that the general systemic condition of our pa- 
tients has changed, they then needed more or less relaxation. 
We will probably soon find that we can satisfactorily carry a 
patient through illness mthout strychnine ; this is the strychnine 
age, and most everyone who is ill receives it. We will probably 
soon find that, in this neurotic age, all patients are over-stimu- 
lated, and would be better ^\ithout strychnine. 

Alcohol has been very frequently resorted to both by the 
laity and by the profession, in combination with other treat- 
ments, to cause vaso-dilatation and profuse sweating in the 
endeavor to abort colds. Alcohol has good and satisfactory 
action in meeting this indication^ but probably it mil be found 
that other drugs, such as camphor and, perhaps, nitroglycerin, 
will act as well. 

Large doses of alcohol have been much used in poisoning, 
especially in snake poisoning, but there is no need for such 
treatment. 

We may sum up the internal therapeutic uses of alcohol as 
follows: Alcohol is not a heart stimulant. It has no tonic 
action, and in large doses causes a patient to feel better by 
its strong narcotic effect. This feeling of betterment is often 
later followed by a depression of all vital activities, viz., there 
may be mental weariness, circulatory^ weakness, loss of appe- 
tite and impaired function of the internal secreting glands. In 
small doses it causes a feeling of rest when one is tired and 
over-worked, both by its sedative action and by its equally 
distributing the blood over the surface of the body. For such 
an effect alcohol should be taken only when physical and 



244 THE PRINCIPLES OF THERAPEUTICS 

mental labors are over for the day. The prohibitionists^ 
however, have deprived the individual of his right to decide 
^ that alcohol is the sedative that he will have, and the question 
Tvill arise as to whether being deprived of that sedative, he will 
not take other means to cause a feeling of well-being and rest- 
fulness. Will he take drugs (not necessarily narcotics, which 
he cannot get), but such drugs as coal-tar products and more 
aspirin ? Or will he, instead of resting from his tire, re-stimulate 
with coflfee and tea? Or will he brace up and depress at one 
and the same time by the excessive use of tobacco? This 
all remains to be seen. Alcohol as a drug is only rarely needed 
in the treatment of disease, and then, as just stated, only in 
small amounts and for a short time, much as a physician would 
use any other narcotic or circulatory depressant drug. 

Nitrites. — Nitrites are the most active vaso-dilator drugs 
that we possess, and in active soluble preparation they will 
always lower the blood-pressure. They vary only in the 
rapidity of their action. Those that act the most rapidly are 
the ones that should be used when vaso-dilatation and a 
change of the circulation is desired immediately; those of 
slower action are the ones that should be used when a less 
rapid and a more prolonged fall of blood-pressure is desired. 

Amyl Nitrite occurs as a clear or yellowish liquid of ethereal, 
pungent odor and aromatic taste. It is very volatile, and must 
be kept in a dark, cool place, and in glass-stoppered bottles. It 
is better prepared and kept for administration in ampules. The 
dose is 0.2 mil (3 minims) by inhalation. The best method of 
administering this drug is by crushing a glass ampule of it in a 
handkerchief and then holding the handkerchief close to the 
nostrils for rapid inhalation. 

Nitroglycerin is official only as the Spiritus Glycerylis Nitratis. 
This spirit of nitroglycerin (spirit of glonoin) contains i per 
cent, of nitroglycerin. It is a clear, colorless, alcoholic liquid, 
and should be kept in a cool dark place in a well stoppered 
bottle. The dose of this preparation is 0.05 mil (about i 
minim). Generally, nitroglycerin is much better administered 
as a soluble tablet, and the average dose is 3-^oo grain, but the 
range of dose is from J^oo to }io grain. 



NITtaTES 



24S 



Sodium Nitrite occurs in white masses or as a granular 
powderj is very soluble in water, and the dose is 0,06 Gm, 
(i grain). This preparation is slightly irritant to the stomach, 
but otherwse it has a similar action to nitroglycerin, 

Erythrol Teiranitrak^ N,N,R, — This is a solid preparation 
which is best dispensed in ready-prepared tablets. It acts 
like nitroglycerin, only its acti\dty is slower and more lasting, 
the action beginning in about fifteen minutes and lasting 
three or four hours. The dose is 0.03 to D.06 Gm. (J^^ to i 
grain). 

Aciion. — Amyl nitrite is slightly irritant to mucous mem- 
branes. Sodium m'trite is also irritant and may disturb the 
stomach, if it is empty. Tablets of nitroglycerin and of ery- 
throl tetranitrate are non-irritant. 

The action from amyl nitrite when administered by inhalation 
is almost instantaneous, and this action is entirely on the 
circulation, A nitroglycerin tablet dissolved in the mouth or 
given hypodermaticaUy acts also ver>^ rapidly. When taken 
on an empty stomach it will be rapidly absorbed; on a full 
stomach it will be more slowly absorbed. The same is true of 
erythrol tetranitrate. Sodium nitrite should never be adminis- 
tered on an empty stomach. 

The first activity of a nitrite is that of causing peripheral 
dilatation, a feeling of fullness in the head, throbbing of the blood- 
vessels, especially in the neck, head and forehead, sometimes 
flushing of the face, and headache, if the dose is sufficient to 
cause much dilatation. The heart is temporarily made more 
rapid. The length of time that the vaso-dilatation lasts varies 
from about half an hour to three or four hours. Although in the 
laboratory the action of nitrites has been proved to be so rapidly 
over, still clinically a faU of blood-pressure that lasts even a 
short time is of benefit to an individual who needs such treat- 
ment, and the value of nitroglycerin for patients with symptoms 
of high pressure such as heart pains and high tension headache 
is great. Part of the blood-pressure fall may be due to a de- 
pressant action on the vaso-motor centers and part may be due 
to actual dilator action on the blood-vessel walls. With com- 
plete action of a nitrite the veins are also somewhat dilated. 





246 THE PRINCIPLES OF THERAPEUTICS 

From these activities the blood-pressure will decidedly fall 
under the action of nitrites. 

If cardiac pain is due to high pressure, or to coronary disease, 
it may be relieved by the relaxing dilating effect of a nitrite on 
the general circulation, and an anginal pain will of ten be imme- 
diately relieved by inhalation of amyl nitrite. Nitrites have no 
action in the body except that caused locally by a change in 
circulation, therefore the action on the brain is due to the cir- 
culatory changes. Nitrites are oxidized into nitrates, and are 
thus excreted in the urine. 

Over-action. — The symptoms of over-action are headache, 
full-headedness, dizziness, andi perhaps syncope. On account 
of amyl nitrite so readily causing such a condition, it is rarely 
used except for emergencies. 

Severe poisoning can hardly occur clinically from a nitrite. 
The most serious symptoms that can occur from too large a dose 
of a nitrite is heart weakness, cyanosis, and coldness of the ex- 
tremities. The treatment would be to give quick-acting vaso- 
constricting drugs, such as the active principle of the posterior 
lobe of the pituitary gland, epinephrine, strychnine, atropine 
and caffeine. 

Uses. — The emergencies in which a quick-acting nitrite is 
needed are angina pectoris and epilepsy. A patient who has 
anginal attacks should always carry soluble nitroglycerin tab- 
lets in his pocket, each 3^^ 00 of a grain, to dissolve quickly in 
his mouth whenever he has an attack. If one tablet is not 
sufficient, in ten minutes he should take another one, and this 
may again be repeated, the only limit being the throbbing in the 
head, especially in the forehead, and a full-headed feeling. If 
deemed best, he may also carry ampules of nitrite of amyl. The 
quicker action of the nitrite of amyl when an ampule is crushed 
in the handkerchief and inhaled is generally reserved for an 
aura of an epileptic attack. An epileptic who has an aura long 
enough for him to crush such an ampule and inhale it may 
prevent the fit. 

The only other emergency use of a nitrite is in asthma, al- 
though the emergency is not so urgent. Such a patient may 
also dissolve nitroglycerin tablets in his mouth and get quick 



DRUGS ACTING ON THE CENTRAL NERVOUS SYSTEM 247 

relaxing results. He should be instructed to dissolve a ^{qq 
grain tablet under his tongue, and repeat it every half hour until 
he obtains relief. 

When it is decided to lower blood-pressure with nitroglycerin 
the choice is generally nitroglycerin or erythrol tetramtrate 
tablets. The frequency of the dose depends upon the eflect on 
the individual, but generally four times in twenty-four hours is 
sufficient, a tablet after each meal and on going to bed. For this 
vaso-dilating effect the tablet should not be dissolved in the 
mouth, but should always be taken i^nth plenty of water, and 
preferably when something is in the stomach. In other words, 
rapid action is not desired, and the disagreeable pressure feel- 
ings in the head need not be caused. 

Symptoms of high pressure such as dizziness, a feeling of 
tension in the head, occipital headache, and cardiac ache, and 
possibly cold hands and feet, may be relieved many times by a 
small dose of nitroglycerin, as } 400 ^^ Moo grain, when a larger 
dose, as J-^oo g^ain may cause headache; but the dose depends 
on the indlviduaL It is rarely necessary, however, to give 
more than Jfoo ^^ ^ grain, although that dose may be needed 
every three or four hours. 

As stated under the subject of alcohol, in high fever, when 
apparently alcohol is indicated, nitroglycerin may act as well to 
dilate the peripheral blood-vessels and promote perspiration. 

In spasmodic conditions such as occur in dysmenorrhea, at 
times vaso-dilatation from nitroglycerin may cause relief. 

In insomnia from high pressure a dose of nitroglycerin taken 
with a cup of malted milk at bedtime will often promote sleep. 

In attacks of asthma nitroglycerin will generally cause 
immediate relief. If the blood-pressure is low, however, and 
there is venous congestion and cardiac weakness, epinephrine 
on the tongue will often act more satisfactorily. 



CLASS V 
Drugs used for action on the Central Nervous System 

This class includes drugs which have a ver>'^ slight effect on 
the brain and spinal cord and drugs that have a profound effect 



248 THE PRINCrPUES OF THERAPEUTICS 

on the central nervous system, as anesthetics. Their action 
can only well be discussed in their separate sub-classes. 

DRUGS USED TO STIMULATE THE BRAIN AND SPINAL CORD 

The once called "antispasmodics'' are drugs that seem to 
modify hyper-exdtability and prevent various pseudo-spasmodic 
conditions and relax pain. These drugs are not narcotics, but 
cause improvement by stimulating the higher brain centers of 
control, actually as by camphor perhaps, or suggestively as by 
the disagreeable odor of the long used asafetida and valerian. 
These last named drugs may aid nervous control in hysteria by 
the psychic eflFect of the smell, or if in alcoholic preparations, 
may cause sufficient alcoholic cerebral effect to quiet the patient. 
Spirit of lavender has been much lauded for hysteria, but it 
is the alcohol only that is effective. 

These drugs, namely, asafetida, valerian and lavender, at 
times so valuable in hysteria, are often less effective than is so- 
called " Christian Science. " 

Camphor is really a cerebral stimulant and dilates the 
peripheral blood-vessels, and may change the view-point of 
the hysteric. However, before hysteria is diagnosed as an en- 
tity in a given case, all other more tangible conditions must be 
excluded. There is generally a cause for these disturbed im- 
pulses, often an endocrine gland dysfunction. The thyroid 
gland is the one most generally in trouble, and frequently the 
ovarian function is abnormal. 

Thyroid gland extracts are cerebral stimulants, especially 
in conditions that need such stimulation. The value of caffeine 
and atropine as circulatory stimulants has been discussed. 
They are also cerebral stimulants, the caffeine especially stimu- 
lating brain activity, and atropine especially stimulating the 
medullary centers and in large doses causing cerebral excite- 
ment. Strychnine is not only a medullary stimulant, but is 
especially a spinal motor stimulant. The discussion of the use 
of these drugs, caffeine, atropine, and strychnine as nervous 
stimulants would take us into the discussion of the treatment 
of shock, coma, and paralysis. Suffice it to say under this 
caption that none of these drugs should be used in nervous 



DRUGS TO STIMULATE BRAIN AKD SPINAL CORD 



249 



irritability or in sleeplessness, and that coffee and tea are often 
the cause of insomnia » 

Belladonna, — ^Belladonna is official both as the leaves and 
the root, but as all activities of beUadonna are those of atro- 
pine, as far as its therapeutic use is concerned, there is no need 
for the preparations of this drug for internal use; we do not 
need the extract, the tincture, or the fluidextract of belladonna. 
The official belladonna plaster which represents 20 per cent, of 
the drug, and the official ointment of belladonna which repre- 
sents 10 per cent, of the drug are useful preparations for ex- 
ternal use. The official liniment of belladonna is superfluous » 
as the absorption of atropine could not be limited and poisoning 
might be caused. 

The only use for belladonna extemaOy is as a sedative to 
relieve pain and irritation. In susceptible indi\'iduals, even 
the belladonna plaster may cause poisoning, and the belladonna 
ointment should, also, not be used in a large amount at any one 
time. 

Byoscyamus. —There seems to be no good reason why this 
drug should be used as such or in its three offidal preparations. 
The tincture of hyoscyamus has been long used as a sedative, 
more especially in irritable conditions of the bladder, and in 
pelvic disturbances. There is no proof that there is an activity 
of this drug other than that of atropine. Its atropine-Uke 
aUialoid is termed hyoscyamine, but this alkaloid, unlike atropine, 
when used alone is likely to cause secondaiy depression. The 
other alkaloid of hyoscyamus, scopolamine (hyosdne) besides 
having a primary' atropine action has a sedative action on the 
central nervous system; this alkaloid is used only as a h^'pnotic. 

Hyoscyamine is official as Hyoscyamin<B Ilydrobromidumy 
but as this drug is likely to cause unexpected depression, there 
seems to be no Justification for its use. 

Scopolamines Hydrobromidum (hyoscine hydrobromide) is 
very soluble in water, and is used principally h^podennatically 
in intense cerebral excitement, in acute delirium, and in the 
sleeplessness of insanity. When given h>T>odermatically, or 
in a tablet to be dissolved in the mouth, it generally quickly 
causes sleep. However, when there is an idiosyncrasy to 



2SO THE PRINCIPLES OF THERAPEUTICS 

atropines, it may cause considerable cerebral excitement. Con- 
sequently, before giving a full dose of this drug, it should be 
ascertained that the patient is not susceptible to atropine. 
After a sleep from scopolamine there is likely to be consider- 
able circulatory depression. Consequently, it is not wise to 
give scopolamine as a hypnotic and then allow the patient to 
be up and about the next morning. 

Scopolamine has also been used in spinal irritability, and in 
paralysis agitans. The dose for these purposes is smaller, not 
sufficient to produce sleep, and it should be administered two or 
three times a day. In such patients a tolerance has sometimes 
been developed, and larger doses may be needed. 

Although scopolamine may cause atropine stimulation, it 
should never be considered that it is anything but a depres- 
sant, and when serious poisoning occurs, depression must be 
combated. 

The average dose is 0.0003 Gm. (Hoo grain). It is often 
necessary, however, to give double this dose, Hoo oi a grain. 

Stramonium is official as the leaves. The action of this drug 
is only that of atropine, and therefore there is no good excuse 
for its four official preparations. Tie action and poisoning of 
stramonium is that of an atropine. 

The only use for stramonium is in the form of the leaves, to 
be made into cigarettes or pastilles, or to be burned as a powder, 
for inhalation in asthma. Generally the leaves are combined 
with nitrate of potassium (saltpetre) which causes the drug to 
bum rapidly, and also gives some relaxation from the nitrite 
formed when the fumes are inhaled. The action of stramonium 
when inhaled is that of a sedative from the action of the atropine 
on the nerves of the mucous membrane of the air passages. 
Although inhaling this fume of atropine may give local sedative 
action to irritated nerve terminals in the region that is spasmod- 
ically contracted, still atropine sulphate given hypodermatically 
or dissolved in the mouth may cause the same satisfactory 
eflFect. 

Atropine. — Administration. — This drug is best used in the 
form of the official sulphate, which occurs as a white powder, 
very soluble in water. The dose varies from 0.0003 to 0.0006 



ATROPINE 



25^ 



Gm. (Hoo to J loo grain). In particular conditions, for specific 
purposes, much larger doses may be given* Although more or 
less rapidly absorbed, tJie full effects of the drug do not occur 
until after several hours, the length of time of course depending 
upon the mode of administration. Also the drug is slow of 
excretion and its action is therefore prolonged, hence atropine 
for any purpose should not be frequently repeated, rarely more 
than once in six hours, and then only for a few doses, unless the 
dose administered is very smaU. 

Actimi. — Atropine more or less inhibits all secretions, and 
therefore may tend to inhibit the gastric secretion, and for this 
reason has been used much for hyperacidity. For this purpose, 
however, its use is not a success. It dulls the peripheral endings 
of the nerves and therefore decreases intestinal irritability, and 
for ttds purpose it is often combined with laxatives with the 
object of preventing bowel cramps. 

After absorption it dries all secretions, especially those of the 
nose, throat, mouth, and bronchial tubes. It also decreases 
perspiration. It is a most active stimulant to the respiratory 
center, more or less accelerates the pulse, somewhat raises the 
blood-pressure by stimulation of the vasomotor center, and 
somewhat constricts the blood-vessels of the splanchnic region. 
At the same time it causes dilatation of some of tlie surface 
vessels, more especially of the face and the upper part of the 
body, and hence often causes flushing, and even a scarlatini- 
form eruption. 

If applied locaUy to the eyes, or if absorbed in any con- 
siderable amount, it causes dilatation of the pupils, and when 
applied locally to the eye in strong solutions (the strength most 
used for this purpose being i per cent.) it causes paralysis of 
accommodation. Atropine may be more or less absorbed from 
the skin and cause dulling of the peripheral ner\^es and cessation 
of peripheral pain. It is excreted mostly in the urine, and per- 
haps may be excreted in the milk of nursing women. 

Cher-action, ^Moxe individuals are susceptible to, and showan 
diosyncrasy against, atropine in any form than to any other 
one drug; some indi\iduals, have an excessive action from 
the drug even from small doses. Besides the scarlatiniform 




252 THE PRINCIPLES OF THERAPEUTICS 

efflorescence on the face and upper part of the body, there is 
dilatation of the pupils, very much drying of the throat and 
mouth, and at times a tachycardia occurs, from paralysis of 
the vagus endings in the heart. There is often also considerable 
cerebral excitation. This is especially noticeable in some in- 
dividuals when scopolamine is given to cause sleep. 

Toxic Action. — Convulsions may be caused by a poisonous 
dose of atropine, and death occurs from both respiratory and 
cardiac failure. 

Treatment of Poisoning. — The treatment is, of course, to 
prevent further absorption of the drug, by emetics if the drug is 
in the stomach, and by catharsis if it is presumed that it is in 
the intestine. Administration of morphine may aid in pre- 
venting the toxic effect of atropine and in quieting excitation. 
Large amoimts of water should be dnmk, and the bladder should 
be frequently catheterized, if the patient cannot pass urine 
freely. Means to promote perspiration are of value. 

Uses. — The indications for the use of atropine are: 

1. To inhibit or dull peripheral nerve irritation and hyper- 
excitability. 

2. To dry up secretions. 

3. To stimulate the heart and raise the blood-pressure. 

4. To stimulate the brain and nervous centers, especially the 
respiratory center. 

5. To stimulate smooth muscle tissue. 

6. To dilate the pupil and paralyze the accommodation. 

7. As an antidote in poisoning. 

I. For neuralgia atropine may be given internally, or may be 
used locally in the form of the belladonna plaster. If given in- 
ternally, the dose should be sufficient to cause some physiologic 
activity. It is very valuable in spasm of muscles caused by 
irritability of the nerves, or when such contractions are due to 
inflammation. For this purpose it is added to morphine when 
the latter is administered hypodermatically for hepatic and 
renal colic. When these drugs are \ised in combination, more 
relaxation of these muscular tubes is caused. It has been lately 
shown that benzyl benzoate will cause the relaxation which is 



ATROPINE 



253 



aimed at with atropine, and at the same time it is a sedative 

similar to morphine. 

Atropine is frequently added (often as the extract of bella- 
donna, but just as valuable are the salts of the alkaloid) to 
laxative drugs to prevent intestinal cramp or intestinal colic 
from the latter. It is also given hypodermatically in various 
forms of intestinal colic and in lead colic. It is at times of 
value in spastic intestinal conditions of infants, when there is 
vomitings bowel and stomach cramps, and a hyper-peristalsis. 
The dose for infants is ver}^ small, perhaps ? f ooo ^^ a grain, but 
even in such small doses it seems to relieve some of this intesti- 
nal irritability. 

Atropine is one of the most used drugs in asthma, generally 
administered, however, during the paroxj^sra by inhalation from 
burning stramonium leaves* It was long used in whooping 
cough to modify and decrease the frequency of the paroxysms^ 
and for this purpose it must be pushed to the point of slight 
intoxication. Antipyrine is, however, a better treatment for 
this disease. 

Atropine is often efficient in bladder irritability when there 
is too frequent urination, and is even valuable in cystitis, giving 
considerable relief while other treatments are being carried out. 
In large doses it is also frequently used for incontinence of 
urine, and is valuable when such is due to abnormal irritability 
of the neck of the bladder, and it also seems to increase the 
tone of the bladder sphincter. The dose must be large, and 
should be given at night. It may be found that pituitary ex- 
tracts are more valuable in this condition. As atropine is only 
a sjrmptomatic treatment for incontinence of urine, the cause 
of such a condition must be removed, if such can be found. 
For irritability of the bladder in men who have enlarged pros- 
tates, atropine should ordinarily not be given, as it tends to so 
dull the sensibility of the bladder as to allow over-distention, 

2. There is no drug that equals atropine for drying up secre- 
tions, especially the perspiration, nasal, phan^mgeal, and bron- 
chial secretions. It is largely used to inhibit the profuse sweats 
of tuberculosis; the dose should be good sized, and given at 
bedtime. 



254 THE PRINCIPLES OF THERAPEUTICS 

Atropine is often successful in aborting an acute cold. The 
dose should be 3^oo oi a grain every two or three hours for ten 
doses. It is often well to begin with a dose every hour until 
three doses have been taken, and then give the subsequent doses 
at three-hour intervals. By the time ten doses have been taken, 
if the cold has not been aborted, other treatment, to relax tissues 
and allow secretion, is indicated. The value of the various 
combinations termed "rhinitis tablets" is due to the atropine 
which they contain. The doses of the other ingredients are 
too small for activity; it is the atropine that is of benefit. 

Atropine is of value in salivation and in profuse bronchorrhea, 
and in increased nasal secretion; but the cause of these condi- 
tions must be sought, as this treatment is purely symptomatic. 
Many times infection in the nose or adjacent sinuses, or in the 
tonsils, teeth, or gums wiU be found. 

Atropine internally, or in the form of the belladonna oint- 
ment applied externally over the breasts, has been used to 
check lactation and acute inflammation of the breasts. 

3. In all conditions of shock, and when the heart is slow and 
weak, and the blood-pressure low, atropine, given hypodermatic- 
ally, is one of the best stimulants. The dose should be suf- 
ficient, but not too large, and not to be soon repeated. Koo oi 
a grain is the average dose. 

Atropine in much larger doses, pushed to the limit of phy- 
siologic activity is used in heart-block to differentiate between 
functional disturbance and disease of the bundle of His. It 
will cause a slow heart to become rapid if the disease is not 
Stokes-Adams disease. 

4. While atropine many times unexpectedly, and when such 
action m not desired, stimulates the brain to excitement, it is 
rarely used for that purpose. It is, however, frequently used 
in depressed conditions, to stimulate the medullary centers, 
especially the respiratory and vasomotor centers, and as a 
respiratory stimulant it is one of the most active of drugs. 

5. As a muscle stimulant atropine has long been used in 
bladder insufficiency, and in paralysis of the bowels, and has 
often been used in large doses in paresis of the intestines after 
operation. It is, however, not as valuable for these purposes 



ATROPINE 



aS5 



as is pituitary extract, ergot, or tyramine* In intussusception^ 
or in twisting of the bowel and a spastic condition, the con- 
tracted region may be relaxed by large doses of atropine, 
pro\4ded it is safe to wait for the test before surgical cure is 
attempted. 

6. Atropine is in daily use to dilate the pupils. It is not 
used in every eye examination, and is used rarely by some 
oculists for eye tests at the present time, other tests being 
relied upon. However, generaUy, more accurate tests can be 
made with the complete paralysis of accommodation that occurs 
from full doses of atropine. Too careful tests cannot be made 
to decide upon the amount of astigmatism that is present and 
to decide exactly what the optical defects of an eye are, hence 
every aid to develop the right decision must be used. Time 
is no object. It is a question of comfort, perhaps health, and 
certainly of money to the indi\'iduaL Too many wTong 
glasses are given; too frequently they are mal-adjusted; and too 
frequently does the individual become a burden to himself or 
herself, to the family, and to the physician because one or 
more oculists or opticians do not do their best. Atropine 
should not be used in the eyes, ordinarily, when the individual 
is over forty ♦ 

Homatropine is more frequently used than atropine, because 
the effects are over in from thirty-six to forty-eight hours; 
but the paralysis of the accommodation from homatropine is 
not as complete as that from atropine. Unfortunately, the 
accommodation does not return to normal after the full local 
action of atropine until a week or more. For an eye test 
a 1 per cent, solution is generally used. 

As a sedative to the eye in various inflammations, atropine 
has no equal. From 0.5 to i per cent, solutions may be used 
several times a day, as deemed ad\'isable. Atropine should not, 
however, be used in the eye after a patient is much over forty, 
lest it cause increased tension by dilating the iris so as to block 
the canal of Schlemm and thus increase the ocular tension; and 
after forty-five there is always danger of causing glaucoma, and 
atropine should never be used in glaucoma, 

To cause contraction of the pupil and reduce ocular pressure 



256 THE PRINCIPLES OF THERAPEUTICS 

in glaucoma and inflammation of the eye after iridectomy, and 
in some corneal ulcerations, eserine is used. 

PhysostigmifUB Salicylas (eserine salicylate) is an alkaloid 
obtained from physostigma (calabar bean). This salt occurs as 
coloriess or faintly yellowish crystals, which are soluble in 
considerable water. It is used locally to contract the pupil 
in 0.3 per cent, solution (3-1,000). 

7. As an antidote in all depressant drug poisonings atropine 
has no equal. It is also of great value in poisoning by mush- 
rooms, as it is antagonistic to muscarine poisoning. It is also 
an antidote to the depression from toxins developed or 
absorbed from the intestine. In morphine poisoning, although 
atropine is somewhat of an antidote, it should not be used in a 
large amount, as very large doses of atropine will depress the 
respiratory center as does the morphine. Consequently, 
atropine is not a very good treatment in morphine poisoning, 
although when a large dose of morphine must be administered 
it is well combined with atropine to prevent too profound an 
action of the morphine on the respiratory center. 

HomatropifKB Hydrobrotnidum (hydrobromide of homatro- 
pine) is an alkaloid obtained by the condensation of tropine 
and mandelic acid. It occurs as a white crystalline powder or 
as prisms, is soluble in water, and is used in about a i per cent, 
solution to dilate the pupil and paralyze the accommodation. 

Camphor. — Administration. — Camphor occurs in white trans- 
lucent masses or granules, has a pungent, characteristic odor, 
and a pungent, aromatic taste. It is very soluble in alcohol, 
but slightly soluble in water. The dose is 0.20 Gm. (3 grains) 
by the mouth, and hypodermatically, in solutions in aseptic 
oil, the dose is o.io to 0.20 Gm. iH to 3 grains). For h3rpo- 
dermatic use the solutions may be prepared extemporaneously, 
but sterile ampules may be obtained. 

The preparations used for camphor action are Aqua Cam- 
phorcd and Spiritus Camphors. The dose of the camphor 
water is from i to 3 teaspoonfuls. The dose of the spirit of 
camphor is i mil (15 minims). 

Action. — On the surface of the body it is slightly irritant and 
astringent, and if rubbed on the skin may cause some reddening 



DRUGS TO DEPRESS THE BRAIN AND SPINAL CORD 257 

and a slight anesthetic effect. In strong preparations, on 
mucous membranes, it is somewhat irritantp and when taken 
internally it should be well diluted. It is rapidly absorbed, and 
is stimulant to the brain and cerebral centers, especially to the 
respiratory center. It may slightly stimulate the vasomotor 
center, but tends to dilate the peripheral blood-vessels and cause 
a general feeling of warmth to the body. It also frequently seems 
to stimulate the heart, especially in collapse and depression. 

OveT'Ociiafi,— It is difficult to cause poisoning in the human 
being unless the amount administered is excessive, and then 
respiratory depression and convulsions might be caused. Ordi- 
nary full dosage could have no effect except that of slight cerebial 
excitement, and possibly flashing and increased perspiration. 

Uses. — The most important use of camphor is intramuscu- 
larly in aseptic oil, for stimulation purposes in shock and circu- 
latory depression. While some laboratorj^ reports and some 
hospital reports show that camphor fails in these conditions, 
clinicany, those who use camphor most for such purposes are 
sure that it is a stimulant of no mean value. It has long been 
used for the depression following chloroform anesthesia, and 
apparently inhibits depression from that anesthetic. There 
is no question that many times camphor, given subcutaneously 
or intramuscularly or by mouth is of value in collapsed condi- 
tions, in conditions of cold skin and chilliness, and in some con* 
ditions of mental depression. It may be administered (ampules 
contain 2 or 3 grains), subcutaneously, every hour for two or 
three doses, and then less frequently. By the mouth it may be 
given every hour for a series of doses, and then less frequently. 

Camphor has a valuable carminative action, and may be 
combined in various methods to promote intestinal action and 
relieve gas pains. Whether administered with hot drinks, as 
hot lemonade or tea, or when combined with opi'im or mor- 
phine, its action in causing perspiration and in modifying the 
congestion in fresh colds is often satisfactory. 



DRUGS USED TO DEPRESS THE BRAIN AND SPINAL CORD 

Some drugs of this class have been termed **depressomotors" 
such as bromide, chloral, gelsemium, physostigma, etc., in 

17 



258 THE PRINCIPLES OF THERAPEUTICS 

contradistinction to those drugs that excite motor activity. 
The drugs of this class are indicated in increased and excessive 
nervous irritability, in muscle spasms, and in convulsions. 
These drugs are all more or less circulatory depressants, hence 
must be used with care in cardiac weakness. Also, the after 
e£fect of all of them is that of general depression, if the doses are 
large. 

Many drugs of this class are used for other purposes and 
depress the central nervous system secondarily; for example, 
acetanilid, antipyrine, phenacetin and aspirin are used as 
antipyretics and to stop subacute pain and aches, but seconda- 
rily they more or less depress the brain and spinal cord, aspirin 
the least. Gelsemium has long been used to stop peripheral 
nerve pain, but not so frequently since the coal-tar drugs 
became so much in vogue. Lately the drug most used as an 
anti-neuralgic, anti-cold, and anti-most anything is aspirin 
(acetylsalicylic acid). This drug is used too much, and often 
causes some cardiac depression. Physostigma (calabar bean) 
and its alkaloids are too uncertain in their action, also too 
likely to cause serious depression, and hence should not be used 
internally. 

The best and most active cerebrospinal depressants are 
bromides and chloral, and these drugs are indicated in cerebral 
excitement, in spinal irritation, and in strychnine poisoning. 
They are also used in tetanus. Morphine is a cerebral de- 
pressant, but primarily a spinal excitant, although large doses 
stop spinal irritation and convulsions by its stupefying action 
on the cerebrum. 

GelsemiuiXL — Administration. — Gelsemium is official as the 
rhizome and roots, but is not used as such, but in one of its offi- 
cial preparations, the best of which are the Fluidextractum 
Gelsemii and Tinctura Gdsemii. The dose of the fluidextract 
is 0.03 mil (3^ minim) ; the dose of the tincture, which represents 
10 per cent, of the drug, is 0.25 mil (4 minims). 

Action. — Briefly, the action of this drug is, in ordinary dosage, 
mildly depressant; it lowers the blood-pressure, slows the heart 
and depresses the irritability of the spinal cord and nerves, both 
motor and sensory. It may cause, in larger doses, some dilata- 



DRUGS USED TO STOP PAIN 



^59 



tion of the pupil. It lowers the temperature somewhat by 
slowing the circulation, dilating the peripheral vessek, and 
slowing general metabolism. If the patient has fever, it will 
cause some perspiration. It is excreted rather rapidly by the 
kidneys. 

(her-aciion.—Jn over-action from this drug the pulse is 
feeble, the skin cold, and the patient feels faint. Besides dilata- 
tion of the pupils, there may be some paralysis of the upper 
eyelids. 

Toxic Action. — The toxic action isj in a word, that of depres- 
sion with shock, and death is caused by failure of the respiration. 

Treatment of Pmsoning.—Yomiting should be caused if it is 
supposed that the stomach contains the poison, after which the 
treatment is circulatorj' and nervous stimulation with strych- 
nine, atropine, digitalis, and pituitary extracts; dry heat to the 
body; and artificial respiration, if needed. 

Uses. — 'The only logical use at the present time for gelsemium 
is as a sedative in peripheral neuralgias. It seems to be espe- 
cially efficient, at timeSy in neuralgia of the fifth nerve, head- 
aches, intercostal neuralgia, and sometimes in sciatica. How- 
ever, this drug has given place to the coal-tar products which 
are much more frequently used as anti-neuralgics. Also, more 
care is now taken to ascertain the cause of the neuralgia, and 
there generally is a definite cause. The cause being found and 
removed, the neuralgia ceases. Various local applications of 
heat or electricity^ in some form are better treatments of neu- 
ralgia than drugs. If the peripheral pain is caused by central 
disturbances, as locomotor ataxia for instance, gelsemium is of 
little value, and would rarely stop that kind of nerve pain, 
unless the dose was exceedingly large. Non-irritant solutions, 
as about 1J2 P^^ cent, of gelsemine in water, dropped into the 
eye will dilate the pupil by paralyzing the endings of the oculo- 
motor nerve. 

DRUGS USED TO STOP PAIN 

The drugs of the previous class will stop aches and subacute 
pain, but acute, severe pain can be stopped only by the anes- 
thetic action of ether or chloroform, or by opium or one of its 
alkaloids. Acute pain must be stopped, and chronic pain can- 




26o THE PRINCIPLES OF THERAPEUTICS 

not be long endured without causing depression of all vital 
functions. The acute pain of renal or hepatic colic may require 
partial chloroform anesthesia until the injected morphine can 
begin to act. Or chloroform may be advisable in such a con- 
dition in order not to give a poisonous or dangerous dose of 
morphine. 

Opium. — Administration. — The Pharmacopoeia recognizes as 
opium the milky exudate of the unripe capsules of papaver 
somniferum. Preparations made from this substance are the 
ones used in medicine. The oflGicial preparations are as follows: 

OpiiPulvis, powdered opium; dose 0.06 Gm. (i grain). 

Opium Deodoratum^ deodorized opium; dose 0.06 Gm. (i 
gram). 

Opium Granulatum; dose 0.06 Gm. (i grain). 

Extractum Opii (a powdered extract); dose 0.03 Gm. (^ 
gram). 

Pulvis IpecacuanfuB et Opii, Dover's powder; dose 0.50 Gm. 
{jH grains). This preparation contains 10 per cent, of ipecac 
and 10 per cent, of opium. 

Tinctura Opii, laudanum, (10 per cent, strength) ; dose 0.5 mil 
{y}^ minims). 

Tinctura Opii Camphorata (paregoric) contains 0.4 per cent, 
each of opium and of camphor; dose 5 mils (a teaspoonful). 

Tinctura Opii Deodorati, tincture of deodorized opium, (10 
per cent, strength); dose 0.5 mil (73^^ minims). 

Opium contains many alkaloids, the most important of which 
are morphine and codeine. The official preparations of mor- 
phine are: 

Morphincd Hydrochloridum, which occurs as a white crystal- 
line powder, very soluble in water, the dose of which is 0.008 
Gm. {}i grain), and 

Morphince Sulphas which occurs as white feathery crystals, 
very soluble in water, the dose of which is 0.008 Gm. (3^^ grain). 

Codeine is official in the form of Codeines Phosphas, which 
occurs as jfine, white crystals, very soluble in water, the dose of 
which is 0.03 Gm. {^^ grain), and Codeince Sulphas, which occurs 
in white crystals, very soluble in water, the dose of which is 0.03 . 
Gm. (l^ grain). 



OPHIM 



261 



An artificial alkaloid is formed from morphine, termed 
heroin, which is recognized in the Pharmacopoeia as Dia^e- 
tyimorpMnw Hydrocbloridujn, which occurs as a white cr>^stal- 
line po%vder, ver>" soluble in water, the dose of which is 0.003 
Gm. (J^tj'o grain). There is no advantage of this drug over code- 
ine. It is very subtle in its ability to cause a habit, and it has no 
activities whatsoever of any advantage over codeine. The drug 
should be abolished. 

Another preparation formed artificially from morphine is 
dionin which is official under the name of MtkylmorpMfUB 
BydrocMoridum, This drug also is not needed, 

A new synthetic has recently been prepared by Macht termed 
Benzyl Benzoaie, This preparation apparently has the advantage 
of stopping spasm and pain, and of relaxing muscle tubes, with- 
out being actively narcotic, and it does not apparently tend to 
cause a habit. This new drug seems to be specifically of value 
in colics and muscle spasms, and seems to be useful in such 
conditions as spasmodic dysmenorrhea, certain forms of asthma, 
and probably will be found of value in many conditions of 
hypertonicity and muscle irritability. The advantage of this 
new preparation over morphine is because morphine alone 
tends to cause contraction of smooth muscle tissue. This of 
course may not be in e\idence when very large doses are given, 
or when morphine is combined with atropine to allay peripheral 
irritation that may be causing the colic, and of course large 
doses of morphine wUl cause general relaxation of all tissues. 
Nevertheless, this new drug is a great addition to useful drugs, 
as it will relax spasm and quiet pain without the unpleasant, 
disagreeable, and often dangerous narcotic effects of morphine 
and codeine or some other form of opium. This drug can be 
given repeatedly, apparently, without the development of 
a habit. This alone is enough to put the drug in a high class. 

Benzyl benzoate is an ester of benzyl alcohol and benzoic 
acid. It is obtainable in the form of a solution termed ** benzyl 
benzoate miscible,** each ten drops of which contains two drops 
of benzyl benzoate, the average dose of which is 25 to 30 drops, 
but a fluidrachm may be taken by adults without poisoning. 
In any form thus far offered this preparation is very disagreeable 



1{62 THE PRINCIPLES OF THERAPEUTICS 

to take. Therefore attempts have been made to offer it in 
an emulsion. It is best administered in milk. The dose ap- 
parently should be sufficient to stop the pain, and it has not 
been shown to cause any serious after effects. It has 
been used with considerable success in dysmenorrhea, in 
asthma, in whooping cough, in hiccup, in diarrhea, in intestinal 
colic, for the pains of mucous colitis, and it has seemed at times 
to lower blood-pressure. 

Action. — It is obvious that the action of opium would be that 
of its alkaloids, and its most important alkaloid is morphine, 
therefore the physiologic action after absorption is really the 
action of morphine. Opium is rapidly absorbed, especially 
when taken in liquid form on an empty stomach. In large 
doses it may cause nausea and vomiting, and the same is true 
of its alkaloid morphine. It inhibits the activity of the stom- 
ach and intestines, slowing or stopping peristalsis and diminish- 
ing the digestive secretions. If nausea and vomiting are caused 
it may increase the gastric secretion, especially of mucus, at 
the same time it increases the salivary secretion, probably due 
to the irritation of the vomiting center. 

The action of this drug and its alkaloid, even when given 
hypodermatically, causes loss of appetite and generally consti- 
pation. If, however, pain is reflexly inhibiting the action of 
the bowels, relief from the pain may allow movements to occur. 

After absorption it inhibits most secretions, especially the 
endocrine gland secretions, and particularly the suprarenal 
secretion. At times it may cause perspiration, especially if 
combined with some other drugs, such as ipecac or camphor, 
but at other times it causes the skin to be dry. 

Opium, and especially morphine, often more or less improves 
the heart tone, and often slows a rapid heart, and a weak heart 
is not made weaker unless the dose is large and there is pro- 
found effect from the drug on the respiratory center. The 
slowing of the heart is due to depression of the accelerator 
mechanism or to slight stimulation of the cardiac inhibitory 
center in the medulla, namely, the vagus center. There may 
be a slight increase in blood-pressure when the blood-pressure is 
low. Even fair sized doses of opium or morphine diminish the 



OPItTM 



263 



irritability of the respiratory center and cause more or less 
slowing of respiration; large doses slow it very greatly. 

Morphine is primarily a stimulant to the spinal cord, and in 
animals will cause con\^sions, while in the human being the 
action is so intense on the brain that the irritation of the spinal 
cord is overcome. After small doses there may be a slight stimu- 
lation of the cerebral centers, although there is a diminution 
of self-control, and the judgment may be impaired. In larger 
doses the effect is quieting and sleep-producing, except in some 
peculiar individuals who have an idiosyncrasy against any 
narcotic of the opium or morphine type* They are mentaUy 
excited, and may even have delirium, unless the dose is exceed- 
ingly large. The same condition is noted when there is cerebral 
inflammation or cerebral excitement, insanity, delirium tremens, 
etc., when a small dose will do nothing but excite the patient, 
and even a medium dose may not quiet him, and perhaps a 
dangerous dose w^ould be required if this drug was the one to 
be used for sedative effect. Young children are very pro- 
foundly affected by opium in any form, perhaps because their 
brains are relatively so much larger than the brains of adults. 
At any rate, the dose of any opium narcotic must be very 
much smaller than the ordinary dose computed by age and 
weight. 

When sleep is caused by opium or morphine it is generally 
profound. The patient may be hard to arouse, the respiration 
becomes slow, the pulse slow and full, and the skin generally 
warm, provided the dose is not too large. 

There is no object in injecting a dose of morphine at the 
site of pain, as the action of the narcotic seems to be entirely 
central and the nerve endings are probably not acted upon by 
this drug. Some patients are sexually stimulated by the 
action of morphine and opium, unless the dose is large. 

Under the action of morphine or opium nitrogenous metab- 
olism is diminished, and wnth the decreased muscle activity 
and the sleep, there is decreased oxygenation and lessened 
excretion of carbon dioxide acid, ix., metabolism is more or 
less at a standstill. Under the normal action of the drug the 
pupil is always contracted, due to action on the brain centers* 




264 THE PRINCIPLES OF THERAPEUTICS 

If the action is intense, the pupil will not dilate in darkness and 
will be pin-point in Ught. 

A large part of the drug is destroyed in the body by oxida- 
tion, but considerable of it is excreted in the urine and some 
into the stomach and intestines. Therefore in any over-action, 
the stomach must be washed out, a purgative given, and the 
bladder cathaterilzed. Under the action of morphine the 
bladder sensibility is so obtunded that it frequently becomes 
distended with urine, and then from partial paralysis is unable 
to expel the urine. Consequently, when morphine has been 
given, the patient must be aroused once in four or five hours 
and told to evacuate the bladder, unless the condition is such 
that a catheter must be passed. The excretion begins soon 
after the drug has been taken, but it may not all be excreted 
for many hours, and after repeated doses perhaps not for 
several days, although the habitu6 does not accumulate it. 

On account of the general inhibition of nerve and muscle 
activity the temperature is generally lowered, by morphine 
and, if the patient is narcotized by the drug, the surface of the 
body rapidly loses heat; consequently, in profound narcosis 
this must be prevented by the application of dry heat. Small 
doses of morphine may increase the output of urine; large doses 
will always diminish its amount, and glycosuria may rarely 
occur. 

Over-action, — Over-action from opium is evidenced by too 
profound sleep, too slow respiration, and profound narcosis. 
Such over-action may occur unexpectedly in some few indi- 
viduals, and is likely to occur when there is serious disease, 
as nephritis or cirrhosis of the liver. Undesirable action occurs 
in susceptible individuals who are unduly stimulated by opium 
in any form, some even having delirium. Such patients should 
not be given any form of opium, unless the indication is very 
unusual. To quiet such a patient requires an enormous dose, 
and many times a dose that is not safe. 

Undesirable after eflfects from morphine occur more or less 
frequently, such as nausea, faintness, depression, constipation, 
and such an obtundity of the bladder sensations as to allow it to 
become distended, and then more or less paralytic. This is a 



OPrcjM 



265 



vety troublesome complication on account of the necessity for 
catheterization and the danger of infection. 

Toxic Adian. — A very large dose of opium or morphine taken 
by the mouth may cause immediate vomiting, and the patient 
be thus saved from poisoning, while medium sized doses will 
be absorbed and cause poisoning. Of course a poisonous dose 
may be taken h>"podcrmaticaUy, The symptoms are profound 
sleep or absolute coma; verj^ much slowed respiration; slow, full 
pulse; contracted pupils; the face may be flushed or congested, 
and if the respirations are very slow the patient is C)^anotic. 
Death is caused by paralysis of the respiratory^ center. 

A patient found in coma calls for a very careful diagnosis 
of the condition. There may be an injury, in which case, 
generally, the pupils are either not contracted, or at least one 
may be contracted and the other dilated. There may be an 
apoplexy, in which condition one side of the body is generally 
more lax than the other side, and the face may be drawn to one 
side. The pupils in this condition may be irregular* In 
coma from alcohol or from wood alcohol the pupils will probably 
react to light, but there is, of course, the odor of alcohol on 
the breath; but the odor of alcohol on the breath is no indi- 
cation that the condition is due to a poisonous dose of alcohol. 
Diabetic coma may be determined by catheterization and 
analysis of the urine, A patient may be found stupid from 
uremic coma^ but there is generally a history of convulsions, 
which some one may have seen. Analysis of the catheterized 
urine will help to make the diagnosis in this case. The pupils 
are also not as tightly contracted. Epileptic coma will give 
a history of preceding convulsions, with sometimes blood drool- 
ing from the mouth from a bitten tongue. In chloral poisoning 
with coma the pupils are dilated. In carbolic acid coma 
there are white eschars on the lips and mouth, and the odor of 
phenol. 

Treatment of Poisoning. — The indications for treatment are: 
(i) wash out the stomach, if the poison was swallowed; (2) 
administer such drugs as have some antidotal action on mor- 
phine and opium; (3) promote respiration; (4) prevent failure 
of the heart. 




266 THE PRINCIPLES OF THERAPEUTICS 

If a poisonous dose of opium has been taken only a few min- 
utes before the patient is seen, an ordinary emetic may act, but 
if the patient is under the influence of the narcotic. Hie emetic 
will not act, therefore the stomach must be washed out by 
means of the stomach tube. Tannic add solutions are some- 
times used, or permanganate of potassiiun solutions, tannic add 
forming more or less insoluble tannates, and the potassiiun 
permanganate decomposing the alkaloid, causing it to be more 
or less inert. Whatever is used, the stomach should be washed 
out until apparently dean. 

To meet the second indication, half a pint of strong coffee 
may be passed into the stomach and left there. Give atropine 
sulphate hypodermatically in a dose of Koo of a grain. Caffeine 
may also be given hypodermatically. 

To meet the third indication every means possible in the 
way of arousing the patient should be tried, but it is not advis- 
able to walk him around to the point of exhaustion, or to un- 
cover a patient too much for different skin stimulations or 
irritations, as in opiiun poisoning heat is lost rapidly, and many 
of the methods previously used to keep a patient awake have 
caused serious heart depression. Sometimes faradic electricity 
applications to different parts of the body act as one of the best 
stimulants. 

If the patient breathes very slowly, artificial respiration 
must be done. This may be kept up for hours. The pulmotor 
may be used, if it is deemed advisable. Artifical respiration 
should not be done too rapidly, twelve to fourteen respirations 
a minute being suffident. 

Large doses of atropine should not be given, as the secondary 
effect of atropine is also to paralyze the respiratory center, 
therefore the single dose of }^{qq of a grain is generally suffident, 
whatever the amount of the opium or morphine that was taken. 
If the respiration of the patient has not greatly improved in two 
or three hours, a second dose oi }ioo oi a grain might be given. 

To meet the fourth indication, the patient should be kept 
warm. A hypodermatic injection of }io o^ ^ grain of the sul- 
phate of strychnine may be administered, which may be repeated 
in an hour. It is generally well to wash out the stomach again 



opniM 



267 



in two or three hours, and also to catheterize the bladder, as the 
morphine is excreted in the stomach and also by the urine, and 
could be again re-absorbed ^ if it was not removed. Artificial 
respirations may be continued for hours, if necessary, and 
patients have been saved by such prolonged treatment 

CkronicPoiscming,— Chronic pohomng due to smoking opium 
is of rare occurrence in this country, but the habit of taking 
opium, morphine or heroin in some form, most frequently per- 
haps hypodermatically, is still of frequent occurrence, although 
under the action of the National law these drug addiction cases 
will gradually be eliminated 

The symptoms caused by suddenly stopping morphine are 
always serious; the nervous irritability and excitement is some- 
times terrible. There may be vomiting; coughing; diarrhea; 
various forms of skin disturbances, itching of the skin; absolute 
inability to sleep ; and there may even be dangerous weakening 
of the heart* Hence, whatever the method used for overcom- 
ing the morphine habit, the patient must be under the constant 
supervision of a competent physician. The gradual method of 

f ^topping morphine is at times selected by the physician, and 
-^ften is satisfactory where the patient has been rccei\'ing the 
drug for some acute illness and has acquired a partial habit. 
The drug in such cases may be gradually stopped without 
causing the patient to suffer. But a patient who really has 
acquired a habit cannot be cured at home in this manner, and if 
he is cured at home by the absolute stoppage of the drug, the 
surroundings must be unusually good. As a working rule a 
chronic morphine habitue must be treated at an institution. 
The method of curing these patients is described on page 716. 
UseS' — The two most important indications for the use of 
opium or morphine are pain and spasm. Acute pain^ whether 
neuralgic, inflammatory, or due to distention of a canal by a 
calculus, or due to some spastic condition as an intestinal colic, 
must ordinarily be stopped by morphine or some other form of 
opium, or by one of its synthetic salts; or if the condition is 
excessively acute, inhalations of chloroform may be required. 
If the dose of morphine must be large for this purpose, it is well 
combined with atropine so that the action on the respiratory 





268 THE PRINCIPLES OF THERAPEUTICS 

center may not be quite so intense, ordinary doses of atropine 
stimulating the respiratory center. Also, sometimes peripheral 
spasm is modified by the action of the atropine. 

Conditions calling for morphine for pain are renal and hepatic 
colic, intestinal colic, lead colic, and very acute inflammatory 
or neuralgic pain. The dose for any of these colic conditions 
should be large, from 3^^ to }i of a grain, to be followed by a 
smaller dose in an hour, if the pain has not been relieved. Asso- 
ciated with this treatment should be a hot bath or hot fomenta- 
tions to the abdomen, to aid in the production of relaxation. 
It may be found that benzyl benzoate will be more valuable 
for these conditions without causing such narcosis as does mor- 
phine. It should be remembered that as soon as the colic ceases 
or the stone has passed, the opposition to the morphine is gone, 
and the patient may immediately become stupid, while inmie- 
diately before he was alert. Therefore, such a patient shotdd 
not be allowed to sleep, but should be kept awake until the pro- 
found effects of the morphine have passed, and if advisable he 
may be given large doses of coffee or caffeine. 

If morphine is required for such a condition as sciatic pain, 
or for neuritis, the dose need not be so large, but must be more 
or less frequently repeated; but it shotdd be remembered that 
all other methods to ease this local pain must be tried before 
morphine is used. However, it is not justifiable to allow any 
patient to suffer, whether an adult or a child. Codeine may 
be the better drug to give, as it is less likely to cause constipa- 
tion and loss of appetite, but it is not as much of an analgesic. 

In recurrent conditions, as asthma and dysmenorrhea, mor- 
phine should be considered the last resort, as a large number of 
morphine addicts have become such through using morphine in 
asthma, and a dysmenorrhea pain is very rarely so intense as to 
require or justify morphine. A hot sitz bath, bromides, and 
alcohol in some form, or benzyl benzoate are efficient in ordinary 
pelvic pain. 

Angina pectoris is generally relieved by nitroglycerin, but 
if the heart ache persists, morphine should be given, but sharp 
cardiac pain is only temporary, if the patient lives at all, and 
chronic heart pain is better relieved by some other method. 



OPIUSf 



269 



Profound nausea and vomiting from any cause may require a 
hypodermic of a small dose of morphine, ordinarily Ho of a 
grain, or at most !s of ^ grain. Such treatment may be justi- 
fiable while other methods of treatment are being tried. 

To cause sleep in great restlessness, other drugs should 
generally be used, but if a patient is very weak, or his condition 
is serious, or he is in the midst of an acute illness, a small dose 
of morphine, perhaps by the mouth, may be all that is required, 
rarely more than }fo of ^ grain. 

Occasionally an acute diarrhea is so serious as to require mor- 
phine to stop it w^hile other more rational treatments are being 
used. A small dose of morphine, } iq of a grain, is all that is 
necessary to stop the active peristalsis; or two teaspoonfuls, 
or more, of paregoric may be the preparation of choice. The 
pain of an acute gastrointestinal disturbance often requires 
a h>T>odermic dose of morphine, V| of a grain or more. 

If a patient who has had an hemoptysis is very nervous a 
small dose of morphine may be ad\dsable, given hypodermat- 
ically, to quiet his nervous system^ slow his heart, and relieve 
him from fear. 

For the severe pains of cerebrospinal meningitis, morphine 
at times must be given in a suflfident dose to quiet the patient. 
It is very regrettable that in locomotor ataxic pains at times 
morphine must be given, as these pains are bound to recur, and 
a morphine habit is easily established. Therefore, before re- 
sorting to morphine all physical and other medicinal methods 
should be tried. 

Occasionally, in uremic conditions, there may be sufficient 
pain, in the form of neuralgias, to necessitate an injection of a 
small dose of morphine, although it is known to act more in- 
tensely in such conditions, but if required for this purpose its 
use is justified. 

In the last stages of pulmonary tuberculosis, when there is 
great distress from air starvation, small doses of morphine are 
justifiable in preventing this terrible air hunger, even if such 
a dose must be for some little time repeated. 

In patients who are suffering from incurable cancer and who 
have pain, morphine or codeine, or perhaps benzyl benzoate, 




270 THE PRINCIPLES OF THERAPEUTICS 

should be given without hesitation. The matter of developing 
a habit is secondary; the patient should not be allowed to suffer. 

For frequent, troublesome coughing, due to nervous irritation 
and without much expectoration, as occurs so frequently in 
acute colds and bronchitis, a small dose of codeine may be com- 
bined with ammonium chloride in a cough mixture, with great 
benefit to the patient. There is no possibility of causing a 
habit. The prescription cannot be repeated without the knowl- 
' edge of the physician, and imless the patient has been a mor- 
phine habitu6, he will not know that he is taking it. To 
repeat what has been said previously, there is no excuse for heroin , 
we do not need it, and it is not necessary in cough mixtures. 
Codeine answers every purpose, and the dose need not be large. 

For acute pain in the beginning of pneumonia, pleurisy, and 
pericarditis, and for acute abdominal pain in peritonitis, mor- 
phine is justifiable, and the dose should be sufficient to stop 
the pain. In peritonitis it may be necessary to repeat the drug 
for several days, provided the surgical condition that is imder 
treatment, does not contraindicate it. 

Although opium and morphine will inhibit the activities of 
the glands of internal secretion, it is generally inexcusable 
treatment for such conditions. It causes more harm than it 
can possibly do good. Large doses of opium or morphine in- 
hibit the activities of the suprarenals, and also inhibit nutrition 
and normal metabolism. Therefore in glandular disturbances 
there is rarely an excuse for using these drugs. 

When there is cerebral inflanmiation and excitement, mor- 
phine is rarely the drug that should be used, as small doses 
tend to increase the irritability, and large doses are inadvisable. 
Therefore other brain and nerve sedatives should be used. 

DRUGS USED TO CAUSE SLEEP 
Hypnotics 

We all recognize the various conditions that prevent sleep, 
from pain to intestinal indigestion and to disturbances of the 
ductless glands, but we do not consider the causes of sleep. 
Various physiologic theories of the cause of sleep have been 
presented, and, probably, they all play some part in its produc- 



HYPNOTICS 



271 



tion. The most logical theories are: (i) the fatigue prod- 
ucts; (2) anemia of the brain; (3) cerebral changes, neuron 
retraction; (4) habit. 

Perhaps the most important of all of these causes is the in- 
herited life habit of a period of sleep once in twenty-four hours. 
Also it is a fact easily demonstrated that a lowered blood- 
pressure, hence lowered cerebral pressure and anemia of the 
brain, causes drowsiness. Also fatigue products in the brain 
due to cerebral activity as well as fatigue products in the muscles 
due to muscle activity call for rest {in the brain procured only 
by sleep) to remove them and allow recuperation. Also, we 
all recognize that when we are mentally weary it is difficult to 
mentally react, to take in what is said or read, or to do the 
simplest thing well, and it is even difficult to do things correctly 
that are acts of habit and should be almost automatic. This 
condition may well be due to a retraction of the neurons, and 
may be the cause of many mistakes and accidents. 

Sleep therefore is essential, but before using drugs to cause 
sleep, all other measures should be resorted to, such as a regu- 
lated diet (stop tea and coffee), hydrotherapy, mental rest, 
fresh air, and normal exercise. However, drugs are very often 
needed, but all are more or less depressant both to the central 
nervous system and to the heart. Any one of these drugs may 
cause a habit. 

The best hypnotic from the standpoint of the ability to pro- 
duce sleep is still chloral, but it is very disagreeable to take, 
and as depression due to it is feared by many practitioners, 
other less efficient h>pnotics are generally used. Bromides (the 
sodium salt the best) are always useful in sufficient doses, but 
they disturb digestion and weaken the muscular power. Scopol- 
amine is the best hypnotic for hyodermic use, and is efficient, 
except when there is an idiosyncrasy against it. This drug is 
much used in excitable insanities and in such cerebral excitation 
as delirium tremens. 

Barbital (veronal), diethylbarbituric acid, and its sodium salt 
(barbital-sodium) have replaced the synthetics sulphonal and 
trional. Barbital is as efficient as these drugs, acts more 
quickly, and the dose is very much smaller; hence there is less 



272 THE PRINCIPLES OF THERAPEUTICS 

to be excreted by the kidneys, and therefore less disturbance 
during its excretion. 

Paraldehyde acts quickly, but it is very disagreeable to take 
and therfore is not much used. 

Potassium Bromide; Sodimn Bromide. — Description. — Po- 
tassium bromide occurs as white colorless crystals or granular 
powder, has a strong, saline, disagreeable taste, and is very 
soluble in water. The dose is i Gm. (15 grains). It is more 
disagreeable to take and a little more depressant to the muscular 
system than is sodium bromide. This latter salt occurs as 
colorless or white crystals or powder, is very soluble in water, 
has a salty taste, and the dose is i Gm. (15 grains). This dose 
is a moderate one when given three times a day for a sedative 
effect, but the ordinary hypnotic dose should be considered 
as 2 Gm. (30 grains) of either salt, given once, two or three 
hours before bedtime. As just stated, for all ordinary purposes 
sodium bromide, which has only a salty taste, is preferable 
to the potassium salt. For epilepsy the potassium salt may 
act better, as being slightly more depressant. These drugs are 
best administered in water, i Gm. to 5 mils, a teaspoonful. 
They should be taken largely diluted, or at least followed 
with plenty of water, else nausea is caused. 

There is no need in medicine for any other preparation of 
bromide. The much lauded strontium bromide has no advan- 
tage over the other salts, costs more, and is not needed in 
medicine. Tablets of either sodium or potassium bromide 
should not be swallowed; they should always be dissolved, else 
serious irritation of the stomach may be caused. 

Action, — Bromides are sedative to the spinal cord and to the 
brain, are depressant to the circulation, lower blood-pressure, and 
quiet and slow the heart. They slow digestion, interfere with 
the appetite, slow all metabolism, cause muscle relaxation, and 
finally muscle debility. They are partially excreted through 
the skin, increase perspiration, and may irritate the glands of 
the skin, sometimes causing papular eruptions. By their 
• action in slowing metabolism, quieting brain activity, and slow- 
ing the circulation, they also lower the temperature. 

They have no external action, and, unless in concentrated 



POTASSIUM BROMIDE SODIUM BROMIDE 



273 



solutions, are not very irritant to mucous membranes, but they 
may cause some nausea and vomiting if not taken well diluted. 
They are more or less rapidly absorbed, and are especially 
efEcient in quieting peripheral irritation and in soothing an 
excited, irritated condition of the brain. 

Excretion begins rapidly^ but when several doses have been 
taken, complete excretion is slow^ and after bromides have been 
long administered, they may not be all excreted until many 
days after the last dose has been taken. Bromides are not only 
excreted by the skin and kidneys, but they are found in the 
saliva, the perspiration, and in the milk, and some may be 
excreted through the intestinal mucous membrane. 

Bromides seem to take the place of chlorides in the system, 
especially if the ingestion of chlorides is diminished. This 
reaction fixes the bromides more in the tissues, and is largely 
the reason for the length of time it takes to entirely eliminate 
them. 

Over-action, — The over-action of bromides is evidenced by a 
diminution of the reflexes, subnormal temperature, loss of 
appetite, coated tongue, dull eyes, mental apathy, increased 
perspiration often with a disagreeable odor, and loss of strength. 
There is also complete loss of sexual vitaUty, all sexual desire is 
lost, and impotenc)' occurs in the male* 

Papular acne-like (sometimes pustular) eruptions on the skin 
are very frequent after even one or two doses of a bromide in 
certain patients who have this sort of idiosyncrasy. If the 
bromide is given for some time, there may occur on various parts 
of the skin peculiar, almost warty-like grow^ths, not dissimilar 
to a tubercular s\T3hilide. 

Patients who are actually suffering from bromism or a bro- 
mide habit have a dull expression, eyes \nthout lustre and the 
pupils somewhat dilated; they are apathetic, have impairment 
of memory and of mentality; the heart is weak; respiration 
is slow^; there are muscular tremors, and lack of codrdination in 
walking, as well as weakness of the leg muscles. The patient 
may have halucinations, and there may be actual deterioration 
of the cerebral cells. Therefore, large doses of bromide, or 
medium doses long continued, are absolutely inexcusable in 





274 '^^^ PRINCIPLES OF THERAPEUTICS 

hysterical conditions and in mental disturbances, and are fre- 
quently not needed in epilepsy. 

The treatment of the bromide habit, or bromism, is to abso- 
lutely stop the drug, to promote excretion by mild hydrothera- 
peutic measures and by mild purgatives; to give massage; to 
push nutrition; to stimulate by strychnine and by digitalis; 
and to treat the anemia. The rest cure, and later gradu- 
ated exercises and perhaps electrical stimulation to bring 
the muscles as well as the nutrition and mental health back 
to normal represent the subsequent course of treatment 
advisable. 

Toxic Action. — ^Acute poisoning from bromides is evidenced 
by complete prostration, stupor, dilated pupils, heart weakness, 
and respiratory failure. 

Treatment oj Poisoning. — ^Acute poisoning by bromides is rare, 
but if it occurs, the treatment is that of a" nervous and circula- 
tory depressant poison. An emetic and a purgative should be 
given, if it is thought that any bromide is still in the alimen- 
tary canal. He should be surroimded by dry heat, with a hot 
water bag over the heart, and he should be given strong coffee 
by the mouth and strychnine and atropine injections. More 
or less frequently the bladder should be catheterized. K 
necessary, the foot of the bed should be elevated, to keep the 
blood-pressure in the cerebral centers normal. Injections of 
post-pituitary extract are advisable, and perhaps injections of 
ergot; injections of camphor are always of value. Artificial 
respiration may be needed. 

Uses. — The most important use for bromides is in spinal 
irritation and in cerebral excitement or delirium, whether due 
to some irritant, or due to inflammation of the meninges. The 
dose should be sufficient and frequent enough to quiet the 
patient. Of course it should be always remembered that 
circulatory depression will follow pushing bromide. In con- 
vulsions, whether due to irritation of the brain or spinal 
cord, in uremia, tetanus, and hydrophobia, the dose of a bromide 
must be large, and it often may be advisable to administer it 
per rectum. Stronger anti-convulsants as chloral and even 
inhalations of chloroform may be advisable. Chloral acts 



POTASSnXM BROMIDE — SODIUM BROMIDE 



275 



much more quickly than bromides^ though the bromide action 
is more prolonged. 

Bromide is a very useful h^-pnotic to produce sleep in any 
nervous, irritable, or peripherally irritated individual, provided 
the circulation is good. It is of special value in hysterical 
restlessness and at times in hyperthyroidism before the patient 
has begun to improve from the rest cure. In some hysterical 
and nervous patients bromide is almost a specific, and the 
little harm that it can do when given for a short time is more 
than counter-balanced by the good that it does. 

Bromides offer a symptomatic treatment for epilepsy, but, 
when all associated possibly irritant causes have been removed, 
a bromide given in small doses daily will not only cause the con- 
vulsions to be less frequent ^ but may even aid in promoting a 
cure. Generally the bromide treatment of epilepsy is regret- 
table, but since its treatment with this drug is better understood 
—namely, that large doses should never be given, that if the 
patient's appetite fails or nutrition fails it is contraindicated, 
and that when it is administered the sodium chloride intake 
should be reduced so that a smaller dose will cause the quieting 
symptoms of bromine— it has done more good than harm. To 
repeat, it should be urged that treatment w^th a bromide is 
generally only symptomatic treatment, and many times not 
curative, and to cause a patient to have symptoms of bromism 
is inexcusable* 

In acute strychnine poisoning, bromides and chloral represent 
the treatment, with perhaps chloroform inhalations in the 
beginning. Whenever there is acute irritation from an over- 
dose of strychnine, bromides are curative. 

A very satisfactory use of a bromide is to prevent the cincho- 
nism of patients who must be given large doses of quinine. If 
three times as much bromide as quinine is given, cinchonism and 
disagreeable head s>Tnptoms will generally not occur, namely 
3 grains of a bromide for every grain of quinine, or i Gm. (15 
grains) of the bromide to every 0,30 Gm. (5 grains) of quinine 
is the dose advisable. WTien enormous doses of quinine are 
given for pernicious malarial fever, it would be inadvisable to 
give the amount of bromide called for by this rule. 




^76 THE PRINCIPLES OF THERAPEUTICS 

• To repeat what was said under administration, there is no 
necessity for any other bromides in medicine than the potassium 
and sodium bromide, and generally the latter is the better salt 
to use. Sodium bromide is a little less depressant than potas- 
sium bromide. Anmionium bromide is intensely disagreeable, 
and is just as depressant as the other bromides. There are 
many other preparations on the market which contain bro- 
mides or bromines, but none of them has any advantage over 
the sodium bromide. 

Chloral Hydrate {Sydrated Chlorai). — Administration. — 
Chloral hydrate occurs as colorless crystals, has an acrid, bitter, 
caustic taste, and is very soluble in water. The dose is 0.50 
Gm. (7)^ grains), and it is best ordered dissolved in water, 
0.50 Gm. to the teaspoonful (5 mils) as syrups do not improve 
the taste of this disagreeable drug. It is well administered in 
carbonated water, should always be well diluted, and the 
patient may eat a piece of orange or lemon after taking the 
drug. Very frequently the dose should be larger than 0.50 
Gm. 

Action. — Chloral is irritant to the skin and mucous mem- 
branes, but in solution and ointments is slightly anesthetic 
and sedative to the peripheral nerves. When it is not well 
diluted and taken on an empty stomach it frequently causes 
nausea and vomiting. It is very rapidly absorbed, and when 
given in concentrated solutions may cause stupor in a very 
few minutes. When criminally administered it has been 
termed "knock-out drops. " 

It circulates in the blood as chloral, and in ordinary doses 
produces a slight diminution in the frequency and strength of 
the heartbeat, and lowers blood-pressure. The slowing of the 
heart is caused by the action on the vagus center in the medulla. 
The lowering of the blood-pressure is due to a probable depres- 
sant action on the vasomotor center and to a diminution in the 
force of the heart beat. It is also depressant to the respiratory 
center. 

The most important action of chloral is on the central nervous 
system, as it is a sedative to both the brain and spinal cord, 
and is especially sedative to the brain cells. Usually it pro- 



CHLORAL HYDRATE 



277 



in half an hour, both on account of its sedative ac- 
tion on the brain and by reducing the activity of the circulation. 
It also has a decided sedative and depressant action on the 
motor tract of the spinal cord, and is somewhat sedative to the 
motor nerves, hence the reflexes are more or less diminished, 
depending upon the amount of the drtig taken. It will not 
quiet acute pain unless the dose is large enough to dangerously 
stupefy the patient. 

It slows metabolism, therefore lowers the temperature and 
impairs the appetite and digestion. 

Chloral is excreted principally by the kidneys, in part as 
chloral, but mostly in combination %vith glycuronic acid as uro- 
chloric (urochloralic) acid. There may be some slight elimina- 
tion through the skin and lungs. 

Over-action. ^Over-action from chloral is evidenced by too pro- 
found sleep, circulator^' depression, lowered temperature, and 
coldness of the extremities. 

Toxic Aciutn.—T\ie symptoms of toxic effect are stupor, 
generally dilated pupils, cold perspiration, weak heart action, 
and feeble pulse. The respiration generally fails, and death is 
caused by paralysis of the respirator)^ center. In serious 
poisoning the heart may fail at the same time as the respiratory 
center, but the patient dies in coma. 

There is a chloral habit, and chronic poisoning from chloral 
is not infrequent. The habit is generally acquired from using 
chloral for insomnia* In chronic chloral poisoning there may 
occur various mental disturbances. The patient may be at one 
time talkative, at another time morose. He may lose his mem- 
ory and be both mentally and morally abnormal. The pupils 
are likely to be dilated, the skin may show eruptions of various 
kinds, and the whole health becomes impaired. There is loss of 
appetite, all kinds of indigestion, a coated tongue, a bad breath, 
cold hands and feet, and a general lack of muscular strength, 
with more or less incoordination. With these symptoms there 
is always progressive cardiac debility. 

Trcaimaii oj Poisoning. —In acute poisoning the stomach 
should be washed out by means of a stomach tube, provided an 
irritant emetic, as zinc sulphate 2 grams, or copper sulphate i 




278 THE PRINCIPLES OF THERAPEUTICS 

grain, does not quickly act. It is best in this poisoning not to 
administer apomorphine, as it would add its depressant action 
on the heart to the depression already caused by the chloral. 

The patient should be kept flat, surrounded by dry heat, and in- 
jections of atropine, strychnine, camphor, and pituitary ex- 
tract should be given. Coffee may be administered by the 
mouth or recttim. It may be necessary to do artificial respira- 
tion, and massage over the heart may be of advantage. 

In chronic chloral poisoning the drug should be rapidly with- 
drawn and every means used to improve the digestion and the 
strength of the heart and circulation. The patient should be 
at rest, daily massage should be given, easily digested food 
should be pushed, laxatives if needed, and plenty of water should 
be taken to promote elimination. 

Uses. —Chloral is rarely used externally, but when it is com- 
bined with equal parts of camphor and rubbed up in a mortar, 
a thick, syrupy fluid is the result, which is sometimes used ex- 
ternally with good results over painful nerves and on parts 
suffering from pruritus. A drop or two of this solution placed 
on cotton and the cotton inserted into the cavity of an aching 
tooth will often stop the pain, but oil of cloves many times acts 
more successfully in stopping such pain. 

Chloral is the most perfect hypnotic that we possess, as it 
generally causes profound and comfortable sleep, without 
dreams, and in ordinary dosage does not affect the heart or 
cause much weakness. It should not be used when sleepless- 
ness is due to pain. It is very successful in all excited, irritated 
conditions of the brain, and in delirium, provided the heart is 
in good condition. It is not very frequently used as a hypnotic 
on account of its disagreeable taste, and on account of tte tear 
of its causing cardiac depression. Probably there is too much 
fear of such depression, and chloral should be used more fre- 
quently, if a hypnotic is needed. 

It has long been used in excited mental conditions and in the 
various forms of noisy insanities, and in delirium tremens. 
When there is meningeal excitement in acute disease, as in 
pneumonia and typhoid fever, provided the heart and circula- 
tion are in good condition, chloral may be used as a hypnotic. 



PARALDEHITDE 



279 



and the rest that it will give is often of great benefit to the 
patient. However, in these conditions one of the synthetic 
hypnotics is more frequently used* 

In chronic insomnia chloral, like any other hypnotic, should 
not be used frequently, lest a habit be formed. In treating 
such kind of insomnia regulation of the diet, the omission of tea, 
coffee and any other excitantj hydrotherapy and out-of-door life 
are much better methods of treatment than the administration 
of drugs* However, life- and health-gi\ing sleep must many 
times be caused by the judicious use of hypnotics. 

In convulsive conditions, whether from cerebral irritation or 
from spinal disturbances, in uremic poisoning, in tetanus, and 
in strychnine poisoning, chloral is one of the best drugs to 
administer. The dose should not be too large. Before the 
administered chloral can act it may be well to give chloroform 
inhalations. In these conditions chloral is quite frequently 
combined with bromides. 

In conditions of high blood-pressure with nervous irritability, 
temporarily small doses of chloral may be of value, as 0.20 to 
0.25 Gm. (3 to 4 grains) given three or four times a day, after 
meals. Bromides may also be valuable in such a condition, 
but they are more likely to cause loss of appetite than the 
small doses of chloral. Of course the chloral should not be long 
given. 

In conditions of very low blood-pressure, and when the heart 
is weak, and when there is gastritis, chloral should not be used. 

Par^dehyde. — Description. — Paraldehyde is a dear liquid, 
mth a pungcntj disagreeable, ether-like odor, and unless very 
well diluted, causes a burning, later cooling, sensation to the 
mouth and throat. The average dose is 2 mils (30 minims), 
but it is often increased to a teaspoonfuL It should always be 
administered on cracked ice and with plenty of water. 

Action. — ^Locally, paraldehyde is an irritant, but if well 
diluted and taken on cracked ice it wiU not ordinarily irritate 
the stomach. When quick action is desired, it should be given 
on an empty stomach, and, as it is very quickly absorbed, it may 
cause sleep within a few minutes. There may be at first a 
slight stimulation of the heart as from an ether, but soon there 



28o THE PRINCIPLES OF THERAPEUTICS 

is slowing of the heart and some lowering of the blood-pressure, 
but the most important action is on the central nervous system. 
It seems to act on the cerebral cells, slightly stupefying them, 
causing sleep which is generally free from restlessness and 
from dreams. On awaking, the patient generally has no un- 
pleasant symptoms. There may be a slight headache, and 
some slight weakness of the circulation and of the muscles. 
The breath smells strongly of the drug, and, as stated, the 
taste is very disagreeable, nevertheless paraldehyde should not 
be often repeated, as a paraldehyde habit can occur. 

It is excreted through the kidneys and lungs, elimination 
beginning almost immediately, but continuing for some time. 
Toxic doses cause death by paralysis of the respiration. 

Over-action. — ^A small dose of half a teaspoonful can rarely 
cause any symptoms other than slight faintness, if the patient 
is up. For this reason it is better that the patient be in bed 
when the dose is administered. A large dose, as a teaspoonful, 
is ordinarily not required, unless there is delirium, and gener- 
ally such a dose will cause sleep, with possibly, at first, some 
throbbing of the arteries and a slight feeling of breathlessness. 

Toxic Action, — It is probably very rare for severe poisoning 
to occur from paraldehyde, unless the dose taken is excessive. 
When death occurs after ordinary doses of paraldehyde there 
must be some other cause for the cardiac or respiratory failure. 

The paraldehyde habit does not produce any special symptoms 
of chronic poisoning. There is the desire for the drug, and 
there may be some digestive disturbances. The paraldehyde 
habit is not frequent. 

Treatment of Poisoning, — The treatment of an overdose of 
paraldehyde would be to evacuate the stomach, if it was thought 
that it had not all been absorbed ; to administer hypodermatically 
atropine and strychnine; to keep the patient warm; and to do 
artificial respiration, if needed. Coffee may be administered 
by the mouth. 

Uses. — The only use for paraldehyde is as a hypnotic and to 
quiet cerebral excitement. Simply to produce sleep it is not 
now often used, other drugs have taken its place. It is dis- 
agreeable, and many patients have for a few minutes a very 



TRIONAL — SULPHONAL 



281 



unpleasant faintness before sleep is produced. It is, however, 
a very useful, and, ordinarily, a harmless hypnotic. 

It has been largely used in delirium tremens; it primarily 
satisfies the craving for a stimulant, and secondarily produces 
sleep. In con\aiIsive conditions it, perhaps, is not used as often 
as it should be, as its action is rapid, and even in good sized 
doses is as safe a drug as large doses of chloraL 

TnonaiiSulpkofiethylmeifmnc) — SvdphoimliSulphonmeikane) — 
Descriptian, — Trional and sulphonal both occur as colorless, 
odorless crystals, the trional having a mildly bitter taste, the 
sulphonal almost tasteless, both practically insoluble in water, 
and the dose of each is 0,75 Gm. (12 grains). Both should be 
ordered in powder, and best administered in hot milk or hot 
malted milk, the trional from one to two hours before sleep is 
desired, and the sulphonal, which acts more slowly, four or five 
hours before bedtime. These doses are small, and frequently 
much larger doses should be given. 

Action » — Trional is absorbed slowly, but less slowly than the 
sulphonal The principal action of these drugs is on the cere- 
brum, producing a quiet sleep. They seem to have no special 
action on the heart, except that during the five to eight hours of 
sleep which they cause the blood-pressure is lowered and the 
pulse is kss rapid. 

There is very little after effect from these drugs, except 
possibly some lassitude, and in the latter part of the following 
day, especially if the drug has been taken on two successive 
nights, there is a desire to sleep. Neither of these drugs will 
quiet pain. 

The drugs are eliminated through the kidneys, and, if large 
doses are taken or if the drugs are continued too long, they may 
irritate the kidneys and cause a destrucrion of the hemoglobin 
of the blood and the appearance of hematoporphj^in in the urine. 
Therefore, if for any reason either trional or sulphonal is taken 
for any length of time the urine should be carefully watched. 
The appearance of hematoporphyrin in the urine shows that 
the drug should be immediately stopped. 

Over-action.— There are no symptoms of the over-action of 
either trional or sulphonal except that of too prolonged sleep, 




282 THE PRINCIPLES OF THERAPEUTICS 

loss of appetite, lassitude, muscular weakness, mental apathy, 
and, as just stated, the appearance of hematoporphyrin in the 
urine. Albumin may appear in the urine before hematoporphy- 
rin is found. Acute poisoning is probably rare, as an excessive 
dose must be taken and absorbed to cause such a condition. 

Treatment of Poisoning. — ^The treatment of poisoning is to 
cause rapid evacuation of the bowels, to cause perspiration to 
relieve the kidney irritation, to give large amounts of water, and 
if there is cardiac depression to give stimulation, it being re- 
membered that to every hypnotic depressant caflFeine, atropine, 
and strychnine are antidotes. 

In chronic poisoning and in the sulphonal or trional habit, 
besides stopping the drug, large amounts of alkalies should be 
given, and the food should be largely carbohydrate. 

Uses. — ^Trional and sidphonal are used only to produce sleep. 
They have been supplanted by barbital (veronal) principally 
because it acts more rapidly, the dose is much smaller, and, 
therefore, the irritation of the kidneys, which may occur from 
these synthetic drugs, is less. 

Barbital (LHethylbarbituric Acid) {Veronal). — Description. — 
Barbital is another synthetic hypnotic which occurs as a white 
crystalline powder, is slightly bitter, and is rather insoluble in 
water. The dose is 0.30 to 0.50 Gm. (5 to y}^ grains). If 
administered in tablets, they should be crushed before swallow- 
ing. It is best ordered in powder, given with hot milk or malted 
milk, one-half to one hour before bedtime. 

Barbital-sodium (veronal-sodium) also occurs as a white 
crystalline powder, has a bitter taste, and is very soluble in 
water. The dose of this preparation is the same as that of 
barbital, and it should be administered in the same way. 

Action. — Barbital and its sodium salt, which is generally the 
best preparation to use, is rapidly absorbed and acts principally 
on the central nervous system. It quiets nervousness and pro- 
duces sleep, but has only a slight analgesic action and cannot 
stop acute pain. It may cause slowing of the pulse and lower- 
ing of blood-pressure similar to all synthetic hypnotics, but it 
rarely causes, in ordinary doses, any unpleasant symptoms. 
During its action the temperature sometimes is lowered and 



SCOPOLAMINE HYDROBROHIDE 



283 



when the patient awakens he may have a slight headache and 
some feeling of lassitude and muscle relaxation. 

Over-actian, —The only over*action is slight cardiac depression 
and too prolonged sleep. Acute poisoning rarely occurs, and 
should be treated similarly to poisoning from sulphonal or trional. 
It should be emphasized that when any of these drugs cause 
poisoning, the patient should be given large amounts of w^ater 
and alkalies, as sodium bicarbonate and sodium citrate. 

Occasionally a patient is found who has the veronal habit. 
It should be rapidly stopped; temporary need for a sedative 
may be overcome by the administration of bromides for a short 
time, and then weaning the patient from all sedatives. The 
rest of the treatment is nourishing food and stimulation, 

t/5e5.— Barbital-sodium represents at the present time the best 
synthetic hypnotic, and the dose should be sufficient^ depending 
upon the individual. It may vary from 0.20 to 0.50 Gm. (3 
to ^}'i grains)* Doses on subsequent nights may be smaller, 
provided the original doses were large. It should be given 
with plenty of water. As with all hypnotic drugs* the phy- 
sician should not be content until the drug has been stopped 
and the patient is made to sleep by physical methods and by 
correcting mistakes in the diet and hygiene. 

Luminal^ N.N,R. (phenobarbital, phenyl-ethyl-barbituric 
acid), is a white pow^der, has a slightly bitter taste, and is in- 
soluble in water. It is a useful hjpnotic in simple insomnia, 
and like all synthetic hypnotics it may cause some morning 
depression. It has been used in epilepsy, best given at bed- 
time. The dose is 0.10 to 0,20 Gm, {i J-^ to 3 grains). 

Luminal'Sadium^ N,N,R. (phenobarbital-sodium) occurs as 
a white pow^der, which is very soluble in water. The dose is 
practically the same as that of luminal. 

Scopolamine Hydrobromide (Hyoscine Eydrobromide). — 
/>C5cri^/i^n.— ^Scopolamine hydrobromide occurs as colorless 
crystals, is very soluble in water, and the dose is 0.0003 Gm, 
(Hoo grain), best administered hypodermatically* 

Action^ — Scopolamine hydrobromide is an atropine, and in 
patients who have idiosyncrasy against atropine it may cause 
considerable cerebral excitement and delirium. Ordinarily, 



284 THE PRINCIPLES OF THERAPEUTICS 

however, its action is principally on the central nervous system; 
it rapidly produces sleep. With this sleep there may be con- 
siderable cardiac depression. The drug will not stop pain, 
but without pain it is generally a useful hypnotic in conditions 
requiring the administration of such a drug hypodermatically. 

Over-action. — Over-action is that of excitement in those who 
have an idiosyncrasy against an atropine, and large doses may 
cause cardiac depression. The treatment of such conditions 
would be to combat the symptoms present by the usual methods. 

Toxic action would require the usual stimulation treatments, 
and frequently there may be, when sleep has been produced by 
the hypodermatic administration of this drug, the necessity 
for administering cardiac and vasomotor simulants. 

Uses. — The principal use of this drug is as a hypnotic in deliri- 
um, in the excitement of insanity, occasionally in delirium 
tremens, and when the stomach will not tolerate other hypno- 
tics. The beginning dose is ^00 ot a grain, but some patients 
require }ioo of a grain, and even larger doses are administered 
at times. 

The drug has been used in such conditions as paralysis agitans 
with more or less success. When the drug is frequently given 
a tolerance to ordinary dosage generally occurs. 

DRUGS USED TO CAUSE GENERAL ANESTHESIA 

Sir Humphrey Davy, about the year 1800, suggested that 
nitrous oxide gas be used to stop pain in surgical operations, and 
Horace Wells, of Connecticut, in 1844, showed its use as an 
anesthetic in dentistry. William Morton, an assistant of 
Wells, and Jackson, a chemist, demonstrated ether narcosis 
in the Massachusetts General Hospital in 1846, but C. W. Long, 
of Georgia, had used ether as an anesthetic in 1842. By the 
year 1847 ether was used as an anesthetic throughout the 
civilized world. 

Chloroform was discovered in 1831, but was first used for 
anesthetic purposes in 1847 by J. Y. Simpson, of Edinburgh. 
For many years chloroform was the most used anesthetic in 
Europe, even up to thirty years ago. 

In spite of many new drugs and combinations of drugs the 



GENERAL ANESTHESIA 



28s 



substances used for general anesthesia are still ether, chloro- 
fonhj nitrous oxide gas, and a combination of oxygen and ni- 
trous oxide. The safest of these for major surgery is ether. The 
safest for very minor surgery, as extraction of teeth, is nitrous 
oxide gas and especially the oxygen-nitrous oxide combination. 
For short periods of relaxation, or for dulling of the sensibility 
to prevent pain, and in certain convulsive conditions, chloro- 
form is the anesthetic of choice, but rarely should chloroform 
be used for general anesthesia. The combination of ox>^gen 
and nitrous oxide as an anesthetic a few years ago had its 
strong advocates all over this country, and was largely used 
in many of our best hospitals. At the present time ether has 
again largely supplanted this oxygen-nitrous oxide combination 
but a few surgeons still believe that it is a safe, useful anes- 
thetic. Some surgeons go so far as to state that it is a very 
dangerous anesthetic to rely upon in long operations. Cer- 
tainly it should never be administered except by an expert, and 
an expert for this kind of an anesthetic can only be found 
associated with a large, first class hospital. 

It should be urged at the start, in a discussion of this subject, 
that anesthesia is a special branch of medicine, and that a 
skilled anesthetist, except possibly in emergencies, should be 
the only one to administer the anesthetic. The life of the 
patient is in his hands. For that reason he should be a con- 
sultant in the case. He should know the condition of the 
patient, the surgical operation to be done, the strength of the 
heart, the blood-pressure, the sufficiency of the kidneys, and 
any other detail that belongs to the history of the patient whom 
he is to anesthetize. He then assumes a large part of the 
responsibility for the life or death of the patient; and it is unfair 
for any surgeon to expect this responsibility when the anesthe- 
tist does not have this knowledge. 

More frequently than statistics show does death occur during 
anesthesia, and the cause of these deaths cannot be better out- 
lined than by a paper presented at a meeting of the American 
Association of Anesthetists, held at Chicago, in June, 1918, 
by Dr. E. M, Sande^s^ Sanders thinks that there is one 
* American Journal of Surgery, April, 1919, p* 43 



286 THE PRINCIPLES OF THERAPEUTICS 

death from anesthesia for every one thousand administrations, 
this death being due to "the anesthetic, to the surgeon, and 
to the hazardous risk.'* Death "due to anesthesia" will 
occasionally occur, because honest surgeons and anesthetists 
assume the risk of a hazardous case, one which has a chance to 
live if the operation is done, and such a death is excusable. 
Inexcusable deaths are those due to inexperienced and imtrained 
anesthetists, to anesthetists who do not minute by minute 
attend to their part of the operation, and to surgeons who 
unnecessarily prolong the operation, unnecessarily expose the 
patient to loss of heat, allow unnecessary bleeding, unneces- 
sarily manipulate organs and nerve plexuses in the abdomen 
which should be handled with greater care, and imnecessarily 
prolong a position of a patient in which it is difficult for him 
to breathe or to have his heart properly beat. 

Sanders lists the causes of deaths on the operating table 
or soon afterwards as "shock; hemorrhage, primary or second- 
ary; overdose of the anesthetic paralyzing the higher centers; 
underdose of the anesthetic allowing fibrillation or paralysis 
of the heart; acute dilatation of the heart; acapnia; post- 
operative pneumonia; and acidosis." Occasionally, of course, 
as he notes, an embolus or cerebral hemorrhage may occur, or 
death may occur from thymus pressure or on account of 
thyroid intoxication. 

As he urges, there can be no question of the necessity of a 
careful reading of the systolic, diastolic, and pulse pressure of 
a patient to be operated, and also the advisability of some test 
of cardiac muscle strength. This knowledge is well gotten first 
hand by the anesthetist. 

The danger of partial anesthesia, which is greater with 
chloroform and with oxygen and nitrous oxide gas, should be 
recognized, and the decision that a patient is not sufficiently 
anesthetized, although he is apparently ready for operation, 
should be made by an expert. Also to carelessly allow a patient 
to partially come out of the anesthetic and then to hustle him 
back into profound anesthesia is many times the cause of an 
over-dose of the anesthetic. 

It has long been urged by a few, but carelessly omitted by 



GENERAL ANESTHESIA 



287 



many, to thoroughly cleanse with antiseptics the mouth and 
throat before operation. Also, if the operation is not one of 
emergencyj all infected teeth and infected tonsils should be 
removed before a major operation is done. Many a post- 
operative pneumonia or other serious infection occurs because 
the patient is a carrier of p-rwunwcocci or of streptococci, often 
the viridans or the JtemolyHcus^ or both. Also, a preventive 
of suction pneumonia is to keep the throat and mouth as clean 
as possible during the anesthesia. 

Sanders urges a recognition of the psychic condition of the 
patient, and of the necessity of overcoming the terrible fear 
which some patients have of operation. It has also been urged 
by Crile that this condition of the patient about to be operated 
upon be noted. There is no question that fear disturbes the 
endocrine glands, injures the tone of the circulation, and causes 
an increased thyroid secretion, hence a larger amount of 
the anesthetic is needed. Therefore, the qaiet assurance of 
the surgeon, and especially the quiet, calm influence of the 
anesthetist is very important for these patients. In theses 
instances it may be well to give a preliminary hypodermic of 
morphine with atropine. It is in these cases that Gwathmey, 
of New York, who has studied the subject of anesthesia so 
carefully and written many articles on the value of the different 
anesthetics, urges the use of rectal anesthesia, the patient 
being given the anesthetic without his knowledge, thinking it 
is simply an enema, 

Crile coined the word or phrase "anod-association" as de- 
scriptive of his method of conducting anesthesia. The object 
of this anesthesia is to block the nerve or nerves of the parts to 
be operated so that reflex influences cannot reach the brain and 
cord. Therefore not only pain cannot be felt, but also shock 
cannot occur. The whole procedure is to duU the patient's gen- 
eral sensibilities with morphine and scopolamine as a prelimi- 
nary injection, then give a general anesthetic in small amount 
(Crile often prefers nitrous oxide) and as soon as the patient is 
anesthetized, to inject the local anesthetic procaine (novocaine) 
I part to 4,000, into the nerve trunks of the part to be operated. 
At the close of the operation, into the cut sensitive tissues is 



288 THE PRINCIPLES OF THERAPEUTICS 

injected quinine and urea hydrochloride. This local anesthetic 
is used for the purpose of preventing post-operative pains. 

It will be seen that this whole treatment represents a great 
deal of anesthesia, and it would seem that so much would 
rarely be needed. 

General anesthesia is always a serious proposition, and both 
ether and chloroform may injure the kidneys, the heart, and the 
liver. Therefore, frequent administration of an anesthetic is 
rarely excusable, and is regrettable when it must be repeated 
within a short time. On the other hand, it is rarely advisable, 
under one general anesthesia, to do minor operations, such as 
tonsillectomies, dental operations, etc., before or after a major 
operation. 

Both ether and chloroform cause progressive paralysis of the 
brain and cord, the highest centers being first affected, and 
finally the fundamental centers in the medulla. The reflex 
centers of the pelvic region, of the rectum, and of the genitalia 
are often the last to be paralzyed in ordinary anesthesia; there- 
fore the anesthesia, if general, must be profound before opera- 
tions in these regions can be performed. However, generally, in 
most patients sensation is lost last in the part to be operated 
upon, probably because the patient's mind is fixed on that region 
before the anesthetic is administered. 

It must be conceded that chloroform is the most dangerous 
anesthetic, and Gwathmey, after studying the statistics, states 
that deaths under chloroform by the usual drop method occur- 
red in from one in a thousand to one in three thousand cases, 
while deaths on the operating table from ether, by the drop 
method, occurred only in from one to five thousand to one in 
ten thousand cases. Gwathmey believes that the vapor method 
of administration of ether with definite quantities of air and 
oxygen is safer than the open drop method. 

Crile^ states that after prolonged anesthesia imder ether 
the brain, suprarenals and liver show marked histologic changes, 
while after the same length of time under nitrous oxide anes- 
thesia there are no apparent changes in these organs. However, 
the alkalinity of the blood was more diminished, and general 
* The Journal A. M. A., Dec. i6, 1916, p. 1830. 



GENERAL ANESTHESIA 



2S9 



iity more increased under nitrous oxide than under ether, 
although the more intense the anestliesia in either case the 
greater the acidosis produced. It seems demonstrated that the 
reserve alkalinity of the blood is greatly reduced during pro- 
found anesthesia, and acidity may play a part in the anesthetic 
action of the anesthetic drugs during anesthesia, and the greater 
the acidosis the more profound the anesthesia. Patients who 
have suflfered severe injury, or prolonged pain, or have been 
starved, or have been subjected to serious exertion or to serious 
infection, have a mild acidosis, or at least are on the verge of 
that condition, and Crile thinks this is the reason that the anes- 
thetic acts more seriously and may be dangerous in these cases. 
Also, any patient who has had a long preceding vonaiting period, 
as the nausea of pregnancy, or has had serious diarrhea and in- 
sufficient food, makes a bad risk for general anesthesia. Crile 
thinks that in such cases nitrous oxide (which he finds safe if 
properly administered) should be the anesthetic of choice, unless 
local anesthesia can be used. 

All this only emphasizes the fact that the anesthetic must 
be chosen to fit the patient. Nitrous oxide— oxygen certainly 
has a field as an anesthetic in minor surgery, i.e,, very short 
operations, and may be of advantage when there is a lung con- 
dition that would make the use of ether dangerous, or a kidney 
inflammation, acute or chronic, that would make either ether 
or chloroform inexcusable. The administration of nitrous 
oxide in any form is inexcusable with high blood-pressure, and 
the administration of chloroform is certainly inexcusable in 
conditions of shock or very low blood-pressure, or when there 
is myocardial weakness. 

While the majority of teeth extractions are perhaps done 
under nitrous oxide, and perhaps more should be done under 
nitrous oxide — ox)^gen, still, prolonged operations on the jaws 
are now much better done under ether anesthesia. 

Alcoholic and hysterical patients are perhaps best anesthetized 
with nitrous oxide — ox>'gen, as they generally take ether badly. 
Especially in teeth and throat operations care should be taken 
that the saliva and blood do not trickledowninto the throat to be 
swallowed and cause nausea, or to be sucked into the trachea 
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. Med. JoBB^ Fcfcu, 193Q, pl^tj. 



GENERAL ANESTHESIA 2gi 

Rectal Anesthesia.— Rectal anesthesia, so thoroughly develop- 
ed by Gwathmey, has been very well described by Johnson.^ 
He states that at that date Gwathmey had performed 2,000 
operations under rectal anesthesia with no fatalities. 

In nerv^ous, irritated, and fearful patients the mixture may 
be administered as an enema, and not knowing its character 
the patient quickly drops off into sleep without alarm or fear. 
Patients are prepared for this rectal anesthesia the same as for 
any other anesthesia, except that the rectum must be as clean as 
possible in order to absorb the anesthetic. The method advised 
IS to administer a dose of castor oil at 2 P. M. on the day before 
the operation. As soon as the oil has acted that evening, a 
colon irrigation is given until the water comes away clear. On 
the morning of the operation, one or two colon irrigations are 
again given, and two hours before the operation 5 to 15 grains of 
chloretone are given by the mouth. Thirty minutes before the 
regular anesthesia, the patient is given subcutaneously from }4 
to }^ grain of morphine and 3 {50 g^^^in of atropine^ and immed- 
iately thereafter is given by rectum the following: 

Paraldehyde , to mils 

Olive oiL , 60 mils 

Ether , 100 mOs 



The patient is kept quiet in a darkened room until he is surgi- 
cally unconscious, which wiU require, says Johnson, from 15 to 
30 minutes. The odor of ether appears on the patient's breath 
in about four minutes after the injection. Johnson finds the 
absorption is slow and uniform, the patient absorbing about two 
ounces an hour* The doses of the drugs are of course deter- 
mined *'by the age, weight, and habits of the patient, about i 
ounce (30 mils) of ether being required for ever>' twenty-five to 
thirty pounds of body weight, *' He says when the paraldehyde 
is used this may be lessened, but that they *^ never give over 6 
ounces of a 75 per cent, oil-ether mixture to adults, regardless of 
weight. Children require only from 50 to 60 per cent, of ether, 
and when under nine years of age, no preliminary treatment. " 
In this rectal anesthesia stertorous breathing and loss of 
* New York Medical Jouraal, Oct. 38, 1916, p. 846. 



292 THE PRINCIPLES OF THERAPEUTICS 

ocular reflexes should not occur, as they are danger signals. 
If they do occur, from i to 2 ounces or all of the mixture 
should be withdrawn from the bowel, and the bowel be mas- 
saged in the direction of the colon outflow, to promote entire 
evacuation of the ether; the bowel may also be irrigated with 
cold water. If the patient seems to be coming out of the 
anesthesia, the mouth and nose should be covered, when they 
quickly go back into smooth, easy surgical narcosis. The 
tongue should be kept forward and the jaw projected, with the 
head extended as is usual in all anesthesias. After the opera- 
tion, the colon is irrigated. 

This method of anesthesia as suggested may be useful 
especially in operations on the head, neck, throat, or chest, and 
for patients who are likely to have bronchial irritation and 
profuse bronchorrhea from the ether inhalations. Contra- 
indications are diseases of the intestines, operations on the 
pelvis, and, in general, laparotomies, on account of gaseous 
distention caused. 

It would seem that rectal anesthesia should be the method 
of choice only in exceptional instances, but in certain con- 
ditions it is doubtless of value. However, with the uncertainty 
of the amount of ether absorption it would seem more unwise 
to administer morphine before the anesthesia than it is in the 
ordinary inhalation method, also the paraldehyde complication 
would tend to befog the signs of the degree of narcosis. 

Pre-operative Care of the Patient.— As previously urged, 
except in operations of emergency, the skilled anesthetist 
should partake in the diagnosis and clinical examination of 
the patient to be operated upon, i.e.y both he and the surgeon 
should share the responsibility of the patient coming through 
the operation safely. 

I. Of primary importance is the condition of the circulation, 
namely, the presence or absence of heart lesions; the blood- 
pressure, systolic and diastolic; the condition of the arteries; 
the estimated strength of the myocardium, as shown by the 
systolic, diastolic, and pulse pressure, and by simple tests of its 
strength (rapidity of pulse, etc., in different positions). 

A high systolic pressure, and especially a high diastolic 




GENEIL^L ANESTHESIA 



pressure, or hardened arteries, should preclude, ordmarily, the 
use of nitrous oxide gas or nitrous oxide — oxygen gas as anes- 
thetics. For short operations in such a condition chloroform is 
probably the safest anesthetic to use, as there is always a fall 
of blood-pressure under chloroform. If the blood-pressure is 
low and the heart weak, and there are valvular lesions which 
may presume more or less cardiac degeneration, chloroform 
should not be used as the anesthetic. For a short operation the 
nitrous oxide— oxygen may be used, but ether is generally the 
safest anesthetic, 

2. When possible, a twenty-four hour specimen of urine 
should be carefully examined, and if chronic kidney disturbance 
is found, prolonged administration of either ether or chloroform 
is not ad\dsable (though chloroform, if the blood-pressure is 
high, is perhaps safer than ether), and the nitrous oxide-oxygen 
anesthetic is the one of choice. If an operation must be done 
and there is evidence of considerable chronic nephritis, the 
ability of the kidneys to excrete had better be tested by the 
phenolphthalein test. If the kidneys are very insufficient and 
the operation must be done, some form of local anesthesia, or 
spinal anesthesia, is generally the safest. 

3. If there is bronchitis, or asthma, or some other more 
serious lung condition present, ether inhalations should, if 
possible, be avoided, and the safest method of administration, 
unJcss otherwise contraindicated, would seem to l>e rectal 
anesthesia. If the operation is a short one, chloroform inhala- 
tions may be given. 

4. The condition of the thyroid should be noted. Hyper- 
thyroidism or a large thyroid tumor should cause the greatest of 
care by the anesthetist and may preclude all major operations. 
In hj-perthyroidism generally the patients are best prepared for 
anesthesia by previous injections of morphine and atropine. 
It is possible that recta! anesthesia is advisable in these cases. 
However, unless an operation is absolutely necessary in a case 
of toxic hyperthyroidism such operations should not be done in 
that condition until the h>T>crthyroidism has been previously 
controlled by medical methods, if possible. 

5. There is not enough data to determine how frequently 




294 THE PRINCIPLES OF TH KIT APETTICS 

enlarged tfaymus glands are the cause of sodden deaths dmii^ 
anesthesia. The thymus gland is fooixl not infrequently 
enlarged in adults, and it may be one cause of death on the 
operating table. The upper sternal region should becarefuDy 
percussed, and if there is any doubt in the mind ai the surgeon 
or anesthetist as to an enlaigement of this ^and, x>ray pictures 
should be taken. A few x-ray treatments of the gland, if it is 
found enlarged, may remove the danger of its causing sudden 
death during an anesthesia. 

6. Very important and not to be ne^ected, provided the 
operation is not one of emergoicy, is to remove infected tonsils 
and infected teeth, and to treat pyorrhea. Not only may the 
germs from these infections be causing s3rmptoms, but they are 
more likdy to cause serious sjrmptoms after an anesthetic and 
an opemtkm. Many a death from pneumonia or from septic 
infection or from streptococcus hemotytiais aitei operation has 
been due to an infected mouth. To repeat, unless an operation 
is one of emergoicy, it is inexcusable to-day to give any inhala- 
tion anesthetic when the mouth is seriously infected. Also 
the post-<q>erative risk is greatly intensified with such fod of 
infection. 

Preparation of tfie Patieiit for Operation. — i. In the first 
place, when the operation is not one of emergency the patient 
should receive for two or three days before the operation an extra 
amount of carbohydrate food with a minimum amount of fat 
and a small amount of protein. This diet will prevent the fre- 
quent acidosis which so often occurs after operations on account 
of the prolonged inability to take starchy foods. 

2. While masses of fecal matters should not be in the bowds, 
and the bowels should be as clean as possible before the opera- 
tion, still the laxatives needed are best given two days before 
the operation, not on the day before or on the morning of the 
operation. In the first place, most cathartics tend to cause 
an increased amount of intestinal gas, to the disadvantage of the 
surgeon in abdominal operations and to the disadvantage of the 
patient after the operation, because paralysis of the bowels may 
occur from the distention, because the diaphragm is interfered 
with in its respiratory work, and because the heart may be 



GENERAL >VNE5TI£ES1A 



295 



prtssed upon. In other words, anything that tends to produce 
tympanites or paralysis of the bowels after operation is \Hcious 
and is inexcusable treatment. K it occurs, the surgeon should 
have the comfortable feeling that he did not cause it. Also 
profuse catharsis just before an operation is \acious because of 
the circulator}^ prostration that it causes. No well indi\idual 
can have several water^^ movements of the bowels without feel- 
ing the circulatory depression that accompanies and follows it. 
Such prostration is certainly not desirable in a patient who is to 
be subjected to an anesthetic, to the cutting of nerves, to per- 
haps unavoidable blood loss, and to the removal of more or less 
important organs* Also such loss of fluid adds its quota to the 
production of surgical shock. 

Although a cathartic should not be given on the night before 
the operation, it may be well to give a small enema two or three 
hours before the operation in the mornings to clean the lower 
part of the intestine. 

3. It is a mistake to too long starve a patient before the 
operation; and the best time for an operation, if it is not one 
of emergency, is in the early morning hours. The patient is 
fresh, and has not had to wait all day expectantly for the oper- 
ation. Also, the surgeon is fresh, and is better prepared men- 
tally and physically to operate. However, starvation from a 
small supper at six o'clock of the night before and nothing in the 
stomach the next morning before the operation, and then the 
patient too ill with the post-anesthesia disturbed stomach to 
take nourishment until perhaps the evening of the day of the 
operation, is a mistake. There is no reason why a patient, two 
or three hours before the operation, should not have some simple 
nourishment, such as a cup of hot bouillon or a cup of black 
coffee, preferably with sugar. If the patient vomits during the 
anesthesia, there is nothing to come up of any harm, even if he 
has retained it in his stomach, which he ordinarily would not do. 
In the case of a young child who does not know that he is to be 
operated upon and therefore has no fear, a small cup of malted 
milk may be given three or four hours before the operation. 

4, False teeth should be removed; the nose sprayed; and the 
mouth and throat cleansed with some mild antiseptic solution, 





296 THE PRINCIPLES OF THERAPEUTICS 

best boric add, before the anesthetic is begun. The patient 
should then pass urine. In women, hairpins should be removed, 
and a firm fitting cap put around the head, but not an air-tight 
cap to cause perspiration. If the anesthetic is to be ether or 
chloroform, the face should be anointed with vaseline or 
cold cream. The anesthetist should notice the character 
of the pulse and its rapidity, and the patient is ready for the 
anesthetic. 

Care of The Patient In The Operating Room. — During the 
anesthesia the patient should be placed in as comfortable a 
position as is possible, and the operating table should not be too 
narrow and should not be too short. It is rarely excusable to 
tie a patient's arms across his chest. This dead weight during 
the profound anesthesia is a great imi>airment to proper res- 
piration, and the position is ordinarily inexcusable. If his 
arms cannot be down at his sides on the table, they may be 
gently fastened upwards and backwards, not far enough to 
strain the axilke; neither should they be allowed to hang ofiF the 
table or in an awkward position, lest injury to some nerve or 
to the circulation occur and paralysis follow. The anesthetist 
may care to watch the radial pulse as well as the temporal or 
facial pulse. The radial pulse is an earlier indication of cardiac 
failure than are the other two pulses. 

In the next place, every move and turn given the patient 
should be as gentle as though he were awake. There can be no 
excuse for operating room roughness. 

Generally it is best for a patient to be anesthetized in a room 
adjacent to the operating room, or perhaps even in his or her 
own bed, and then be placed on a carriage and gently rolled to 
the operating room. 

Many times it may be best to administer morphine and atro- 
pine a half hour or more before the anesthetic is begun, but as 
routine it is not advisable. Morphine interferes with the res- 
piration, and atropine interferes with the normal reaction of 
the pupil. Consequently, the indications relied upon for over- 
action of ether and chloroform are more or less interfered with 
when these drugs have been previously given. However, such 
administration does prevent severe nervousness and dread of 



GENERAL ANESTHESIA 



297 



the anesthetic, and also may allow less of the anesthetic to be 
used. On the other hand, it is not as easy to decide that the 
patient is sulBciently anesthetized for the operation to begin, 
and many times serious nerve shock is caused by such insuffi- 
cient anesthesia. 

It is unwise for much talking to be done in the operating 
room. Speed with effectiveness should be the rule. Speed 
with carelessness is inexcusable. The skilled anesthetist should 
be the commander, to decide when the operation should begin, 
to decide wheUj in certain conditions it is necessary to stop the 
operation, and to decide when it is necessary to change an abnor- 
mal position of the patient^namely, one that interferes with res- 
piration or with normal cerebral blood -pressure. In plethoric 
patients a high Trendelenburg position should not be allowed, 
at least for any length of time; also not in high blood-pressure. 
On the other hand, a prolonged Trendelenburg position should 
not be rapidly dropped; the table should be lowered gradually 
to accustom the anesthetized patient to this sudden loss of cere- 
bral pressure. Also in lithotomy positions or for peHic oper- 
ations the heavy legs should not be allowed to hang too long in 
harness or to fall too far over, to strain the sacro-iliac joints. 
Many a sacral disability has begun on the operating table. 

During the operation the patient is rarely allowed to lose 
bodily heat, but after the operation is finished, during the 
cleaning and the bandaging, many a patient is allowed to be- 
come seriously chilled. Care should be taken that this does not 
occur. If it is necessary for a patient to be raised to properly 
bandagCj he should never be held upright for even a moment, or 
even partially upright, or even rolled on his side, especially the 
left side, while he is profoundly anesthetized, nor for hours after 
he comes out of the anesthetic. 

The skilled anesthetist knows how to care for the tongue; that 
the epiglottis does not fall over the glottis; how to care for the 
saliva or perhaps regurgitated gaseous fluid from the stomach, 
so that it is not sucked into the larynx. A suction apparatus 
(often best combined with an anesthetic vaporizer) should be 
used, especially in mouth and throat operations. The anes- 
thetist decides when to push the anesthetic and when to slow it, 



298 THE PRINCIPLES OF THERAPEUTICS 

and when the heart needs stimulation by some hypodermic treat- 
ment, or when more strenuous treatments are necessary, such 
as artificial respiration or raising the feet and legs or perhaps 
the body. Hiccough in profound anesthesia is a bad symp- 
tom, calling for a careful study of the patient. These things 
cannot be taught by book; they must be learned as any other 
specialty is learned, from a skilled specialist. 

Care of the Patient After OperatioiL — ^The patient should be 
returned to a warm bed; but hot water bags should not be put 
on his bare skin, or used hot enough to cause blisters. The 
still insensible patient cannot tell how hot the application is. 
He should lie flat, without pillows, the head best turned to the 
side, the nurse watching the pulse, and removing with swabs or 
soft towels the strings of mucus from his mouth. Whether it 
is advisable, as he is coming out of the anesthetic (provided he 
has not had morphine and atropine or scopolamine before the 
anesthetic was given) to give him an injection of 3^ or J^ of a 
grain of morphine to prevent post-operative pain, must be 
decided by the anesthetist and the surgeon. Sometimes it is 
good judgment; many times it is not needed, and especially not 
as often since less cathartics and less starvation occurs before 
the operation. Also, if carbohydrates have been pushed several 
days before the operation, there is less vomiting, and the 
patient can take nourishment sooner, and acidosis is not as 
likely to occur. Especially inadvisable is a morphine injection, 
unless it is positively needed, if the patient is known to be 
prostrated or nauseated when he comes out of the quieting 
effect of the morphine. 

If considerable anesthetic has been given, and the op>eration 
was a long one and the patient has perspired freely, or if much 
blood has been lost, it is advisable, before the patient leaves 
the operating table, to give a small enema of physiologic saline 
solution. This gives liquid to the patient, who cannot take 
liquids by the mouth for some hours and retain them, and also 
tends to cause more rapid diuresis, and therefore quicker 
elimination of the waste products of the anesthesia. 

If the patient's pulse is not strong after the operation and 
there is no contraindication to increased peristalsis of the 



GENERAt ANESTHESIA 



299 



W 



intestines or to contraction of the uterus, injection of post- 
pituitary extract may be good treatment, as this not only 
raises the blood-pressure but promotes diuresis. 

Whether, or not, other stimulation of the heart is needed 
post-operatively, must be decided by the physician in charge 
and by the watchful nurse. As soon as the patient begins 
to vomit or to be nauseated, it is well for him to take small 
draughts of hot water, or if he actually vomits, he should be 
given considerable hot water, which will cause him to get rid, 
either by vomiting or by passing it on to the intestines, of the 
mucus with ether gas which he has swallowed. After he has 
vomited several times and the stomach seems empty, if the 
vomiting persists, it may be advisable to give him a hypodermic 
of morphine and atropine, provided he has not previously had 
it. The dose of morphine need not be large, perhaps not more 
than Ho c>f a grain, with }{^q of atropine. If he is very 
thirsty and desires ice in his mouth he may have it, but to 
drink ice water or swallow much cold water is inad\^sable, as it 
often tends to promote nausea rather than to stop it. If the 
patient cannot take anything into the stomach without feeling 
distention^ and he seems to have hard work to breathe, the 
bandages around the abdomen, after a laparotomy, may need 
to be loosened; in fact, abdominal bandages are often put on 
too tight. 

If the patient vomits bile and is terribly nauseated and pros- 
trated, sometimes 5 drops of dilute hydrochloric acid in half a 
glass of water will cause the pylorus to close and check the 
regurgitation from the duodenum, and the vomiting will cease. 
H there is any blood extravasation into the stomach, and 
**coffee-ground" stuff is vomited, or if the vomiting of bile 
continues, or if the patient has swallowed blood which does not 
come op but is retained in the stomach, the stomach may be 
washed out, but this is not often necessary after ordinary 
operations. Sometimes, if there is an irritated condition of 
the stomachy pure olive oilj taken in ounce doses j may stop the 
nausea. At other times eating a lump or two of sugar has 
stopped vomiting. A thin cereal gruel or a thin oatmeal gruel 
will sometimes stay down when other substances are vomited. 




I 



300 THE PRINCIPLES OF THERAPEUTICS 

If the patient does not vomit, the let-alone treatment for a 
number of hours is the best treatment. 

When it is decided that the patient is ready for some nourish- 
ment, cereal gruels are the best; raw egg albumin nonsense 
should be abolished. It is not a food, and is of no value to the 
patient, and to stop nausea and vomiting and to promote the 
patient's welfare carbohydrates are what is needed. A cup 
of coffee, or a cup of tea if the patient prefers, is always a good 
stimulant, or a cup of bouillon may be given. Milk toast or 
malted milk, and soon dry toast crunched (if the patient is 
able, the chewing of starchy foods is of advantage to him) and 
swallowed should be the next food. Soon poached eggs, if all 
goes well, may be added to the diet. 

The great aim of surgeons after operation has been to cause 
the bowels to move. How soon after an abdominal operation 
they should be forced to move is a question that cannot be 
decided by any rule or regtdation. The individual and the 
symptoms must be studied, the exact operation and the con- 
ditions present at the operation must be known, and then the 
decision can be made as to what it is best to do in regard to 
moving the bowels. An enema of an oimce of glycerin and an 
ounce of water will evacuate the lower part, at least, of the 
large intestine. Also a saline enema will cause evacuation 
of gas from the colon, and this alone may start p>eristalsis in 
the small intestine. 

It does not seem necessary to revert to that ancient and 
honorable substance, the compound cathartic pill. Why that 
pill, in most hospitals, must follow an operation can only be 
decided by why it is necessary to put the zodiacal dash over the 
letter R at the head of a prescription. Other drugs will act as 
well if the surgeon will only learn to use them. However, the 
compound cathartic pill is a little better for the patient than 
divided doses of calomel. Of all treatments for the poor duode- 
num, after an operation, that is the worst. If the surgeon decided 
that calomel should be given, let him give the dose he thinks 
advisable (i, 2, or even 3 grains, with 15 grains of sodiimi bicar- 
bonate) and at the same time a compound aloin pill, and prob- 
ably the results will be perfectly satisfactory. This dribbling 



GENERAL ANESTHESIA 



301 



irritation of a small dose of calomel frequently repeated, so that 
when the first dose gets there with results the other dose is far 
in the rear, is inexcusable post-operative treatment. 

WTiether it is advisable to give divided doses of a saline, 
IS certainly a question for careful decision. It would seem 
much better to give such a dose of a saline as it is estimated 
the patient needs for effective action at one time and get through 
with it. On the other hand, without pre-operative purging 
and therefore without as much tendency to distention of the 
bowels, such active cathartic remedies may not be needed. It 
should be recognized that pituitary extractSj hypodermatically, 
are splendid stimulants to intestinal peristalsis. Ergot is 
effective when given intramuscularly. 

Much lauded by many surgeons have been asafetida pills, as 
tending to promote peristalsis by their carminative effect. 
There is certainly no harm in giving a patient asafetida pills. 
On the other hand, a cup of bouillon with onion (a thin onion 
soup) would probably be as effective in causing the downward 
movement of intestinal gas* 

A patient should not go too many hours without the attempt 
to pass urine, as he may be long nnore or less indifferent to this 
call of nature. Therefore, if, after some hours, he makes the 
attempt and cannot evacuate the bladder, it is better to cathe- 
terize him (carefully and aseptically) rather than to allow vesi- 
cle distention to occur. One catheterization may, under the 
circumstances, be sufficient, while if the bladder is allowed to 
become distended, the patient may have to be catheterized for 
a number of days. The urine should be examined daily for 
several days after the operation, and longer if found abnormal. 

Whatever the operation may have been, even if it is on the 
neck or head, it is inad\asable to sit the patient up on the day 
following, or even the second day following the operation, unless 
he has an unusually good vasomotor tone. Many a patient has 
been gotten upright too soon after an anesthesia, thus causing 
dilatation of his heart and then requiring weeks and even 
months, before his cardiac strength returned. Before a surgical 
patient sits up the vasomotor tone should certainly be approach- 
ing normal It is absolutely inexcusable, in even a simple appen- 



302 THE PRINCIPLES OF THERAPEUTICS 

dix operation, to have a patient up and out in a week, or even in 
nine or ten days. Two weeks is soon enough for such a patient 
to go home. The surgeon may not have that proud record of 
up and out in eight days, but he has the splendid record of know- 
ing, if anything happens to his patient, that it was not because 
he was too previous. 

It should be urged that the operated patient who does not 
sleep, or does not digest well, or does not have an appetite, or 
does not do some other thing right, should not be given a quanti- 
ty of unnecessary medicine. Surgeons, with all their skiUed, 
wonderful and life-saving work, do not always spend much 
time on the study of the action of drugs and of medication. 
They give a few stock mixtures, without knowing what they 
contain, frequently to the disturbance of their patients. When 
medication is necessary the surgeon should either study more 
carefully the art of the physician, or allow a physician to decide 
what the patient should receive. 

When the removal of dressings and drains will cause acute 
pain, the simple expedient of stopping the patient's suffering 
by allowing him to inhale a little chloroform should be consider- 
ed. If, as Sollmann has suggested, a measured teaspoonful of 
chloroform is put on a piece of cotton and the patient allowed 
to hold it to his nostrils and inhale the fimies, his hand will drop 
away before he receives too much, but he will inhale sufficient 
to stop his suflfering. Another method is to pour half a tea- 
spoonful of chloroform onto a piece of blotting paper in the 
bottom of a cup, and let the patient hold the cup and inhale. 
The patient's hand will relax and he will cease inhaling as soon 
as he receives enough to dull his sensations. This very partial 
anesthesia will do him less harm than the shock of acute pain 
will do, and as there are no nerves to be cut, he will not be shock- 
ed from the imperfect anesthesia. If the patient's condition is 
too weak for this partial anesthesia, he is also too weak for the 
acute pain of removing some kinds of dressings, and he is well 
prepared to endure the pain by a good sized dose of whiskey 
or brandy, or by an injection of morphine and atropine. 

The Anes&etist's Table in the Operating Room. — On a 
table at the side of the anesthetist should be: 



GENERAL ANESTHESIA 



303 



I* Tongue forceps. 

2. A large needle threaded with strong silk, for holding the 
tongue forward, 1/ it is necessary. 

3. A cork, a piece of mbber, or a mouth gag. 

4. Long forceps and properly made gauze pledgets for swab- 
bing out the mouth and throat. 

5. An emesis basin. 

6. Towels, 

7. Two or three hypodermic syringes. 

8. Atropine sulphate tablets, j^ioo ^^^ Moo grain, 

9. Str}^chnine sulphate tablets, ^ig and 3|o grain. 

ID. Ampules of post-pituitary solution, each i to lo^ocx), 

1 1 . Ampules of camphor solution each representing 2 grains. 

12. Ampules of ergot. 

13. A mouth suction appliance, as used by dentists. 

A faradic batter^;, a tank of fresh oxygen, a transfusion 
apparatus, and physiologic saline ready for transfusion should 
be at hand. It is probably rare that in ether or chloroform 
anesthesia oxygen is needed in an emergency, although artificial 
respiration may be necessary. Henderson has shown that 
what is often needed to raise the blood-pressure and prevent 
shock and collapse is reaUy more carbon dioxide, as the patient 
IS over-ox>^genated, which is the cause of the apnea. 

Recently^ Henderson^ Haggard and Coburn have especially 
outlined the use of carbon dioxide in emergencies or in shock after 
anesthesia. They believe that post-operative depression is really 
due to insufficient venous circulation. Consequently improve- 
ment must be caused by a return of improved arterial pressure 
and a consequent better venous circulation^ and the proper 
administration of diluted carbon dioxide vdll bring about this 
satisfactory change in circulation. They caution that without 
a reliable method and apparatus the administration of carbon 
dioxide might be dangerous, and if not properly diluted with air 
or oxygen, would be fatal. They have devised a simplified 
apparatus which should be installed in every operating room, 
This apparatus may be studied in the journal named. 

^ Tbe Journal A. M. A., March 20^ igao^ p. 783. 



304 IHE PRINCIPLES OF THERAPEUTICS 

These investigators find that within a few minutes after in- 
halation of carbon dioxide has been begun, there is an increase of 
the volume of respiration, even to as much as six times more 
litres of air p>er minute. This increased respiration deetherizes 
and therefore denarcotizes the patient rapidly and he soon re- 
turns to consciousness. 

After ordinary op>erations the arterial blood-pressure drops on 
an average perhaps 15 millimeters of mercury, but these investi- 
gators find that under the inhalation of carbon dioxide this 
blood-pressure rises rapidly, sometimes from 30 to 40 millimeters 
in four to five minutes, and at the end of fifteen minutes the 
blood-pressure is 10 to 20 millimeters above normal. After the 
termination of the inhalations the blood-pressure returns to 
normal, and in their experiments never fell to the previous low 
levels. 

Patients thus treated after operation quickly have the normal 
color of the skin restored, and seem to have less vomiting. 

These findings suggest the advisability, after an operation is 
complete, of giving a patient, with the proper apparatus, a 
short period of carbon dioxide inhalations. 

Chlorofomi. — Administration. — Chloroform occurs as a clear 
liquid, with a characteristic odor and a burning, sweet taste. 
It is not used internally as such, except for inhalation to cause 
anesthesia. It is occasionally used externally as a counterirri- 
tant, and it may be used to cause blisters. When given inter- 
nally it is best administered in the form of the official Spiritus 
Chloroformi, the dose of which is small, 0.25 mils (4 minims), if 
the dose is to be frequently repeated, else nausea is caused. 
Larger doses are used to eradicate intestinal parasites, but other 
treatments are better. Spirit of chloroform is given internally 
in cough mixtures for the evaporation which occurs in the 
throat, as such action sometimes quiets an irritating throat 
cough. It also has some carminative action. It should always 
be administered with a syrup, as the syrup of tolu, and taken 
well diluted, as otherwise it causes considerable irritation of the 
throat and stomach. 

Externally the official Linimentum Chloroformi is much used 
to promote counterirritation. When rubbed on the skin a 



CHLOROFORU 



30s 



r 



rubefacieot action is caused; if the part to whicli it is applied is 
immediately covered some coDsiderable burnt ag sensations are 
produced. If the part is left uncovered, a cooling sensation is 
caused, on account of the evaporation. 

Adwn,—hocB.]}y on the skin chloroform and ether act simi- 
larly; both may cause irritation if rubbed on, and if the part is 
covered up, they may cause vesication. On parts exposed to 
the air chloroform may cause a coohng, benumbing sensation. 

The principal action of chloroform after inhalation is on the 
central nerv^ous system and on the circulation. On the nerv^ous 
system it first affects the brain, then the sensor)^ part of the 
spinal cord, next the motor part of the spinal cord, and finally 
the centers of the medulla, especially the respiratory and the 
vasomotor centers. It always causes, as so well showTi by 
Hare in his investigations, vasomotor depression, and usually, 
death from chloroform is caused by loss of blood-pressure, and, 
as in shock, the patient bleeds into his ovm blood-vessels and 
paralysis of the brain and cerebral centers occurs. For this 
reason in heart failure from chloroform more than in almost any 
other poisoning, the inversion of the body, causing gravity to 
fill the blood-vessels of the brain, is the logical immediate treat- 
ment. The body rapidly loses heat under chloroform narcosis, 
therefore the patient should be kept very warm during chloro- 
form anesthesia. 

When chloroform is properly given by inhalation there is 
rarely an excitable stage. There is a sensation of warmth and 
slight irritation in the mouth and throat, the pulse soon becomes 
slower and fuller, but the blood-pressure is lowered. There 
is very little irritation of the air passages as compared with 
that caused by ether. As in ether, dilatation of the pupils 
from profound action of the anesthetic occurs, but it is of more 
serious moment than when the patient is under ether. When 
the dilated pupils do not quickly react to light in chloroform 
anesthesia, the patient is severely narcotized. 

Chloroform is eliminated by the lungs and by the kidneys, 
and the kidneys may be severely injured when they have been 
previously diseased. They are not likely to be as much injured 

as by ether under the same conditions, but it should be remem- 

20 




;406 TIIIC PItlNClPLES OF THERAPEUTICS 

lirwl thiit rthcr and chloroform can cause degcncntion o£ the 
kldiiryti, llvrr, and heart muscle. It should be empla^Mrd 
ihMl ihloniform nhould never be used as an anesth^ic if the 
pitllritt han vrry low blood-pressure, or the heart >s v^^ «" 
Irrraular, or when there is a possibility that tharc is scrioos 
•hiB»Mirratl«m of the heart muscle. 

i hw of the numt nerlous dangers during chloroform anestlicia 
iH ♦ wrn Uxm hejdnnlng the operation of cutting and severing 
wwvn and »»enKltlve tissues before the patient is complet^y 
HH»*«»thi*tUiMl The early stage of chloroform anesthesia 
«|i»v«»Im|»«» nx\ i\\\Uk\y and seems so sleep-like, that operaticHis 
Hiiiv !»»» heu^in during this stage, and, m such a condition, ^*cii 
llu^ \ fim»nu>tor tone is reduced, the pain may reflexly act <m the 
vtiul \\v\ yvn and the heart may suddenly stop. 

Piinuully, in administering chloroform for anesthetic pur- 
|iMQi^«». It should be remembered that the patient must also 
lidiiilr plenty of air, in fact the more fresh air there is, with 
iiiMMi windows, or on verandas, or even in tents, the safer is the 
♦ hloniform anesthesia. In a close, hot, stuflFy room, chloro- 
rdtiH anesthesia is more dangerous than in the summertime 
wlu*n the windows can be open. The Esmarch inhaler is 
|irrhaps one of the best for the drop method of administration, 
itb tin* gauze is some distance from the nostrils. 

Thr least disturbance of the regularity of the respiration 
bhould be noted as Hare urges, as before serious disturbance of 
Ihr circulation occurs respiration indications will be given. 

'Hie percentage of chloroform to air should be, for safety, at 
1)1 t)l not more than i per cent., and to produce safe anesthesia 
for operative purposes not more than 2 per cent. Much more 
lliMfi that strength of chloroform to air is dangerous. 

Although it has been discussed when chloroform should be 

ime/l in preference to the safer anesthetic, ether, it may be 

repeated that chloroform is better when there are hardened 

arteries; atheroma; very high blood-pressure; serious lung 

blc; cerebral excitement; convulsions; where muscle 

tion is quickly needed for dislocations and for reductions 

ia; and when there is Bright's disease. 



CHLOROFORM 



307 



Inhalations of chloroform are sometimes given in severe 
whooping-cough spasms; in epileptic and uremic convulsions; in 
eclampsia; and as an anesthetic during parturition. 

During the severe pains in the second stage of labor, if an 
anesthetic is advisable, the patient may be allowed to hold a 
cup with a piece of blotting paper in the bottom wet with 
from a few drops to half a teaspoonful of chloroform. She 
will relax her arm and cease to inhale it as soon as she has 
received enough to quiet her pain. Of course she should not be 
allowed to begin this inhalation of chloroform too soon; it 
should generally be delayed until the child's head is passing 
over the perineum. 

Chloroform inhalations are also often used in the intense 
pain of renal and hepatic colic, and partial anesthesia may 
prevent the necessity of large doses of morphine. It should 
always be remembered, however, that whenever chloroform 
is taken, even in small amounts^ slight cardiac disability may 
follow. When large amounts of chloroform are taken by a 
struggling, fighting individual, more prostration may follow 
than when the patient quietly inhales it, even if he is 
weak. 

Canlraindi€aHans,~ThG contraindications to the use of 
chloroform as an anesthetic are: very low blood -pressure; 
myocardial weakness; generally valvular lesions; obesity witli 
possibly fatty heart; anemia; enlarged thymus; adenoids and 
enlarged tonsils; any operation on the head that requires the 
patient's head to be much elevated (one of the dangers of using 
chloroform for extractions of teeth); jaundice or any serious 
liver condition; diabetes or starvation, and an increased danger 
of acidosis; after prolonged septic conditions; and serious 
disease of the kidneys. 

Toxic AcHon. — Sudden death may occur under chloro- 
form anesthesia without any mistake on the part of the 
anesthetist or of the surgeon. Although death occurs more 
frequently under chloroform anesthesia than with any other 
anesthetic, still, with proper care, perhaps no more fre- 
quent, unexpected, unavoidable deaths occur than under other 
anesthetics. 




3o8 THE PRIXCIPIXS OF THERAPETTICS 

After cUorofonn anesthesia not only inay serioos acidosis occur, 
but glycosuria is not infrequent, and fatty degeneration of the 
different organs of the body has been found. But as chloro- 
form should not be administered when the anesthesia must be 
prolonged (another contraindication to the use oi chloro- 
form) such pathologic conditions from this anesthetic must 
be rare. 

Although ether must not be used at night in a room lighted 
by gas, or where there is a stove, still chloroform used under 
such conditions may be broken up into chlorine and hydro- 
chloric add, and even into ozychloride of carbcm (phosgene) 
which is a deadly poison, and very serious effects may occur to 
all in the operating room. 

TreatmetU of Poisoning. — ^As stated, disturbance of respira- 
tory rhythm should give the warning of over-action of the chlo- 
roform, but in sudden stoppage of the respiration or of the 
heart, the patient should be immediately inverted, to send 
the blood to the head and increase the circulation at the base of the 
brain. It may also be weU to tightly bandage the legs from the 
feet up, to force the blood into the upper part of the body and 
the head. Artificial respiration must be done, and should be 
prolonged, if there is any action of the heart whatever. Carbon 
dioxide inhalations, properly given, are advisable. Hypoder- 
matic injections of strychnine, atropine, caffeine, and camphor 
may be given, and either epinephrine or pituitary extract as 
deemed advisable. 

Uses. — Besides its use as an anesthetic, the only good use for 
chloroform internally is in certain kinds of throat coughs. For 
this purpose it may be combined with other substances in tab- 
lets to dissolve in the mouth, giving a slight vapor of chloroform, 
which is soothing to the irritated region. Or, chloroform in the 
form of the spirit may be combined with some cough mixture. 
The dose should be small, not more than 5 to lo mils to the 100 
mil mixture. 

Chloroform water has been used to disguise bad tasting drugs, 
but this is not a good method; other preparations are better for 
this purpose. Chloroform has also been recommended for 
intestinal worms, but other treatments are better. 



ETHER 



309 



r 



Externally, chlorofonn in liniments and the official chloro- 
form liniment are valuable for rubefacient effect. 

Ether. — Administratimi.^EtheT is a colorless liquid, has a 
burning, sweetish taste, and contains about 96 per cent, of 
ethyl oxide. 

There is no good use for ether, except as an anesthetic. It 
has sometimes been used internally in the form of the official 
Sp^iritus Mtheris (Hoffmann's drops), but there is no indication 
for this preparation. Ether has been used externally on the 
skin (when the part to which it is applied is covered up) to 
cause blisters, and (when it is sprayed on the part) to cause 
local anesthesia and freezing, but for both purposes other pre- 
parations are better, such as cantharides in the first instance and 
ethyl chloride in the second. 

Ether may be inhaled through a tube passed through the 
nostrils, when operations must be done on the mouth and face, 
and rectal anesthesia is inadvisable. 

^c/ia«.-^Externally, especially when sprayed on a part, ether 
causes benumbing and freezing. 

When inhaled, it irritates the eyes, if they are kept open, 
and the face, unless it is covered with vaseline or other fat; it 
irritates the mouth and throat, if it is given too concentrated; it 
may cause spasm of the larynx, if it is not well diluted vd\h air; 
and many times it causes profuse bronchial secretion, as well as 
profuse salivation. To prevent this increase of liquid in the 
air passages, it is sometimes advisable to give a hypodermic of 
atropine an hour or more before the anesthetic isadministered, or 
the atropine may be combined with morphine. But, as pre- 
viously stated under the general discussion of the subject, it is 
not generally wise to combine the action of these drugs with the 
action of ether. 

There is always a stage of excitement more or less in evidence 
at the beginning of ether administration* If the ether is not 
crowded and plenty of air is given the patient, and he is allowed 
to move his arms, and feel that he is not bound down and is not 
going to be suffocated, the stage of excitement is at a minimum, 
in fact, there may be no excitement. Unless the patient is an 
alcohohc or is seriously hysterical, or there is some cerebral 




3IO THE PRINCIPLES OF THERAPEUTICS 

irritation or delirimn, a large part of the excitement, disturbancef 
and thrashing in the first stage of ether narcosis is due to fear 
and the sensation of suffocation. 

During the early part of ether anesthesia the face generally 
becomes flushed, the pulse more rapid but fuller and often of 
better tone than .before the ether was started, and during the 
surgical degree of narcosis the pulse slows and the circulation is 
often better than it was previous to the administration of the 
anesthetic. 

At first imder ether anesthesia the pupils become slightly 
dilated, but quickly contract if exposed to light, and, during the 
surgical stage of anesthesia, should, on raising the eye>lid, 
quickly contract to light. If they do not do so, the anesthesia 
is, ordinarily, too profound. 

Whether ether is a stimulant to the vasomotor center is a 
question that is still imder discussion, but certainly, during 
good ether narcosis when profoimd anesthesia is not present, the 
pulse is generally regular and the blood-pressure is good. 
However, this does not signify that ether should be given, either 
by inhalation or h)rpodermatically, or in any other way, as a 
heart stimulant in any kind of heart failure. Other drugs are 
better. 

When ether is too rapidly pushed there may be not only spasm 
of the glottis but also disturbed activity of the diaphragm. 
Hence it is essential that ether be given slowly and gently that 
sudden spasm or stoppage of respiration be not caused. As 
soon as surgical narcosis develops, respiration is generally calm, 
quiet, and regular. The proper amount of ether may have but 
little effect on the respiratory center. 

As pointed out by Hare, if diaphragmatic respiratory move- 
ments are not regular and coordinated, or hiccough occurs, the 
anesthesia is not satisfactory. Sometimes there is this disturb- 
ance when the anesthesia is insufficient, at other times because 
the anesthesia is too profoimd. The anesthetist must make the 
decision as to which condition is present. In over-doses in a 
too profound anesthesia the respiratory center is depressed and 
death is caused by paralysis of this center. 

The main action of ether is on the central nervous system, 



ETHHR 



3" 



depressmg first the higher centers of the bram, then the sensory 
portion of the cord, then the motor tract of the cord, and finally 
the centers of the medulla oblongata. 

Heat is lost from the body, not so rapidly as in chloroform 
narcosis, but more or less continuously, as there is more perspi- 
ration caused by ether ^ hence care must be taken to keep the 
patient warm. Also it is especially essential that the atmos- 
phere of the room is sufficiently warm that the ether vapor in- 
haled into the lungs is not cold enough to produce chilling of the 
passages. Apparatus has been de\dsed to cause warming of 
ether, as the inhalation of warmed ether is less likely to cause 
pneumonia. The can or bottle of ether may be kept warm in 
a hot water bath. 

Ether is excreted principally by the lungs, and partly by the 
kidneys. 

Toxic Action-* — While ether is a much safer anesthetic, es- 
pecially in the hands of a no\ice, than is chloroform, it should 
not be considered that there is no danger. Sudden heart failure 
and sudden respiratory failure may both occur. Severe throb- 
bing of the blood-vessels and congestion of the brain may occur, 
and cyanosis is not infrequent. These symptoms are especially 
Ukely to occur with high blood-pressure. 

The paralytic stage of ether is the stage of danger. The 
pupils are widely dilated and inactive to either light or sensation, 
the breathing is ver>^ stertorous, the patient is likely to be pale, 
possibly c>'anotic, and respiratorj'' failure or cardiac failure may 
occur at this time unless the excess of ether is eluninated. In* 
any such condition the ether must be stopped, and the patient 
allowed to come out of the profound narcotism. He may re- 
quire nothing but the extra amount of air to accomplish this. 

On the other hand, sudden stoppage of respiration or a pro- 
longed sigh often denotes that the patient is insufficiently anes- 
thetized. Also, in some few patients, serious poisoning must 
occur before the eyes are insensitized, and the patient may 
watch the anesthetist for a considerable time during the surgical 
narcosis. To push such a patient to profound narcosis causes 
the administration of too much ether. Other patients are not 
surgically anesthetized unless the pupils are paralyzed. These 



312 THE, PRINCIPLES OF THEKAPiXTICS 

pecnliar cases render the woik of the anesthetist harder, and his 
supervision most be the more acute. 

A noisy, stertorous breathing due to vibration of the soft 
palate, is not indicative of s«ous anesthesia in ether naroosis, 
and, provided the tongue is wdl fcM^rard and the jaw devated, 
the symptom is not a bad cme. 

The treatment of re^xiratory failure or d cardiac faihire, or 
of both, is practically the same as in chloroform pcMsoning, 
except that, if there is plethora and congestion of the face, the 
head should be raised, rather than lowered. While vasomotor 
depression may be present, it is not as constantly present as it 
is in chloroform narcosis. The hypodermic medication should 
depend entirely upon the condition. Atropine for respiratory 
stimulation is generally needed. Artificial respiration and car- 
bon dioxide inhalation from proper apparatus are eqxedally 
valuable in promoting the elimination of ether from the lungs 
and blood. Rh^-thmic pulling forward of the tongue, at inter- 
vals of five seconds, may start respiration. 

Vomiting is more frequent after ether than after chloroform 
narcosis. There is more likely to be serious kidney irritation 
after ether than after chloroform, and there may be entire 
suppression of urine. 

Ether is contraindicated by high blood-pressure; seriously 
diseased kidneys; liver disturbances; diabetes; arteriosclerosis; 
atheroma; and in pneumonia, bronchitis, and emphysema. 

Acapnia is a name used by Henderson to signify diminished 
carbon dioxide content in the blood. Henderson says that 
oxygen inhalations should not be given in ether apnea, but that 
oxygen and carbon dioxide gas may be combined for inhalation 
as the anesthetist deems ad\'isable. An efficient method of 
using this combined gas is described by Ewart^ and a simplified 
method by Henderson and others.* 

Uses. — The only use for ether is as an anesthetic, and while it 
is generally now considered that the drop method is the best, 
some surgeons and anesthetists believe that it had better be 
administered in greater concentration, provided there is a suffi- 

* The Journal A. M. A., Oct. 7, 191 1, p. 805. 
•The Journal A. M. A., March 20, 1920, p. 783. 



NITROGEN MONOXIDE 



313 



dent amount of air, and provided the ether is warm. The drop 
method may be administered with the Esmarch inhaler, or 
perhaps better with the Allis inhaler, which gives it more con- 
centrated. It takes longer to anesthetize the patient by the 
drop method than by a more concentrated method. The con- 
dition of the patient and the amount of ether required to pro- 
duce surgical anesthesia should be estimated' by the anesthetist. 
A long tedious drop method with very slowly developing surgi- 
cal anesthesia is not successful anesthetizing. Therefore many 
patients require a method other than the so-called drop method. 

When an anesthetic is required in colics, spasms, convulsions 
hiccoughs, etc., chloroform is better than ether. 

Nitrogen Monoxide* (Nitrous Oxide) Adminislratian.^ 
Nitrous oxide (laughing gas) is a colorless gas, which has a 
slightly sweetish taste. This gas is compressed in metal cyl- 
inders which may be obtained for anesthetic purposes. Its 
only use is to produce anesthesia. 

Actum. — When nitrous oxide gas is inhaled for a few seconds, 
mixed with air, an intoxication occurs, the individual becoming 
talkative and laughing^ and if much is given, he may become de- 
lirious. If the gas is administered without air, concentrated, in 
a few seconds he is thoroughly anesthetized, the face becomes 
gray or cyanotic, the respiration stertorous^ the blood-pressure 
raised, and, if the anesthesia is longer pushed, respiration ceases 
although the heart continues to beat for some time. The tight 
fitting rubber inhaler should be immediately removed as soon 
as stertorous breathing is evident, which, as stated, is in a few 
seconds, and the minor operation should be immediately done, 
as the anesthesia lasts but a short time. 

This anesthetic has been found to be very safe, and it is 
exceedingly rare that death has occurred, unless it has been 
several times repeated for a prolonged operation, and in such a 
case the danger is very greatly increased* This gas alone, with- 
out oxygen, should not be used for anything more than a very 
short operaton. 

During the anesthesia the face and hands have a very bad 
slate-like look, which soon disappears, however, after a few 
inhalations of air. The anesthesia is due in part to non-oxygen- 





314 THE PRINCIPLES OF THERAPEUTICS 

ation of the blood, carbon dioxide poisoning; and in part to the 
direct action of the gas on the cerebral cortex. During this 
anesthesia, as stated, the pulse becomes fuller, the blood- 
pressure higher, and the heart may throb forcefully. The 
pupils may not lose their reflex action even when the anesthesia 
is profound. 

Some individuals have practically no after effects from a 
short anesthesia with this gas; others are dizzy, have nausea, 
some vaso-depression, and may feel weak for some hours. If 
a patient is anemic, it may take several da3rs before he feels 
as well as usual. 

To prevent over-action and to aid the returning respiration 
after this anesthesia patients should have all the clothing of 
the neck, chest and abdomen loose. There should be no tight 
constriction of any part of the neck or body. Also the patient 
should not take this anesthetic after a meal; the stomach should 
be empty. 

Toxic Action. — The toxic effect is that of failure of respi- 
ration, and the antidote is plenty of fresh air, oxygen inhala- 
tions, and artificial respiration, which should be immediately 
started and prolonged for some time, as the heart fails only 
in very rare instances. Hypodermic injections are generally 
not needed. If anything is given, atropine is the drug of 
choice. 

Uses. — The use of this gas alone without oxygen as an 
anesthetic should be limited to very short operations, notably 
extractions of teeth. If teeth are to be extracted, a cork or 
rubber must be placed between the jaws (attached to a strong 
cord so that it cannot be swallowed), else it may be difficult to 
oi>en the jaw after the patient is anesthetized. 

Nitrous oxide is contra-indicated when there is high blood- 
pressure; myocardial disease; arteriosclerosis; atheroma; and 
when there is any obstruction in the air passages, as adenoids, 
enlarged tonsils, swelling in the larynx, goiter, enlarged thymus, 
or asthma, as in such obstructions from over-action of this gas 
it might be impossible to sufficiently aerate the limgs to save life. 

Nitrous Oxide — Oxygen* — In 1878, Bert began to use a 
mixture of nitrous oxide and oxygen as an anesthetic, first on 



tBSfQtWSI 



31S 



animals, and then on men, and the anesthetic combination 
proved a success. A number of surgeons, notably Bcvan, 
Crile, Halsted, Kelly, and Meyer, found that this anesthetic 
was very satisfactory in major operations, and apparently 
safe, less likely to cause pneumonia, and not likely to cause 
post-operative nausea. One of the great advantages is that 
it produces anesthesia rapidly, and the patient soon recovers 
from the anesthetic, and Crile especially urged that it seemed to 
prevent post -operative shock. This anesthetic, howevefj does 
not allow as much muscle relaxation, and some surgeons object 
to it in abdominal operations on this account* It is adminis- 
tered by a special apparatus, which allows the anesthetist to 
mix the gases as he finds advisable. 

Very many hospitals adopted this anesthetic and used it 
largely, but many have dropped it and have reverted to the 
long used and satisfactory ether. 

Combinations of these gases with ether have also been urged 
for anesthetic purposes, and the gas administered warmed. It 
requires an anesthetist especially skilled in the administration 
of these combinations for such anesthesia to be safe and 
successful 

The contraindications to the use of nitrous oxide — oxygen are 
the same as for nitrous oxide, with the exception that with 
these combined gases long anesthesia may be maintained. 

Oxygen, — It may be well to briefly refer to the use of ox>^gen 
inhalations at this point. Besides administering oxygen with 
m'trous oxide for anesthetic purposes, oxygen gas, passed 
through a wash bottle containing warm water, has been much 
used in the dyspnea of pneumonia and for cardiac stimulation 
in various diseases; but it has been found that plenty of good 
fresh outside air is of as much advantage as oxygen^ although 
momentary primary cardiac stimulation may certainly be 
given by inhalations of straight oxygen. A good method is 
to insert the ox>^gen tube into one nostril, the patient breathing 
with the mouth closed. If more concentration is desired for 
a few minutes the other nostril may be closed during inspiration. 

Sometimes oxygen has been combined with nitrous oxide gas 
both to quiet cerebral excitement, and also to cause circulatory 



3l6 THE PRINCIPLES OF THERAPEUTICS 

stimulation, but this combination is not much in vogue. The 
real use of oxygen inhalations is in certain kinds of respiratory 
failure, typically in that from nitrous oxide gas, in illuminating 
gas poisoning, in different kinds of asphyxia, and in combination 
with carbon dioxide gas, as advised by Henderson, in profound 
chloroform and ether narcosis. 

Other Anesthetics. — ^AU the alcohol, chloroform and ether 
mixtures, the so-called A.C.E. mixtures, represent chloroform 
anesthesia, and should be mostly abolished. 

DRUGS USED TO CAUSE LOCAL ANESTHESU 

Very many minor, and sometimes major, operations are done 
under local anesthesia. Ever since the local anesthetic pro- 
perties of cocaine were discovered, it has been used to anesthetize 
mucous membranes, and injected under the skin to anesthetize 
the soft tissues. Schleich introduced the so-called infiltration 
anesthesia, using cocaine in different strengths which he com- 
bined with morphine and administered in salt solution. Part 
of this infiltration anesthesia is due to distention of the tissues, 
and distention with even cold water will produce a certain 
amoimt of anesthesia. If the distention from these solutions 
is great, much absorption of cocaine cannot take place. The 
value of morphine as a local anesthetic is so questionable that 
it seems absurd to add it to a solution for local anesthetic 
purposes. 

Sometimes morphine and scopolamine are administered h3rpo- 
dermatically a sufficient length of time before the operation 
under local anesthesia to obtund the whole central nervous 
system, and then the local anesthesia with cocaine or some other 
local anesthetic is begun. 

The importance of nerve blocking with either water or some 
local anesthetizing preparation has long been urged by Crile, 
and is adopted more or less frequently, especially in operations 
on the jaws. Crile urges such "anoci-assodation" for larger 
nerves for more serious operations. 

Infiltration anesthesia consists in distending the lower layers 
of the skin with fluid and then pimcturing just at the border line 
of this distention, projecting the needle into the next tissue in 



LOCAL ANESTHESIA 



317 



orderj and so on until the nodular distention is caused over or 
around the region that is to be incised. This method is success- 
fully used by many surgeons in operations for hemorrhoids. If 
deeper tissues must be incised, a second infiltration is done 
below the skin, generally with salt solution containing the local 
anesthetic to be used. Of course distention of a nerve trunk 
will stop sensations below the point of distention. By repeat- 
ing this infiltration anesthesia as the tissues are incised,some 
major operations may be successfully done when it is inadvis- 
able to give a general anesthetic. If after the infiltration the 
tissues are rapidly incised, poisonous doses of the anesthetic 
are rarely absorbed, because the liquid containing the drug 
flows out, and if mopped away, cannot be absorbed by the 
tissues. However, if the anesthetic action of a drug is desired, 
ix,, plus the distention benumbing, enough time must be allow- 
ed for the drug to cause anesthesia, which is generally several 
minutes. The anesthesia of a part, if the solution is not too 
soon evacuated, will last from fifteen to twenty minutes. 

Several efficient local anesthetic drugs are now offered. 
The most important of these are the hydrochloride of cocaine, 
holocaine hydrocliloride, beta-eucaine hydrochloride, procaine 
(novocaine), alypin, and quinine and urea hydrochloride. 
Apothesin hydrochloride is another preparation offered. Ben- 
zoyl carbinol, according to Hjort and Kaufmann/ is soluble in 
water, not very irritant and a good local anesthetic, 

SoUmann,^ experimenting with these anesthetics, has shown 
the efficiency to be as follows: cocaine, procaine (novocaine), 
tropacocaine and al>T>in hydrochlorides have the greatest effi- 
ciency in producing infiltration anesthesia; while beta-eucaine 
hydrochloride has only half the efficiency of these four ; quinine — 
urea hydrochloride only one-fourth that efficiency ; and apothe- 
sin one-eighth that efficiency. On nerve trunks he found that 
the greatest amount of anesthesia was caused by cocaine, pro- 
caine (novocaine), and tropacocaine hydrochlorides. Half of 
this efficiency was developed by alypin hydrochloride, and only 



' Proceedings of the Society for £i^»enmentaJ Biology and Medicine, 1920, 
xvii, p. 79. 

^'Ilie Journal A. M. A., Jan. 36, 1918, p. 216. 



3l8 THE PRINCIPLES OF THERAPEUTICS 

one-eighth of this efficiency by quinine — urea hydrochloride. 
On mucous membranes SoUmann foimd that the most efficient 
local anesthetics were cocaine and holocaine hydrochlorides. 
Half this efficiency was produced by beta-eucaine hydrochlo- 
ride, and only one-fourth the efficiency by tropacocaine, al3rpin, 
and quinine — urea hydrochloride. He foimd that alkalizing the 
solutions increased the efficiency of the anesthetic on the mu- 
cous membranes, but not for infiltration anesthesia, and there- 
fore suggests that the solutions of the anesthetic salts for mucous 
membrane anesthesia be mixed with equal volume of a half per 
cent, sodium bicarbonate solution, but the alkali should not be 
added to the anesthetic solution until just before it is to be used. 
Sollmann did not find that the addition of epinephrine increased 
the efficiency of the local anesthetic on mucous membranes, but 
it did increase the efficiency for infiltration anesthesia by pro- 
longing the anesthetic action. He recommends that it should 
always be added for infiltration anesthesia, except to tropaco- 
caine. Epinephrine may be added in the strength of i part to 
10,000. He also found there was no advantage in combining 
two or more of the local anesthetics. 

Eggleston and Hatcher^ have recently made a study of the 
pharmacology of the local anesthetics, and they are right in pre- 
suming that more frequent acute poisoning is caused than is re^ 
corded. They studied all reported cases of such poisoning, and 
also made 300 experimental investigations. They studied nine 
of the local anesthetics, and came to the conclusion that the 
relative toxicity from the least poisonous to the most poisonous 
is in the following order, viz.: procaine (novocaine), nirvaine, 
stovaine, tropacocaine, apothesin, cocaine, beta-eucaine, al3rpin 
and holocaine; procaine having about one-fourth the toxicity 
of alypin and holocaine, as tested on cats. They found that, 
if the circulation and respiration can be maintained for a time, 
these local anesthetics are rapidly destroyed in the liver. 

It must be recognized as a fact that sometimes an ordinary 
non-toxic dose causes excessively impleasant symptoms, show- 
ing that some patients have a hyper-susceptibility to some of 
these drugs, especially to the cocaine type. 

^ The Journal A. M. A., Oct. 25, 1919, p. 1256. 



SCOPOLAMINE AND MORPHINE ANESTHESIA 



319 



The necessity is certainly emphasized, by the results of these 
mvestigations, that every time these local anesthetics are used, 
means must be at hand to overcome the effects of over'action of 
the dmg. 

Eggleston and Hatcher also emphasize the advantage in 
infiltration anesthesia of adding epinephrine to the solytion, 
as it not only prolongs the anesthetic action locally, but also 
prevents rapid absorption of the drug. 

Scopolamine and Morphine AnestIiesia.~The combination 
of morphine sulphate and scopolamine hydrobromide (Scopo^ 
laminae Hydrobromtdum) came into prominence by being used 
for so-called painless labor, "twilight sleep/' This combined 
anesthetic was urged by some few obstetricians, and used in 
some lying-in hospitals, and became so popular as to be lectured 
upon by more or less ignorant lecturers, even to the public in 
department stores at noon hours, and during "twilight sleep*' 
was stated by the newspapers and magazines to be the only 
right way for a child to be born into the world* 

This sort of anesthesia during parturition is absolutely 
inexcusable except in an institution with a skilled physician in 
constant charge of each patient subjected to such drugging. 
This combination pushed to the point of anesthesia is probably 
now not frequently used. It certainly often had a bad effect 
on the mother, sometimes prevented normal uterine pains, and 
often asphyxiated the child. 

The method was to inject }i of a grain of morphine sulphate 
and Hso of a grain of scopolamine hydrobromide hypoder- 
matically as soon as the uterine pains of the second stage became 
frequent. Sometimes the scopolamine, and occasionally the 
morphine, was repeated; but as just stated, the treatment is 
not often excusable. 

This same combination has been used to produce benumbing 
of the nervous system before local anesthesia is used. Also, 
at times, morphine and scopolamine, but safer morphine 
and atropine, are given before general anesthesia. However, 
it cannot be too many times urged that a multiplication of 
drugs in anesthesia is not a safe procedure. It is much safer 
for the anesthetist to know that but one stupefying drug is 




320 THE PRINCIPLES OF THERAPEUTICS 

being used, and that that drug causes certain symptoms in 
over-action, and, also very important, produces certain symp- 
toms in normal and sufficient action. He then knows in what, 
condition the patient is, and what to do to increase or diminish 
the activity of the drug used. 

Spinal Anesthesia* — Spinal anesthesia is generally caused by 
injections of tropacocaine hydrochloride, which is an alkaloid 
obtained from coca erythroxylon. It is much less toxic than 
cocaine, and it has the advantage of not having its chemical 
constitution changed by sterilizing. It may be obtained in 
ampules ready for use. The dose, depending upon the size, 
age, and strength of the individual, is from about 0.65 mil to 
1.30 mils of a 25 per cent, solution. The back of the patient 
in the region from the fourth dorsal vertebra to the sacrum is 
painted with iodine, he being in the position for limibar pimc- 
ture, namely, lying on his left side, with his knees drawn up to 
his chin. The spinal puncture is made between the second and 
third, or third and fourth lumbar vertebrae. Some fluid is 
withdrawn, the pressure noted, and this fluid may be used 
for any tests deemed advisable, Wassermann or other. Some 
of the warm spinal fluid is then sucked into the syringe which 
contains the solution of tropacocaine from the sterile ampule, 
and this diluted preparation (which should have a specific 
gravity heavier than that of the spinal fluid) is then ready for 
injection. The solution is then slowly injected, and the 
needle quickly removed. The patient should now recline with 
the head and shoulders slightly raised so that there can be no 
possibility of the fluid going beyond the upper dorsal or into 
the cervical regions. The patient almost immediately, in a 
minute or two, feels a numbness of the legs, and of the organs 
and tissues of the pelvic region. It is probably not safe 
to attempt to benumb tissues above the line of the umbili- 
cus, and when the anesthesia reaches that point the patient 
should be made to sit upright, and, if necessary, fluid should be 
withdrawn from the spinal canal. The dose of tropacocaine 
hydrochloride used is from 0.065 ^^ ^-^o Gm. (i to 1}^ grains). 

Although some surgeons use this method of anesthesia fre- 
quently, and think that it is comparatively safe, many accidents 



COCAINE HYDROCHLORIDE 



321 



have ocairredj and it must be considered much more dangerous 
than general anesthesia. It has been used mostly for operations 
for hernia, hemorrhoids^ plastic operations on the perineum, and 
for some uterine and prostatic operations. If the heart is weak 
and general anesthesia is inadvisable, it probably has its uses. 

A frequent after effect is headache, which may be prolonged 
for several days, and may be ver}"^ severe. Vomiting has oc- 
curred, and occasionally serious disturbance of the respiration 
has been caused. With great care not to remove too much fluid 
from the spinal canal, and not to force too much fluid into the 
spinal canal if the pressure is high, and to keep the patient at 
rest for some days after the injection, headache may be avoided, 
but it is not an infrequent occurrence, even in spite of care» 

This method of anesthesia seems to prevent shock, and 
certainly precludes an anesthesia pneumonia. The blood- 
pressure generally falls during the anesthesia* 

Cocaine Hydrochloride, — A dministraiimi.—The active princi- 
ple of coca (er>'thro3^ion) leaves is cocaine, and the preparation 
that is generally used is the hydrochloride. There is no special 
medicinal excuse for using coca or preparations of coca internally. 

In South America, the home of erythrox\'lon, the leaves are 
chewed by the natives, both as a stimulant and to prevent 
muscle fatigue, and for such purposes it is certainly efficient. 
How serious the coca habit is with these natives has not been 
determined. 

The hydrochloride of cocaine occurs as colorless prisms or 
as a white crystalline powder, is very soluble in water, and the 
-dose is stated as 0.015 Gm. (li grain). There is no good excuse 
for using cocaine internally or hypodermatically for any purpose 
except to produce local anesthesia. When internally adminis- 
tered it readily produces severe poisoning, and if small doses are 
repeated, it quickly causes the cocaine habit. Therefore, to 
repeat, there is no good excuse for using cocaine internally. It 
also should not be used in sprays or ointments for the nose, or in 
sprays or gargles for the throat. It should only be used in the 
nose, throat, or eye by the physician. Prescriptions for cocaine 
should not be given to a patient, except in rare instances. 

Cocaine hydrochloride in solutions is decomposed by more 



322 THE PRINCIPLES OF THESAPEDTICS 

than a few minutes' boiling, but tablets of cocaine dissolved in 
sterile salt water furnish a sufficiently aseptic solution. 

Action. — ^Externally there is very little action of cocaine on 
the unbroken skin. On mucous membranes it is readily ab- 
sorbed, causes vaso-constriction, blanching of the part, and 
therefore inhibits mucous secretion and prevents rapid absori>- 
don, provided the solution is strong. If the solution is very 
weak, more of the cocaine may be rapidly absorbed. A i per 
cent, solution is the strength most used for infiltration and a 
2 to 4 per cent, solution for mucous membrane anesthesia. 
The anesthesia is complete in from seven to ten minutes, and 
lasts from ten to fifteen minutes^ depending upon the amoimt 
absorbed. It will not penetrate deeply into the tissues below 
the mucous membrane unless it is injected into them. 

When cocaine is used for infiltration anesthesia, part of the 
immediate anesthetic action is due to the distention from the 
water or salt solution in which the cocaine is dissolved. The 
addition of epinephrine to the cocaine solution lengthens the 
time the parts will be anesthetized, as it prevents rapid absorp- 
tion. Also the addition of the epinephrine allows less bleeding 
when the tissues are incised. As soon as anesthesia is com- 
plete, the parts injected should be quickly operated upon so as 
to release the cocaine in the tissues, aUow it to flow externally,, 
and prevent much absorption. If much absorption occurs^ 
poisoning may result. 

The first eflfect of absorption is frequently some cerebral 
stimulation; the patient may be rendered talkative, to be later 
followed by some depression. At first the respiratory centers 
are stimulated, the blood-pressure is raised, and the heart is 
somewhat stimulated. Later, depression of the respiratory 
center occurs. Consequently, although cocaine may primarily 
cause stimulation in depression from diflferent drugs or in cir- 
culatory failure, its secondary action is depressant and therefore 
it should never be used for this purpose. When injected into 
nerve trunks it first paralyzes the sensory fibers and finally the 
motor fibers; but it should also be recognized that even plain 
water, from pressure, may have this same effect. The pupils 
are dilated when it is absorbed, or when it is taken internally* 



COCAINE H\'DROCHLORIDE 



sn 



When appli€;d locally to the eye the pupils dilate, and it is 
sometimes used for this purpose by ophthalmologists. It may 
be rapidly absorbed from the stomach, and in weak solutions 
from the nostrils and throat; on the tongue it inhibits the sense 
of taste. From the urethra it may be rapidly absorbed and 
cause poisoning, and hence should rarely be used to facilitate 
the passage of catheters or for other instrumentation, as it has 
frequently caused poisoning when so used. 

Cocaine is partly destroyed in the body and partly slowly 
excreted in the urine. 

Over'aciion, — It may cause very high blood -pressure, rapid 
heart action, great cerebral excitation, and sometimes convul- 
sions. On the other hand, it may cause the opposite, consider- 
able faintness, prostration, collapse, and respiratory failure. 
While deaths may not often occur from acute poisoning, serious 
symptoms do frequently occur, although such cases are not 
often reported. 

Treatment of Pmsoning.—Ii the drug is in the stomach, tan- 
nic acid and emetics should be given, or the stomach should 
be washed out. Antidotes to the depression are atropine, 
strychnine, camphor, and caffeine; and the usual treatments of 
collapse, as dry heat, elevation of the feet and legs, and artificial 
respiration, if necessary, 

Cocaifie Habit, — This habit was greatly on the increase before 
the State and National laws prevented the sale of cocaine with- 
oot the prescription of a physician. Also many nostrums were 
on the market which contained cocaine, and many snuffs and 
catarrh powders contained this \ncious drug. In spite of the 
length of time since these laws have been in operation, the co- 
caine habit is still frequently in evidence, and is more serious 
than is the morphine habit. The periods of depression, when the 
desire for the cocaine is in e\idence, are terrible, but are im- 
mediately allayed by the usual dose. Sometimes there is an 
unusual stimulation from it, and the individual is loquacious 
and excited; the difference is readily noted between his moods 
of excitement and depression, and the pupils are very evidently 
dilated soon after the drug has been taken. Patients with this 
habit have a great deal of indigestion. 



324 THE PRINCIPLES OF THERAPEUTICS 

Some patients have a combination of the mprphine and co- 
caine habits. With such patients the pupils do not react as 
usual to these drugs. 

The treatment is to withdraw the drug as rapidly as possible, 
but as there is likely to be very serious symptoms of depression, 
the patient should always be in an institution, under the best 
medical care. There is no way to cure such a patient except by 
the institutional method. Catharsis and the substitution of 
other drugs for the time being are part of the treatment. 

Uses. — ^As above stated, there is no good logical use for co- 
caine internally. As a local anesthetic either it or some closely 
allied drug is very valuable. Injections of i or 2 per cent, 
solutions into the tissues will stop local pain, but for anesthesia 
a stronger solution may be needed. Sometimes cocaine is in- 
jected into a nerve trunk to block pain, thus allowing an opera- 
tion to be done painlessly on the region of the nerve distribution. 
Sometimes in ether and chloroform narcosis it has seemed wise 
to block the nerve trunk of the region to be operated to prevent 
shock, Crile's anod-association method. 

To anesthetize the mucous membrane for operation, pledgets 
of cotton soaked in the solution of cocaine are pressed firmly 
against the tissues, and the tonsils may be painted with the solu- 
tion. Care should be taken in the nose and throat that these 
solutions are not swallowed. Infiltration anesthesia has already 
been described. 

Beta-eucaifUB Hydrochloridum. — Beta-eucaine hydrochloride 
is similar to cocaine in its action, but weaker, and it does not 
cause the cerebral or vasomotor stimulation that cocaine does. 
It is more used in ophthalmology because it is less irritant to 
the conjunctiva than is cocaine, and its solutions may be boiled 
without causing disintegration. It may be used in solutions of 
various strength from 2 per cent, for the eye to as much as 10 
per cent, for the nose and throat. As a local anesthetic it may 
be even used in much weaker solutions than i per cent. 

Holocaine Hydrochloride, N,N.R. — This drug acts like cocaine, 
and more quickly, and is popular with the ophthalmologists. 
It seems to cause less irritation of the conjunctiva, and is used 
in I per cent, solutions. 



ANTIPYRETICS 



325 



Procaine^ N.N.R. — Novocaine is much used now as a local 
anesthetic in operations on the mouth and teeth. It is less toxic 
in its action than cocaine and acts more quickly, but unless 
combined with epinephrine^ its anesthetic action does not last 
as long as cocaine. This drug is very frequently used for in- 
filtration anesthesia, and in spinal anesthesia. 

Several efficient preparations of this drug are on the market, 
and, also, it may be obtained combined with epinephrine. 
Instructions come with each package as to how to make solu- 
tioDs of varying strength for different purposes. 

Siovain€ and Alypin^ N.N.R. are closely allied anesthetics of 
about the same activity as cocaine, but they do not cause 
contraction of the blood-vessels or dilatation of the pupils. 
These drugs are said to be less toxic than cocaine, but the same 
care should be used mth any of these local anesthetics as is 
taken in the use of cocaine. 

Apothesine is offered as effective for producing local anesthesia 
both by infiltration and intraspinally. It seems not to be as 
active on the mucous membrane as is cocaine. 

Benzyl Alcohol, —Though Sollmann* has found this sub- 
stance to be a local anesthetic on mucous membranes, it seems 
to have no advantage over cocaine and cocaine-Uke preparations. 

Ethyl Chlonde,— Ethyl chloride comes in hermetically sealed 
glass containers with an attached atomizing apparatus. When 
this tube is held a short distance from the skin and the spray is 
directed against it the part is quickly frozen and benumbed, 
allomng incisions into boils and abscesses to be made painlessly. 

Ethyl chloride has been used as a general anesthetic, but it 
should not be used for such a purpose. 

Anesthal is stated to be a mixture of ethyl chloride, chloro- 
form and ether, 

CLASS VI 

Drugs Used to Lower the Temperature of the Body 
antipyretics 

Fever may be defined as an abnormal elevation of tempera- 
ture of the body, due to a disturbed state of the system of which 
1 JouroaJ of Pbarm. and Eip, Thera., July, igig- 



326 THE PRINCIPLES OF THERAPEUTICS 

the temperature is a very prominent symptom. To constitute 
a fever this abnormally high temperature must be continued 
for several hours, or if not continuous, at least be intermittently 
repeated. The cause of fever is most frequently an infection. 
Other causes of fever are the absorption, either accidentally or 
by design (injections), of some foreign protein; the absorption 
of some toxins or abnormal protein break-down in the intes- 
tines; or the absorption of broken-down tissue substances from 
injuries; or, finally, fever may be due to some disturbance or 
injury of the head, which causes a mal-function of the heat- 
regulating mechanism or of the thermogenetic centers. 

The types of fever are divided into intermittent, remittent, 
and continuous; the intermittent fever having periods of entire 
absence of fever, the remittent having decided exacerbations 
and decided lowering of temperature but not to normal, while 
a continuous fever is more or less permanently high with, 
generally, variations at different times of day. 

When a fever ends by crisis there is a sudden fall in tempera- 
ture, often to subnormal; muscle relaxation and therefore 
greatly diminished production of heat; generally lowered 
metabolism; weakened heart action; dilatation of the surface 
blood-vessels; great amount of perspiration; increased output 
of nitrogenous waste products in the urine; and general prostra- 
tion. The period of rapid crisis is one of more or less circulatory 
danger, which should be properly combated. But few fevers 
at the present time end by crisis, the majority ending by lysis, 
a gradual reduction of temperature from day to day. This 
kind of temperature reduction does not cause shock to the 
system. The typical reduction by lysis occurs in typhoid 
fever. 

The typical termination by crisis occurs in the old unmixed 
lobar pneumonia. When several types of pneumonia germs 
are associated in the same case, or when these germs are 
associated with streptococcic infection or with the germ of 
influenza, a crisis rarely occurs; the reduction of temperature 
is gradual, by lysis, or there may be very prostrating periods 
of low and even subnormal temperature. 

The exact value of fever in fighting protein intoxication 



ANnPYRETICS 



327 



or infection has not been determined, but it seems to represent a 
normal reaction of the body mechanisms to combat or eliminate 
the poisons and germs. Both theoretically, therefore, and 
practically it is unwise to too actively combat an increased 
temperature, unless the temperature is high enough to cause 
destruction of tissues and therefore is toxic and likely to 
cause death. An intennittent temperature, even if high, is 
well tolerated by the system. A remittent temperature with 
considerable low^ering is also for a considerable time well 
tolerated. A continuous temperature over 103 '^ F. soon wears 
out the body and is more or less destructive in itself, A very 
high temperature of 105^ or 106^ may be well tolerated for a 
short period, but it is soon destructive to tissue, and the exces- 
sively high temperature which occurs in sunstroke very" quickly 
destroys the brain centers, therefore it must be actively and 
immediately combated. 

Macleod states that during fever there is more or less con- 
striction of the surface vessels, especially of the extremities. 
This he thinks is compensatory, to send more blood to the internal 
organs which may be in trouble. Therefore it would seem un- 
wise to long administer drugs that reduce the temperature by 
dilating the peripheral blood-vessels and low^er the blood- 
pressure, and this has been found to be clinically true. Macleod 
believes that during fever the regulation of heat production to 
heat loss is adjusted at a higher level, but still the mechanism 
responds to stimulation as usual. In other w*ords, the usual 
things that would increase temperature normally will do so 
during fever. There is ^however, an increased heat production 
during fever, and, in continued fever, an interference with nor- 
mal heat loss. Fever patients are more susceptible to cold and 
chilling than are normal patients. Also a patient who is con- 
valescent from a serious acute illness has lost the finer regulation 
of his heat apparatus, and for some weeks more easily has his 
temperature raised and more easily has his temperature lowered^ 
f.e., his mechanism is imperfect. 

The waste of tissue during remittent and continuous fever 
is shown by the loss of fat» which breaks dowm and causes a ten- 
dency to acidosis. For this reason, as now generally recognized, 



328 THE PRINCIPLES OF THERAPEUTICS 

caxbohydrate foods should be pushed during all continuous 
fever processes. There is, also, protein breakdown, as shown 
by the increased creatinin and purin bases in the urine, and 
Macleod says that the diazo reaction of the urine shows an 
abnormal protein breakdown. In many fevers, more in some 
than in others, he states there is a tendency for the tissues to 
retain sodium chloride, and at the same time retain water, 
especially in the blood, and at the time of the crisis more water 
and more sodium chloride are excreted. 

The heat production center, the thermogenic center, seems 
to be in the region of the optic thalami or the corpora striata 
in the brain. Barbour, of the Yale Medical School, has shown 
that applications of cold directly to this center increases metab- 
olism and diminishes heat loss, while the application of warmth 
to these centers increases heat loss and diminishes heat produc- 
tion. This would seem to emphasize the fact of the fallacy 
of the ice cap on the head to combat high temperature, unless 
there is an actual meningeal inflammation, or unless it is applied 
during cold water applications to the body. To continue the 
ice cap on the head with the idea of reducing temperature is a 
mistake. 

If a feverish process is short-lived, the administration of food 
is unimportant, provided the patient receives plenty of water, 
or possibly some cereal gruels; but if the temi>erature is to be 
prolonged and infection is to be fought, proi>er food, containing 
all the nutritive elements must be given. If the temperature 
is very high, or the pulse weak, or there is cerebral disturbance, 
digestion will not be good. During fever the hydrochloric 
acid of the stomach is more or less diminished, hence the diet 
must be more or less fluid and easy of digestion; also it is often 
wise to administer dilute hydrochloric add after the protein 
meals. 

All infections more or less, and some infections especially 
(typically diphtheria and influenza) tend to lower blood- pres- 
sure and cause prostration, because, probably, they more or 
less directly inhibit the normal activity of the suprarenal 
glands, and suprarenal activity is necessary for normal abdomi- 
nal tone of the blood vessels and for normal digestion. In such 



ANTtPYRETICS 



329 



diseases the depressant coal-tar antip>Tetics should not be given, 
as they depress the suprarenal glands. It is often well in acute 
disease with depression to begin early the administration of 
small doses of suprarenal extracts. 

As above stated, it is necessary in all prolonged fever pro- 
cesses, and especially when there has been diminished nutrition 
or a prolonged period of low^ food intake, to push carbohydrates, 
, as acidosis is the final outcome in many acute diseases, and it 
may be prevented by such foods. 

In reducing temperature in continued fever, all of the side 
disturbances which cause increased temperature should be re- 
moved or prevented* Toward this end the patient must be 
kept cool by not being over-covered ; by electric fans, if possi- 
ble; and by the windows being open; or the patient may be on a 
veranda, if the weather is warm. Cool drinks and plenty of 
water should be given; proper movements of the bowels should 
be encouraged; the patient should not be disturbed mentally or 
physically ; he should be allowed to sleep, if he is sleeping quietly, 
without unnecessary awaking to give food or medicuies, or for 
any other purpose. The temperature will be lowered by these 
methods alone. 

It is important that the patient should receive plenty of 
water, and, if he is too stupid to ask for it, he should be given a 
drink at least once an hour, unless he is quietly sleeping. If he 
wants ice to dissolve in his mouth, he should be allowed it. 
Cool water, or allowing ice to di^olve in the mouth, is better 
than drinking ice water. Sometimes it is advisable to give a 
soothing drink, as barley water. The patient should also have 
either lemonade or orangeade, or he may chew and swallow 
orange pulp. These fruit juices stimulate the flow of saliva, 
and are valuable foods for fever patients. 

The height of the temperature is often increased by secondary 
infections and by the absorption of protein poisons or of the 
toxins of secondary infections. A large part of these causes may 
be prevented by care. Every fever patient should have the 
bowels properly moved, best at first with calomel perhaps 
followed by a saline, or with castor oil, or with some other 
effective cathartic. The bowels should then move daily, either 




33© THE PRINCIPLES OF THERAPEUTICS 

by a laxative or by an enema of glycerin and water, unless 
there is some contraindication. By this care of the bowels 
secondary bowel toxemias will not occur. 

If there is any localization of suppuration, or of exudate, or 
of any pathogenic condition that needs attention, it should be 
properly treated constantly and sufficiently during the con- 
tinuous fever. This means that the local condition of the 
throat should be cared for in diphtheria, even if sufficient antitoxin 
has been injected. The tonsils, throat, and mouth should be 
kept dean by gargling if possible, or by spraying, or swashing. 
Pyorrhea regions should be kept clean with some antiseptic 
solution, the one deemed best by the physician. 

The mouths of patients who have fever should be carefully 
watched, and especially in young children and old people. The 
greater the debility and the greater the fever, the more the 
mouth requires attention. The teeth and gums should be 
properly cared for several times a day, and the mouth should 
always be rinsed before food is taken. Normal physiologic 
saline solution or saturated solutions of boric acid, or some pleas- 
ant alkaline mouth wash may be used. If the lips are dry they 
should be softened with a boric acid ointment, or with glycerin 
and water equal parts, or with white vaseline. If canker sores, 
or cracks, or fissures occur, they should be swabbed,twice 
daily, with peroxide of hydrogen solution, full strength, and 
swabbed several times a day with a potassium chlorate solution. 
Occasionally it is necessary to use the nitrate of silver stick to 
hasten the healing of such a condition. The tongue should be 
gently cleaned, if it is heavily coated; but with proper care of the 
mouth and of the bowels, the tongue will usually remain in good 
condition. Scrubbing of the mucous membrane of the mouth 
or tongue should not be allowed. Proper care of the mouth 
will generally prevent glandular swellings in the neck and in- 
fection of the thyroid and parotids. 

In short attacks of high temperature the patient may be 
made more comfortable by some antipyretic drug; such treat- 
ment can do no harm and will do a great deal of good by hasten- 
ing the expected defervescence and the sweating stage, as 
t)rpically occurs in intermittent fever attacks. Also in the 



ANTTPYRETICS 



$3^ 



myalgias, headache and other disturbances of acute tonsillitis, 

or in the beginning of a fever, as scarlet fever, measles, or 
typhoid fever, a few doses of a coal-tar antipyretic, or a syn- 
thetic antipyretic, or a salicylic acid preparation is not unwise 
and is good therapeutic treatment. But in any continued fever, 
after the first two days antipyretic drugs are generally better 
omitted; to reduce fever reliance must then be on cold applica- 
tions, namely, on hydrotherapy. The very high temperature 
which occurs in sunstroke must be rapidly reduced by proper ice 
and water applications. In these instances drugs will not act, 
and reliance must be on measures that quickly abstract heat. 

During continuous fever all drugs that tend to increase the 
temperature, as caffeines, atropines, strychnine, etc, should not 
be administered unless positively indicated. If, on the other 
hand, some cerebral stimulation is advisable, or some circula- 
tory stimulation is needed, especially in the morning, a cup of 
coffee is good treatment When the temperature tends to be 
too low, or there is prostration, or there is too much prespiration 
atropine and strychnine are valuable, and suprarenal should 
be given. It should also be noted that hypnotics, if they are 
needed, will always cause some depression and some lowering 
of the temperature. 

The antipyretic drugs are all more or less analgesic; they will 
stop certain kinds of pain. They will not stop acute inflam- 
mator}^ pain, nor the pain of a colic, but they will stop the aches 
and pains of ordinary infection* Whether they should be given 
long for such a purpose depends on the circulation and the 
disease. The great over-use at the present time of an tipyrine, 
acetanilid, and more especially aspirin, for ever>^ ache and pain 
and every other disturbances that may occur to the individual 
is a serious therapeutic and physiologic mistake, and many 
individuals are suffering from the over-use of aspirin. Aspirin 
is a depressant to the suprarenals, and more or less depressant 
to the heart, and a patient who has been taking a great deal of 
aspirin is not weU fitted to combat any acute infection or dis- 
turbance that he may develop. 

The point at which temperature should be actively combated 
in continuous fever varies with the opinion of different cUni- 



332 THE PRINCIPLES OF THERAPEUTICS 

cians. It is well to consider that a temi>erature above 102® in 
typhoid fever is undesirable, but a temi>erature below that 
need not be much combated. Continuous fever of 102®, or 
over, will cause degeneration of the liver, kidneys, muscles, and 
heart. Therefore, a temperature of 102°, or over, should be 
kept down by proper hydrotherapeutic measures. 

To properly study the temperature it need hardly be stated 
that the thermometer reading must be taken at the same 
hour each day, and in the same manner, and if placed in the 
mouth, the patient must be watched lest the mouth is opened 
and the consequent reading be incorrect. If the axillary 
temi>erature is taken, the arm should be firmly held in place, 
after the moisture in the axilla has been removed, else the arm 
relaxes and the temperature reading, consequently, will be 
incorrect. Only in exceptional instances is it advisable to 
take rectal temperatures. It is a nuisance, and unpleasant 
to adult patients, and often the reading is higher than is ex- 
pected, even when the patient is apparently convalescent, and 
hence may cause more mental disturbance to physician, nurse, 
and patient than is necessary. Even in young children the 
rectal temperature is not constantly necessary; the thermometer 
may be placed in the folds of the groin with the leg held tightly 
to give the correct reading. 

The urine should be more carefully watched in fever than has 
been done, and many a lumbago, or myalgia of the lumbar 
region, which occurs with most infections, is really due to 
some kidney congestion, and albumin will frequently be found 
in the urine of such patients. 

The coal-tar antipyretic drugs are acetanilid, antipyrine, and 
acetphenetidin (phenacetin). While .there are very many 
newer coal-tar and synthetic drugs that will reduce temperature, 
these three are still the most important and serviceable, and 
are as safe as any coal-tar drugs. Lately acetylsalicylic acid 
(aspirin) has become the most used drug to stop headaches, 
myalgias, and neuralgias; to abort colds; and, in fact, to abort 
most anything to which human flesh is heir. It does not 
reduce temperature as much as the coal-tar drugs. Its action 
is that of a salicylic acid, only more depressant than salicylic 



ACETANILID 333 

add. Acetylsalicylic acid will reduce the temperature some- 
what in fever, but not much in normal indi\dduals, as shown 
by Barbour and Devenis.^ These investigators also showed 
that the loss of temperature under acetylsalicylic acid is due to 
increased heat elimination, and that it also decreased the pulse 
rate. Barbour and Herrmann^ have found that **antipyretic 
drugs increase the blood content of dextrose, a substance itself 
often exhibiting temperature-reducing properties when intro- 
duced from without. '' 

Acetanilid {Antifebrin) . — Adminhtralimx, — Acetanilid occurs 
as a colorless, crj^stalline powder, has a slightly burning taste, 
and is very slightly soluble in water. The Pharmacopceial 
dose of 0.20 Gm. (3 grains) is often too large, unless but a 
single dose is administered; o. 10 Gm. (i J-l grains) to be repeated 
once or twice, is a better dose. When this coal-tar preparation 
was first offered, the dosage used was much too large. 

Combining any coal-tar product with an alkali, as sodium 
bicarbonate, seems to more or less prevent its depressant action. 
The addition of caffeine to these drugs has been shown not to 
decrease the depressant action on the heart, but in many 
instances rather to increase it. However, a combination with 
citrated caffeine is often of value in some kinds of myalgias, 
and also in headache. Many pharmaceutical preparations of 
acetanilid, acetphenetidin, and antipyrine are offered which are 
effer\^escent, and ver^^ many similar headache nostrums are sold. 
The following combination makes an effervescing mixture : 

Acetanilid. o . 10 Gm. 

Citrated caffeine 0.05 Gm. 

Sodium bicarbonate i . Gm. 

Tartaric acid i . Gm. 

Make one powder. Place in w&xed paper and keep dry. 

Dissolve in half a glass of water and take as it finishes efferv^esdng. 

If acetphenetidin is desired instead of the acetanilid, the 
dose of acetphenetidin in the above powder would be 0.30 Gm. 
If antipyrine is desired, the dose would be 0.50 Gm. 

* Archives Internal Medicine, Dec., 1919, p. 617, 

* Proceedings of the National Academy of Sciences, Vol. 6, March, 1920, p. 136. 



334 THE PRINCIPLES OF THERAPEUTICS 

Action. — ^Acetanilid is the most active of the three official 
coal-tar antipyretics^ but if the dose is small it is a perfectly safe 
drug to use for a few doses in the beginning of a feverish process, 
or to stop headache and myalgias. 

Until the drug laws required that when a preparation con- 
tained acetanilid it should be so stated on the label, acetanilid 
was the most used drug in nostrums and proprietary mixtures 
because it was very active, and because it was very cheap. 
After many deaths had occurred from acetanilid, and the name 
of this drug was required to be placed on the label of prepar- 
ations that contained it, and the patent was removed from 
acetphenetidin (phenacetin), phenacetin was largely substituted 
in these nostrum and proprietary preparations. This was an 
improvement, as phenacetin is less debilitating and less depres- 
sant than acetanilid. Still, when any one of these coal-tar 
preparations is frequently taken for recurrent pains, or for 
other reasons, not only will the heart be weakened and the 
blood-pressure lowered, but more or less anemia develops. 
Rarely from acetanilid or acetphenetidin, but not infrequently 
from antipyrine, will kidney irritation be caused, if the drug 
is long repeated. 

There seems to be more or less of a tolerance acquired for any 
one of these coal-tar preparations, and there may even be an 
acetanilid habit, much as there is an acetylsalicylic acid (aspirin) 
habit, but there is no healthy future for the long repetition of 
any one of these drugs. 

The proportionate doses of these drugs to produce the same 
lowering of temperature and analgesic effect are about as 
follows: 

Acetanilid o . lo Gm. (i }4 grains) 

Acetphenetidin o .30 Gm. (5 grains) 

Antipyrine o . 50 Gm. (y}i grains) 

Externally acetanilid has no action except that of a mild anti- 
septic, and it is not now much used for that purpose. It is not 
irritant to mucous membranes, and is absorbed rather rapidly 
from the stomach. The blood-pressure is always lowered and 
the heart quieted by acetanilid, also it seems to have a sedative 
action on the brain. 



ACETANIUD 



335 



The temperature is always lowered in fever by ordinary 
doses, probably due to action of the drug on the thermogenetic 
centers in the brain. It also promotes perspiration, largely by 
dilating the peripheral blood-vessels; therefore heat loss is also 
increased. 

The drug seems to have a particularly dolling action on the 
sensory nerves, but the motor nerves are hot little affected, al- 
though there is general muscle weakness after even ordinary 
doses of acetanilid. For this reason, a patient who takes this 
drug, even for an ordinary headache, should be at rest, and 
should not go out or be subjected to physical strain or to cold» 
as he is likely to become chilled or to have cardiac depression. 

It may be partially oxidized in the body, but is principally 
excreted by the kidneys in the form of paramidophenol sulphate. 
If large doses have been taken the urine may become darkish 
browTi in color on exposure to the air. 

Over-actiofi. — The over-action is that of depression, perhaps 
collapse, sometimes cyanosis. Often there is a clammy perspi- 
ration. The blood-pressure is low and the heart is slow but 
made rapid by the least exertion. There may be some chemical 
disturbance of the hemoglobin, and methemoglobin may be 
prcduced, resulting in decreased power of oxygenation. 

Toxic Action.— The toxic action of this drug is simply an 
exaggeration of the symptoms of over-action. There may be 
dyspnea, absence of radial pulse, and very serious heart failure, 
i.€.y collapse. Death occurs from failure of the respiration. 

Treaimeni oj Poisoning. —The treatment is to remove the 
drug by washing out the stomach or by emetics, if it is consid- 
ered that some of the drug is still in the stomach. Surround 
the body with dry heat; give such hypodermic stimulants as 
strychnine, atropine, and pituitary extract; coffee by the month 
or rectum; and large doses of sodium bicarbonate. 

In chronic poisoning from this drug, or any coal-tar drug, 
the treatment is, of course, to stop the drug, let the patient rest, 
push nutrition, give tonics especially iron, and, often, digitalis. 
Prolonged rest and good nutririon is the main treatment. 

Uses, — ^Acetanilid is used for two purposes only, first, to lower 
temperature, and second, to stop pain. 



336 THE PRINCIPLES OF THERAPEUTICS 

This drug is used less frequently to meet the first indication 
than are other drugs, at the present time. Acetylsalicylic add 
has practically displaced acetanilid, as being considered safer, 
and perhaps acting sometimes as well. Acetanilid, however, is a 
very valuable drug with which to lower temperature, and when 
properly used is the best, although the dose is much smaller than 
was once considered proper. Acetylsalicylic add is somewhat 
stimulant to the brain, as all preparations of salicylic acid, but 
it is not as perfectly safe for the heart as it was thought to be. 
However, to use any antipyretic very frequently or very long 
is a mistake. If the temperature is too high for more than a 
day or two, cold water applications represent the proper treat- 
ment. To reduce temperature, acetanilid may be ordered as 
follows: 

Acetanilid 0.30 Gm. 

Sodium bicarbonate 3 . Gm. 

Make 3 powders. 

Take one powder every three hours, if needed. 

When this amount of acetanilid has been taken and the tem- 
perature remains high, other treatments should be instituted. 

Acetanilid, as other coal-tar products, has a dedded anal- 
gesic effect when the cause of the pain is general toxemia; a 
local congestion; a muscle strain; or a headache due to eye- 
strain, or, perhaps, due to pituitary congestion. Sometimes 
the pains of dysmenorrhea, and some forms of neuralgia are 
stopped by acetanilid. It will not stop acute inflammatory 
pain or colics, and should not be administered in such con- 
ditions. When used as an analgesic the dose should not be 
large, and it should not be frequently repeated; also it {should 
not be used every time the patient has a pain somewhere. Aspi- 
rin has now entirely superceded this drug, and it is taken 
every time there is an ache or a pain or a possible cold 
developing. 

Acetphenetidin {Phenacetin). — Administration. — Acetphe- 
netidin occurs as white crystalline scales or as a fine crystalline 
powder, has a slightly bitter taste, and is practically insoluble 
in water. The dose is 0.30 Gm. (5 grains). 



r 



ANTIPYRINE 337 

Action, — This drug has similar activities to acetanilid but it 
is much less likely to cause cardiac depression or poisonings 
unless the dose is ver>^ large. 

This drug is used for the same purposes as is acetanilid. A 
useful combination is as follows: 

n 

AcetphcnetidiA . . * , .....,.,, t ,s<^ ^^* 

Citraled calTeme 0.25 Gm. 

Phenyl salicylate. .,...-... i , 50 Gm. 

Make 5 powders. Take one powder every three hours. 

This combination is especially efficient in stopping the aches and 

pains of an acute infection, as tonsillitis, measles, or influenza. 

Such dosage, as above suggested (modified for children), will 

not cause depression, and will lower temperature and stop the 

myalgias. 

Alitip}rrine (Phenazone). — Adminislraium.—Antipynne oc- 
curs as a white crystalline powder, has a slightly bitter and, 
in solution, nauseating taste, and is very soluble in water. The 
Pharmacopoeial dose is 0.30 Gm. (5 grains). This dose is rather 
small* The drug may be administered in capsules which may 
be uncapped before swallowing, which obviates the disagreeable 
taste; or it may be administered in solution. 

i4c(i^J. — This drug has often been used in the mouth and 
throat as an antiseptic, either in spray or gargles, in such a con- 
dition as whooping cough. It is rapidly absorbed from the 
stomach, and has the same activities as acetanilid, with the 
exception that it seems to cause more perspiration, and is less 
likely, in full doses, to cause cardiac depression. It seems to be 
more analgesic in neuralgias^ neuritis, and in pains emanating 
from the spina! cord than is acetanilid, and large doses have been 
frequently given, on this account, in locomotor ataxia. Large 
doses may cause a methemoglobin to be formed, and it may 
cause some irritation of the kidneys during its excretion. 
Antipyrine may cause an urticaria from irritation of the 
ducxlenum. 

Over-action, — The over-action is that of depression, occasion- 
ally cyanosis, but generally the only symptom of over-action is 
too profuse, prostrating and continued perspiration. 

The treatment of over-action or of poisoning is the same as 
22 



338 THE PRINCIPLES OF THERAPEUTICS 

that for acetanilid, except that for a long tune large doses of 
alkalies should be administered. 

Uses. — ^Antipyrine has frequently been used as an antipyretic, 
and as such is valuable. The best dose is 0.50 Gm. to i Gm., 
repeated in four or five hours, if deemed advisable. It has not 
been used as much for headaches as the other two coal-tar drugs, 
but large doses have been given for the pains of locomotor 
ataxia, and patients who receive these doses for some time seem 
to become tolerant to the drug and have no depression from it. 
However, it is not always successful in stopping that kind of 
pain. 

Antipyrine has often been, used to relax muscle spasm; it 
seems to diminish reflex irritability of the nerve centers. For 
whooping cough it is one of the most valuable treatments, and 
the dose for a child is 0.05 Gm. (a little less than a grain) for 
every year of the child's age. As it is disagreeable, it is well 
ordered in plain water, and administered in some drink, as 
lemonade or orangeade. The above dosage may be given three 
or four times in twenty-four hours, depending upon the niimber 
of the paroxysms of coughing. Older children may take the 
drug in capsules. It is always well in whooping cough under 
any treatment, but especially with the treatment with antipy- 
rine, to give digitalis coincidently, in the proper dose for the 
age of the child. 

At times antipyrine has seemed to be as efficient a treatment 
in stopping muscle twitching in chorea as are bromides, but 
both treatments are depressant, and these children generally 
require forced nutrition. 



CLASS VII 
Drugs and Preparations that are Spechhc 

A specific treatment in medicine means a treatment that has 
positive antidotal activity against the disease or condition 
present. The few specifics known to medicine are listed in the 
classification. A description of a few drugs not described 
imder more appropriate headings are here given. 



MERCDltY 



339 



MERCURY 



Mercury (Quicksilver),— Administration. — MetalUc mercury 
is used only m one of its official preparations, the most impor- 
tant of which are: Massa Eydrargyri (blue mass, blue pill) 
which is an ancient preparation that is not needed^ as calomel 
wUl act as well; Ungnentum Eydrargyri (mercurial ointment) 
and Ungnenium Eydrargyri Diluium are used externally for 
inunctions and in certain parasitic diseases of the skin. 

Calomel (Mcrcurous Chloride), — Descripii(}n.~Caiomd is a 
white powder, insoluble in water. It is used internally mostly 
for its cathartic action; occasionally for its general action as 
an antisyphilitic; sometimes, in small doses, as a diuretic in 
cardiac dropsy when combined with other drugs* Calomel 
should » however, rarely be used for systemic purposes as it 
readily causes salivation. Also there is frequently found an 
idiosyncrasy against mercury, especially calomel, stomatitis 
occurring in these patients with ordinary cathartic doses. 

Calomel is frequently given in small doses, as 0.006 Gm. 
(Ho S^*^^) repeated every half hour for ten doses, for a laxative 
and so-called antiseptic effect in the bowels. Such treatment 
is rarely advisable. Other antiseptics are better, and if calomel 
is needed, it is much better administered in a full dose suitable 
for the individual. The cathartic dose of calomel is from 0.05 
to 0,25 Gm. (about i to 4 grains) and it is often best given 
coincidently with aloin. If it is given at night, on the following 
morning a saline should be given, unless deemed inadvisable. 

Calomel is an ingredient of the Compound Cathartic Pill, an 
ancient preparation which is not needed. 

Ydlaw Iodide of Mercury (Mercurous Iodide), — Descrip- 
tion, — Protoiodide of Mercury is a bright yellow amorphous 
powder, insoluble in water. This drug is often used for system- 
ic action in a dose of 0.D1 Gm. (jr^ of a grain). 

Red Iodide of Mercury {Mercuric Iodide), — Description,— 
Biniodide of Mercury occurs as a scarlet red amorphous powder, 
which is practically insoluble in water. It is used only for 
systemic purposes, and the dose is 0.003 ^^* ^Ho g^ain). 

The official Eydrargyri Oxidum Flavum and Eydrargyri Oxi- 



340 THE PRINCIPLES OF THERAPEUTICS 

dum Rubrum (Red Precipitate) are not used internally, bat are 
used externally in the form of ointments. The official Unguen- 
tum Hydrargyri Oxidi Flavi, represents lo per cent, of the drug. 

The official Hydrargyrum Ammaniatum (White Precipitate) 
is used only externally as an ointment, and the Unguentum 
Hydrargyri Ammoniati represents lo per cent, of the drug. 

Hydrargyri Salicylas occurs as a slightly yellowish or pinkish 
powder, is practically insoluble in water, and has been used in 
suspension for intramuscular injections in syphilis. 

Corrosive Sublimate {Mercuric Chloride), — Description, — 
The bichloride of mercury occurs in crystalline masses or as a 
white powder, and is soluble in water. The dose is 0.003 Gm, 
(Mo of ^ grain). It is used externally as an antiseptic wash in 
solutions from i part in 500 to i part in 10,000, or even weaker. 
The official tablets for antiseptic purposes to be dissolved in 
water (the amount depending on the required strength) are 
termed Toxitabelke Hydrargyri Chloridi Corrosivi (Poison 
Tablets of Corrosive Sublimate). 

Action. — Almost the only used preparation of mercury for 
external antiseptic purposes is corrosive sublimate. If the 
solution is used too strong, severe irritation of the skin and 
the parts to which it is applied is caused. If there is a large 
absorptive surface, or if the solution remains too long in a 
cavity which has been washed with the solution, systemic poison- 
ing may occur. Corrosive sublimate antiseptic solutions have 
been used too much, and especially too frequently on fresh wounds 
as such treatment tends to prevent healing. 

There has recently been offered a new salt, a combination of 
fluorescein and mercury, termed "Mercurous Chrome — 220." 
A description of this drug and its uses as a germicide is offered 
by Young, White and Swartz,^ who present their conclusions 
that this preparation has great germicidal value, and in a solu- 
tion of I to 1,000 will kill the bacillus coli and the staphylococcus 
aureus in urine in one minute, and that this preparation may 
remain in the human bladder in i per cent, solutions from one to 
three hours without irritation. Though they find the drug of 
value as a local genitourinary antiseptic, its greatest value seems 

^ Journal A. M. A., Nov. 15, 1919, p. 1483. 



MERCURY 



341 



to be as an antiseptic injection in infection of the bladder and 
the peK-is of the kidney. 

Mercury in various fonns in oily or fatty preparations may be 
rubbed into the skin, be absorbed, and cause systemic action, 
and even the insoluble preparations are used for this purpose, 
but they are probably not as satisfactory as the carefully pre- 
pared mercurial ointments. 

Internally, except in minute doses, the soluble mercurial 
preparations, and typically mercuric chloride, are corrosive 
poisons. Calomel is, ordinarily, not absorbed in the stomach, 
but is absorbed from the intestines, and if it does not quickly 
cause catharsis, may cause symptoms of mercurial poisoning, 
but not of corrosive poisoning. 

The systemic action of mercuiy' is shown by a tendency to 
looseness of the bowels, and sometimes slight diuresis. Soon, 
if the dose is too large, or there is a h>T>ersusceptibillty of the 
patient, salivation is caused, with, if the drug is not quickly 
stopped, softening of, and bleeding from, the gums, loosening of 
the teeth J and general stomatitis. Mercury may irritate or 
slightly stimulate the liver, but it has not been shown that the 
bile is increased in amount. If brisk catharsis is caused by 
calomel or by any other form of mercury, the liver is relieved 
by the improvement of the portal circulation, and by the elimi- 
nation from the bowels of substances that, during constipation, 
are re-absorbed and must be again detoxicated by the liver and 
re-excreted in the bile. Hence the liver is often improved by 
catharsis caused by a mercurial salt. 

There is no excuse for administering mercury internally 
except as a purge (and for that purpose calomel is the best prep- 
aration) and for the treatment for syphilis. S>T)hilis cannot 
be successfully treated, mth our present knowledge, without 
the use of mercury in some form, either by inunctions, by intra- 
muscular injections, or by the administration internally of one 
of its salts, as the yellow iodide, the red iodide, or sometimes 
corrosive sublimate. 

Mercury is excreted in the form of an albuminate both by the 
intestines and by the kidneys, and the kidneys may become irri- 
tated and inflamed, if the dose has been large. If mercury has 



342 THE PRINCIPLES OF THERAPEUTICS 

been given for some time it will not all be excreted imtil some 
weeks after the last dose has been taken. When it is necessary 
to give mercury for a long time, as in syphilis, it is often advis- 
able to give Turkish baths, or electric light baths, or hot air 
treatments, to promote elimination and to prevent too much 
accumulation of the mercury in the tissues of the body. 

Over-action. — Over-action of mercury is shown by loss of 
appetite, diarrhea, perhaps gastrointestinal inflammation, 
salivation, muscular weakness, and loss of weight. When there 
is an abnormal susceptibility to the internal administration of 
mercury, as shown by salivation and loose bowels, and when it is 
necessary to push this drug internally rather than by other 
methods, some drug may be given to control the laxative action 
of the mercury, and mouth washes should be used constantly to 
prevent salivation and inflammation of the gums. Potassium 
chlorate mouth washes are perhaps the best for this purpose, 
although various astringents are used, as tannic acid 
preparations. 

Chronic mercurial poisoning is not frequent, but can occur 
in those who handle mercury, as artisans in mirror, thermometer 
and barometer factories. The symptoms are likely to be loss of 
appetite, emaciation, indigestion, disagreeable breath, soreness 
of the gums, sometimes neuritis and muscular weakness, and 
progressive anemia. There may be eruptions on the skin, and 
there is likely to be albuminuria. 

Toxic Action. — ^Acute poisoning by mercury (generally by 
corrosive sublimate taken internally by mistake or by intent) 
gives the typical symptoms of corrosive poisoning. This is 
described under poisons, and the treatment is especially out- 
lined on page 761. Occasionally the vapor of mercury has 
caused acute poisoning. The symptoms are those of multiple 
neuritis and paresis. 

Uses. — There is no internal systemic use for mercury except 
in the treatment of syphilis. Whenever mercury is used for 
this purpose, the nutrition should be watched, and the patient 
should not be allowed to lose his appetite or become emaciated 
during its administration. K the kidneys are diseased, mercury 
in any form must be used with a great deal of care, if used at all. 



raSVENTION AND TREATMENT OF SYPHILIS 



343 



Also, when mercury has been given for some timet the thyroid 
gland is likely to become more or less inhibited in its activity, 
and this may be one of the reasons that, after sj'philis and the 
treatment of syphilis, sclerosis of so many of the tissues of the 
body is likely to occur, f.e., conditions which are termed tertiary 
syphilis, 

PREVENTION AND TREATMENT OF SYPHILIS 

Before discussing the treatment of s>^hilis, the methods for 
successful prevention of venereal diseases may be itemized, 
without discussion, as: 

1. Education in schools and colleges, and by social service 
instruction. 

2. Dissemination of the knowledge of the best methods for 
the prevention of this disease when opportunity for infection 
has occurred. 

3. Compulsory reporting of indi\iduals infected by these 
diseases, 

4. The insistence that an indi\idual must be treated until 
he is cured. 

5. The restraint of public carriers. 

The moral end of this discussion is left for other teachers and 
the detaDs of carrying out the above suggestions are left for 
papers and books treating of these diseases. The treatment of 
gonorrhea and of venereal sores is outside of the scope of this 
book, but the treatment of syphilis depends so much on the 
action of drugs that the management of that disease is here 
outlined. 

The menace of syphilis is at the present time very great as 
this infection is on the increase in ci\ili2ed communities. 
The danger of the spread of the infection has increased 
because modern treatment prevents secondary symptoms 
occurring, and the individual thinks he is cured, and the physi- 
cian loses sight of his patient. Consequently, the uocured 
man or woman may transmit the disease to others, and also may 
in after years develop s>T>hiUtic disease in any part of the body. 
There may be paresis, locomotor ataxia, arteriosclerosis, liver, 



1 



344 THE PRINCIPLES OF THERAPEUTICS 

kidney or stomach disease, all due to the uncured syphilis. A 
small proportion of individuals acquire syphilis extra-genitally, 
but perhaps not more than 5 per cent. 

That aortitis and aneurism are frequently caused by syphilis 
is recognized, but hjrpertension and cardiac disease are more fre- 
quently caused by syphilis than has been noted. Also, heredi- 
tary syphilis is not infrequent, and may occur in families where 
it is least suspected. 

Syphilis of the nervous system, with its many manifesta- 
tions, is now generally recognized, and the disturbance may be 
insomnia, headache, epilepsy, paresis, locomotor ataxia, gum- 
mata of the brain, or insanity. 

To insure the early diagnosis and a consequent successful 
treatment, every suspicious sore should be studied microscopic- 
ally for spirochetes, and if the result is negative, the nearest 
lymphatic glands should be watched for several weeks for signs 
of infection. In suspicious cases where spirochetes are not 
foimd, the Wassermann test should be made in four weeks from 
the time of the suspicious sore, and again in two or three months. 
This test is positive in practically all cases of active syphilis, 
and if present shows that whatever else the patient has, he prob- 
ably also has syphilis. If the test is negative, he may still have 
syphilis, and later in the disease when the blood is negative to 
this test, the spinal fluid may be j)ositive. This is especially 
true if there are symptoms of nervous syphilis. If both tests 
are negative, he may still have syphilis, and the tests may be- 
come positive later under mercurial treatment. 

The Wassermann test may not only vary greatly in intensity 
from time to time, but it may be absent during treatment or 
without treatment. Also it seems to be an unfortunate fact 
that ref)orts from even the best of laboratories may not always 
be the same with the same sample of blood. Hence, several 
examinations should be made before a result is declared f)ositive, 
provided that the clinical symptoms and signs are not present. 

The luetin skin test, if positive, is indicative of syphilis 
and especially is valuable in latent, tertiary and hereditary 
syphilis, provided the patient has not taken iodine in any 
form just before the test is made. 



TREATMENT OF SYPHILIS 



34S 



TreatmenU — As soon as syphilis is jjositively diagnosed, 
arsphenamine should be given intravenously, and the adminis- 
tration of mercury should begin. Some specialists in the 
treatment of syphilis believe that mercury should not be given 
until after the arsenic treatment is over, belie\dng that the 
fight against the germ is more effective by this di\^ded treat* 
ment. Also mercury may slow the excretion of arsenic and 
hence cause poisoning. The intensive treatment cannot be 
better outlined than by quoting Fordyce*, who advises that 
five or six intravenous injections of arsphenamine should be 
given at intervals of about one week, Coincidently, he advises 
**that injections of mercury be given intramuscularly, every 
other day, if it is a soluble form of mercury, or once a week, if 
it is an insoluble form*" He gives arsphenamine (salvarsan) 
in doses of 0.30 to 0,50 Gm, for men and 0.25 to 0.40 Gm. for 
women. If he uses a soluble form of mercury for these injec- 
tionsj he prefers the bichloride, and gives twenty to thirty 
injections, either daily or every other day. If he uses the 
insoluble form of mercur>' he prefers the grey oil, '*(in the form 
of mercurial cream) of which 5 minims represent i grain, in a 
series of 10 to 12 injections, or salicylate of mercury (40 per 
cent, suspension) in dosage of i to 3 grains, gradually increased, 
ten to twelve injections constituting a course.*' After this 
course of arsenic and mercury treatment he gives a rest period 
of six weeks, and then repeats the treatment, even if the 
Wassermann test has become negative. 

Many clinicians believe that the old treatment of mercurial 
inunctions is really the best, as injections are very painful 
and are often not well tolerated by the patient. Known quanti- 
ties of mercurial ointment of known strength are now obtain- 
able, and the dosage is thus rendered exact. The mercury 
ointment may be rubbed in daily or every other day, or in 
50 per cent, strength twice a week, as directed, first on one 
part of the body and then on another; the inner sides of the 
arms, thighs, legs, and the abdomen being utilized in turn. 
Some clinicians believe that preparations of calomel can be 
thus u^ed satisfactorily; others do not believe that it is as satis- 
' Amer. Joum, Med. Sci., Oct., 1916, p. 469. 



346 THE PRINCIPLES OF THERAPEUTICS 

factory as is the mercurial ointment as it is absorbed more slowly. 
Two to three grams of calomel in one gram of hydrated wool fat 
and two grams of benzoinated lard may be used at each inunction. 

If a syphilitic woman becomes pregnant, she should receive 
active treatment, and such treatment may prevent a mis- 
carriage or premature birth, and her child may not show 
congenital syphilis. 

In nervous syphilis, syphilis of the brain and cord. Swift 
and Ellis first advised injections of salvarsan preparations into 
the spinal canal, and a number of clinicians have developed 
this treatment, either of intraspinal injections of arsphenainine 
or of arsphenaminized serum. It was first thought that 
arsenic given intravenously did not reach the cerebrospinal 
fluid, hence this method of treatment was advised. However, 
it has since been shown that arsenic given intravenously does 
reach the cerebrospinal fluid, hence at least intraspinal treat- 
ment is not always a necessity. However, it seems advisable 
at times in serious cerebral syphilis, or in locomotor ataxia, to 
give arsphenamine both intraspinally and intravenously, and 
at the same time or soon after, mercury should be administered 
by inunctions or otherwise. Kolmer^ offers a method for 
treating neuro-syphilis by intensive treatment. 

There is also still a belief that iodides are of value in tertiary 
syphilis, and an iodide seems to be good treatment after a 
course of mercury. The best form is sodimn iodide, and 
the dose need not be large. The enormous amount of iodides 
given in tertiary syphilis is inexcusable and also useless. Small 
amounts of iodide, not only for the iodine action on the thyroid 
gland, but to aid in the elimination of stored mercury, which 
may be doing harm in the body, and to thus re-mercurialize the 
fluids of the body, is logical treatment. 

In giving spinal injections, the usual care should be exer- 
cised, namely, that too much fluid be not given, and that too 
great force be not used, and that the patient should remain 
quiet for twenty-four hours to avoid the headache that may 
occur. In locomotor ataxia the injections often cause most 
intense pain of the locomotor ataxic type. . 

^ Journal A. M. A., March 20, 1920, p. 794. 



TREATMENT OF SYPHILIS 



347 



It is a question for most careful decision when there are symp- 
toms of internal ear disturbance or when there is optic atrophy, 
as to whether arsenic should be administered or not, as arsenic 
has caused serious results in such conditions. On the other 
hand, if the dose is not large, it may do good, and may prevent 
the progress of the optic atrophy. 

If there is acute or subacute nephritis, arsenic in any form 
should not be injected. Also it should be used with great care 
in chronic nephritis, and before it is used, when chronic nephri- 
tis is present, tests of the excretion ability of the kidneys should 
be made* If a syphilitic has chronic nephritis, any treatment 
of the syphilis is a matter of serious consideration, as not only 
arsenic, but mercury and iodides are likely to increase the kidney 
trouble. However, the risk must often be taken, but the deci- 
sion should generally be against the use of arsenic, as the 
largest part of the arsenic injected must be excreted in the urine, 
hence the likelihood of irritation and increased disturbance of 
the kidneys. Also the excretion of arsenic by the kidneys is 
very slow; it may not be all excreted until two or three weeks. 

The arsphenamine treatment may certainly stop the progress 
of locomotor ataxia, and may cause considerable improvement 
of the condition and may even restore the muscular power of a 
bladder paralyzed by this disease. 

The treatment of paresis by intraspinal injections has not 
been very successful, but the statistics are not quite sufficient to 
advise against its use. 

In every case of epilepsy, whether some other tangible cause 
is present or not, the Wassermann test should be made, as 
hereditary syphilis is not an infrequent cause of this serious 
condition, 

Arsphenamine {Salvarsan), — Arsphenamine is an American 
preparation of arsenic for the treatment of syphilis, and occurs 
as a yellowish crystalline powder, readily soluble in water, and 
in watery solutions gives an acid reaction* This drug is offered 
in sterile ampules ready for solution in distilled water, which 
solution is made alkaline by adding a sufficient amount of a 
solution of caustic soda. The exact method of preparing the 
solution, its proper temperature, and the rapidity of the flow for 



I 



348 ^I'HE PRINCIPLES OF THERAPEXTTICS 

intravenous injections is stated on the package. Such contents 
of the sterile tubes as are not used after the ampule is broken 
should be thrown away, as the substance disintegrates. 

Directions also come with each package to show how arsphena- 
mine or neoai^henamine may be prepared for administration 
intraspinally. It has been considered best to give arsphena- 
minized serum intraspinally. This is prepared from the blood 
of the patient as follows: the arsphenamine is given as usual, 
intravenously; an hour later 40 mils of the blood is withdrawn 
from a vein; this blood is allowed to dot and is placed on ice for 
twenty-four hours; the serum exuded from the dot is then cen- 
trifuged, and 12 mils of this upper centrifuged senmi is added 
to 18 mils of sterile physiologic salt solution; this diluted serum 
is then heated to body temperature, and, after an equal amoimt 
<rf spinal fluid is withdrawn, is injected intraspinally; the patient 
is then placed in the Trendelenberg position, to allow the fluid 
to gravitate toward the brain. 

It may later be foimd that suffident arsenic reaches the men- 
inges from intravenous injections to predude the necessity for 
direct spinal treatment. 

Neoarsphenatnine (also termed sodium arsphenamine) con- 
tains sodium and is weaker in arsenic content than is arsphena- 
mine, three parts of neoarsphenamine being equal to two parts 
of arsphenamine. Therefore, the dose may be larger. Al- 
though this preparation is preferred by some spedalists, prob- 
ably arsphenamine, which is a little more difl&cult to prepare, 
is the better treatment. Neoarsphenamine must not be 
warmed, as heat causes changes in its chemical constitution. 

Sometimes impleasant reaction takes place from these arsenic 
injections, such as a temperature of 100° or 101° F., vomiting, 
diarrhea, dizziness, headache, edema of the face, cyanosis, 
and circulatory depression. Any one or several of these symp- 
toms may occur and last for twenty-four hours. Occasionally 
there has been irritation of the auditory nerve and of the optic 
nerve, and sometimes a serious neuritis has developed. Not 
infrequently albiunin is foimd in the urine, and from intensive 
treatment with arsphenamine chronic arsenic poisoning may 
occur. It has been suggested that, if an intramuscular injec- 



TREATMENT OF SYPHILIS 



349 



tion of I to 1,000 epmephrine solution be given about ten 
minutes before the injection of arsphenamine, these unpleasant 
symptoms are not so Ukely to occur. If they do occur injec- 
tions of tyramine or epinephrine are indicated, as the suprarenal 
glands seem to be inhibited. 

Serious^ even fatal poisoning (unless the dose is small) may 
occur from both neoarsphenamine and arsphenamine injections, 
such as toxic jaundice, exfoliative dermatitis, thrombosis, phle- 
bitis, and gangrene. 

Kolmer and Yagle* have come to the following conclusions 
concerning arsphenamine and neoarsphenamine: 

1. All solutions of arsphenamine are hemolytic, but they are 
from three to ten times less hemolytic in isotonic saEne solution 
than in solutions in water. 

2. The hemolytic action of arsphenamine is increased un- 
avoidably by the addition of sodium hydroxide for neutralization, 
and an excess of the alkali increases the hemolytic activity. 
Also, concentrated solutions of arsphenamine, either in water 
or isotonic saline are more hemolytic than dilute solutions* 

3. Neoarsphenamine is not hemolytic, though very dilute 
solutions are, owing to hypotonicity of the solution. Concen- 
trated solutions, as 0,9 Gm. in 30 mils or less of water are not 
hemolytic. 

4. **To avoid hemolysis in the administration of dilute solu- 
tions of neoarsphenamine sterile physiologic sodium chloride 
solution prepared of freshly distilled water should be used; when 
the concentrated solutions are administered (each 0,1 Gm. 
dissolved in 3 mils or less) sterile distilled water may be em- 
ployed, " They also caution that injections of arsphenamine 
and neoarsphenamine solutions should be slow, to allow a grad- 
ual mixing with the blood. Schamberg, Kolmer, and Raiziss^ 
find that neoarsphenamine is safer than arsphenamine. 

As stated, neoarsphenamine is more easily prepared for 
administration. On the other hand, when arsphenamine is 
ver>' carefully prepared, not given too concentratedj and prop- 
erly alkalinized (not too strongly alkaline) disagreeable after 

* Journal A. M. A., March 6, 1910, p. 643. 

* Amer, Journ. Med. Sci., July, 1920, p. 35; and Aug., 1920, p. 18R. 



350 THE PRINCIPLES OF THERAPEUTICS 

symptoms will not often occur. In other words, it is a case for 
the specialist. Only one who has become expert and has the 
proper facilities for properly preparing and properly administer- 
ing arsphenamine should perform this operation. Also, it 
should be considered an operation, and the patient should re- 
main quiet for at least twelve or fifteen hours after the injection. 
It seems inexcusable to give such a treatment in the physician 's 
office and then send the patient home within an hour or so. 

It does not seem advisable to administer mercurialized serum 
intraspinally, as has been suggested, or perhaps intravenously, 
but intramuscular injections of mercurialized senmi may be an 
improvement on injections of stronger preparations of mercury. 

Bailey and MacKay^ have studied the disturbances caused by 
injections of arsenic in the treatment of syphilis and especially 
the disturbances of the liver. They think that an increase of 
cholesterol in the blood is an early prominent sign of imminent 
liver congestion and toxic jaimdice, and suggest frequent exami- 
nation of the blood for this substance during the intensive treat- 
ment of syphilis as a warning against too frequent injections of 
arsenic. They also urge the restriction of exerdse during the 
active treatment, and advise a diet rich in carbohydrate and low 
, in fat and protein before, during, and immediately succeeding 
the arsenic treatment. The amount of protein later allowed 
and the return to exercise and work should depend upon the 
amount of urea in the blood. 

These recommendations are timely, as this active, perhaps 
necessary, more or less dangerous treatment of syphilis is often 
recklessly carried out. The watchward should be skilled treat- 
ment, caution, rest, and frequent study of the exact condition 
of the patient, best carried out at a hospital. 

If for any reason it is deemed imwise to administer ars- 
phenamine intravenously, it may be given by enteroclysis with 
reported good results. The preparation of the patient and the 
technique have been recently described by Wright.^ 

Intramuscular Injections of Mercury. — Sterile ampules may 
be obtained of several forms of insoluble mercury for intra- 

* Arch. Int. Med., June, 1920, p. 628. 

* New York Med. Joum., Aug. 28, 1920, p. 275. 



TREATMENT OF SYPHILIS 



351 



muscular injections. Consequently, it would seem as though 
the doubtful preparation of such solutions extemporaneously 
is not excusable. 

Sterile ampules may be obtained of salicylate of mercury, 
each containing 0.13 Gm. (2 grains), with quinine and urea 
hydrochloride } 2 P^^ cent, suspended in oiL The dose is J^ to i 
ampule^ the quinine and urea hydrochloride acting as an anes- 
thetic* The ampules should be warmed before the solution is 
drawn into the syringe for injection. 

Besides the salicylate, ampules of mercury succinimide may 
be obtained. Each ampule contains i mil of the sterilized 
aqueous solution of mercury sucdniimde o.oi Gm. {}4 grain). 
The dose is one to tw^o ampules. 

These injections are usually made into the gluteal muscles, 
not so low down that the patient cannot sit, also the region of 
the sciatic nerve must be avoided. The two sides of the body 
are used alternately; care should be taken not to puncture 
a vein, therefore the barrel should be detached from the needle 
to see if blood flows. If blood does flow, the needle should 
be withdrawn and another puncture made. There should be 
no massage of the injected tissues. 

The soluble salts of mercury should be used by preference 
when rapid mercurial action is desired, and in the beginning of 
the treatment. Later the less soluble salts may be used. The 
injections (salicylate salt best) should not be more fre- 
quent than once a week, as absorption is slow. The dis- 
advantage of this treatment is the pain w^hich is caused, and 
with the soluble salts the pain may begin at once and may 
last several hours. With insoluble preparations the pain may 
not begin until after an hour or two, but may last for 
several days. 

Sometimes hard tumor masses form which absorb very 
slowly, depending upon whether the injection has been made 
close to fascia rather than into the muscle substance. Abscesses 
may rarely occur^ and embolism has occurred. 

The same general hygienic care of the mouth and of the 
bowels, a nutritious diet, and hot water bathing should be 
ordered when mercury is given by injection or by inunction, 





352 THE PRINCIPLES OF THERAPEUTICS 

as when it is given by the mouth. It seems to be doubtful 
if mercury reaches the meninges of the brain and cord, hence 
the advisability of both the arsphenamine and the mercury 
treatment for syphilis of the central nervous system. 

THE SPECIFIC TREATMENT OF TETANY 

Tetany has been shown to be due to disturbance of the 
parathyroid glands, and when the parathyroids are removed 
the animal develops tetany. This tetany is stopped by para- 
thyroid gland extracts, and by the administration of calcium, 
best associated with the administration of cod liver oil. 

Calcitim. — Calcii Chlaridum. — Calcium chloride occurs as 
a white, very deliquescent salt, has a sharp, saline taste, is 
irritant, and is soluble in water. This disagreeable preparation 
has no advantage over more pleasant salts of calcium. The 
dose is 0.30 Gm. (5 grains), generally administered three 
times a day. It must be given in solution and with some 
thick syrup, else vomiting will be caused. 

Calcii Lactas. — Caldum lactate occurs as an odorless, taste- 
less powder, not very soluble in water, is only slightly irritant, 
and does not disturb the stomach when taken well diluted or 
after meals. The dose is 0.30 Gm. (5 grains), best administered 
in powder and taken with milk after meals. 

Calcii Glycerophosphas. — Calcium glycerophosphate occurs 
as a fine, white powder, is almost tasteless, is practically 
insoluble in water, and is best administered in powder or 
capsules. The average dose is 0.50 Gm. C7H grains) three 
times a day, after meals. This is a pleasant and efficient 
method of administering caldum. 

Liquor Calcis (Solution of Caldum Hydroxide). — Lime 
water is a bland, non-irritant solution, mildly antadd, and 
slightly constipating. It is absolutely tasteless, if taken in 
milk. It is often added to the milk of infants, as the alkali 
tends to prevent the formation of large curds in the stomach. 
The dose of lime water as generally administered is too small, 
and 2 or 3 teaspoonfuls should be added to each milk feeding, 
depending upon the age of the child. 

Lime water is combined with linseed oil, equal parts, to form 



TREATMENT OF TETANY 



353 



the official Linimentum Calcis (Canon Oil), which is a soothing 
alkaline preparation largely used for burns. 

Cakii Carbonas Prmcipiiahis (Precipitated Chalk) is some- 
times used as an antacid. 

Creia Ptdparata (Prepared Chalk) is administered internally, 
mostly in the form of the official Misiura Creim (Chalk Mbcture), 
which is given, in a dose of 15 mils (about 4 fluidrams), for 
diarrhea in infants. Precipitated chalk and prepared chalk are 
used mostly externally, and the latter is the main ingredient of 
many tooth powders. 

Syntpus Calcii Laciophospkatis is used for marasmic children 
in the dose of 10 mils {2}- 2 fluidrachms) ; but good food and plenty 
of milk makes this preparation rarely needed. One quart of 
milk represents about 2 Gm. of calcium, and i Gm. (15 grains) 
of calcium is about sufhcient for normal metabolism for twenty- 
four hours. 

Holt, Courtney and Fales^ have determined that an excessive 
calcium intake dose not apparently increase the calcium absorp- 
tion, the excess being excreted. They also determined that the 
calcium absorption by rachitic infants was much lower than by 
healthy infants, and that the administration of cod liver oil 
increased the absorption of calcium, unless diarrhea was present. 
This means, as has long been clinically known, that cod liver oil 
is a valuable treatment for marasmic and rachitic children, 
combined, of course, with proper food and plenty of milk. 

Action. — The importance of calcium to the economy (it rep- 
resents about one-fiftieth of the body weight) is being more and 
more recognized. A child cannot grow properly when deprived 
of calcium, neither can an adult be normal when deprived of it. 
Also, anything that causes a great loss of calcium to the body 
causes symptoms more or less serious, due to such loss. 

The seriousness of acidosis and its frequency as a terminal 
condition in many chronic and acute diseases has only recently 
been known* Even a mild form of acidosis may cause vomiting, 
diarrhea, and cerebral irritation, and serious acidosis will cause 
coma, as seen in diabetes. Prolonged privation of carbohy- 
drates and starv^ation will cause acidosis and the symptoms 
^ Amer. Joiim. Dis. Child., Feb., i92o> p. 97. 



354 THE PRINCIPLES OF THERAPEUTICS 

above described. There may also be an increased temperature, 
rapid pulse, and tetany. 

A shortage of caldum seems to cause disturbance of the para- 
thyroid glands, and nervous irritability, sleeplessness, spasmo- 
philia, or convulsions may occur depending upon the amount of 
parathyroid disturbance present. Privation of carbohydrate 
foods and perhaps especially of calcium may be a cause of 
meningism in typhoid fever and other serious infections. 

The part played by the parathyroids in epilepsy is not known, 
but it is a fact that the less meat and the more starch in the food, 
the less frequent are the convulsions. The administration of 
calcium as well as other alkalies frequently prevents the necessity 
for large doses of bromides in epilepsy; a small dose of a bromide 
combined with alkaline treatment is often satisfactory. 

The relation of the pituitary secretion to the parathyroids 
is not known, but in hypersecretion of the anterior pituitary an 
extra amoimt of bon6 is produced. This means an extra amoimt 
of calcium is utilized for bone growth. 

In hyperactivity of the thyroid, whatever other treatment is 
instituted, the administration of caldimi always quiets nervous 
irritability, as it seems to soothe the central nervous system. 

The calcium metabolism of the mother is disturbed to her 
disadvantage by too frequent pregnancies, and even in a single 
pregnancy, many times, the mother's teeth become decayed, 
her hair falls out, and her finger nails become brittle, showing- 
that she requires more calcium than she is receiving, or at least 
than she is utilizing, extra calcium being required for the growth 
of the child. Too frequent pregnancies exaggerate this condi- 
tion, and lactation will use up the mother's calcium, and she 
requires more, and if her metabolism does not properly utilize 
the calcium that she receives she becomes nervous, irritable, has 
headaches, loses weight as well as her teeth and hair, and may 
have bone softening, as occurs in osteomalacia. 

Whether ovarian disturbance or the extra ovarian activity in 
frequent pregnancies is the cause of osteomalacia, or whether 
the too frequent formation of the corpora lutea of pregnancy is 
the cause, osteomalacia certainly occurs generally only after such 
ovarian or corpora lutea hyperactivity. A patient with osteo- 



TREATMENT OF TETANY 



355 



malada requires large amounts of lime. Sometimes removal of 
one or one and a hall ovaries has been ciu'ative. 

On the other hand, normal activity of the ovaries and of the 
testicles may have something to do with normal calcium elimina- 
tion, as at the time of life when the acti\ity of these glands is 
diminished, hardening of arteries and other signs of calcific 
cation often occur. 

Givens has shown that we cannot by food increase the calcium 
of the body without also increasing magnesium^ and there is 
generally more calcium than magnesium excreted in the urine. 
Both can be increased by the ingestion of milk, Givens finds 
that calcium lactate always increases the urinar>^ calcium output, 
but relatively not more than when milk is given. He also found 
that the ingestion of dilute hydrochloric acid does not much 
affect the calcium and magnesium metabolism. 

It seems to be a clinical fact that a hyper-acid individual is 
more likely to have neuralgias and neuritis than when his diet 
is changed to one of more carbohydrate and less meat, and 
when he is given alkalies; and the best alkali for nervous irri- 
tability of all kinds is calcium. If milk is well tolerated, it is 
one of the best means of administering more calcium, and the 
best medicinal way is to give calcium glycerophosphate. 

Children seem to store calcium more readily than adults, 
probably because physiologically they need more calcium, not 
only for their normal metabolism, but also for their bone 
growth. 

Only a small amount of calcium intake is actually absorbed, 
a large portion forming salts and passing off in the stools, and 
even a portion of tiie calcium that is absorbed is excreted into 
the intestines through the epithelium. The calcium excreted 
in the urine occurs mostly as a phosphate. 

It seems to be a clinical fact that patients with active tuber- 
ctilosis excrete an abnormal amount of calcium; they lose cal- 
cium which they need for the cure of the tuberculosis. There- 
fore milk or extra amounts of calcium should be fed these 
patients, and sometimes cod liver oil. 

While it is unusual for ordinary diets to cause lime priva- 
tion, a meat and bread diet will do this. Also, lime may be 




3S6 THE PRINCIPLES OF THERAPEUTICS 

taken, yet for some chemical reason may be lost to the body; it 
may not be normally absorbed. On the other hand, as pre- 
viously stated, calcium may be excreted in an abnormally large 
amoimt, and such patients will show symptoms of lime starva- 
tion. This condition of non-utilization of calcium is similar to 
the condition of chlorosis where iron may be taken in normal 
amoimt in the diet by a girl, and yet she becomes chlorotic. 

Lime is essential for the normal clotting of blood, although 
it does not enter into the formation of fibrin. Although cal- 
cium will not often stop the bleeding of hemophiliacs, and may 
not stop a tendency to hemorrhages, still it should be admin- 
istered in all individuals who are bleeding, from the bleeding 
gums of scorbutus to the oozing hemoptysis of tuberculosis, 
and when there is actual hemorrhage. Surgeons who must 
operate upon jaundiced patients believe that by a previous 
feeding of calcium they lessen the tendency to hemorrhage, 
and the danger of hemorrhage is always present when there 
are bile salts in the blood. 

It would seem a biologic necessity to see that a pregnant 
woman receives more caldvmi than she previously has been tak- 
ing, not only to supply the fetus with its needs, but to cause her 
not to be depleted of the calcium that she needs. 

In rickets and in all softening of bone, and possibly after 
fractures, an extra amoimt of calcium is needed, and as above 
stated, in cachectic children calcium and cod liver oil are 
valuable added treatments. 

While caldum phosphate may be logically the salt that seems 
advisable for bone growth, administration of this salt is not 
more effective, perhaps not as effective, as the administration 
of a preparation like calcium glycerophosphate; but in whatever 
form the calcium is administered it must be broken down and 
rebuilt for the needs of the body and tissues. All iypophos- 
phite combinations, whether with or without calcium, are use- 
less medicaments, and there is no justification for the faith in the 
value of hypophosphites. The doubt of their value is also 
shown by all proprietary medicine firms, who offer hypophos- 
phite preparations, almost invariably adding quinine, iron, 
strychnine, or something else to their hyfK)phosphite mixtures. 



CmCHONA 



CINCHONA 



3S7 



CmchonR—Caiisaya; Calisaya Bark; Yellow Peruvian Bark,— 
Cinchona origmally came from Peru (hence called Peruvian 
Bark), and became known as a cure for malarial infections in 
1638, and from this date there has never been found a better 
cure for malarial fevers. It was named Cinchona on account of 
its having cured the Countess of Chinchon, of Spain. At the 
present time cinchona is mostly obtained from India and Java. 
Cinchona is not used as such. The only preparation of 
value is Tindura Cindt&na^ which represents 20 per cent, of 
the drug, and the dose of which is a teaspoonfuL This prepara- 
tion is as valuable as a bitter tonic as is the tincture made 
from the red cinchona, namely, Tindura Cinckond Composita 
(Huxham's Tincture). This compound tincture of cinchona 
contains serpentaria, and there is no necessity for officializing 
or using the plant serpentaria. If it is desired, syrup of orange 
may be added to the Tindura Cinchona, which makes a 
pleasant, bitter preparation. 

Ciftciwna Rubra (Red Cinchona, Red Peruvian Bark) is not 
used as such. 

The official alkaloids of cinchona are quinine, cinchonidine, 
and cinchonine. There is no necessity for officializing the last. 

Cinclwnidinm Sulphas occurs as white silky needles or 
prisms, has a very bitter taste, is slightly soluble in water and 
the average dose is 0.15 Gm, (2} 2 grains); however, the dose 
depends upon the object for which it is used. 

Qmnine. — Administraiimt, — This alkaloid is usecl mostly in 
the form of one of its salts. 

Quininm Bisulphas (Quinine Bisulphate) occurs as colorless 
or whitish crystals, has a very bitter taste and is soluble in 
water. The dose is o.io Gm. (iH grains). 

Quininw Dikydrochl&ridum (Quinine Dihydrochloride) occurs 
as a white powder, has a very bitter taste, is very soluble in 
water, and the dose is o.io Gm. (if^ grains). 

Quinina el Urea Bydrochloridum (Quinine and Urea Hydro- 
chloride) is a compound of the hydrochlorides of quinine and 
urea. It occurs as colorless prisms or as a white granular 
powder, has a very bitter taste, and is very soluble in water. 



358 THE PRINCIPLES OF THERAPEUTICS 

This drug is used mostly hypodermatically, and the dose, once 
a day, is i Gm. (15 grains). It is also (now rarely) used as a 
local anesthetic in about 15 per cent, solutions for mucous 
membranes, and in 0.5 to i per cent, solutions for injections. 

QuinifUB Eydrobramidum (Quinine Hydrobromide) occurs 
as white needles, has a very bitter taste, is not very soluble in 
water, and the dose is o.io Gm. (i^ grains). 

QuinifUB Hydrachloridutn (Quinine Hydrochloride) occurs as 
white needles, has a very bitter taste, is soluble in water, and 
the dose is o.io Gm. (i^ grains). 

QuinifUB Sulphas (Quinine Sulphate) occurs as white crystals, 
has a very bitter taste, is practically insoluble in water, and 
the dose is o.io Gm. (i>^ grains). This is the preparation of 
quinine that is the most used. The anti-malarial doses of all 
quinine salts are very much larger than the tonic doses. 

The salicylate and the tannate of quinine, though official, 
are not important. 

When soluble preparations of quinine are desired for internal 
administration, the bisulphate or the dihydrochloride are the 
preparations to use. The hydrobromide is supposed to have a 
slight sedative effect and not to be quite as excitant to the 
brain as are the other quinines. As the most insoluble prepar^t- 
tion, namely, the sulphate, causes quinine activity almost as 
rapidly as the more soluble forms, this is the preparation that 
is most used. It may be administered in flexible capsules 
(which may not always dissolve) or in freshly made gelatin 
capsules. If rapid action is desired, a capsule may be uncapped 
before swallowing. There is absolutely no excuse for ordering 
the sulphate of quinine, and adding add to dissolve it, in a 
liquid preparation. If a soluble preparation is required, as 
just stated, the dihydrochloride or the bisulphate should be 
used. When quinine is administered to a child that cannot 
swallow a capsule or a pill, several methods of administering the 
alkaloid may be tried. A freshly made pill may be crumbled 
and placed in a teaspoonful of jam or thick chocolate or other 
soft food that the child can take. Or a solution of the bisul- 
phate or the dihydrochloride in water may be administered, in 
the dose desired, in a cup of cocoa or chocolate. The so-called 
tasteless quinines are mostly tannates, and are for that reason 



QUININE 



359 



very insoluble in the alimentary canal, and but little quinine 
is absorbed. 

As a tonic quinine may be given as the tincture of cinchona 
in teaspoonful doses before meals; the bitter often acts as an 
appetizer. Or, if quinine is taken in a capsule or pill after 
meals, enough of the quinine is excreted in the saliva to cause 
a bitterish taste before the next meal, and for this reason 
quinine thus administered acts as a stomachic. 

Action, — Quinine is a protoplasmic poison, has antiseptic' 
and germicidal qualities, and, when in solution, acts more or 
less as a preservative and may destroy many bacteria. It 
specifically destroys the plasnwdium fnalaria, acting more 
efficiently on the full growTi parasite than when it is in the 
sporule stage- 
Locally on the unbroken skin quinine has no action; on mu- 
cous membranes it causes a slight irritation ; and in the stomach 
it is distinctly stimulating to the secretions. The acid of the 
gastric juice renders the sulphate of quinine soluble and causes 
it to be more or less rapidly absorbed. Probably the quinine 
that is not absorbed in the stomach, and reaches the intestines 
and therefore alkaline media, is not absorbed at all, and passes 
out of the body with the feces. 

Except in small doses, quinine, even in capsules, should not 
be taken before meals or on an empty stomach, but always 
after meats; or, if a large dose must be given at some other 
time, it may be administered w4th milk, or with malted milk^ or 
with some other simple food, else irritation and even vomiting 
may be caused. Sometimes constipation is caused by quinine, 
possibly on account of its inhibitory action on the normal bacteria 
of the intestines. 

The larger part of an ordinary dose is generally absorbed in 
two or three hours, and in the blood it quickly inhibits the 
activity of, and destroys, malarial parasites. It may also more 
or less inhibit ameboid movement of the polymorph leucocytes. 
For this reason it has been thought that it is not well to give 
quinine in septic diseases, as it may interfere with normal phago- 
cytosis, and there is no question but that too much quinine has 
been given in all kinds of disease. 



A 



360 THE PRINCIPLES OF THERAPEUTICS 

Quinine in small doses is more or less stimulant to the heart, 
especially noticeable in those who frequently take quinine and 
rely on it for stimulation. In large doses it is depressant to the 
heart and may considerably lower the blood-pressure. Full 
doses of quinine dilate the blood-vessels, especially of the face 
and head, and may cause considerable fullness of the head and 
ringing in the ears, perhaps suffusion of the eyes, and may cause 
headache from the increased cerebral circulation. With this 
'effect on the head there may be dizziness, in part due to in- 
creased pressure in the head and in part due to disturbance in 
the middle ear, and large doses cause ringing, buzzing, and even 
roaring sounds in the ears. During this action there may be 
some deafness, especially in individuals who are already partial- 
ly deaf. If large doses are prolonged, rarely, more or less 
permanent deafness may be caused. Very rarely a single large 
dose has caused deafness, but probably in these instances some 
disease of the middle or internal ear was already present. 
Occasionally there has been temporary blindness caused by the 
drug, but this is very rare. The pupils may dilate, and there 
may be imperfect acconmiodation. Sometimes delirium is 
caused by quinine. 

Large doses in feverish processes will reduce temperature, 
but such an effect is combined with so much disagreeable action 
that there is no excuse for using quinine as an antipyretic, 
expect in the specific case of a malarial fever. Some of this 
diminution of fever is probably due to action on the heat pro- 
ducing centers in the brain, and also perhaps due to the de- 
creased general metabolism which large doses of quinine causes. 
It seems probable that small doses of quinine are more or less 
stimulant, and large doses of quinine are always more or less 
depressant to nitrogen metabolism. 

Quinine is probably destroyed by many tissues of the body, 
perhaps largely by the liver. It is excreted mostly through the 
kidneys, and may be found in the blood and in the urine an 
hour after it has been administered, but the whole dose is excreted 
slowly, and, if several doses have been taken, it may take several 
days before it is all excreted. Considerable quinine may be 
found in the feces, some passing through the intestine unab- 



QUININE 



361 



sorbed, and perhaps some is excreted with the bile, after passing 
through the liver. Quinine may also be found in the perspira- 
tion, in the saliva, and in the milk of nursing women. 

Quinijie has an oxytocic effect, causing contraction of the 
utems during and after parturition. It may also cause con- 
traction of the uterus when abortion is about to take place. It 
is probably very rare that quinine, in any dose, will produce an 
abortion unless muscular contractions of the uterus have al- 
ready begun. The coincidence of miscarriage occurring after 
large doses of quinine have been administered has been probably 
inexcusably laid to the quinine. A severe chill and fever from 
malarial poisoning can alone produce an abortion. 

Quioine is not now often administered to women to prevent 
or stop the after-pains j if a uterine contractor is needed, pitui- 
tary extract is more popular. 

Oyer-o^/ttW-— Unexpected action from quinine is not infre- 
quent, and not a few individuals have an idiosyncrasy against 
it. The common effects of a large dose are what has been 
termed in totality "dnchonism," namely, ringing in the ears, a 
full-headed feelingj flushed face, sometimes a rapid heart, some- 
times dizziness, and sometimes disturbed vision. Not infre- 
quently quinine will cause an urticarial eruption on the skin. 
This condition of cinchonism may generally be prevented by the 
coincident administration of a bromide. 

Unexpected symptoms, or symptoms of idiosyncrasy, are 
great cerebral excitement even delirium, and more frequently 
swellings of the face, tongue, and other parts of the body, and a 
general anaphylactic disturbance. Individuals who have this 
idiosyncrasy may have serious symptoms from a very small 
dose, even 0.05 or o.io gram of any alkaloid of cinchona, and 
perhaps more frequently from quinine than from cinchonidine. 

Many of these patients who have this idiosyncrasy against 
the first dose of quinine are then not over-susceptible to ordinary 
dosage during that particular illness, but in a subsequent illness 
may be again poisoned by the drug. On the other hand, some 
few individuals should never be given a second dose of quinine. 

O'Malley and Richey* have found that patients showing 
» Archiv, Internal M©d-, Oct., 1919, p. 37S. 



362 THE PRINCIPLES OF THERAPEUTICS 

idios3mcrasy to quinine will give a positive reaction to the skin 
antigen test. They found in some instances that they could 
desensitize a patient by giving a very small dose, as 0.005 G™- 
of quinine with 0.50 Gm. of sodium bicarbonate, and then 
in an hour and a half the patient could take o.io Gm. of the 
bisulphate of quinine with 0.50 Gm. of sodium bicarbonate in a 
cachet without sjrmptoms. Each day they desensitized with 
the same dose and gradually increased the therapeutic dose of 
quinine. 

Toxic Action. — ^The fatal dose of quinine is excessively large, 
and death from even enormous doses is probably almost 
unknown. At the same time, serious cardiac depression may 
be caused, as well as there may be serious eflFects on the eyes 
and ears from excessively large doses. However, a patient 
with a severe malarial fever will withstand enormous doses of 
quinine that would be poisonous to individuals who do not 
have this infection. 

TreatmerU 0] Poisoning. — This depends on the sjrmptoms. If 
the sjrmptoms are cerebral, bromides in large doses, with ergot 
intramuscularly is the treatment. If there is collapse, the 
patient should be kept warm and given suprarenal extract and 
perhaps atropine. Sodium bicarbonate in large doses will prob- 
ably always be of benefit in quinine poisoning. Also plenty 
of water should be administered. 

THE SPECIFIC TREATMENT OF MALARIAL FEVERS 

For very many years cinchona and its alkaloid quinine have 
been used for all malarial fevers, but it was not until the 
Plasmodium malarue was discovered that it was known exactly 
how quinine acted. Quinine is especially efficient in the tertiary 
and quotidian types of malarial fever, less rapidly efficient in 
the quartan and estivo-autumnal types. 

A form of malarial fever is termed "pernicious," in which the 
chill is excessive, the prostration profound, and the patient 
may die in coma, or the fever may be so excessive as to be itself 
dangerous. In this form, quinine if given soon enough and in 
large enough doses is also curative. In this type, namely, per- 
nicious malarial fever, quinine is often given intravenously or 



TREATMENT OF MALAiaAL FEVERS 



363 



subcutaoeously . Although in tropical climates the intravenous 
method has seemed to save lives that otherwise would not have 
been saved, still large doses of quinine intravenously are danger- 
ous, especially if the blood-pressure is low. Also these injections 
should be given slowly. 

Stephens* found that the administration of 30 grains of 
quinine by the mouth on two consecutive days, once a week for 
a period of five weeks, would eradicate malarial germs. He does 
not find that the combination with arsenic is any more efficient 
than when quinine is given alone. 

Two principal methods of administering quinine have been 
used. One method is to give a large dose four or five hours be- 
fore the expected chill. The other method is to give a small 
dose repeatedly, every hour or two. The success of the treat- 
ment perhaps largely depends on the region in which the patient 
who has the malarial poisoning lives. Quite generally in the 
temperate climate, if the dose of quinine sulphate is given in 
soluble capsules four hours before the expected chill, when the 
type is learned and it is known when the chill will occur, it is 
verj'' successful in preventing or at least greatly modifying the 
next paroxysm. Namely, if the chill is expected at 10 A. M.^ 
the patient is given 0,60 Gm. {10 grains) of quinine at six o^clock 
in the morning with some cofJee and toast, or with some milk. 
He then goes to bed, and receives no more quinine until the 
evening of that day, at which time he should receive 0.30 Gm. 
(S grains) after the evening meal, and the same dose three times 
a day, after meals, on the following day. At six o Vlock on the 
second morning he should take another lo-grain dose. Ordi- 
narily the patient will have no more chills. If he omits the 
chill on the second period, he need take no more quinine on that 
day. On the following day he may take 5 grains twice a day 
for several days, then 3 grains three times a day for several more 
days, and finally 2 grains three times a day for several weeks. 

To prevent cinchonism from the larger doses a sodium bro- 
mide mixture should be prescribed, each 5 mils representing i 
Gm. of the bromide, and the patient may be given 0.20 Gm. (3 
grains) of the bromide for every 0,06 Gm. (i grain) of the qui- 
* Annals of Tropical Medicine and Pamsitology, Liverpool, May 12, 1919, p. 69. 



364 THE PRINCIPLES OF THERAPEUTICS 

nine. In other words, when he takes 0.60 Gm. (10 grains) of 
quinine he takes 2 Gm. (30 grains), 2 teaspoonfuls, of the bro- 
mide; and when he takes the 0.30 Gm. (5 grains) of quinine he 
takes I teaspoonful, representing i Gm. (15 grains) of the bro- 
mide, and dnchonism will ordinarily not occur. If a patient 
b weak and it seeems inadvisable to give him bromide, ergot 
may be given an hour or so before th^ dose of quinine, and dn- 
chonism may thus be prevented. 

The size of the dose of quinine of course depends upon the age 
of the patient, the intensity of the chill, and the severity of the 
illness. 

As above stated, quinine will probably not kill the malarial 
Plasmodium when in spore form. Therefore, quinine must be 
more or less in evidence in the blood awaiting the development of 
the spores into mature plasmodia, when the quinine is actively 
effective. Some clinicians believe that the patient should 
receive a dose of quinine in the middle of the night, as not 
sufficient quinine will remain in the blood to kill these maturing 
spores. But when it is recognized how slowly quinine is ex- 
creted, at least after several doses have been taken; also when it 
is remembered how long it takes the spore to develop, it would 
seem unnecessary to give the quinine at night, unless there was 
a double infection and the type was quotidian. 

It is always well to give a good purgative, either calomel or 
castor oil, before beginning the quinine treatment, if one can wait 
for the action of the purgative, as it is best that the intestines 
should be clean and that the liver should be relieved of impaired 
bile and should be ready for its detoxicating action both on the 
quinine and on the results of the infection. The diet should 
also be low on the first day or two of treatment, but as soon as 
the patient is without fever he certainly should receive good 
nourishment, but not much food for five or six hours, at least, 
before the expected chill. Large amounts of water should 
always be given during the treatment. 

When it is deemed advisable to give quinine frequently rather 
than in the above infrequent doses, the amount should generally 
be either o.io Gm. (ij^ grains) every two hours, or 0.15 Gm. 
(2M grains) every three hours, in capsule, and this dose should be 



TREATMENT OF MALARIAL FEVERS 



3^5 



continued night and day for two days, and then a little less 
frequently for a few more days. 

At times it seems well to stop the quinine for three or four 
days and give iron, which seems to help drive the plasmodia 
from the parts of the body in which they hibernate (perhaps 
mostly in the spleen), allow them to mature, and then give a 
day or two of intensive treatment with quinine, and then con- 
tinue the small tonic dose for a long period. Often it is best to 
give arsenic, either atone or coincidently with quinine, o.ooi or 
0.002 Gm. (3 eo or ?.fo grain) of the trioxide, three times a day, 
perhaps well combined in a dry capsule \Wth quinine o.io Gm, 
and reduced iron 0,05 Gm. This capsule may be given for some 
time, perhaps omitting it during the menstrual period of women, 
pro\ided that there are no active malaria symptoms. 

It has lately been shown, especially in the Southern parts of 
the United States, that the malarial plasmodium is harbored for 
many months in the body unless it is positively driven out* 
Hence intensive treatment of malarial fever is urged, on the 
belief that it requires long treatment with large doses to posi- 
tively detoxicate an individual who has once been infected by 
the malarial plasmodium. 

Mayne and Carter^ offer the following scheme for the treat- 
ment of a patient who has malarial plasmodia in his blood: give 
40 grains of quinine a day for five days; half this dose for double 
the number of days, namely, 20 grains for ten days; and then the 
same ratio of reduction of the dose and of increase of the days, 
namely, 10 grains for twenty days, and lastly, 5 grains for 
forty days. 

Bass,^ who has for years carefully investigated the subject 
of the treatment and prevention of malaria, believes that the 
detoxication treatment should be as follows: 10 grains of qui- 
nine sulphate every night before retiring for a period of eight 
weeks. For children the dose should be 3 2 ^ grain before one 
year of age, i grain after one year of age, 2 grains after two 
years of age, 3 grains for the third and fourth years of age, 4 
grains for the fifth, sixth and seventh years of age, 6 grains for 

* The Journal A. M. A», Oct. 11, 19 19, p. 11 19. 
*Thc Journal A. M. A,^ April 26, 19191 p. iai8. 



366 THE PRINCIPLES OF THERAPEUTICS 

the eighth, mnth, and tenth years of age, 8 grains for the eleventh 
twelfth, thirteenth and fourteenth years, and 10 grains for all 
over fifteen years of age. 

There probably is no way to eradicate malarial fever except by 
preventing an infected patient from becoming a carrier. During 
the acute infection the room should be screened so that there 
is no possibility of mosquitoes biting him and becoming trans- 
mitters of the disease. Also the patient should be so detoxicated 
that he can never cause a mosquito to become infected, which 
might occur if he is a carrier, though he himself may apparently 
be immune to the disease. 

There seems to be no excuse for administering quinine during 
the chill and subsequent fever. If the patient is seen first dur- 
ing the chill, the sweating stage should be hastened by giving 
him drinks of hot lemonade, and surrounding him with hot 
water bags. If the patient is seen during the intense headache 
and high fever, he should be given a dose of an antipyretic, 
as 0.20 Gm. (3 grains) of acetanilid, with 0.50 Gm. (7)^ grains) 
of bicarbonate of sodium, with hot tea or hot lemonade, or, if 
he prefers, lemonade of ordinary temperature, certainly not 
iced. Or he may be given i Gm. (15 grains) of antip3nine. As 
soon as the sweating stage develops, he is comfortable, and 
except for preventing his becoming chilled, he should receive 
no treatment, unless it seems advisable to begin the quinine, 
which ordinarily, however, may wait until a few hours later. 

Lately there has been considerable discussion as to the value 
of so-called prophylactic doses of quinine, such doses being 
given to individuals who must go to, or remain in, climates 
where malarial infected mosquitoes are known to be abundant. 
Such treatment, however, has proved not to be very successful, 
and the only successful prevention is to abolish the mosquito 
in the regions where civilized man must remain. That this can 
be done is shown by the wonderful prophylactic sanitation of the 
Panama Canal region. As just stated, it is still disputed 
whether from 3 to 5 grains of quinine taken daily will prevent 
infection from a bite of an infected mosquito. Cowan and 
Strong^ have recently stated that some patients, having taken 

* Quarterly Joum. of Med., Oxford, Oct., 1919, p. i. 



TREATMENT OF MALARIAL FEVERS 



36? 



quinine for a long time, really suffer from quinine poisoning, and 

especially is it inadvisable to give very large doses in chronic 
malaria. They would rely on arsenic in chronic malaria. 

This difference of opinion from different parts of the world 
may represent different types of the disease. There is no 
question that we must recognize that the constant taking of a 
protoplasmic poison as is quinine cannot be to the advantage of 
the individual. It is an appetizer and a stimulant, but at the 
same time it may inhibit many cellular and glandular activities. 
It also is a habit-forming drug; the patient soon misses the 
stimulation when the drug is stopped. At times it has been 
noted in tropical regions that if hemoglobinuric fever develops^ 
those who have taken considerable quinine previously have the 
disease more severely. We must, how^ever, come to the con- 
clusion that for short periods at least, a prophylactic dose of 3 
to 5 grains of quinine aids in preventing malarial infection. 

The treatment of estivo-autumnal fever combines so much 
more than the administration of quinine that it belongs to a 
book on therapeutics. The relation of hemoglobinuric fever 
to malaria and the treatment with quinine is also too broad 
a subject to here discuss. Suffice it to say that in some cases 
the administration of quinine may increase the danger from 
hemoglobinuria, however, it seems still to be the best treatment 
for this form of fever. The germs of hemoglobinuric fever can 
undoubtedly, without any action of quinine, cause hemoglo- 
binuria. Also this infection may p'roduce a nephritis. 

Pernicious malarial fever, so called congestive cMUs, is 
recognized as of great danger to the patient; therefore intensive 
treatment with quinine is necessary. If there is not time be- 
fore the expected next chill for the absorption of a large dose of 
quinine, perhaps 40 to 50 grains, it has been advised to give the 
drug either subcutaneously, intramuscularly, or intravenously. 
It seems that intramuscular or subcutaneous injections of 
quinine are hardly safe, even in the form of the quinine and urea 
hydrochloride, as serious destruction of tissue may be caused. 
Also intravenous injections may cause serious symptoms, 
especially if the blood-pressure is low. 

In so-called chronic malarial poisoning, often associated with 



J 



368 THE PRINCIPLES OF THERAPEUTICS 

an enlargement of the spleen, various treatments have been 
suggested, all with quinine as a basis. Hydrotherapeutic 
measures, sweating treatments, and the administration of iron, 
arsenic and quinine represent the best treatment. 

For patients who cannot take quinine and who have malarial 
fever, arsenic and methylene blue are the best, but poor, 
substitutes. 

Other Uses. — Quinine in small doses has long been used as 
a tonic. It increases the appetite and tends to raise the blood- 
pressure. 

The dihydrobromide of quinine is many times very successful 
in the tachycardia of Graves' disease. The dose must be large, 
at least 0.30 Gm. (5 grains) three times a day, and it must 
be given for some time. The disagreeable dnchonism at first 
caused is soon not in evidence, and the drug is generally well 
tolerated. 

The anesthetic properties of quinine and urea hydrochloride 
have been much lauded, especially to cause desired necrosis. 
It would seem hardly safe to inject this drug into the thyroid 
gland in Graves' disease, although it has been advocated. The 
use of the drug to destroy tissue has been well described by 
Babcock.* The first sensation caused by this drug, when in- 
jected, is intense burning, which is soon dulled by the anesthetic 
action. When injected under the skin Babcock states that 
the tissue becomes at first anemic, then necrotic, and a few 
days later there is a black eschar. When injected into mucous 
membrane, the black eschar does not occur. There is likely 
to be a good deal of edema develop in the region of the injection, 
and there also is considerable danger of a patient having an 
idiosyncrasy against quinine and developing unpleasant 
symptoms. An idiosyncrasy could probably be readily deter- 
mined by the skin antigen tests, as above suggested. Babcock 
believes this anesthetic destroyer of tissue may be valuable 
to use in port wine stains or birth marks, for some growths on 
the skin, and to destroy warts and moles . 

This drug may be obtained in ampules, from a few drops to 
2 mils of which may be injected, depending upon the area it is 
* New York Med. Joum., March 3, 191 7, p. 385. 



SERUMS IN HEMORRHAGE 



369 



deared to destroy. It would seem that other methods of 
cauterization and destruction of tissue would be safer. 



SERUMS AS SPECIFICS m HEMORRHAGE 

The drugs used to stop external bleeding have been termed 
styptics. The best for local use are peroxide of hydrogen 
solutions; ferric salts; suprarenal extracts; ice; and, perhaps, 
cauterization. It should not be forgotten that the most effec- 
tive means of stopping external bleeding is by pressure, either 
at the point of bleeding or on the artery above. 

The method used to stop internal bleeding depends somewhat 
upon the location of the bleeding part, but anything that 
lowers blood-pressure and quiets the heart's action tends to 
stop hemorrhage; hence resj, quiet, and at times, in nervous 
excitement, small doses of morphine, if the hemorrhage has not 
been too great in amount, are of great benefit in causing the 
bleeding to cease. 

Nitroglycerin is valuable in lowering blood-pressure and in 
stopping internal hemorrhage, especially in hemoptysis. It is 
a mistake to give drugs that raise the blood-pressure during 
hemorrhage unless that hemorrhage is venous and is due to 
insufficiency of the heart* Venous bleeding is likely to be 
from the nostrils, or it may be from the lungs In such a case 
digitalis w^ll be of benefit, although it does not act until some 
hours after it has been administered. In most internal hemor- 
rhage, strychnine, suprarenal, atropine, caffeine, ergot, tyra- 
mine, etc., are contraindicated. Ergot is of value in uterine 
hemorrhage when the uterus is dilated, as it contracts that organ, 
and therefore closes the bleeding vessels. 

Bleeding from the nose may be checked by cotton tampons, 
dry or soaked in peroxide of hydrogen soluUon or in some more 
active stjrptic, or by post-nasal packing. Applications of an 
epinephrine solution may stop the hemorrhage, but it is likely 
later to cause local congestion. 

Hemoptysis may be checked by rest, nitroglycerin, and 
morphine in a small dose if needed. Repeated bleeding may 
require calcium, digitalis, or some serum injection^ and possibly 
the injection of gas or air into the pleural cavity. Hematemesis 

24 



370 THE PRINCIPLES OF THERAPEUTICS 

may be stopped by a suprarenal solution taken into the stomach, 
or by swallowing ice, and by rest. 

Intestinal hemorrhage may be combated by some tannic acid 
preparation, as protan (^'tannin nucleo-proteid")> by gelatin, 
by calcium, and by rest. Morphine may be necessary to 
cause peristaltic rest. Kidney hemorrhage perhaps is well 
treated by gallic add. It is doubtful if cotamine salts, as 
cotamine hydrochloride or cotamine phthalate (styptol) are 
of any value. 

Of course it is understood that in every case of internal 
bleeding, the exact cause must, if possible, be determined, and 
often surgery must be invoked to cure the condition of which 
hemorrhage is a symptom. If the blood does not normally 
coagulate, calcium must be administered in the form of lime 
water or as calcium lactate, and plenty of milk must be given. 

Thromboplastic substances and fibrin ferments, brain extract 
and so-called kephalin and coagulin are described on pages 371, 
and 509 but the serum from blood seems to be the most active 
coagulant that we can administer. 

The blood serums used are from the human, from the horse, 
and from the rabbit. The senmi of the rabbit is perhaps more 
similar to human serum than that of the horse, but horse serum 
is always available, as it can be obtained in sterile ampules or 
in the form of diphtheria antitoxin, and when other serum 
cannot be obtained, the contents of an ordinary tube of diph- 
theria antitoxin, representing the fewest units, may be injected. 
Subcutaneous injection of course is a slower therapeutic method 
than the intravenous injection. It must be known whether 
the patient is susceptible to the emanations of the horse, f.«., 
whether he has any hay fever or asthma when in the region of 
a horse or a stable, else serious poisoning, serum sickness, may 
be caused. 

Theoretically when it can be obtained, normal human serum 
from a person who is known not to be diseased, and in whom the 
Wassermann test is negative, is the best serum to use. From 
xo to 20 mils of the serum may be given to hemq[>hiliac patients 
daily for a short time, until the bleeding stops. While human 
bkxid should not be administered intra\-enousIy to a patioit 



COtCHICUM FOR GOUT 



371 



luiless ike tests have been made to show that the donor's blood 

is not destructive to the recipient's blood, semm from a donor 
may be injected without such an examination. At the present 
time transfusion has become so successful that, when possible, 
it should be the treatment for a hemophiliac or for one who 
has a serious hemorrhage, unless more simple treatments are 
quickly successful. 

At times profuse bleedings occur on account of endocrine 
gland disturbances, and sometimes the administration of 
thyroid extract is successful in stopping such bleedings, and 
at other times suprarenal extract is successful 

Coaguloscy which is a dried product prepared from horse 
serum, comes in ampules, ready for use. It may be placed dry 
on a bleeding surface, or it may be dissolved in sterile water 
and injected subcutaneously. The whole contents of the 
ampule J representing about 10 mils of the fresh scrum, may be 
injected and repeated , every few hours if deemed advisable. 

Gelatin may be dissolved and given for hemorrhage from the 
stomach and intestines, and may be of some value, when 
absorbed, for other forms of internal hemorrhage; but to inject 
preparations into the muscle tissues, even if sterile, is inadvis- 
able. If gelatine is used for injection purposes it must be 
thoroughly sterilized, as it may contain the germs of tetanus. 

Thromboplastin solutions for injection come in sealed vials 
containing 20 to 25 mils of the solution. These preparations 
are likely to deteriorate, and therefore should be kept where 
they are cool, like other serum products, and should be dated. 



CLASS VIII 

Drugs Used as Specefics 
colghicum m the treatment of gout 

The cause of gout is unknown, but it is of interest to note 
that as arthritis deformans, which is due to some focal infection, 
is more and more frequently recognized, gout is becoming less 
frequent. However, there is a disease or a condition of gout, 
and the tendency to gout is inherited. 




372 THE PRINCIPLES OF THESAPEUTICS 

At the present time gout need not be listed with the infec- 
tions, but rather with the metabolic disturbances, and it seems 
to be due to some mistake in the nitrogen metabolism some- 
where from intake to output. 

It also seems to be a fact that the more purins ingested, 
the more the gouty symptoms in gouty patients. However, 
uric add is not a cause of gout, and ''uric add diathesis" and 
"uricaddemia" are not good terms. Still, in acute gouty 
disturbances the uric add output is likdy to be diminished, and 
relief occurs when the output of that substance is increased. 

It is not necessary here to discuss the relationship of the 
liver to gout, except to note that urea is largely formed and 
uric add largely destroyed in that organ, and a disturbance 
of the liver might be a cause of gout. Also, doubtless the 
suprarenals and the thyroid take part in nitrogenous metab- 
olism, and generally in gout intestinal mal-function is in evi- 
dence. Also the gonads play some part in the development 
of gout. 

As to food for gouty patients it is necessary only to state 
that the purins should be removed from the diet, except that 
meat may be allowed once a day. Some gouty patients are 
always disturbed if they ingest certain purins, and a gouty 
patient perhaps generally has a higher percentage of uric add 
in his blood than is the normal average. 

To properly treat gout we must carefully study the fxmctions 
of each organ, and study the nitrogen and uric add excretion in 
the urine on a known diet. The foods and liquids found to 
cause the least disturbance (to be the best digested and the 
best excreted) should be the diet for each particular patient. 
Whatever acute conditions are present should of course be 
treated. In other words, there is no one way to treat or manage 
chronic gout, and a food that is inadvisable for one patient 
might be perfectly well taken care of by the next patient. Even 
to order an increased amount of water drunk may be a mistake 
for some patients, although more water than these gouty patients 
ingest is generally advisable. It is not proposed to discuss the 
whole treatment of gout, but only the value of colchicum in 
the treatment of that disease. 



COLCHICUM 



373 



r 



Colchicum is of very little value in chronic gout, and in acute 
gout its greatest value may be due to its purgative properties. 
In subacute and chronic gout salicylates are not very satis- 
factory, although they may be of some value. Cinchophen 
(atophan)j Acidum Phefiylcinchmdnkum^ to increase the 
output of uric acid may be of great value, and pushing 
alkalies to increase metabolism and decrease acidity is often of 
value. 

Coichicmn St^--Adfninhiraiimi.^Qo\c\ixzvLm seed is best 
used in the form of the official tmcture {Tindura Cokhici Scm- 
iniSj a solution representing lo per cent, of the drug)j the dose of 
which is 2 mils ( 3| a fluid rachm) . It should be given in sufficient 
dose to cause slight purging; too much purging should be pre- 
vented by proper treatment. Colchicum should always be 
administered in a liquid preparation. 

The alkaloid of colchicum is oflicial as Cokhtcina (colchi- 
cine). This alkaloid occurs as pale, yellow scales or powder, is 
soluble in water, and the dose is 0.0005 ^^- (ii20 g^'^^)- 
Pearls or capsules of this drug may be obtained in which the 
alkaloid is dissolved in oil of wintergreen. Such a preparation 
is much used in subacute gouty conditions. This is a very 
active alkaloid, and may cause some depression, 

Actioti. —Vtlhen taken internally solutions of this drug may 
cause some gastric irritation, but if diluted, the bitter taste may 
increase the appetite. It is rapidly absorbed; may increase the 
secretion of the salivary glands and other digestive secretions; 
increases peristalsis; and in large doses acts as a purgative. It 
may slightly depress the nervous system, slow the heart, and 
lower the blood-pressure. The output of urine is often in- 
creased under the action of colchicum, and, if there is 
increased temperature in an exacerbation of gout, per- 
spiration may be caused by the full action of this drug. It is 
excreted partly through the intestines and partly through the 
kidneys. 

(her-aclion. — The only over-action of colchicum is purgation 
and some circulatory depression, though there may be vomiting 
and abdominal pain. If such a condition is not properly treated, 
collapse might occur. 



374 THE PRINCIPLES OF THERAPEUTICS 

Toxic Action. — Rarely serious poisoning may occur from a 
very large dose of colchicum. The main symptoms are gastro- 
enteritis with bloody stools, intense colics, and collapse. The 
condition is difficult to cure, but fortxmately such poisoning is 
exceedingly rare. 

Treatment of Poisoning. — ^The treatment of poisoning is to 
give an emetic if it is considered that part of the drug is still in 
the stomach, and to hasten the movement of the drug through 
the intestines by a saline purgative, and later to stop the peris- 
talsis and colic by a hypodermic of morphine and atropine. 
The usual soothing treatments should be given to the gastro- 
intestinal canal. Of coxirse, if prostration is present it is inad- 
visable to give emetics or purgatives. In that case, tannic add 
should be given, and supporting treatment, as caffeine, atropine, 
and perhaps strychnine. 

Uses. — There is no therapeutic use for colchicum except in 
gouty conditions, and, as stated, it is of little value in chronic 
gout. Also when joints are acutely inflamed, due to gout, it is a 
question if free purgation and the administration of salicylates 
will not be of as much benefit as colchicum. Colchicimni should 
never be administered, if there is acute gastric or intestinal 
inflammation, neither should it be pushed in debilitated 
patients. 

Although it has been thought that the preparation of the 
root is better than the preparation of the seed, also that 
the wine of the root is the best preparation, it is probable that 
colchicum is colchicum, and if a good preparation of the seed is 
given in sufficient amoimt, the action must be the same as with 
any other form of colchicum. 

At times alkalies seem to be of value in gout, and the best is 
potassium citrate. There is absolutely no use for lithium, either 
as a drug, or in waters containing lithium. They have no sol- 
vent properties on uric add or urates or any other concretions. 
The multitude of "anti-gout" preparations, mostly supposed 
to contain lithium, and all supposed to prevent the formation of 
uric add and increase the output of uric add, are all inefficient, 
useless remedies. The best preventive of the formation of con- 
cretions is distilled water. 



SALICYLIC ACID 



375 



P 



SALICYLIC ACID m THE TREATMENT OF RHEUMATISM 

While salicylic acid is not a real specific for acute rheumatism, 
it is the most efficient drug that we possess for modifying the 
joint pains, safely reducing the temperature, and promoting 
eliminating perspiration in that disease. 

As there are many joint disturbances that are misnamed 
rheumatism, it may be well to first define what is rheumatism, 
and especially the kind of rheumatism that is best treated by 
salicylates. Acute rheumatism, rheumatic fever, is an infec- 
tious disease, probably rarely contagious, caused perhaps by 
several germs, characterized by inflammation of the structures 
in and around joints, namely, arthritis, and with a very decided 
tendency to cause inflammation of the heart. So-called sub- 
acute rheumatism is simply a mild attack of acute rheumatism 
without much fever, without the tendency to migrate from joint 
to joint, but with the same tendency (only not as decided) to 
affect the heart. Chronic arthritis, arthritis deformans, and 
gouty arthritis are entirely different conditions, in which the 
salicylates are not of much value. 

The infection of acute rheumatism most frequently enters 
the body through the tonsils, hence infected tonsils are a menace. 
Recurrent follicular tonsUlitis makes the individual likely to 
develop acute rheumatism at any time. Children and youth, 
who are more likely to have enlarged and diseased tonsils, are 
the ones most likely to have this disease and chorea, a closely 
allied disease. Chorea, as well as inflammatory rheumatism, 
frequently causes the serious complication of endocarditis. 
Also both acute and chronic endocarditis may develop in chil- 
dren and adults from infected tonsUs and teeth without any 
joint trouble appearing; hence the menace of these focal infec- 
tions. It may here be interpolated that the greatest menace in 
the United States to-day is that of crowded, bridged, and 
pivoted teeth. Arthritis deformans is due to infection, mostly 
from the mouth. 

The germs that cause rheumatism and chorea are not pus- 
forming, hence the infected joints and tissues do not suppurate. 
It has been thought that one attack of rheumatism predisposes 
to another, probably because the focal infection has not been 




376 THE PRINCIPLES OF THERAPEUTICS 

eradicated. However, the disease does not confer an immunity, 
and hence may be repeated. 

• This is not the place to discuss the advisability of eradicating 
enlarged tonsils, but certainly there can be no question of the 
advisability of removing all diseased portions of tonsils and all 
focal mouth infection. 

Salicylic Add* — Salicylic add exists in natural combination 
in various plants, and is also prepared sjmthetically. It occurs 
as fine needles or crystalline powder, has a sweetishj^acrid taste, 
and is slightly soluble in water. The dose is 0.75 Gm. (12 
grains). 

Sodium Salicylas. — Sodium Salicylate occurs as a white crys- 
talline or amorphous powder, has a sweetish taste, and is very 
soluble in water. The dose is i Gm. (15 grains). Sodium 
salicylate does not keep well in weak solutions. 

Methylis Salicylas, (Oil of wintergreen; oil of betul; oil of 
sweet birch). — Methyl salicylate is made synthetically or is 
produced by distillation, and the label should designate by 
which method the preparation is obtained. It occurs as a 
yellowish or reddish liquid with the odor and taste of winter- 
green. The dose is 0.75 mils (12 minims). 

Acidutn Acetylsalicylicutn. — Acetylsalicylic add (aspirin) 
occurs as small crystals or as a white crystalline powder. It 
has an add taste, is slightly soluble in water, and the dose is 
0.30 Gm. (5 grains). 

Administration. — Salicylic acid is more irritating to mucous 
membranes than is sodium salicylate. Also sodium salicylate 
is much more soluble, and hence more readily absorbed. There 
is, therefore, rarely any excuse for giving salicylic add internally 
in preference to sodium salicylate. As sodium salicylate has a 
wintergreen taste, it is well to give it dissolved in wintergreen 
water, and a prescription containing i Gm. of sodium salicylate 
to 5 mils of wintergreen water is a useful one, as it may be given 
in J^ teaspoonf ul, teaspoonful, or 2 teaspoonf ul doses, as deemed 
necessary. Both salicylic add and sodium salicylate should be 
given well diluted. Syrup of orange or syrup of ginger may be 
added to a sodium salicylate liquid solution, if the sweet winter- 
green taste is espedally disagreeable to a patient. 



SAUCYTJC ACID 



377 



Methyl salicylate is not much used internally, although there 
is no good reason why it should not be, provided it is well 
diluted and the stomach is not empty. Methyl salicylate is 
frequently used in ointments or liniments on rheumatic joints, 

AcetylsaUcyUc add (aspirin) is now very popular for colds, 
headaches, muscle pains, and joint pains, but in rheumatism it 
cannot be pushed to the point of salicylism as effectively or as 
safely as is sodium salicylate. Aspirin is more sedative in 
painful conditions not due to rheumatism. On the other hand, 
it is more or less of a cardiac depressant and it should be recog- 
nized that whenever aspirin in full doses is given the patient 
should remain at rest, as he has taken a drug that acts not im- 
like acetphenetidin. 

There has long been a discussion as to whether synthetic 
salicylic acid preparations were more depressant to the heart 
than natural salicylic acid preparations. Clinical and labora- 
tory experiments have seemed to show that there is no difference 
in the toxicity of the two kinds of preparations. Also thera- 
peutically natural oil of wintergreen seems to be of no greater 
value than the synthetic preparation, methyl salicylate. 

There are very many salicylic acid preparations on the 
market, proprietary preparations which are supposed to offer 
salicylic add action without the sting of salicylic add, i.e., they 
do not disturb the stomach, and are supposed to be as effident. 
These drugs do not represent nearly as much salicylic add, dose 
for dose, as does sodium salicylate, hence to obtain the same 
action and effect very much larger doses must be given, and 
with such doses the same unpleasant symptoms as with sodium 
salicylate will generally occur. 

SaUcylic add is strongly antiseptic and mildly escharotic, 
and a lo to 20 per cent, ointment of salicylic add will remove 
warts and callous skin< An efficient solution for this purpose is 
made by dissohdng i Gm, of salicylic add in 30 mils of collodion. 

Action. — Salicylic add as such is irritant to the skin and 
mucous membranes, and, when taken into the stomach, will 
cause nausea and vomiting, as well as irritation and inflamma- 
tion, unless it is well diluted. All salicylic add preparations, 
except those insoluble in the stomach, slow digestion. Salicyl- 



378 THE PRINCIPLES OF THERAPEUTICS 

ates are rapidly absorbed, and soon appear in the urine as 
salicyluric acid. Salicylic add seem to be slightly stimulant 
to the liver, and may increase the secretion of bile. 

Small doses do not much affect the circulation. There may 
be slight stimulation of the heart, perhaps a slight increase of 
blood pressure, but large doses may depress the heart. With 
full doses the rapidity of the heart is increased, there is a feeling 
of fullness of the head, ringing in the ears (and there may even 
be deafness) , and flushing of the face. This condition is termed 
salicylism, and is very similar to dnchonism. 

Normal temperature is not much affected, but in feverish 
processes the temperature is reduced, and the perspiration is 
increased, especially in rheumatic fever. All salicylates in- 
crea^ waste metabolism, and the body loses weight xmder their 
full action. 

Salicylates are excreted chiefly by the kidneys, partly as 
salicylic add, partly as salicyluric add, and perhaps in part as a 
salicylate. Some of the salicylic add may be excreted in the 
sweat, and some in the feces, and some may be destroyed or 
retained in the body. There is at first an increased excretion 
of urea and uric add, although the function of the kidneys may 
be soon disturbed. Hanzlik and Karsner^ found that full doses 
of salicylates very easily cause albumin to appear in the urine; 
that renal function, on repeated full doses, is soon impaired; and 
that urea nitrogen accumulates more or less in the blood. 
Hanzlik and others found the administration of bicarbonate of 
sodium with the salicylate does not prevent this bad effect of 
the salicylates. 

Fan tun, Simmonds and Moore* found that sodiimi salicylate is 
not well tolerated in animals infected with hemolytic strepto- 
cocd, and that the coinddent administration of sodiimi bicar- 
bonate does not prevent this harmful action. They also foxmd 
that acetylsalicylic add (aspirin) was more toxic to normal 
animals than sodiimi salicylate, and also harmful to infected 
animals. 

These experimenters apparently demonstrate that salicylic 

* Archives of Internal Medicine, June, 191 7, p. 1016. 
'Archives of Internal Medicine, April, 191 7, p. 529. 



SALICYI.IC ACED 



379 



add in any form should be used, if at all, with great care when 
the kidneys are imperfect. Also, that salicylic acid should not 
be given in any general infection except as a specific in acute 
rheumatic fever. However, salol in small doses may be of 
benefit as a bowel antiseptic in t>T>hoid fever, but the dose 
should always be small, and it should be stopped as soon as 
albumin is discovered in the urine. 

Over-actimi. — Over-action from salicylates is evidenced by the 
symptoms above described, termed "salicylism;*' by flushing of 
the face and of the whole skin; by erythemas and urticarias; 
sometimes by rapid heart action; by albuminuria; and by 
great diminution of the amount of urine, or suppression. All 
of these symptoms generally quickly disappear on stopping 
the drug, giving alkalies, large amounts of water, and adminis- 
tering a bromide. 

Toxic Action. — More serious poisoning may be caused by 
large doses of salicylates, in which the sight is impaired^ the 
patient becomes deaf, has dyspnea, may be delirious, and may 
even become collapsed and have a weak pulse and cold perspi- 
ration. Patients who are suffering from cerebral disturbances, 
as in alcoholism, seem to have more of the head symptoms 
from salicylates than patients who have not such disturbances. 
Occasionally hemorrhages have been caused by salicylates, 
either nasal or uterine. 

Treatment of Poisoning, — Patients severely poisoned by this 
drug should receive not only the treatment above suggested 
for over-action, but also, if collapsed, require cardiac stimulants, 
and should be surrounded by dry heat. 

Uses, — Sodium salicylate is generally the drug of preference 
in acute rheumatism, and it acts almost specifically in quieting 
the pain, lowering the temperature^ and modifying the intensity 
of the whole disease. It has not been shown that it will shorten 
the disease or abort it, but it does make the patient's condition 
more comfortable. Morphine may be needed to assist in 
stopping the pain before the salicylate has reached its full 
effect. It seems generally advisable to push the drug until 
some signs of salicylism are present, aod the adult dose of 
sodium salicylate is i Gm. (15 grains) administered, at first, 




380 THE PRINCIPLES OF THERAPEUTICS 

four or five times in twenty-four hours. As soon as signs of 
salicylism develop, the frequency of the dose may be diminished. 
If, in acute rheumatic arthritis, the patient is not improved by 
this drug in four or five days, or at least at the end of a week, 
the salicylic add treatment should be stopped and other drugs 
substituted. Coinddently, or certainly after the drug is 
stopped, alkalies seem to be the best treatment. 

As above stated, acetylsalicylic add is too depressant to 
push to full physiologic effect in acute rheumatic arthritis; 
it is much more depressant to the heart than sodium salicylate. 

K desired, an effervescing mixture may be prepared, as: 
salicylic add, i gram, and sodium bicarbonate, i gram. This 
powder, which is placed and kept in waxed paper, when dis- 
solved in a glass of water, makes a pleasant effervescing drink. 
Oil of wintergreen may be given in a dose of i mil (15 minims) 
dther in ready prepared capsules, or dropped into some demul- 
cent drink. It should not be given on an empty stomach. 
Oil of wintergreen (methyl salicylate) may be rubbed over the 
affected joints, or applied on cotton to the joints. 

It has been considered by some physicians that after a patient 
is convalescent from acute rheumatism, it is well to give another 
few days of treatment with salicylic add in some form. 

As salicylates all promote waste and seem to more or less 
destroy or prevent the development of red corpusdes, all these 
rheumatic patients become anemic, and they require iron as 
soon as the acute fever has passed. If the feverish process is 
prolonged, they should be given iron in small doses, daily, and 
should receive iron during convalescence and for a long period 
thereafter. 

If endocarditis develops, it is generally considered best 
to stop the salicylate, espedally as it has been shown that 
salicylic add does not abort or shorten the rheumatic attack, 
it only makes it more comfortable. It is not a specific anti- 
dote to the disease. 

After every attack of acute rheumatism the patient should 
be carefully studied for focal infections, espedally of the 
tonsils and mouth, and if fod of infection are foxmd they 
should be eradicated before another attack develops. 



SAUCYUC ACID 



381 



As above stated, other forms of rheumatism are not as sue- 
cessfully treated with salicylates, with the exception of subacute 
arthritis. However^ in many patients who seem to be rheu- 
matic and who have sciatica or other neuralgic conditions due 
to some infection or to some uric acid mistake in the metabolism, 
salicylates^ given for a few days^ often improve the condition. 
Of course in every such case the diet should be so regulated as to 
remove most purins, and frequently meat should be stopped 
entirely, and patients with acute rheumatism should generally 
not be allowed meat for several weeks. Although uric acid is 
not the cause of rheumatism, it may be increased in amount and 
be retained in rheumatic conditions. Also, these patients are 
very generally hyper-acid, and are much benefited by alkaline 
treatment, and are frequently improved by a vegetable protein 
and carbohydrate diet. 

Contraindications to the use of salicylates are cerebral 
inflammations and disturbances, disease of the ear, deafness, 
acute cardiac inflammation, and nephritis. 

Phenyl Salicylate {Salol). — Phenyl salicylate occurs as a 
white crystalline powder, has an aromatic odor, is insoluble in 
water, and the dose is 0.30 Gm. (5 grains). 

Phenyl salicylate (salol) should not often be used in rheuma- 
tism. Its greatest efficiency is as an antiseptic in the bowels 
and in the urinary tract. When this drug is given in too fre- 
quent or too large doses, poisoning occurs, with black urine and 
the nerv'ous disturbances caused by its phenol. Occasionally 
it may cause salicylism* 

Salol is not dissolved in acid media, but breaks up in the 
intestine into its component parts of phenol and salicylic acid, 
and, therefore, acts more or less as an antiseptic in the upper 
part of the intestines and tends to prevent putrefaction and fer- 
mentation, and causes constipation. In any acute diarrhea salol 
is a most efficient remedy, always provided there is no albumin- 
uria or other serious disturbance of the kidneys, as it should not 
be given when the kidneys are in trouble. 

Acute diarrhea is weU treated by a purgative, followed by 
bismuth subcarbonate i Gm. (15 grains), and phenyl salicylate 
0.30 Gm. (5 grains), one such powder given every two or three 



382 THE PRINCIPLES OP THERAPEUTICS 

hours for ten doses. Most diarrheas will stop with such treat- 
ment. 

In typhoid fever salol is frequently given as a bowel anti- 
septic, and the dose should be 0.25 Gm. (4 grains), in capsule, 
once in six hours, unless the kidneys are in trouble. It may be 
given throughout the acute illness, if some other treatment is 
not preferred. It may prevent the t3rphoid germs from migrat- 
ing upwards in the intestine, and the typhoid and colon bacilli 
from locating in the pelvis of the kidney. There is no question 
of the antiseptic action of salol in the upper part of the intestines, 
and also in the kidneys and bladder. 

Salol has been much used in infection of the pelvis of the kid- 
ney and in infection of the bladder, and also in specific urethri- 
tis. Hexamethylenamine has more or less supplanted this drug, 
but salol is many times a valuable treatment during acute in- 
fection of these parts. It has been thought, in specific urethri- 
tis that it at times prevents the gonococd from reaching the 
posterior urethra and bladder. 

Salol is not a good treatment in acute rheumatism, as in 
such a condition the dose must be large and phenol poisoning 
would be readily caused. 

CXASS DC 
Drugs used to Modify Metabolism 

ARSENIC 

Arsenic in sufficient dose is a germicide, and is especially 
efficient in combating certain germs. In large doses it is a 
promotor of waste metabolism to the point of destruction of 
tissue and stoppage of function. In small doses it is stimulant 
to most functions of the body, and if not too long continued acts 
as a tonic, and may cause increase of weight Repeated over- 
doses or long continued small doses may seriously impair the 
suprarenal glands. 

Arseni Triaxidum (White Arsenic). — ^Arsenous add occurs as 
a white substance, is tasteless but soon irritant, is soluble in 
water, and the dose is 0.002 Gm. (Ho grain). The most used 
preparation is the Liquor PotasHi Arsenitis, (Fowler's Solution), 



ARSENIC 



383 



which is a I per cent, solution of arsenous acid, and the dose is 
0.2 mO (3 minims). 

Arseni lodtdum.^ Arsemc iodide occurs as an orange-red 
crystalline powder, is soluble in water, and the dose is 0.005 
Gm. (H2 grain), 

Sodii Cacodylas (Sodium Dim ethylarsenate) .^Sodium caco- 
dylate occurs as a white granular poivder, is very soluble in 
water, and the dose is 0.06 Gm. (i grain). 

Sodii Arsenilas (Atoxyl) occurs as white crystals, which are 
soluble in water, and the dose is 0,02 Gm. (} 3 grain) . This drug 
should not be given by the mouth, as it is likely to be decom- 
posed by the acid of the stomach and cause poisoning. It is 
intended for hypodermatic administration in the dose above 
suggested. The dose may be increased, as with any other 
arsenic treatment, to the point of tolerance. It is best admin- 
istered every other day, so that it will not be as likely to accumu- 
late in the system. 

This preparation has largely been recommended in anemias 
and in certain diseases of the skin, but, like any other arsenic 
treatment, it may cause serious symptoms, as destruction of 
blood corpuscles and optic neuritis. 

The arsphenamine preparations are described on page 347. 

Admtnisiralian. — ^^^'hen arsenic is given in small doses for its 
stimulating effect on metabolism, or as a stimulant to the blood- 
forming organs, it may be given in solid form, as the arsenous 
add, and is well given in a soluble tablet, or in a pill or capsule, 
or in the form of the sodium cacodylate. This latter preparation 
has, however, no apparent advantage over the older trioxide of 
arsenic. When it is desired to push an arsenic treatment, 
it should be administered in solution, and the best solution is the 
Liqtwf Poiassii Arsemtis (Fowler *s Solution), This may be 
administered in drops, gradually increased to the point of toler- 
ance, and there is nopossibility of any accumulation of this soluble 
form of arsenic in the gastrointestinal canal. If it is deemed 
best to give the arsenic hj'podermaticaUy for systemic effect, the 
sodium arsenilas is perhaps the best form. For intravenous 
treatment and for intraspinal treatment, mostly in s>'philis, 
arsphenamine or neoarsphenamine are the preparations to use. 



384 THE PRINCIPLES OF THERAPEUTICS 

Action. — Locally strong preparations of arsenic are escharotic, 
but arsenic should rarely be used for that purpose; other treat- 
ments to destroy tissue are preferable and much less painful. 

Arsenic is more or less rapidly absorbed from the stomach and 
intestines, and many times acts as a stimulant to the organism, 
increasing the appetite, improving digestion, causing the patient 
to add weight by the deposition of fat, improving the nutrition 
of the hair, nails and skin, increasing the exfoliation of the q>i- 
dermis, and causing a more healthy nutrition of the skin in 
general. For this purpose arsenic is often used in the scaly, 
dry skin diseases. 

After absorption into the blood, arsenic is found chiefly in the 
corpuscles rather than in the serum. It is a stimulant to the red 
bone-marrow, and increases the production of red corpuscles up 
to a certain point. Therefore it is of advantage in many cases 
of anemia, and has been used largely in pernicious anemia and in 
leukemia. However, when the drug is pushed, or has been 
given for some time, there may occur a rapid destruction of red 
corpuscles, the arsenic seeming to have a hemolytic effect. 
Sometimes in such conditions as l3rmphatic leukemia the white 
corpuscles are occasionally increased in nimiber by the action 
of this drug. 

Arsenic seems to be a stimulant to all glandular tissues, and 
probably to the thyroid. It has often been used to reduce the 
size of enlarged l)anphatic glands, especially of the neck. Its 
success is perhaps largely due to its germicidal effect on what- 
ever organism was causing enlargement of the glands. It is also 
quite probable that its good effect in pernicious anemia and 
leukemia is because it acts as a germicide to the infecting or- 
ganisms that are probably causing these diseases. These 
diseases are probably due to some focal infection, the germs of 
which may frequently enter the body by the way of infected 
areas in the mouth. Arsenic has no special action on the heart 
or blood-pressure or on the central nervous system, unless 
poisoning occurs. 

Arsenic is chiefly eliminated in the urine, but is foimd after 
it has been given for some time in the feces, in the bile, in the 
perspiration, and in the milk of nursing women. The rapidity 



ARSENIC 



385 



of elimination varies. A single dose may be entirely eliminated 
in a few hours, or it may not be eliminated for several days, and 
after many days of treatment the urine may contain arsenic for 
one or two months, or even longer, after the cessation of the 
administration. 

Cher-actimi.—'When during the administration of arsenic the 
limit of tolerance to it has been reached it is evidenced by 
nausea, vomiting, diarrhea, red eye-lids, puffing under the eyes, 
skin eruptions, and albuminuria. If any of these sjinptoms of 
primary poisoning develop, the arsenic should be stopped, and 
generally the symptoms quickly disappear. 

In some diseases, typically chorea, pernicious anemia, and 
leukemia, it has been deemed advisable, after the appearance of 
these symptoms and after their abatement, due to stopping tlie 
drug for a few days, to start again with a dose less than the dose 
that was given when the symptoms weiQ caused and to gradu- 
ally increase the dose to the point when intolerance is again 
shown by the above symptoms. After another period of in- 
termittency the drug may be given again to a third point of 
intolerance. After another intermission the drug may be 
given for some time at a dose less than that which caused the 
symptoms at the third point of intolerance. The exact value 
of the drug given in this manner is questionable. However, 
some success in causing a remittance of the disease has fre* 
quently been recorded in pernicious anemia and leukemia. As 
above stated, probably these diseases are due to infection and 
the infection is overcome by the arsenic. Chorea is a self- 
limited disease, and probably is due to an infection, but it is 
hardly excusable to use the poison, arsenic, in this disease. 

When arsenic is pushed to its full primary toxic effect it 
may do serious harm in causing multiple neuritis, dermatitis, 
destruction of red corpuscles, a greatly disturbed digestion, 
exhaustion, prostration, and fatty degeneration of some organs, 
f.f ., chronic poisoning may develop. 

Toxic Action, — The symptoms of a toxic dose of arsenic may 
appear ^^thin a few minutes, or not for an hour or more after 
such a dose has been taken, depending upon whether, or not, the 
stomach is empty. There is often pain in the mouth, throat, 

25 



386 THE PRINCIPI£S OF THESAPEUTICS 

esophagus, stomach, and finally over the idide abdomen. 
There is nausea, vomiting of the contents of the stomadi, then 
of mucus, and often of blood; soon loose movements of the 
bowels occur, accompanied by intense colidcy pains. The 
pain is so severe as to cause more or less cardiac shodL, and 
soon, heart failure. There is dizziness and headadie, and con- 
vulsions may occur. 

In a short time, provided the patient does not die soon from 
shodL, the urine becomes scanty and albuminous, and there 
may be tenesmus and strangury, and finally suppression. 
Soon intense thirst develops, with a dry mouth and tcmgue, 
and distention of the abdomen occurs. If the patient survives 
there is likely to be an eruption on the skin, whidi may be 
erythematous, petechial, papular, or vesicular. 

In poisoning from smaller doses long continued, or occasion- 
ally when the gastrointestinal symptoms do not cause death 
when large amounts are absorbed, paralyses occur, eq>ecially 
of the paraplegic type. There is often intense pain and cramps 
in the muscles of the extremities. In slowly developing poison- 
ing from large therapeutic dosage, multiple per^>heral neuritis 
may occur. 

After poisoning, unless the patient soon dies, fatty d^ener- 
ation of the liver and kidneys develops, and if the drug is taken 
by the stomach there is likely to be localized inflammation of 
the stomach and intestines, with eroded areas and ecch3anotic 
q>ots. 

Treatment of Acute Poisoning. — ^If a patient is not vomiting 
when first seen, he should drink freely of water containing the 
official arsenic antidote, namely, Ferri Hydroxidum cum 
Magnesii Oxido. This preparation is kept in drug stores in 
two bottles so that the mixture can be freshly made. The dose 
is at least 100 mils (about 33^^ oimces). If vomiting does not 
quickly occur, the stomach should be washed out by means of 
the stomach tube. On accoimt of the prostration that is 
almost sure to develop from arsenic poisoning, apomorphine, 
administered hypodermatically, is not advisable, as there is 
always prostration from this emetic. If a stomach tube is 
not at hand or the arsenic antidote is not at hand, milk and 



ARSENIC 



3S7 



water should be immediately given, and if there is no vomiting, 
mustard water should be administered. 

Later, castor oil should be given, not only to soothe the 
mucous membranes, but to hasten the passage of the arsenic 
through the intestines. Large amounts of water and demulcent 
drinks, as starch water, flaxseed tea, or slippery elm tea, should 
be given frequently, not only to soothe the gastrointestinal 
membranes, but also to promote the excretion of the poison by 
the kidneys and to reduce their irritation to the minim imi. 

If the pain is intense, and to prevent shock, morphine should 
be given hypodermatically, but unless the pain is intense it 
should be withheld, as it will inhibit the excretion of the ab- 
sorbed arsenic through the kidneys. The later complications 
of poisoning will suggest the treatment necessary. 

When acute poisoning does not cause immediate death, and 
in chronic poisoning, the suprarenals are probably seriously 
affected, and the administration of extracts of the whole 
suprarenal gland is advisable, and also injections of tyramine 
hydrochloride, which acts like epinephrine only less intensely 
and longer, are indicated. 

Chrofik Pmsoning,—Chiomc poisoning from arsenic is due to 
the prolonged administration, or to the accidental ingestion for a 
long time, of arsenic in any form. Accidental poisoning from 
arsenic is perhaps more frequent than is noted, as arsenic is 
found in some metals, and is used in certain dyes and pigments. 
Probably with the restrictions in the use of arsenic in artificial 
coloring of wall papers, artificial flowers, boxes, cretones, toys, 
etc., such poisoning rarely now occurs, but it is still possible 
that accidental poisoning from such articles may be the cause 
of unexplained disturbances. Chronic poisoning, if arsenic 
articles are handled, may cause ulcers on the fingers; or if dust 
containing arsenic is inhaled, it may cause disturbances of the 
upper air passages and broncliial tubes and congestions in the 
eyes, or there may be stomach and gastrointestinal disturb- 
ances, if the arsenic is swallowed into the stomach. Various 
skin diseases may occur, w^th darkening of the skin, due to 
suprarenal disturbance. Other glands of the body may be 
disturbed, and anemia may develop; jaundice may occur, and 





388 THE PRINCIPLES OF THERAPEUTICS 

albuminuria may be present. TThere may also be suflBicient 
suprarenal and pancreatic disturbance to cause sugar to appear 
in the urine. 

The nervous s)anptoms vary from depression to insomnia, 
but the principal nerve disturbances are due to multiple periph- 
eral neuritis, with the symptoms and consequences of that 
condition. 

Chronic poisoning from arsem'c should be identified from 
chronic liver disturbance, suprarenal disease, and from other 
causes of anemia. Multiple neuritis from arsenic may resemble 
locomotor ataxia in its symptoms. Chronic lead poisoning 
causes neuritis more especially of the forearms. In alcoholic 
neuritis there is less likely to be skin disturbances, and more 
cerebral symptoms are present. Also peripheral neuritis may 
follow some serious acute infection. 

The treatment of chronic poisoning is, of course, to remove 
the patient from all possibility of the absorption of more arsenic; 
to promote the general health by fresh air, the best food, iron 
and other tonics; and to promote elimination by hot baths, by 
body baking, or by electric light baths, and possibly later, by 
the administration of small doses of sodium iodide, to hasten the 
elimination of arsenic that has been deposited in the tissues. 
All complications and whatever neuritis is present must be 
properly managed. Treatment to be successful must be carried 
out for a prolonged period of time, and chronic debility may be 
permanent in spite of treatment. 

TO STIMULATE METABOLISM 

Arsenic is used (i) as a tonic (small doses); (2) as a 
stimulant to the production of blood corpuscles; (3) as a germi- 
cide; (4) as a stimulant to the skin. 

Small doses of arsenic certainly seem, many times, to stimu- 
late the digestion and the general metabolism of the body, and 
also seem to stimulate the glandular tissues, particularly the 
thyroid. The dose is small for this purpose, from o.ooi to 
0.002 Gm. {yio to }io of a grain) three times a day. It should 
not be too long continued. 

In some sections of the world there are, so-called, arsenic 



IODINE 



389 



eaters, notably in some regions of the Alps, and these arsenic 
eaters think they have a better respiratory ability under the 
action of the drug. They become tolerant to large doses. 

To meet the second indication, namely, to increase the blood- 
corpuscles, arsenic has long been given, probably too much and 
too frequently. It does stimulate the blood-forming organs^ 
but sooner or later may cause destruction of red corpuscles, 
therefore for that purpose alone it seems hardly indicated. 

As a germicide in syphiUs, in malarial infections, and in some 
other infections as pernicious anemia and leukemia, arsenic 
certainly has efficient activity. Its use in s>^hilis has already 
been described. Its value in malarial infections, when qui- 
nine cannot be taken, seems established, and its use in anemia 
and leukemia has also been mentioned. Arsenic for these pur- 
poses should be pushed to the point of tolerance, but it should 
always be kept within the range of safety, as over-action can 
develop at any time. 

To meet the indication of a skin stimulant arsenic is used 
largely in chronic scaly skin diseases, typically in psoriasis. 
It may even be a question whether psoriasis may not be due to 
an infection, and, perhaps^ therefore the reason that arsenic has 
been so long recognized as of value in this disease. It is not 
of much value in chronic eczemas, as it may even cause more 
itching and more disturbance. 

As a gland stimulant arsenic is sometimes indicated, and some 
lymph gland enlargements improve under the action of arsenic. 
The thyroid seems to be stimulated more or less by arsenic, and 
sometimes when there is loss of hair arsenic improves the con- 
dition, perhaps by stimulating the thyroid. 

As above stated, there seems to be no excuse for giving 

arsenic in chorea, and it has been used too much as a tonic and 

in too large doses in blood diseases. Arsenic is a poison, and 

should be used only when there is a distinct positive indication 

for it, 

IODINE 

Iodine is necessary for the welfare of the body, as in its ab- 
sence the thyroid gland cannot properly function, and normal 
thjTToid activity is absolutely necessary for health, if not for 



390 THE PRINCIPLES OF THERAPEUTICS 

life. Iodides prevent sclerosis, more or less, and promote 
absorption of more or less organized abnormal tissue, perhaps 
by increasing the thyroid gland activity. The actual amoimt 
of iodine needed daily to supply the thyroid and satisfy the 
tissues that contain minute amoimts is very little. 

The proprietary iodine compoimds are legion, but the official 
sodiimi iodide and potassiimi iodide are sufficient for the iodine 
needs of the metaboUsm. The Sodii iodidum is the best, as the 
sodiimi element is less depressant than the potassiimi element, 
and other things being equal, it should be the drug of choice. 
If the dose of these proprietary "iodides without their sting*' is 
made equivalent to the iodine dosage of sodiimi or potassium 
iodide, the patient will have the same symptoms as from the 
Pharmacopoeial preparations. It has not been shown that the 
so-called organic preparations of iodine, except thyroid extracts, 
have any more beneficial action than the inorganic salts. 

Potassii Iodidum. — ^Potassium iodide occurs as crystals or as 
a white granular powder, is very soluble in water, and the dose 
ranges from 0.05 Gm. to i Gm. (about i to 15 grains) depending 
upon the action desired. The Unguentum lodi of the Pharma- 
copoeia contains 4 per cent, of iodine, and may be used on the 
skin to cause absorption of the iodine, but it is somewhat 
irritant. 

Sodii Iodidum. — Sodium iodide occurs as crystals or as a 
white powder, is very soluble in water, and the dose is the same 
as that of potassium iodide. 

Administration. — Both sodium and potassium iodide should 
always be administered in solution. Often the saturated solu- 
tion in water is preferred, where a minim represents a grain of 
the drug. Iodides should not be combined with other drugs and 
preparations, as with many of them they are incompatible. If 
a preparation is to be used infrequently, as one dose a day, as is 
so many times advisable in thyroid insufficiency, the iodide had 
better be dissolved in some antiseptic solution, as camphor 
water. As above stated, the dose may be from as little as 0.05 
Gm., from one to three times a day or o.io Gm. once a day, up 
to the amount the physician deems advisable for the patient. 
The large doses once used in tertiary and secondary syphilis are 



IODINE 



391 



inexcusable; most of the iodide was never absorbed but passed 
out of the body in the feces. 

Fairly large doses are sometimes of more benefit than small 
doses in certain forms of asthma, but more than i Gm. (15 
grains) three times a day is never needed, and 0*50 Gm, (jj^i 
grains) three times a day is generally sufiBdent* If the iodide is 
dissolved in plain water, it is well given in a small portion of mUk 
after meals; the milk entirely disguises the taste. If the iodide 
is taken well diluted after meals it will rarely disturb the stom- 
ach. Strontium iodide and synip of hydriodic acid have no 
advantage over sodium iodide. If preferred the official tinc- 
ture of iodine may be administered in one drop doses, taken well 
diluted. The so-called water-soluble iodines are not needed, 

Aciimt,^ — Iodine as an antiseptic and a parasiticide has already 
been discussed under another classification, pages 119 and 127* 
It is only necessary to discuss here the action of absorbed iodine 
and the absorbed iodine element of an iodide. 

In weak solutions iodine is not irritant to the mucous mem- 
branes. It is quickly absorbed, and more or less rapidly 
excreted in the urine, but a very small portion may remain in 
the body and be used for body purposes over and over again. 

Iodine is excreted in the saliva, and, with the food, is again 
swaUowed and again utilized, and while most of one ordinary 
dose of iodine will be excreted in ten or twelve hours, when sev- 
eral doses have been taken or a large dose has been taken, it may 
be several days before it is all excreted. Iodides are not well 
excreted w^hen there is kidney insufficiency. 

Io<lides seem to stimulate the activity of the lymphatic glands 
and may increase the mmiber of lymphocytes in the blood, 
especially in the lymphatic type of leukemia. Iodine also in- 
creases the bronchial secretion, and is stimulant to the tubercu- 
lous process in tuberculosis, therefore it is contxaindicated when 
tuberculosis is present, as it may cause rapid breakdown of the 
tubercles and, consequently, dissemination of the tuberculous 
infection. On the other hand, in asthma and bronchitis when 
tuberculosis is not present, it is a stimulant to the mucous mem- 
branes and causes a more healthy secretion, and may finally cure, 
or at least temporarily arrest, the condition. 



392 THE PRINCIPLES OF THERAPEUTICS 

When in subacute bronchitis the secretion is adhesive, in- 
sufficient, and difficult to expectorate, an iodide is the proper 
treatment, as it moistens and relieves the congestion of the 
mucous membranes and promotes normal secretion. It is 
especially valuable in the dry cough of tracheitis, and sometimes 
in a lingual tonsil cough, as normal mucous secretion of the 
throat, larynx, trachea, and larger bronchi is necessary for 
health and comfort, and a dry condition causes irritation and 
cough. 

The necessity for iodine for the normal activity of the thyroid 
gland need not be here discusied, as it will be taken up under 
the discussion of that gland. 

Over-action. — Over-action of an iodide is shown by some slight 
digestive disturbance; a disagreeable metallic taste in the 
mouth; an increased nasal secretion, sufficient to cause the 
patient to think he has a coryza; some frontal headache from 
congestion of the frontal sinuses; and often an acne-like, papular 
eruption. Sometimes there is an increased flow of tears and 
saliva. 

In patients who are on the verge of hyperthyroidism even 
small doses of an iodide may cause tachycardia and other 
symptoms of hypersecretion of the thyroid gland. 

Chronic Poisoning. — Chronic poisoning, which may occur 
after large doses have been long taken, is shown by thyroid 
atrophy, testicular and probably ovarian atrophy, loss of 
weight, and general disturbed nutrition. 

Treatment of Poisoning. — Acute poisoning will not occur 
from an iodide. Chronic poisoning should be treated by 
stopping the administration of the drug and by every possible 
means of increasing nutrition and strength. The drug will be 
more or less rapidly eliminated without help. If hyperthyroid- 
ism has been caused, that condition should be treated by rest, 
and abstention from meat, coffee, tea, and other stimulants. 

Uses. — As stated, sodiimi iodide should be, ordinarily, the 
drug of choice, although potassium iodide has long had the 
lead, and is the drug most generally used. 

The use of an iodide in small doses as a stimulant to the 
thyroid gland will be discussed under thyroid. Also its use for 



IODINE 



393 



diagnostic purposes, to determine whether or not the gland is 
hypersecreting in doubtful cases, will be there discussed. 
Small doses of iodide are {requently needed by many patients 
who are suffering from subthyroid activity. 

To Modify Sclerosis .^In tertiary syphilis iodide has long 
been used, and generally in enormous doses. Large doses are 
not needed, but ordinary doses seem to prevent sclerosis and 
the formation of gumma ta, probably by activating the thyroid 
gland, by circulating iodine in the blood, and, perhaps, by 
causing deposited mercury to become soluble and re-circulate 
in the system. Improvement in tertiary syphilis is caused by 
the proper action of an iodide. 

Iodides have been largely used in asthma when there is 
bronchitis, and, when there is expectoration of rice-like particles 
and of Charcot'Leyden crystals, iodides are of great benefit. 
But before asthma is treated by iodides, or coincidentlywith 
such treatment, possible reflex and protein poisoning causes of 
the asthma should be sought, and especially should the con- 
dition of the nose be studied; also focal infections should be 
eliminated. 

Iodides have largely been used in various joint aflFections, 
and some patients have improved under sucli treatment. 
However, focal causes of the joint trouble should be sought, 
and x-ray pictures of joints should be more frequently taken 
to determine the exact disturbance. In acute joint inflamma- 
tions salicylates are of more value than iodides. In gout 
colchicum and dnchophen are more valuable, and alkalies are 
almost always needed. However, in certain conditions iodides 
in small doses may be of value. 

For arteriosclerosis, iodides have long been used. The 
dose certainly need not be large, and its advantage is probably 
in inhibiting sclerosis through increasing the activity of the 
thyroid gland. In arteriosclerosis and in aneurism caused by 
syphilis an iodide is, of course, good treatment. 

The blood-pressure is sometimes lowered by iodides, and for 
this purpose the dose need not be large; this action may be 
due to an increased vasodilator secretion of the thyroid. 

When exudates, whether in joints, in the pleural cavities, 



394 '^^^ PRINCIPLES OF THERAPEXmCS 

in the pericardium, or on the valves after an endocarditis, are 
not progressively resorbed, iodides are of benefit, perhaps by 
activating the whole system. Again the dose should not be 
large, as large doses will cause more debility and interfere with 
the progress toward health. 

In chronic lead poisoning an iodide in small doses, not 
more than 0.20 Gm. (3 grains) twice a day, will aid in the 
elimination of the lead. Too large doses may precipitate sub- 
acute lead poisoning and lead oolic. Such treatment should, 
of course, be combined with good nutrition and with hydro- 
therapeutic or other sweating treatments, to cause elimination 
of the lead. 

Iodides are always contraindicated in tuberculosis. 

IRON 

We cannot live without iron, hence the absence of* iron from 
the food and drink will cause anemia, exhaustion, dyspnea and, 
death. The body contains about 3 Gm. of iron, the largest 
part of which is contained in the hemoglobin. One-tenth of the 
hemoglobin is probably destroyed daily and some of it is used by 
the liver to produce the bile pigments. The iron is stored in 
the liver, is given to the blood, goes to the bone marrow and is 
used over again in making hemoglobin. Perhaps o.oi Gm. of 
iron is sufficient to satisfy the daily iron metabolism, unless 
there is some abnormal destruction of red corpuscles, or there is 
hemorrhage. The food generally contains more than enough 
for the daily need. 

In all anemias iron is helpful, if not curative, but in 
some anemic conditions other treatments are as helpful, and 
hence in most cases it is wise to give other medication with the 
iron. 

Ferri Carbonas Saccharatus. — Saccharated ferrous carbonate 
occurs as a greenish brown powder, has a slightly sweetish 
taste, is slightly soluble in water, and the dose is 0.25 Gm. 
(4 grains). The official Massa Ferri Carbonatis (Vallet's 
Mass) is an old honey mixture, and is not needed. 

The official PilukB Ferri Carbonatis (B laud's Pills) is a very 
much used, and generally a satisfactory, method of giving iron. 



IROK 



395 



P 



Each pill contains about 0*06 Gm. (i grain) of the carbonate of 
iron, and the dose is one or two pills three times a day. 

Ferri Phosp has. ^So\nh\e ferric phosphate occurs as bright 
green scales, has a slightly acid taste, and is soluble in water. 
It contains about 12 per cent, of iron, and the dose is 0.25 Gm. 
(4 grains). 

Ferrum Reductum^ — Reduced iron occurs as a fine grayish- 
black powder, is tasteless, is not astringent, and is insoluble in 
water. The dose of this very useful preparation of iron is 0.06 
Gm, (i grain). 

Syrupus Ferri lodidi. — The syrup of ferrous iodide contains 
about 5 per cent, of iron, and the dose is i mil (15 minims). 
This preparation is not as much used as formerly, but is often 
preferred when there is anemia and enlarged glands. It should 
be taken very well diluted. 

Tinciura Ferri Cklaridi. — The tincture of ferric chloride is a 
very astringent solution, and the dose is 0.25 rail (4 minims), 
which should be taken very well diluted, preferably after meals. 
It is well administered in syrup of citric acid and w^ater, or in 
freshly prepared lemonade. 

Ferri Sulphas. — Ferrous sulphate occurs as bluish-green 
prisms, has a very styptic taste, is soluble in water, and the dose 
is o.io Gm- (ili grains). This preparation is too astringent for 
ordinary internal use. 

Liquor Ferri SubstdphaUs.—Monsd's solution is used ex- 
ternally as a styptic. 

Administration. — There are many other iron preparations 
but they are not needed, and even all of those mentioned may 
not be needed. There are many organic preparations on 
the market, but an organic iron is no more valuable, and many 
times not as valuable, as an inorganic iron. Too much iron 
is administered; a small dose is all that is needed phj^iologically, 
and 0.20 Gm. (3 grains) of an iron preparation is generally 
enough for twenty- four hours. Consequently, if the dose of 
iron is small, constipation or other unpleasant symptoms that 
iron may cause will not occur. Occasionally, perhaps by some 
chemical mistake in the body, the iron of the food may be lost 
and not metabolized. In such a case, which may sometimes 




396 THE PRINCIPLES OF THERAPEUTICS 

be the trouble in chlorosis, larger doses of iron may be of value, 
as furnishing something that will control or change the 
abnormal chemical reactions. 

One of the most useful iron preparations is the saccharated 
oxide of iron (Eisenzucker), which may be obtained in tablets 
representing 3 grains. One or two of these tablets a day is 
sufficient, and it is readily taken by children or any other 
patient. 

Action, — Some solid and some liquid preparations of iron are 
styptic to mucous membranes and to broken or moist skin. 
Other preparations of iron are astringent only as they tend to 
produce constipation. 

Probably most forms of iron are more or less changed in the 
stomach to a chloride by the action of the hydrochloric acid, 
and, provided the preparation is not irritant or too strong, 
the appetite improves. But little iron from any one dose 
is absorbed and metabolized by the body, most of it passes 
through the intestines and out of the body with the feces as 
sulphides and often tannates. The iron may be absorbed from 
the upper part of the intestine partially as a chloride and par- 
tially as a carbonate. A large part passes on through the intes- 
tines, is changed to a sulphide and renders the feces black. 
The larger part of the absorbed iron is carried by the blood to 
the epithelial cells of the large intestine and is there excreted. 

Iron is probably more or less of a stimtdant to the red bone- 
marrow. This is especially true when there is anemia and 
the red cells are diminished in number. If iron is given to a 
patient who is normal, with appetite and nutrition good, with 
blood coimt sufficient and hemoglobin content perfect, it does 
not seem to cause plethora, i.e., it does not increase the red 
cells or the hemoglobin. On the other hand, if the patient 
is plethoric, the administration of iron is likely to cause fullness 
of the head, perhaps headache, and sometimes hemorrhage, 
especially from the nose. The flow of blood is increased by 
the administration of iron during the menstrual period. 

While most of the systemic iron is excreted through the 
cecum and large intestine, small amoimts occur in the urine, in 
the saliva, and in the perspiration. 



IRON 



397 



Over-action,— Evidence of the over-action of iron is a feeling 
of fullness in the head, headache, constipation, and sometimes 
a tendency to hemorrhage and to profuse menstruation. There 
is no poisoning from iron unless a dose of styptic iron is taken 
into the stomach, and then the only action would be that of 
acute irritation. 

Uses. — Iron as a styptic or astringent is now rarely used, as 
the dots formed are likely to decompose and cause infection, 
unless they are soon carefully removed; this is especially true 
in nose-bleed. Other treatments of hemorrhage are generally 
better. The hemostatic action of iron preparations is due to a 
precipitate of albumin which forms a dot; it is not due to a true 
fibrin coagulation. 

For its astringent action the tincture of iron is an old 

and good treatment for relaxed or inflamed conditions of the 

throat and tonsils, but iodJne and silver preparations are now 

generally used, 

TREATMENT OF ANEMIA 

The main condition for which iron is used is anemia, and it 
b useful in all forms, but most efficient when the hemoglobin 
content of the blood corpuscles is low, as in chlorosis. As 
above stated, it does not matter much which preparation of iron 
is given, the body will metabolize most any organic or inorganic 
iron. The dose ordinarily need not be large, and the general 
condition of the patient will almost always improve, unless 
there is some serious repeated destruction of the red corpusdes. 
The most deadly destructive organism for red corpuscles is the 
strepiococcus hemolyticusj w^hich is so frequently present in 
acute infections, and is so often present in the disease that 
causes the greatest number of deaths at the present time, 
namely, pneumonia. 

Not every patient who is pale is anemic; not every patient 
who has no appetite and whose nutrition is low needs iron. On 
the other hand, the great majority of patients who are run down, 
or who are convalescing from some serious disease, are anemic, 
and do need ironj but very frequently an increased amount of 
meat or of vegetables that carry large amounts of iron, as greens, 
will soon improve the anemia. 



398 THE PKINCIPLES OF THERAPEUTICS 

Symptoms of anemia, besides the positive finding of a low 
blood count and a low hemoglobin content, are dyspnea, pale- 
ness of the face, especially pale gums, bluish sclerotics, and in 
women, amenorrhea. Anemic patients often suffer from neu- 
ralgias, which are cured by the administration of iron. 

Whatever the kind of anemia present its cause should be 
sought, and no matter of how much benefit the administration of 
iron may be, the anemia will recur imless the cause is removed. 
Besides the more serious diseased conditions, as tuberculosis, 
cancer, and actual hemorrhage (as from hemorrhoids, gastro- 
intestinal ulcers, too profuse menstruation, etc.) chronic sup- 
puration is a frequent cause, as are also focal infections and 
albuminuria. 

TO INCREASE THE URIC ACID EXCRETION 

PHENYLCmCHONINIC ACID 

CmcHOPHEN. Atophan 

This drug occurs in small needles or as a white or yellowish 
powder, insoluble in water, and the dose is 0.30 Gm. (5 grains). 

At the present time this is the most active drug we possess 
to cause an increase in the uric acid output. It is a stimulant 
to the kidneys, increases the amoimt of urine, and under its 
action the uric acid of the blood is decreased in amount. 

From the action of cinchophen the urine may contain such 
a large amount of uric acid crystals that severe irritation and 
even renal colic is caused. Consequently,the amount of the 
drug given should not be as large as formerly used, and 0.30 Gm. 
(5 grains) is a large enough dose, given two or three times a day. 
At the same time, the patient should take an alkali, best the 
bicarbonate of sodium. 

Cinchophen may quiet the pain of acute gout and sometimes 
acts very satisfactorily in other forms of joint pains. 



r 



PART W 
THE ENDOCRINE GLANDS AND ORGANOTHERAPY 

Preparations of the Endocrine Glands, — (a,) Those that have 
recognized positive therapeutic value.— Thyroid; parathyroid; 
pituitary; suprarenal; corpus luteum, 

{b) Those that have therapeutic value but not as evident, 
hence not as generally accepted.— Ovaries, placenta; mammary; 
testicles; thymus; pineal. 

(c) Glandular tissues that have important functions, but 
whose extracts have not been shown to have therapeutic value 
other than that of foods or digestants. — Pancreas; spleen; 
secretin; liver; kidneys; parotid; prostate; lymph glands; brain; 
meat extracts; nuclein. 

GENERAL CONSIDERATIONS 

To understand both the rational and the experimental thera- 
peutic uses of endocrine gland preparations the clinician must 
note the normal functions of these glands and the symptoms and 
signs of their dysfunction. Hence to decide that one or more 
endocrine glands are abnormal the clinician must know the 
physiology and pathology of these glands as far as laboratory, 
clinical and post-mortem experience has developed. 

To determine the physiologic condition of these glands in 
an individual one must learn to study the patient and his 
pre\'ious history with the object of developing a picture that will 
show normal or abnormal endocrine gland acti\ities* Toward 
that end details of the physical condition and previous develop- 
ment of the individual, as well as details of his habits, mental 
attitude and general mentality must be ascertained and out- 
lined. A careful study of the activities of the endocrine glands 
is very profitable for both physician and patient, as the right 
treatment for the cure of his abnormal condition may thus be 
made evident. Such a careful study of patients will not only 

39Q 



400 THE PRINCIPLES OF THERAPEUTICS 

show gross types of hyper- and hypo-secretions of the different 
endocrine glands, but will also discover signs of dightly increased 
or dightly diminished secretions. 
The lines of investigation may be suggested as follows: 

Sex; age; size; general build. 

General characteristics of the family; family history. 
Babyhood: rate of growth; babyhood food; eruption of teeth. 
Childhood: rate of growth; character of food preferred; fat 

deposits; ability to study and learn; likes and dislikes of 

work, play and amusements; age of development of secondary 

sexual characteristics. 
Age of puberty: growth of hair, axillary and pubic; in the male, 

date of change of voice and growth of beard; in the female, 

date of beginning of menstruation and development of the 

mammary glands. 
Adult: social life; temperament; temper; food best liked; food 

cravings; digestive disturbance^; urinary peculiarities; habit 

of perspiration; sexual life. 
Physical examination: note mentality; build of body, head, 

tnmk, legs; fat deposits; facial tsrpe; spacing of eye-brows; 

external genitals. 
Skin: texture; sensations; pigmentation; hair. 
Mouth: arch of palate; spacing of teeth; tonsils; adenoids. 
Glands: thyroid; mammary; thymus; lymph glands. 

It should be recognized that when one gland is mal-function- 
ing others are also disturbed and may thus cause atjrpical 
conditions. 

Under the discussions of the various endocrine gland activi- 
ties the types of disturbances caused by their mal-function will 
be described, but a few indications of endocrine disturbances 
are here mentioned. However, the student is urged to refer to 
books on endocrinology for detailed descriptions of endocrine 
pathology. 

With good thyroid activity the teeth are generally white and 
well formed. If the thymus, and perhaps the parathyroids, are 
insufficient, calcium nutrition may be disturbed, and the teeth 
show pitting and imperfect enamel. If the anterior pituitary 



THE ENDOCRINE GLANDS 



401 



hypersecretes, the teeth are lOtely to be wide spaced. Pigmen- 
tations on the teeth as pigmentations everywhere, on the skin and 
mucous membranes, show cortical disturbance of the adrenals. 
Large canine teeth seem to be associated with increased 
adrenal secretion, and normal sized lateral incisors show normal 
gonads. 

Many of the endocrine glands take part in the production of 
hair, more especially the thyroid, the adrenals and the gonads. 
The thyroid seems to have a special function in controlling the 
amount of hair on the scalp and upper parts of the body, and 
also determines the character of the eye-brows. WTien the 
thyroid subsecretes there is a diminished amount of hair 
development, the hair falls out, or it does not grow normally 
on the body. When this gland is only mildly insufficient the 
eye-brows are very thii^, while when the eye-brows are heavy 
and meet at the bridge of the nose there is increased adrenal 
secretion. Cretins generally have a normal or increased 
amount of hair on their heads, although a myxedematous 
patient may have entirely lost the hair from the scalp. In- 
creased thyroid secretion may sometimes show lessened hair 
development and sometimes an increased hair development, 
the variations probably due to associated other glandular 
disturbances, as increased adrenal secretion always increases 
the growth of hair on the body. Coarse hair is due to increased 
adrenal secretion, and Kaplan states that abnormally colored 
hair, as blond hair in a Spaniard and black hair in a Swede, is 
due to disturbed adrenal secretion. Also he states that the 
majority of red-haired individuals have increased adrenal 
secretion. 

The ovaries and testicles seem to control the amount of pubic 
and axillary hair, while the testicular secretion also seems to 
cause the growth of hair on the face, i^e.^ the beard and mustache. 
In testicular insufficiency there may be very little hair on the 
body yet a good deal on the head, and eunuchs have a large 
growth of hair on the scalp. A growth of hair on the face in 
females is generally due to ovarian disturbance, and at the 
menopause many women have hair develop on the chin. In 
pituitary disturbances there may be patches of hair as well as 




402 THE PRINCIPLES OF THERAPEUTICS 

warty growths appear on different parts of the body, arms and 
legs. 

A soft, fat skin is typical of insufficient post-pituitary secre- 
tion; a thin, soft skin of hyper thyroid secretion; a thick, dry 
skin of hypothyroid secretion. Freckles, brown spots and dark 
skin show adrenal disturbances. Hot flashes, blushing, and 
dilatation of the peripheral blood-vessels are typical of hyper- 
thyroidism, and individuals who suffer from this condition are 
always too warm, and object to hot weather. In sub-thyroid 
conditions the skin is pale, rarely flushes, and the individuals 
feel the cold and dislike it. 

Hypersecretion of the adrenals makes the individual muscu- 
larly strong. Insufficiency of the thyroid and of the anterior 
pituitary^stunts growth and makes a dwarf, while hypersecre- 
tion of the anterior pituitary causes giant growth, and abnormal 
secretion of the pituitary will cause acromegaly. Increased but 
normal secretion of the pituitary gland in the male (which 
gland seems to be typically a gland of more importance for the 
female) produces a tendency to femininity. An increased 
secretion of the adrenals in the female (and these glands seem to 
be of more importance to males than to females) tends toward 
masculinity. Insufficiency of the gonads causes various forms 
of infantilism, and if the testicles are insufficient the man 
becomes effeminate, and if the ovaries are insufficient the 
woman becomes masculine. Hyposecretion of the thyroid, 
I of the post-pituitary, and of the adrenals tends to cause obesity 
and deposits of fat. 

Disturbances of the internal secretions in childhood and before 
puberty may cause the relation of the length of the body to the 
legs to be abnormal. Disturbances of the thymus gland and of 
the pituitary as well as of the gonads may cause such abnormal 
relationships. An early development of the menstrual function 
will cause the girl's legs to be short and the general growth is 
stopped, while a late development of this function allows growth 
to be continued and the legs become long. 

The relationship of the endocrine secretions to mental types 
and mental conditions is not sufficiently recognized. Some 
individuals are well balanced, perfectly normal, and react nor- 



THE ENDOCKINE GLANDS 



403 



mally to every mental impression. Such individuals have 
normal endocrine glands. Other individuals are neurotic or 
unbalanced J are tempermental, moody, and "queer" because 
they have inherited or acquired deficient or abnormal endocrine 
glands* Some indi\'iduals have malicious instincts because of 
such disturbances, and other individuals deserve no credit for 
perpetual good behavior because the glands that furnish im- 
pulses are insufficient* 

It is also not recognized that many headaches are due not 
only to presislent enlargement of the pituitary, but to tem- 
porary enlargement of this gland and to its hypersecretion. 
This headache t>^!cally occurs in women before or during the 
early part of menstruation. The headache may be described 
as back of the eyes, or referred to the temporal region, or to the 
top of the head. 

WTiile on the subject of disturbances caused by insufficiency 
of glands it may be well to note that some careful observers be- 
lieve that the consequences of completely removing tonsils may 
be serious. There may be disturbances of the blood and of the 
circulation, and persistent headache has been noted, and it has 
even been suggested that hypertrophy of the appendix and 
chronic appendicitis have resulted from extirpation of the tonsils. 
Undoubtedly too many tonsOs have been removed, but nothing 
in the above findings or consequences should prevent the ex- 
tirpation of totally diseased tonsils or the extirpation of diseased 
portions of tonsOs, but it should be declared that only obstruc- 
tive portions of healthy tonsils should be removed, and perhaps 
rarely need both tonsils be totally extirpated. 

Insanity. — The relationship of mental disturbances to the 
endocrine glands is being more and more carefully studied, and 
it is especially important to determine what causes abnormal 
mental conditions in boys and girls. In a recent article by 
Sajous he states that statistics show that thirty thousand of our 
boys and girls are sent to insane asylums each year, to remain 
there until they die, on account of dementia praecox, which form 
of insanity represents 53 per cent, of our asylum inmates. 

In the first place, in all cases of insanity focal infections, 
especially of the mouth and tonsils, should be sought, and, if 



404 THE PRINCIPLES OF THERAPEUTICS 

present, eliminated. In the next place, it should be determined 
whether or not the thymus gland is enlarged, and Sajous believes 
that the thymus plays some part in causing this disease. 

Prior^ presents the statistics of forty-six post-mortem exami- 
nations of mental cases in which twenty-five had a definite thy- 
mus gland. Of these forty-six, thirty-two were epileptics and 
twenty-two of these had a persistent thymus. The largest 
glands were found in epileptics and eight epileptics died sud- 
denly, and all of these had enlarged thymus glands. There was, 
also, in many of these patients degeneration of the suprarenal 
cortex. 

It is especially interesting to note the important part the 
thymus gland seems to play in the early life of children, and 
Sajous finds that the thymus has been absent in more than 50 
per cent, of young idiots and mentally defective children. 
Hence it probably is subnormally secreting in children who are 
partially mentally defective. 

Sajous thinks that an efficient thymus aids the ductless 
glands in general in preventing toxic irritants reaching the brain, 
hence its deficiency allows such irritations to occur, and he 
suggests that insufficient nucleins or some mal-chemical com- 
binations due to poor functioning or to early decreased thymus 
function may be the cause of dementia praecox. Perhaps there 
is a phosphorus disturbance. 

In many forms of insanity other ductless glands play an im- 
portant part. Hyperactivity of the thyroid is known to cause 
serious mental excitement, at times even mania, while a sub- 
thyroid secretion tends to produce melancholic types. Para- 
thyroid disturbances are known to cause a condition bordering 
on spasmophilia and to cause tetany, and parathyroid and thy- 
roid disturbances not unlikely have a relation to epilepsy, and 
the thymus is persistent and enlarged in some forms of epilepsy. 

The adrenal glands have been found disturbed in some types 
of insanity. Adrenal insufficiency causes mental depression, 
even melancholia, perhaps due to low blood-pressure and poor 
circulation in the brain. 

The eflfect of pituitary disturbance on the brain is perhaps 
* Journal of Mental Science, I^ondon, Jan., 1920, p. 23. 



THE ENDOCRIXE GLANDS 



40s 



r 



more or less due to pressure symptoms, as all kinds of mental 
disturbances can occur m acromegaly, in which condition this 
gland is enlarged or diseased. 

Diseased ovaries have seemed at times to cause mental dis- 
turbance, and operations on the ovaries and on the thyroid 
glands have sometimes cured such conditions. 

The neurotic indi\idual is such because of thyroid hypersecre- 
tion, but a neurotic child may have several disturbed endocrine 
glands, and the patient should be very carefully studied to de- 
cide just what IS causing the trouble. 

Vasomotor Disturbances. — If a patient has evident exter- 
nal symptoms of Raynaud's disease and spasm of the blood- 
vessels, many undiagnosed internal conditions may be due to 
the same sort of blood-vessel spasm. Severe abdominal pains 
for which operations have been done and no disease found, may 
be due to spasm of some blood-vessel in the abdomen. Fainting 
attacks, semi-paralytic attacks, queer head^attacks, and petit 
mal and epileptic attacks may be due to the same arterial 
spasm of some blood-vessels of the brain. Also, when there are 
angioneurotic edemas externally, there may be smaller disturb- 
ing edemas internaUy causing conditions that cannot be diag- 
nosed* Consequently, when the cause of an internal distur- 
bance is not readily understood, a study of the endocrine gland 
conditions should be made. 

For quick reference the following list of disturbances of the 
endocrine glands will be useful, although it should be recognized 
that associated disturbances of several endocrine glands will 
cause atypical signs and symptoms. 



1. Thyroid absent = a cretin. 

2. Pineal disturbance ^ precocious sejtuality. 

3. Thymus insufficiency =» too early sexuality^p 

4. Thymus too long active « delayed puberty. 

5. Pituitary hypersecretion = a giant. 

6. Pituitary posterior hyposecretion 
Pituitary anterior hypersecretion 

7. Thyroid subsecretion = slow growth; poor mentality; obesity. 

S, Suprarenal hypersecretion = early maturity; mentally active; physically 
active; if a female - masculinity « 

9. Suprarenal hyposccretioa - geneml weakness; non-aggressive mentality; 
if a male « femininity. 



Overgrowth; a fat child. 




4o6 THE PRINCIPLES OF THERAPEUTICS 

10. Gonads hjrpersecretion « sexual perversity. 
Gonads hyposecretion =« sexual insufficiency; obesity. 

11. Thyroid hypersecretion = Graves' disease. 

Thyroid hyposecretion » many types of abnormal conditions. 

Teeth 

I. Thyroid normal = good white teeth. 

a. Pituitary hypersecretion = large incisors, separated. 

3. Gonad hyposecretion = small lateral incisors. , 

4. Suprarenal hypersecretion » sharp, long canines. 

Hair 

1. Thyroid normal « fine hair; normal growth. 

2. Thyroid hyposecretion = loss of hair. 

3. Suprarenal hjrpersecretion = hairy; eye-brows heavy and meet. 

4. Suprarenal hyposecretion » scanty hair; moles and pigmented spots. 

5. Pituitaiy hypersecretion = hairy. 

The following discussion of the activities and therapeutic uses 
of the endocrine glands represents the best consensus of opinion 
at this date. The text is derived from a careful study of the 
literature combined with the writer's own long clinical studies 
of the action and use of the organ extracts and a personal study 
of very many cases of endocrine disturbances. It should be 
recognized that the rapid development of new data concerning 
the physiology and chemistry of these glands may make parts 
of this discussion at any moment obsolete. 

Endocrine Glands that have Positive Therapeutic 

Value 

thyroid gland 

Physiology. — ^Although the thyroid gland weighs only about 
one ounce, it is estimated that, with a normal rapidity of the heart, 
all of the blood of the body passes through the gland about once 
an hour. If the blood-vessels of the thyroid are enlarged, or if 
the heart acts more rapidly, theoretically the blood of the body 
would pass through the thyroid much more frequentiy than 
once an hour, and even with a normal thyroid secretion the blood 
could take up more of it than is necessary for health. 

There may be small supernumerary thyroids, and there may 
be an intrathoracic thyroid. Fetal thyroids are relatively larger 



THriTtOrD GLAND 



407 



and contain relatively more iodine than adult glands. Females 
have more thyroid tissue and consequently normally more iodine 
than males. Some drugs increase the acti\aty of this gland, 
notably strychnine and caiTeine, hence tea and cofifee are stimu- 
lant to it. Animal proteins increase its activity. Quinine in 
large doses and morphine diminish thyroid activity. Privation 
of milk and vegetables and drinking a very soft water, as rain 
water, may cause not only calcium deficiency but thyroid 
disturbance* 

Normal function of the thyroid promotes the normal skeletal 
growth of children; diminished function inhibits such growth* 
Good thyroid activity causes the growth and development of 
perfect teeth, both as to color and spacing. 

The thyroid normally enlarges and hypersecretes during 
pregnancy. If it does not do so, the teeth of the pregnant woman 
decay, her naEs become brittle, and she loses some of her 
hair; i.e., she shows signs of too much loss of calcium, her re- 
serve being used for the growth of her child. She then shows 
the need both for more iodine to properly stimulate the thyroid, 
and for more calcium. Insufficient thyroid secretion in the 
pregnant woman may cause an enlarged thyroid in the child at 
birth, or the child may have an insufficient thyroid. 

If the thyroid does not hypertrophy in pregnancj^ there is a 
tendency to toxemia in the mother and to imperfect develop- 
ment of her child. If the mother has sub thyroid secretion 
after the child is born, she should not nurse her child, unless she 
is given thyroid extract, or the child is given it. Often, also 
her milk may not be sufficient in other qualities for the welfare 
of the child. It may not contain the normal amount of vita- 
mines. A child's brain does not well develop, if the thyroid 
secretion is insufficient. 

The thyroid seems to have a close relation to the pancreas, 
and its secretion is perhaps inhibitive to hyper-functioning of 
the pancreas, as when the thyroid subsecretes the pancreas 
often over-secretes and glycosuria results. On the other hand, 
in cretins and in myxedema the blood sugar is often decreased. 
There is also a tolerance for sugar, and often a great desire for 
it. All metabolism is slowed in subsecretion of the thyroid, 



408 THE PRINCIPLES OF THERAPEUTICS 

and fat is deposited, perhaps due to a disturbed carbohydrate 
function. 

One of the most important activities of the thyroid is its 
ability to prevent poisoning of the body, especially the poison- 
ing that occurs from acute or chronic infection. If the thyroid 
is insuflBicient or becomes insuflBcient from such poisoning or 
irritation, life is endangered, and the patient is benefited by 
the administration of iodine or thyroid extract. In' thyroid 
InsuflBiciency there are more or less poisonous substances cir- 
culating in the blood. The seriousness of chronic focal infec- 
tion, either of the mouth or tonsils, in causing primarily enlarge- 
ment of the thyroid and secondarily insuflBciency of the thyroid, 
should be recognized. On the other hand, such an infection 
often causes the thyroid to hypersecrete, and Graves' disease 
develops, hence a focal infection as the probable cause should 
be sought. If the thyroid under-secretes, the danger may 
not be recognized, but the patient is more likely to succumb to, 
or to be seriously affected by, any acute disease that attacks 
him. With mouth infections, and the streptococcus viridans 
as the infecting agent, it may be for a time difficult to tell 
whether the irritated thyroid or the germ is the cause of the 
cardiac symptoms. Both causes may be active at the same 
time. 

An enlarged thyroid is frequently an evidence that it is 
trying to overcome a chronic toxemia. Therefore many times 
the thyroid is supposed to be at fault when it really is doing 
its best to overcome some other condition that needs treatment. 
An individual who has survived many infections and serious 
conditions in all probability has a very normal thyroid. When 
the thyroid is hypersecreting it may cause serious cerebral 
disturbance by its ability to break down the phosphorized 
fats. 

If there is too much thyroid secretion, or if thyroid extract 
is given a child when it is not needed, there will be an early 
development of the secondary sexual characteristics and an 
early maturity. If a child does not grow, such slow growth 
not being due to thyroid insufficiency, thyroid feeding will 
not increase the growth and may even retard it. 



THYROID GLAND 409 

If the thymus secretion is insufficient in childhood, and 
thymus gland is administered, a too early maturity will be 
prevented; but, if the thymus is sufficient and thymus gland is 
fed, the general growth may be increased but secondary sexual 
characteristics and maturity will be postponed. Too much 
thyroid secretion soon after puberty in girls may cause them 
to be immoral. 

In Graves' disease there is a diminished tolerance to carbo- 
hydrates, perhaps due to an increased secretion from the 
posterior lobe of the pituitary, or due to pancreatic disturbance, 
or to liver irritation, or perhaps due to all of these factors, 
hence glycosuria is frequently a symptom. Also, feeding large 
doses of thyroid extract may cause glycosuria. 

Feeding of thyroid to married women tends to allow preg- 
nancy to occur. This is especially true in sub-thyroid cases, 
even when there has long been sterility. 

One of the chief fimctions of the thyroid is to take iodine 
from the blood and store it to form its active substance, thyrox- 
in. If the thyroid cannot do its work, the pituitary may 
assume some of the thyroid activity. In certain forms of 
thyroid insufficiency and in certain forms of enlargement of the 
thyroid, iodine in small doses, or an iodide in small doses, may 
cause the gland to return to normal. 

In endemic goiter there is likely to be a diminished amount 
of iodine in the thyroid and retention of calcium in the body. 
In toxic goiter, there is likely to be a large amount of iodine 
in the thyroid, and calcium is rapidly lost from the body. 

Feeding of iodine may change an enlarged hyperplastic 
thyroid to one of the colloid type. In hyperthyroidism caldiun 
should be given both with the food (milk) and as a drug, and 
calcium deficiency, either from an increased loss, or from lack 
of it in the food, is the cause of some of the symptoms of 
hyperthyroidism. Starvation seems to reduce the size of the 
thyroid and to decrease its normal activity. Therefore it is 
important when there is serious vomiting, or for any reason 
the patient cannot receive food, that small doses of iodine 
should be given in some manner, perhaps by allowing iodine 
to evaporate in the room. 



4IO THE PRINCIPLES OF THERAPEUTICS 

While thjnroid tissue can be planted and live for a time, it 
is absorbed, but until such absorption has taken place, it 
may ameliorate the symptoms caused by the absence of thy- 
roid secretion. By the time the graft has absorbed, in some 
patients the portion of the gland left after operation, or super- 
niunerary glands, may have become enlarged and furnish suffi- 
cient secretion. 

Thyroid substance given by the mouth is not injured by 
digestion, and it not only causes thyroid activity, but increases 
the amount of urine and the nitrogen output, especially in 
nephritis. If there is a need for thyroid, small doses will not 
cause loss of weight, and may even cause a gain of weight, al- 
though large doses long continued will always cause a loss of 
weight. 

In hyperthyroidism the blood is less coagulable, which may be 
due perhaps to the coincident extra loss of calcium from the 
body. There is much more tendency to hemorrhage in hjq>er- 
thyroidism than in normal thyroid activity, and in hypothy- 
roidism the blood generally coagulates more rapidly than in 
hjq>erthyroidism. 

If the thyroid gland is removed, the hypophysis, both anterior 
lobe and pars intermedia, become enlarged, showing some 
cooperative function of these two glands; and in acromegaly, 
which is due to pituitary disease, the thyroid is hypertrophied. 

There has been shown to be a greatly increased basal metab- 
olism, even to 80 per cent, in Graves' disease, and a greatly 
diminished basal metabolism, even to 40 per cent, in myxedema. 
This shows the necessity for normal thyroid secretion for normal 
metabolism. Recent statistics of examination of men recruited 
for the army in this coimtry have shown an enormous number of 
enlarged thyroid glands, and in a considerable number of these 
cases the glands were notably enlarged. While a good many 
of these men may have come from districts where there is 
endemic goiter, unfortimately it was not noted, and therefore 
we have not sufficient data to show, how frequently with these 
enlarged glands there was mouth or tonsil infection. Probably 
there was such infection in a large percentage of the cases. 

There are various types of enlargement of the thyroid gland: 



THY1R0ID GLAND 



4^t 



normal hypertrophy; colloid growth; cystic degeneration; con- 
nective tissue enlargement; sometimes acute inflammation and 
abscesses; and rarely cancer and sarcoma. 

To briefly sum up the activities of the thyroid gland, it may 
be stated that its secretion is necessary for the proper skeletal 
growth of the child and for its mental development, and it is 
necessary for the proper mental health of the adult. Its secre- 
tion is necessary for the proper growth and health of the teeth, 
hair, and naDs, and for the proper menstrual and maternal 
functions of women. It is necessary for normal nitrogenous 
metabolism of the body, for normal carbohydrate function, and 
for the normal amount of fat deposits in the body. Its secretion 
is necessary to prevent poisoning from disturbances of the nitrog- 
enous metabolism, and perhaps from disturbances of fat metab- 
olism. It is a detoxicant, and prevents toxic symptoms from 
toxins circulating in the blood from acute and chronic infection. 
This gland is present at birth, and functions throughout 
childhood, has an increased function at puberty, and continues 
its increased activity to about the age of forty-five, from which 
time onward it gradually decreases its activity, and more or 
less atrophies in old age. It acquires and stores iodine, and 
produces the active principle termed thyroxin, which is so 
necessary as an activator for all parts of the body, and which 
will be described under the heading of chefnisiry of this gland. 
It also furnishes a substance that is a vasodilator, and this 
gland may coordinate with the glands furnishing vasopressor 
stuff, and, in conjunction with the vasomotor center, may assist 
in regulating the circulatory blood-pressure. Its secretion is a 
distinct stimulant to the heart, and its increased secretion causes 
tachycardia- 
There is likely to be an abnormal condition of the blood when 
there is a disturbance of the thyroid secretion, showing that it 
is more or less essential for the normal production of normal 
blood. 

Men and animals may live after the thyroid gland has been 
removed, provided the parathyroids are not extirpated. Sooner 
or later, however, disturbances occur which will lead to greatly 
impaired health, if not to death, unless thyroid extract is fed. 



412 THE PRINCIPLES OF THERAPEUTICS 

Hoskins and Hoskins^ came to the conclusion from their own 
investigations and those of others with amphibian larvae that 
"removal of the thyroid hastens their growth but causes hyper- 
plasia of the hypophysis and prevents metamorphosis; that 
removal of the hypophysis retards general growth, retards the 
development of the thyroid, prevents metamorphosis, and re- 
tards development of the cutaneous pigment; that feeding 
thyroid or hypophysis (or iodine) to normal larvae hastens 
metamorphosis; that feeding thyroid or hypophysis (or iodine) 
to thyroidectomized larvae brings about metamorphosis, that 
feeding hypophysis to hypophysectomized larvae stimulates 
growth but does not cause metamorphosis; that feeding iodine 
to larvae with both the thyroid and hypophysis removed causes 
metamorphosis. " 

Chemistry. — One of the most interesting chemical studies of 
the body is the need of the thyroid gland for iodine to render 
its secretion active. It has been known for many years that 
iodine was present in the thyroid gland, and that the substance 
which was combined with iodine was an active one in maintain- 
ing health, and that an over-amount of it would cause the 
symptoms recognized as those of hypersecretion of the thyroid. 

The average iodine content of a normal thyroid gland is 
0.0025 Gm., while in the colloid thyroid gland there is only 
0.0015 Gm., and in the hypertrophied gland 0.0005 Gm., per 
gram of the dried gland. 

Kendall has recently shown by great refinement of chemical 
determinations, that there is approximately 0.015 milligram of 
iodine per hundred c.c. of blood, while the iodine content in 
tissues is about 0.03 milligram per hundred grams, and in the 
liver about 0.04 milligram per hundred grams of that tissue, 
while the substance which he has named "thyroxin" contains 
about 60 per cent, of iodine. 

The older the patient generally the less iodine the gland 

contains, and many times the more the hyperplasia of the 

• thyroid, the less the iodine, and in typical exophthalmic goiter 

the gland may contain only a small percentage of the total 

amoimt of iodine contained in a normal gland. However, 

* Endocrinology, Jan. -March, 1920, p. i. 



THYROID GLAND 



413 



generally in Graves' disease the admimstration of iodine in- 
creases the hyperthyroidism symptoms. It has long been 
shown that there are great variations in the amount of iodine in 
the glands of animals in different seasons. 

Fenger^ found no more phosphatids in thyroid than in other 
lean meat, though the phosphatids are increased in the pituitary, 
suprarenal, pineal, the infant thymus, and in the corpus luteum 
of pregnancy, as compared wdth muscle tissue. 

Kendall first isolated the chemical entity which he terms 
thyroxin in 1914. Since that date, in the Rochester Labora- 
tories, about 33 grams of this substance have been separated 
from more than three tons of fresh thyroid material It has 
been found possible to synthetize this most active substance* 

In 191 5 Kendall^ described his two groups of thyroid pro- 
teins. Group A he named the acid insoluble compounds, and 
group B the acid soluble compounds. From group A he isolated 
a pure crystalline compound containing 60 per cent, of iodine. 
Group B contains iodine in some imknown form of combination. 
It is a mixture containing amino acid complexes. Kendall, 
later, called this iodine crystalline extract *' thyro-oxy*indol," 
or ** thyroxin,** and this is the energy factor of the thyroid, and^ 
as he states, the generator of the rate with which we live. 
According to Plummer, normally, there is about 0.013 Gm. of 
this energy stuff in the body, and each increases of about 0-033 
milligrams of thyroxin in the body increases the energ>' output 
I per cent. Hence the energy of the body varies ^^th the 
amount of thyroxin, and Graves* disease may increase this 
energy even to 100 per cent. Plummer states that the thyroid 
secretion persists in the body for about eighteen days. The 
size of the thyroid gland is no due to its activity, as has long 
been knoT;\Ti, and large colloid deposits are more or less inert as 
far as furnishing energy or activity is concerned. 

Kendall' stated that injections of amino adds may cause 
polyuria, normal or high temperature, good or fast pulse, in- 
creased sensitiveness of touch, tremor, twitching, and tetany, 

* Journal of Biological Chemistry, Nov., 1916. 
"Journal A. M. A,, June 19, 1915, p. 2042* 

* Joumul A. M. A., Aug. 25, 1917^ p. 613. 



414 THE PRINCIPLES OF THERAPEUTICS 

and the autopsies will show very hyperemic intestines, suprare- 
nals, thymus, and pituitary. Or such an injection may cause a 
diminished amoimt of urine, low temperature, slow pulse, 
sluggishness, and stupor. He foimd that a starved animal will 
show the former symptoms, and an animal who has been fed 
plenty of meat will show the latter symptoms. He believes the 
former condition is caused by piling up of pre-urea stuff, which 
he terms "X, " from an excited (active) cortex of the suprarenals. 
The latter symptoms are caused by the piling up of ammonia 
in the blood. Hyperactivity of the thyroid is generally accom- 
panied by hyperactivity of the suprarenal cortex. 

Kendall^ describes the physiologic activity of thjnroxin as 
follows: when injected subcutaneously into animals there is at 
first no effect on either the pulse-fate or the blood-pressure, 
but after twenty-four to thirty-six hours the animal appears 
restless, there is a slight increase in temperature, and a decided 
increase in pulse-rate, and if several injections are given on 
successive days, these symptoms are all aggravated. He 
foimdthat successive daily administration of thyroxin causes 
death, while a single injection of an enormous dose produces, 
in most instances, no effect. Therefore he concludes that 
thyroxin itself is not toxic, but toxic effects are caused by 
changes of this substance in the body when a dose is repeated 
and the thyroxin itself cannot be utilized. In other words, 
although an intravenous injection of thyroxin may produce 
no changes in the blood-pressure, pulse-rate or nervous system, 
or any of the so-called hyperthyroid symptoms, the long 
continued presence of thyroxin itself in the tissues of the 
body produces the picture of hyperthyroidism in its entirety, 
terminating in emaciation and death. He found that when 
a large single dose of thjnroxin was injected into the vein of a 
dog, about 43 per cent, of the iodine contained in the thjnroxin 
was excreted in the bile in fifty hours, and 13 per cent, by the 
urine in the same time. Probably the remainder of the iodine 
was retained by the thyroid gland, and as Marine and others 
have shown that the thyroid absorbs iodine from the blood, 
it probably may also absorb thyroxin. 

» Endocrinology, April-June, 1919, p. 156. 



IHYHOID GLAND 



41S 



If a large dose of thyroxin is several times repeated, the 

excretion by the bile and by the urine, and the storing by the 
thyroid may be so disturbed that the tissues receive more 
thyroxin than they can handle, and their energy is increased, 
and the sjrmptoms of toxemia occur, 

Plummer finds that the physiologic effects of a single dose 
of thyroxin is greatly delayed in man, but the duration of the 
effect is exceedmgly long, and he finds that the masdmum effect 
from a single injection in a myxedematous patient is not reached 
until the tenth day, and it may be three weeks before a single 
dose has ceased to function. He also finds that o.ooi Gm. of 
thyroxin in an adult weighing 150 pounds increases the meta- 
bolic rate 2 per cent. Myxedematous patients have their 
metabolic rate 40 per cent, below normal, on account of the 
absence of thyroxin. Such privation does not cause death, but 
their metabolic activities are aU at a minimum, and their func- 
tions cannot be normal without the administration of thyroxin. 

Kendall says that "the amount of thjTOxin mthin the tissues 
is undoubtedly a physiologic constant, a figure as constant per 
weight of tissue as the normal number of red cells per cubic 
millimeter of blood.'' 

It would seem probable that while a certain amount of 
thyroxin is necessary to circulate in the blood to activate the 
tissues to a proper amount of energy, there must be some 
mechanism whereby that energy could be increased, if called 
for, by perhaps more thyroxin being produced, or by the 
removal of stored thyroxin. 

Seidell and Fenger* and Fenger^ have shown that in the 
winter months the thyroid glands of beef, sheep and hogs aU 
contain less iodine than during the smnmer months. To keep 
up the body temperature during the winter months the animals 
require more energy, and, hence, probably draw thyroxin from 
the thyroid gland, where perhaps it has been stored during the 
summer months. 

PEithology. — ^The thyroid gland may be enlarged by hyper- 
trophy, or enlarged by the increase in coUoid; it may be cystic, 

^ Journal of Biological Chemistty, 191 3-13, 
* Endocrinology! 1918, No. 3, p. 98. 



4l6 THE PRINCIPLES OF THERAPEUTICS 

adenomatous, and rardy cancerous; and it may be atrophied. 
That the thyroid gland is enlarged is no indication that it is 
hypersecreting, and on the other hand, it may hypersecrete 
and yet not be enlarged. Its activity may be increased to 
fight some infection, and later it may become enlarged on 
accoimt of this increased activity. 

It is not purposed here to describe all of the pathologic 
conditions of the thyroid gland, but an enlarged thyroid in 
children and yoimg adults is likely to be hyposecreting, and 
generally calls for iodine. Physiologically the gland enlarges 
with menstruation and with pregnancy. It also probably is 
extra active in the first stages of, and perhaps during, acute 
infection, and if that infection is severe and lasts for some time, 
the thyroid may deteriorate and become less active later. 
Long continued irritation, especially nervous irritation, often 
causes hypersecretion and perhaps later a toxic goiter. 

It has recently been shown that goiters, in young girls 
just before puberty, may be prevented, provided they receive 
a small amoimt of iodine. It seems to be inmiaterial 
whether they inhale this iodine from vaporizing iodine. in 
the schoolroom or in their bedrooms, or whether they receive 
a small amoimt of iodine daily as a medicine, for success in 
preventing this kind of enlargement of this gland. An ounce 
of an ordinary tincture of iodine kept in a large mouthed open 
bottle will gradually vaporize in the room and may last for 
a month. Also satisfactory in preventing goiter in youth 
is the administration of about 2 Gm. (30 grains) of sodium 
iodide in 0.20 Gm. doses for ten days or o.io Gm. doses for 
twenty days, and this dosage repeated two or three times a 
year. When iodine is administered to young girls who have 
an enlarged thyroid gland without toxic symptoms, 0.05 Gm., 
or even less, of sodium iodide once a day is suflBdent. This 
dose may be continued for many weeks. 

While all disturbances of the thyroid gland were considered 
very much more frequent in women than in men, and it was 
stated that 80 per cent, of the cases occurred in women, at the 
present time this percentage is not true. Probably now 60 per 
cent, of all cases occur in women and 40 per cent, in men, al- 



THYROID GLAND 



417 



though the more serious symptoms of both hyperthyroidism and 
hypothyroidism do occur in women in the majority of instances. 
Thyroid disturbance has become more frequent in men, owing 
largely to mouth infection from crowns, bridges and dead teeth. 
Possibly some of the thyroid disturbance in young men is due 
to excessive athletics, A goodly number of the so-called neuro- 
drcuJatory asthenia cases, especially of drafted men, is due to 
hyperthyroidism. 

The men recruited from different sections of the country, in 
the late war, showed that there was a great deal of goiter in 
certain districts, but although probably these goiter districts are 
such because of the drinking water, it still has not been shown 
what factor in these waters causes the development of goiter. 
Drinking water low in mineral content has seemed to promote 
the development of goiter. Large amounts of minerals may kill 
the cause of goiter. However, it has long been known that an 
indi\ddual going to a goiterous district might avoid goiter by 
drinking imported water, or by drinking the water of the region 
only after it was boiled* McCarrison seemed to show that fecal 
contaminated water caused goiter^ and that goiter was pre- 
vented by furnishing pure water for drinking purposes. He 
showed in his original investigations that about 5 per cent, of 
children bom of goiterous parents were cretins, and that 63 per 
cent, of the children of parents with goiter were born with con- 
genital goiter. 

Pregnancy should, if possible, be prevented in Graves' disease, 
and if pregnancy occurs, and serious symptoms develop, the 
pregnancy should be terminated. A goiter may become so con- 
gested during parturition as to cause dyspnea; any cystic adeno- 
ma of the thyroid may rapidly enlarge from some acute infec- 
tion and cause sufficient dyspnea to require removal of the fluid. 

Intrathoracic goiters are probably more frequent than has 
been noted, and when they occur, cause more or less constant 
dyspnea by pressure on the trachea. The associated enlarge- 
ment of the thymus gland which occurs in perhaps 50 per cent. 
of exophthalmic goiter cases is probably not a cause of Graves' 
disease, and it may not add, unless from pressure, any unpleas- 
ant symptoms to the case. It is possible that it hypertrophies 

27 



4l8 THE PRINCIPLES OF THERAPEUTICS 

to help do what the thyroid is not well doing, or to control what 
the thyroid is over-doing. The thymus is more likely to be 
enlarged in exophthalmic goiter in yoimg people than in older 
individuals. Also, when the thyroid in these cases grows 
smaller and lessens its activity the thymus gland is likdy to 
diminish in size. 

A goiter that is largely cystic or largely colloid is probably 
not hypersecreting, and is ordinarily not toxic, while a hyperplas- 
tic goiter is either toxic, or can easily be irritated to produce a 
toxemia and Graves' disease. 

The term thyrotoxicosis is applied to the toxic symp- 
toms produced by an over-acting thyroid. The definite term 
of hyperthyroidism when there are the symptoms of Graves* 
disease, and hypothyroidism when there are symptoms of 
marked xmdersecretion seem to be useful and good terms, but 
for the large number of border-line cases, in which there are only 
a few symptoms of hyperthyroidism or a few symptoms of hypo- 
thyroidism, the term dysthyroidism is perhaps better, which 
signifies a disturbance of the fimction of the thjnroid gland. It 
is also quite probable that some fimction of the thsnroid may be 
increased and other functions decreased. Therefore, neither 
term of hyper- nor hypo-thyroidism would be applicable. 

To determine that a thyroid is enlarged when such enlarge- 
ment is not in evidence, the head should be bent backward and 
turned from side to side while the gland is manipulated. If by 
auscultation of the thyroid arteries loud circulatory soxmds are 
heard, the thyroid is receiving too much blood and is probably 
hypersecreting. 

It is not recognized that in every serious illness the thyroid 
is an important part of the body in fighting infection, and re- 
peated infections may wear out the thyroid gland. In some 
serious conditions the thyroid may need assistance during the 
infection, either by small doses of an iodide, or even by very small 
doses of thyroid gland substance, or possibly by minute doses 
of thyroxin. The thyroid gland is always disturbed in tuber- 
culosis, and some of the symptoms are due to such a disturb- 
ance. Cxoiter is frequently in childhood, and sometimes in 
adults, due to diseased tonsils. 



THYEOID GLAND 



419 



There may be thyroid disturbance when there is recurrent 
severe headaches, in epilepsyj in psychoses, in dementia pre- 
cox, and perhaps in other insanities. Some statistics have 
shown that in 25 per cent, of insane women there is goiter. 
These statistics do not state in how many of these cases there 
were focal infections in the mouth, which represent the most 
frequent causes of dysfunction of the thyroid. In subsecretion 
of the thyroid there may be mental depression and melancholia. 
Enlarged goiters of the right side may, by pressure, cause 
paralysis of the recurrent larj^-ngeal nerve, therefore, before any 
operation on the thyroid is done, a laryngoscopic examination 
by an expert should be made. 

In toxic goiter with a rapid heart there may be no myocardial 
changes, but if the tachycardia continues, the heart may hyper- 
trophy and later^ if the disease progresses, myocardial degenera- 
tion win occur. 

The thyroid is always disturbed in syphilis, and is injured by 
mercury and arsenic, and when idiots have insufficient thyroid 
glands congenital syphilis should be suspected. 

The emaciation so frequently seen in toxic goiter or 
Graves' disease may be due to two causes, one being the 
increased activity of the metabolism from the increased 
amount of thyroxin, i.e., the energy is enormously increased; 
the other cause may be the inability of the thyroid to prop- 
erly care for iodine, and an extra amount of iodine in the body 
will cause loss of weight* In uremic poisoning there is prob- 
ably some disturbance of the thyroid and of the parathyroid 
glands. 

Real inflammation of the thyroid, thyroiditis, is not frequent, 
but may occur from infection in the mouth, throat or larynx, 
and especially from the tonsils; but abscess of the thyroid gland 
is ver}^ rare. 

Reflex causes of goiter from disturbances of the pelvic organs 
in women is less and less frequently referred to in literature. 
There is no doubt that in some instances with uterine and 
ovarian disturbances the thyroid, which is so closely associated 
with the function of these organs, becomes disturbed, hyper- 
trophies, and hypersecretes. It is the writer's belief, however. 



420 THE PRINCIPLES OF THERAPEUTICS 

that hyperthyroidism in the majority of cases is caused by 
infection in the mouth or adjacent sinuses. 

Hypersecretion. — To primarily prevent goiter and disturb- 
ances of the thyroid gland all focal infection in the mouth and 
adjacent sinuses must be eradicated. Also goiter may be pre- 
vented by small doses of an iodide, given intermittently, or by a 
small amount of iodine vaporizing in the sleeping rooms, or in the 
school-rooms of girls and boys who are about reaching puberty, 
at which time girls especially are likely to have enlargement of 
thb gland. 

If it is impossible to determine by the symptoms that the 
thyroid is hypersecreting, small doses of an iodide, and best so- 
dium iodide, as 0.05 to o.io Gm. (about i or 2 grains) once or twice 
a day, will aggravate the symptoms, provided that the gland is 
hypersecreting or about to furnish an abnormal amoimt of secre- 
tion. Border-line disturbances caused by the th3rroid may be 
improved by such iodide treatment. 

The symptoms of hyperthyroidism, which has been termed 
Graves ' disease and Basedow 's disease, and which Plummer well 
terms "thyrotoxicosis," or poisoning by thyroid, are as follows: 
nervous irritability; insomnia; hot flashes; increased perspira- 
tion which may be due to suprarenal action on the sympathetic 
system (the suprarenals are always disturbed, often enlarged, 
in h)rpersecretion of the thyroid); tachycardia; tremors; loss of 
weight; exophthalmos; digestive disturbances which may be due 
to the disturbance that caused the thyroid trouble, i.e., various 
mouth infections; and, later, cardiac weakness. There may be 
h)rperchlorhydria. Often these patients are too hot, and suffer 
from the heat in hot weather. There may be hypertension, 
which is probably due to coincident suprarenal or pituitary 
disturbance, although it is disputed that the suprarenal gland 
takes much part in the physiology of the blood-pressure. 
These patients also may be subject to psychoses. They often 
have irregular night sweats, diarrheal attacks, and attacks of 
polyuria. Many of these symptoms may precede the actual 
h)rpersecretion symptoms. Enlarged th5anus occurs in nearly 
half of the cases of Graves' disease, but it is doubtful if it in- 
'. creases the disturbance of the patient, and its secretion may 



THYROID GLAND 



421 



inhibit the extra metabolisiB caused by the increase in thyroid 

activity. If the thymus is much enlarged, its pressure on the 
trachea might be a cause of the sudden death which sometimes 
occurs in thyroid operations. 

Hypersecretion of the thyroid, if not toxic, causes increased 
cerebral activity, sleeplessness, and a neurotic condition. A 
thyroid that is furnishing an over-amount of normal secretion 
causes the interesting personalities and the vivaciousness as 
seen in many of our American women. And the reverse is true; 
a diminished secretion causes mental depression, mental apathy 
and lack of \'ivaciousness, if not moroseness. 

Graves' disease is very much more serious when it is fully 
developed in men than in women, although, fortunately, real 
Graves' disease is verv' much less frequent in men than in women, 
perhaps occurring in men in not more than 20 to 30 per cent, of 
the cases. If it is associated with much adrenal disturbance, 
especially if there is enough adrenal disturbance to cause darken- 
ing of the skin and a low blood -pressure, the prognosis is bad, 

A thyroid patient is always too hot or too cold. There 
seems to be a vasomotor ataxia; their peripheral circulation 
seems not to be in normal relation with the outside temperature. 
Hyperthyroidism may increase the temperature, even one or two 
degrees, especially in the afternoon, and sometimes with a heart 
that is rapid there is a rise of temperature on the least exertion- 

Besides the pituitar>', suprarenal, and thymus glands, the 
parathyroids, the pancreas, and the ovaries may be disturbed in 
hyperthyroidism. Some of these glands may have their secre- 
tion lessened, and some may have their secretion increased. 
Therefore, the composite symptoms which comprise the phe- 
nomena of Graves' disease are caused by disturbance of many 
glands. 

Glycosuria not infrequently occurs in h>^erthyroidism. 
Sometimes there is a diminution of the pol>Tnorph leucocytes. 
Very generally in hyperthyroidism there is an increased nitro- 
gen output due to the extra activity of the tissues caused by too 
much thyroxin. Also the increased rapidity of the heart, the 
rapid circulation, and the mental irritability all tend to in- 
crease metabolism, cause waste and consequent loss of weight. 



422 THE PRINCIPLES OF THERAPEUTICS 

Some of the increased irritability is caused by the increased 
loss of caldiim from which these patients sometimes suffer, due 
perhaps to a disturbance of the parathyroids. 

Various tests have been suggested to conclude whether or not 
the thyroid is in trouble, in border-line cases. Pressure on the 
eye-ball to cause slowing of the pulse is of no great diagnostic 
value in Graves' disease. Goetsch's test is made by injecting 
3^ a C.C. of a I to looo solution of epinephrine into the deltoid 
muscle, which tends to cause a rise in pulse-rate and in blood- 
pressure and an aggravation of the symptoms in h)rperthyroid- 
ism. Goetsch^ states that he has carried out his test in 300 
cases of th3nx)id disease and in 100 conditions simulating hyper- 
thyroidism. His technique is to place the patient at rest in bed 
for at least a day before the injection as necessary to reduce 
nervous irritability and excitation and cause the epinephrine 
h)rpersensibility to be more evident. Before the injection two 
or three readings at five minute intervals are taken of the 
systolic and diastolic blood-pressure, of the pulse-rate, and of 
the respiration. If these three readings are fairly constant, the 
epinephrine in the above dose is injected into the deltoid. 
Then the pulse, blood-pressure and respiration readings are 
made every two and a half minutes for ten minutes, then every 
five minutes for one hour and then every ten minutes for half an 
hour longer. At the end of one and a half hours, or less, the 
reaction has usually entirely passed off. Some reactions 
are noted in less than five minutes after the injection 
of the epinephrine solution, and a positive reaction is 
evidenced by an early rise in the systolic and a fall in the 
diastolic blood-pressure. If the reaction is very mild only the 
fall in diastolic pressure may occur, "in the course of thirty 
or thirty-five minutes there is a moderate fall of pulse and 
blood-pressure, then a characteristic secondary slight rise, then 
a second fall to the normal in about one and a half hours." 
During this time all of the nervous symptoms complained of by 
the patient are increased in intensity. A normal person seems 
to show no, or at least very slight, reaction to this injection. 
Also Goetsch says that "in colloid goiter cases without sympn 
1 Penn. Med. Joum., May, 1920, p. 431. 



THYROID GLAND 



423 



toms of hyperthyroidism the reaction is negative/* Conditions 
presenting some of the symptoms of thyroid disturbance but 
without hyperthyroidism react negatively to this injection, and 
Goetsch states that the greater the amount of hyperthyroidism 
present the more positive and decided is the reaction, 

A most useful simple test is that with an iodide. Ahnost 
invariably a few doses of an iodide will increase the symptoms, 
if the case is one of Graves' disease, and such treatment is 
perfectly safe, even if the administration of a small dose of thy- 
roid is questionable. Another test is to determine the sugar 
tolerance, an intolerance being supposed to show hyperthyroid- 
ism, perhaps due to coincident disturbance of the pancreas and 
of the posterior pituitary. This very fact that so many other 
glands are involved in the sugar metabolism seems to minimize 
the value of tWs test. 

The cause of hypersecretion of ^the thyroid is probably, 
occasionally, some nervous disturbance, as has been noted in 
sudden exophthalmic goiter from sorrow and from mental shock. 
It is, possibly, quite frequently due to disturbances of the uterus 
or ovaries in women, but the most frequent cause is some chronic 
toxemia or infection, especially when that is located in the 
mouth and throat. Diseased tonsils are frequently the cause of 
thyroid disturbances, and many times removal of infected ton- 
sils cures the goiter and the h>T>erthyroidism. The same suc- 
cess generally follows the removal of infected teeth. 

OccasionaUy the thyroid disturbance is due to its attempt 
to compensate for some disturbance or mal-function in some 
other part of the body. Such instances are the ones in which 
thyroid feeding has been said to cure an exophthalmic goiter 
case. These cases are rare. Such a thyroid disturbance, 
namely, hypertrophy and increased secretion, may be because 
the gland is attempting to detoxicate toxins in the blood, 
perhaps even when such toxins proceed from intestinal dis- 
turbance. Certainly an added amount of toxins abst»rbed 
from the intestines will aggravate any case of Graves' disease, 
hyperthyroidism, or thyrotoxicosis. Therefore some cases of 
simple thyroid disturbance have been corrected by correcting 
intestinal toxemia, and in every case of hypersecretion foods 



424 THE PRINCIPLES OP THERAPEUTICS 

that cause gastrointestinal disturbance should be interdicted, 
the bowels should move daily, and fermentation should be 
corrected. All purin foods more or less stimulate the thyroid, 
and, consequently, they should be removed from the diet; 
h)rperthyroid patients should not receive tea, coffee, or meat. 
Patients who have a tendency to hypersecretion should abstain 
from all foods and drugs that increase the thyroid activity. 
Alcohol must always be prohibited in thyroid cases. 

Any constantly recurring excitement, especially mental 
irritation, may cause h)rperthyroidism in an individual who has 
that tendency. As just stated, pelvic disturbances, and 
especially ovarian mal-fimction and uterine growths may cause 
hyperthyroidism. Graves' disease may or may not be aggra- 
vated by pregnancy, but if the extra thyroid secretion is needed 
and utilized during the pregnancy, the hyperthyroidism S3anp- 
toms are likely to again develop soon after parturition. Ab- 
normal and excessive sexual excitements will cause hyper- 
thyroidism. 

There is often hyperthyroidism in tuberculosis. Fatal 
heart disturbances in hyperthyroidism probably are frequently 
due to coincident infection from the mouth, namely, to the 
streptococcus viridans^ although any heart disturbance will be 
excessively aggravated by the tachycardia of Graves' disease, 
and the heart muscle must wear out and eventually dilatation 
will occur. 

More or less disturbance of the sympathetic system occurs 
in Graves' disease, and sympathetic ganglia have been found 
degenerated. Dilatation of the blood-vessels back of the 
eye seem to be the cause of the exophthalmos which occurs 
so many times in Graves' disease, and when the circulation is 
quieted and the patient improves, the exophthalmos improves. 
It is either improved or cured after the removal of a goiter, 
and it is not in evidence after death. Therefore, whatever 
is the actual cause of exophthalmos, it is closely associated 
with hyperplasia and hypersecretion of the thyroid gland. 

There are many causes of hyperthyroidism, but whatever 
other symptoms are present, associated with Graves' disease, 
producing various kinds of clinical pictures, part of that clinical 



THYHO; 



42s 



picture is always caused by hypersecretion of the thyroid. 
In other words, the thyroid disturbance is the most important 
part of the pathology of Graves' disease, as the disturbance of 
the pituitary is the most important part of acromegaly* 

Whatever it is that has disturbed the thyroid, the majority 
of symptoms in Graves' disease seem, from Kendall's and from 
Plummer's investigations, to be due to an increased amount of 
thyroxin produced by the gland. This thyroxin, reaching all 
the cells of the body, and, in an excessive amount, enormously 
increasing their activity and increasing all metabolism » seems 
to be the real cause of many of the sjTnptoms of this disease. 
Also, many of the symptoms of Graves* disease could occur even 
with an intermittent hypersecretion of the thyroid gland, as the 
thyroxin circulates in the tissues, according to these investiga- 
tors, for two weeks or more. Consequently, a one day's extra 
dose of thyroxin could cause symptoms for many days to 
come, even if the thyroid quieted doi^Ti and did not furnish 
the extra secretion daily. Basal metabolism is increased in 
hyperth jToidism , and anything that increases the temperature 
increases metabolic activity, and hence increases the basal 
metabolism. The increased nervous irritability and muscle 
restlessness as well as the rapid heart will Increase the basal 
metabolism in these thyroid patients* Therefore any drug 
that will increase the basal metabolism, such as strychnine, 
cafifeine, and atropine in small doses, should not be given 
patients who have hyperthyroidism. 

Basal metabolism is determined by calorimetric measure- 
ments of respiratory exchange, namely the oxygen intake and 
the carbon dioxide output. Needless to state that such deter- 
mination can only be made in a hospital or laboratory vnih an 
equipment for such scientific investigation, and this phrase, 
namely, "basal metabolism'* is based upon what has been found 
normal for an individual at rest from twelve to eighteen hours 
after a meal. As it has been shown by Kendall and Plummet 
that the secretion of thyroxin from the thyroid determines the 
speed of the rate of basal metabolism, and that this rate is 
greatly increased in hyperthyroidism and greatly decreased in 
hypothyroidism, a determination of basal metabolism in a thy- 



426 THE PRINCIPLES OF THERAPEUTICS 

roid patient is of diagnostic and prognostic interest. Also 
while the patient is under treatment repeated determinations of 
the basal metabolism will disclose the success of the treatment. 
If a determination of the basal metabolism showed that it was 
not increased, hyperthyroidism and thyrotoxicosis could be ex- 
cluded. If there was great increase in basal metabolism, hyper- 
thyroidism is in evidence. Increased suprarenal activity may, 
however, also increase basal metabolism. If the determination 
showed that the basal metabolism was greatly reduced, hypose- 
cretion of the thyroid could be diagnosed. 

Kendall thinks that besides thyroxin the amino adds, protein, 
creatin and creatinin are also stimulants to basal metabolism. 

Treatment of Graves^ Diseaser-As prevention is better than 
cure, it is necessary to carefully study all benign goiters, 
especially in women, who so regularly during the child-bearing 
period have this gland normally disturbed. Therefore, as the 
thyroid normally hypersecretes during menstruation and during 
pregnancy, if there is a goiter, it may be stimulated to produce 
toxic symptoms, i.e., it may finally develop into Graves' disease. 
Hence all causes of enlargement of the thyroid gland should be 
sought and removed, if possible. Also, iodine or iodide treat- 
ment should be instituted, to ascertain if the colloid can be 
diminished and the gland reduced in size. 

If all sources of infection have been removed, or none foimd, 
and if an iodide does not cause a benign goiter to become nearly 
normal in size, its surgical eradication should be considered. 
This does not mean that every goiter should be removed, but 
the probability of a patient having trouble from a goiter should 
be very seriously considered. 

At the present time there is a strong feeling that in Graves' 
disease, in hyperthyroidism, and in thyrotoxicosis operations on 
the thyroid gland have been too frequent, and that the medical 
treatment is the safest, and generally offers the best future 
prognosis. Briefly, the treatment should be absolute rest, 
mental and physical. The diet should be milk and cereals, per- 
haps a few green vegetables, later eggs and vegetable proteins. 
Meat in all forms, and tea and coffee should be prohibited. The 
patient should receive an extra amount of calcium, besides 



THYROID GLAND 



427 



what he gets in his milk. Bromides may be, at first, necessar>% 
but soon are not required* The hydrobromide of quinine in 
large doses has often been successful in quieting the tachycardia. 
Sometimes the tincture of strophanthus acts well. Thymus 
gland extracts many times seem valuable in favorably modifying 
hyperthyroid symptoms. The bowels should move daily, and 
intestinal fermentation should not be allowed. The diet should 
be so arranged that gastrointestinal indigestion does not occur. 
But of all treatments the most important is absolute rest. If 
in spite of this rest the patient does not do well, the heart con- 
tinues rapid J and the thyroid is still over-active, other treat- 
ments must be considered. 

Injections of hot water into the thyroid gland, while at 
times successful, is not good treatment. Injection of quinine 
arid urea hydrobromide is dangerous treatment- Pressure on 
the neck and ice applications are not good treatment. There is 
a difference of opinion as to the value of ligating the thyroid 
arteries, one or two at a time, on account of the great 
circulation through the thyroid, although some of the most 
able surgeons believe such ligations to be of advantage and 
life-saving. 

Radical operations during an exacerbation of the symp- 
toms seems generally inexcusable. The danger is very great 
from this extra amount of secretion from the thyroid on 
account of its action on the heart. If tbe heart does not 
quiet, and the sjinptoms do not abate with rest, the prog- 
nosis from thyroidectomy is not good. Also, the more there 
are lymphoid enlargements, as enlarged tonsils and adenoids, 
and the more there are lymphatic gland enlargements, the 
greater the danger from any operation. An enlarged thy- 
mus has seemed to increase the danger from the operation, 
but some surgeons do not think that it ever contraindicates 
an operation. 

Before operative measures should be considered, it is well 
to try the x-ray treatment of the thyroid. The x-ray has been 
especially recommended for the treatment of large thjonus 
glands, and we know the thymus can be frequently made 
smaller by radiations; but it is still a question whether 



428 THE PRINCIPLES OF THERAPEUTICS 

the thymus gland is adding to the nndesired symptoms in 
Graves' disease, or is trying to combat these symptoms. 

Before using the x-ray treatment on the thyroid gland, it 
should be noted that occasionally the symptoms are made 
worse by it. Improvement by such treatment is shown by 
slowing of the heart, increase in weight, diminution of the 
cerebral irritation, and better sleep. There is no rule as to how 
long the treatment should be continued. Sometimes, how- 
ever, the thyroid gland has rapidly changed its activity to a 
condition of hypothyroidism, and sometimes the x-ray treat- 
ment has seemed to have been the cause of death. 

Radium treatment of the thyroid is now advised, and many 
cases of improvement have been noted, but it is doubtful if the 
success is commensurate with that caused by treatment with 
the x-ray. 

Serums prepared from thyroidectomized animals have been 
used in hyperthyroidism, but these serums probably represent 
the solutions of suprarenal, pituitary, and other glandular 
extracts without the thyroid. Hence they cannot really cause 
antagonism to hyperthyroidism and may do harm by adding to 
the blood extra amounts of secretions from these other glands, 
which glands may be hypersecreting in the patient to whom 
the treatment is administered. 

However much statistics may show that the majority of 
h)rperthyroid patients should not be operated upon, still every 
surgeon and internist has had patients who, after improve- 
ment from medical treatment, could not remain well until 
after thyroidectomy. Apparently, all patients with severe 
symptoms of thyrotoxicosis should receive medical treatment 
only (unless in some cases ligations are advisable), and while 
the majority of thyrotoxicosis patients may be more or less 
permanently improved or cured by such treatment, even if 
they have recurrences, some patients remain chronic invalids 
until they are operated upon. As above stated, the general 
trend to-day is to do fewer and fewer operations on patients who 
suffer from h)rperthyroidism; but perhaps more patients should 
be operated upon who have for the time being benign goiters 
that may later cause h)rperthyroid symptoms. 



THYROID GLAND 



429 



The better the hearty of course the better the prognosis of 
operation. If there is myocardial degeneration as determined 
by symptoms and tests, the risk of opera tion is great. The 
length of time the patient has had more or less hyperthyroid 
symptoms does not seem to be of great importance in detemiin- 
ing the operative risk, but the condition of the heart is of 
primary importance. 

Pressure symptoms may call for immediate operation, and 
a malignant growth of the thyroid gland should generally be 
surgically removed, unless x-ray treatment is deemed better. 

The surgical mortaUty is greater than has been stated, 
some patients dying perhaps from a thymus gland pressure, or 
from an intrathoracic thyroid, others from shock, perhaps 
from the great amount of thyroxin thrown into the circulation 
by the nervous excitation before the operation or by careless 
manipulation of the gland, some because of degeneration of the 
heart muscle, and some because of a lymphadenoid condition, 
the so-caUed lymphatic state. Webster has found that one 
cause of sudden death after thyroid operations is collapse of the 
trachea, due to a softening of the cartilage by the long pressure 
of the enlarged gland. The unsatisfactory after effects are 
that too many of the parathyroids have sometimes been 
removed, although this is now rare. Sometimes there is injury 
to the recurrent laryngeal nerv^e, with paralysis of the vocal 
cords. Sometimes, if too much of the gland has been left, it 
hypertrophies and hyperthyroid symptoms again occur; and 
sometimes so much of the gland has been removed that hypo- 
thyroidism occurs. In other words, the surgical treatment of 
exophthalmic goiter to-day should not be considered until 
prolonged medical treatment has been shown to absolutely fail. 
If necessary, months should be given to the cure of an exoph- 
thalmic goiter patient, and even after surgical removal of half 
or two-thirds of the gland, prolonged medical treatment must 
be instituted before the patient is cured. 

To sum up the treatment of Graves' disease, it may be stated 
that it is properly a medical disease, and should be medically 
treated; that if, after prolonged rest and proper management, 
the heart does not quiet and weight is not gained, and several 



430 THE PRINCIPLES OF THERAPEUTICS 

examinations of the basal metabolism do not show improve- 
ment and the patient is still racing at high speed, the roentgen- 
ray treatment, or radium treatment, of the thyroid should be 
tried for a considerable length of time. If there is no permanent 
cure from these treatments, at least there will be enough 
improvement to consider the advisability of surgery. On the 
other hand, thyroidectomy seems inexcusable during active 
thyrotoxicosis, when there are signs of cardiac degeneration, 
when there are signs of much suprarenal associated disease, 
and when the patient is typically lymphatic. 

Hyposecretion. — The symptoms of cretinism and of myxedema 
are well known, but many symptoms caused by hyposecretion 
of the thyroid are not recognized. Absence of the thyroid, or 
of its secretion, in infancy causes cretinism. With diminished 
thyroid secretion in young children, there is slow growth, and a 
general lack of mental and physical development. Other symp- 
toms from hypothyroidism which may. occur at any age are a 
dry skin, sometimes almost an ichthyosis, and many times eczema, 
especially around the mouth, nose, and ears, and sometimes 
chronic eczema in adults. The thyroid secretion is decreased in 
amenorrhea, in chlorosis, and in the depressant forms of liysteria, 
and hyposecretion is often one of the causes of the vomiting of 
pregnancy. Epilepsy developing at the time of the menopause 
may be associated with subthyroid secretion, and melancholia 
is frequently associated with hypothyroidism. Adiposis dolorosa 
and obesity are associated with hyposecretion of the thyroid. 

The thyroid normally begins to lessen its secretion after 
forty-five. At the time of the menopause in women, if its 
secretion has not diminished, hot flashes, rapid hearts, and 
general circulatory disturbances are in evidence. If its secre- 
tion diminishes too rapidly the woman puts on weight. Also 
men who, from forty to fifty, rapidly add weight often have 
hyposecretion of this gland, and senility is closely associated 
with its hyposecretion. Dry and shriveled skin, hard arteries, 
diminished general metabolism and sluggish mentality, i.e., 
senility, is hypothyroidism. 

Loss of hair, headaches, and frequently digestive disturbances 
may be due to h)rpothyroidism. Sometimes there is profuse 



TH1l"R0ID glakb 



43^ 



hemorrhage, especially from the utems» and bleedings from 
diflfeient parts of the body, which may be due to^ or at least are 
associated with, hypothyroidism, and may be cured by feeding 
thyroid. 

A normally acting thyroid is necessary for normal sexual 
functions of the female. When there is hyposecretion, these 
functions are interfered with and abnormal. There are several 
t>T>es of subthyroid secretion of the milder forms in women. 
One type has infrequent and scanty menstruation, though nor- 
mal periods, and vasomotor disturbances, as cold hands and feet, 
cold fingers and chilblains (the type seen in Raynaud's disease) • 
Other patients show subthyroid disturbances by a dry skin, 
falling of the hair, constipation, and a diminished activity of 
the whole system. Others have amenorrhea, add weight, have 
diminished sexual appetite, are more or less apathetic, and are 
often sleepy during the day. Other patients have a subnormal 
digestion, fatigue easily, have low blood-pressure, and are 
always weary; others have the symptoms of adiposis dolorosa; 
others show a subnormal condition of the thyroid by a disturbed 
surface circulation and sweating of the hands and feet; and stiE 
others have headaches. All of these conditions are improved 
by the administration of thyroid extract. 

If the secretion of the thyroid is much diminished, the whole 
basal metabolism is decreased; there is likely to be diminished 
secretions of the gastrointestinal tract; diminished oxidation; 
diminished excretion of salts; the nitrogen metabolism is dis- 
turbed; often there is obstinate constipation, with perhaps auto- 
intoxication from the bowels, with associated headaches; and 
occasionally epileptic fits occur, and sometimes dementia 
prsecox. 

The nails become brittle in subthyroid patients, they lose 
their hair, and the teeth decay. There is very frequently a 
puffing of the hands, feet, face, or of different parts of the body, 
not a real edema, but on the plan of myxedema, and there may 
be eruptions on the skin, all of which improve with thyroid 
feeding. 

Thyroid feeding in all of these cases will improve the condi- 





432 THE PRINCIPLES OF THERAPEUTICS 

tion and increase the basal metabolism which is diminished. 
The dose of thyroid needed is very small, perhaps not more than 
from )^ of a grain to, at most, 2 grains a day of the dried gland. 

All possible causes for the subthyroid condition should be 
sought, and not infrequently the thyroid is decreased in activity 
by mouth infection, though not as frequently as it is increased 
in activity by such infection; but every thyroid gland that has 
been overworked at some time may underwork at a later time. 

Thyroideum Siccutn. — ^Desiccated thyroid gland is prq)ared 
from the thyroid glands of animals, and must contain about 0.2 
per cent, of iodine. It occurs as a yellowish powder, and the 
average dose is o.io Gm. (i3^ grains). Thyroid preparations, 
imless carefully standardized, vary as to their iodine content. 
If there is any doubt as to whether the preparation is saturated 
with, or contains sufficient, iodine, coincident with the adminis- 
tration of the thyroid extract a small dose of iodine may be given, 
and best the sodimn iodide, and 0.05 or o.io Gm. (about i to 
1 3^ grains) a day is sufficient. Also, many times, one dose of 
thyroid extract a day is sufficient, or a small dose twice a day. 
The dose should vary within wide range, from perhaps 0.005 
Gm. to 0.30 Gm. or more a day. A small dose may be given 
two or three times a day, or a little larger dose once a day, or 
possibly a still larger dose once in three or four days, as thyroid 
extract has been shown to be stored in the system and used 
gradually as needed. The dosage, of course, must depend en- 
tirely upon the object for which the thyroid is given. 

Thyroxin. — Kendall's active principle of the thyroid gland 
for administration by the mouth can now be obtained, and it is 
stated to contain 65 per cent, of iodine. It is offered in tablet 
form of several sizes, the tablets containing 0.2 of a milligram, 
0.4 of a milligram, 0.8 of a milligram, and 2 milligrams respec- 
tively. 

The indication for this active principle is the same as for the 
dried thyroid extracts, except that it is much more potent, and it 
should be used at first in the smallest dose to determine its 
activity in the given individual. Over-dosage will soon develop 
the symptoms of hyperthroidism. When it is administered 
for hypothyroidism and the condition has been improved, a 



THYROID GLAND 



433 



very small dose may be all that is necessary to continue the im- 
provement. The taljet of thyroxin should be taken on an 
empty stomachy crushed mih the teeth and taken with plenty 
of water. At the same time the patient should take about 
1.30 Gm» (20 grains) of sodium bicarbonate, which seems to aid 
the absorption of the thyroxin. Just how many times a single 
dose a day should be giv^en, or after a few doses just when it 
should be repeated, must be determined by clinical investiga- 
tion. The data so far offered largely relates to the injection 
treatment. 

Uses of Thyroid Preparations. — Ordinarily, thyroid prepara- 
tions are indicated only when there is some form of hypothy- 
roidism. Howx^ver, in some depressed conditions in acute 
infection without delirium and without a rapid heart, smaU 
doses of thjToid may be of benefit, and perhaps when the de- 
toxicating power of the thyroid gland has been exerted to ex- 
haustion during an infection a little help may be of advantage 
to the patient. However, generally, such stimulation or aid to 
the thyroid may be given by a small dose of an iodide once or 
twice a day. 

When there are indications of defedive grmtih in children 
very small doses of thyroid are generally indicated. This is 
true when the teeth do not w^ell develop, the hair does not grow, 
the skin is dry, and there are enlarged tonsils and adenoids, 
subnormal temperature, and especially when there is sluggish 
mentality* The nearer the chUd approaches a cretin, the larger 
the dose of thyroid required, for a time at least. When the 
symptoms of h)T>othyroidism are but few and not very marked, 
the dose should be small, if it is given at all. 

It is difficult to determine that a child is a cretin until at 
least he is six months of age, and perhaps it cannot be deter- 
mined until he is a year old, and if the secretion is only deficient 
and not absent, such deficiency may not be determined until 
after the child is two or three years of age. A cretin is evi- 
denced by a thick tongue generally protruded between the lips, 
more or less drooling, sluggish dentition, imperfect hearing or at 
least imperfect recogm'tion of sounds, the eyes are far apart, 
there is often conjunctivitis and eczematous patches about the 



434 THE PRINCIPLES OF THESAPEUTICS 

face, there is likely to be enlarged tonsils and adenoids, and 
perhaps puffing of the eye-lids, espedaUy in qx>radic cases. 
These symptoms are associated with slow development of the 
teeth, slow growth, and later the mentality is that of a moron, 
or even that of idiocy. 

The dose for a cretin a year old may be considered as 0.06 
Gm. (i grain) two or three times a day. If the thyroid is begun 
when the child is older, the dose is larger. Its favorable action 
is shown by an improved mentality increased general growth, 
and a better growth of the hair, nails and teeth. When im- 
provement is in evidence, the dose should be diminished, al- 
though a small dose should probably be given daily, or at least 
every other day, for months and perhaps years. In these cases 
the undesired action of thyroid is generally a tachycardia, and 
when this occurs the dose is too large and the administration 
should be stopped. After the heart has returned to normal 
rapidity, smaller doses should be given. 

Thyroid transplants have been tried in cretinism, but they 
must be termed a failure. They may help the child until the 
transplanted gland is absorbed, but the transplant does not con- 
tinue to grow. When the thyroid secretion is not entirely 
absent in a child, thyroid treatment for a time may stimulate 
the gland to increased activity, and the dose of thyroid extract 
may then be much diminished. 

With the minor symptoms of subthyroid secretion in children 
the dose is very much smaller, even as little as 0.005 Gm. 
daily being often sufficient, and certainly o.oi or 0.02 Gm. 
daily is generally enough. 

Certain types of eczema which occur in children are typical 
of subthyroid secretion, such as occur at the orifices of the 
body, and as fissures under the ears, at the comers of the mouth 
or around the nostrils. These patients are often improved by 
thyroid. 

At any age dry, scaly skin^ of all grades up to actual ichthyosis, 
with profuse desquamation, are benefited by thyroid, as all 
such cases have subthyroid secretion. 

Some children have a great deal of headachCy cold hands and 
feet, and sometimes great lassitude, showing sluggish drcu- 



THYROID GLAND 



435 



r 



lation. Many times these patients are improved by small 

doses of thyroid, all of these symptoms disappearing and the 
child becoming much improved, even when all other treatments 
have failed. The dose for such patients is not more than \i 
grain, sometimes less, once a day for two or three weeks. In 
the beginning one larger dose may be given, as i grain. Many 
of these children show signs of insufficient calcium, and espe- 
cially if there is irritability of the nervous system, which 
suggests parathyroid disturbance, calcium is indicated. Some- 
times in imperfectly developing children a combination of a 
small dose of thyroid and a fair dose of thymus extract is 
indicated, or calcium in some form may be given without the 
thymus extract, 

Infanlile obesity may be associated with subthyroid secre- 
tion, but is more likely to be associated with a disturbed 
pituitary secretion, probably a subsecretion of the posterior 
lobe of the pituitar^\ These children improve on small doses 
of thyroid and coincident doses of pituitary. But these cases 
are likely to be associated with disturbances of other endocrine 
glands, and a careful study of the patient may show what 
combination is needed and what the exact treatment should be* 
The abnormal growth associated with more or less obesity ia 
generally due to pituitary disturbance. 

If puberty does not occur at the proper time, and especially 
in girls, there is generally a lack of th}^Toid secretion, and 
small doses of thyroid, mth perhaps ovarian extract, or perhaps 
only small doses of iodine, is what these patients need, and such 
dosage should be given for a considerable period. Symptoms of 
ncrv^ousness, sleeplessness, and tachycardia, show that either 
the treatment is not needed at all, or the dose is too large, 

CItlorosis is often as well cured by the administration of 
thyroid extract as by the administration of iron, and when 
normal menstruation develops and continues the chlorosis 
disappears. Too profuse menstruation in young girls shows, 
generally, too much thyroid secretion, and mammar>' extract 
should be given as ad\ised under- the uses of the mammary 
gland. 

The importance of iodine saturation in young girls at or 



436 THE PRINCIPLES OF THERAPEUTICS 

before puberty has abready been described, and such iodine or 
iodide treatment will prevent the development of simple 
goiter, to which they are prone if they do not have sufficient 
iodine in their circulation. 

Sometimes thyroid extract in small doses combined with 
pituitary extract will cure noclurnal enuresis in children, 
especially if these children show symptoms of lack of develop- 
ment. 

Amenorrhea is of frequent occurrence in women who are not 
pregnant and is generally associated with more or less muscular 
weakness, a tendency to sleep in the daytime, more or less indi- 
gestion, and with the deposit of fat on the breasts, over the 
shoulders, on the hips, and sometimes on the upper part of the 
arms. When this development is excessive, the type of disease 
termed adiposis dolorosa is in evidence, and that disease is 
undoubtedly due to a disturbance of the endocrine glands, and 
is always associated with subsecretion of the thyroid. This 
disease occurs in all degrees of intensity. At least in all of the 
moderate types, and generally in the more severe types, thyroid 
treatment is successful in aiding the patient, and sometimes in 
curing the condition. As soon as the woman menstruates 
normally and sufficiently, all the other symptoms are amelio- 
rate(}; she loses more or less weight although it may not come 
down to normal. On the other hand, having once shown this 
type of condition, unless her whole life is changed, either she 
marries, or she becomes pregnant, or something changes the 
whole condition of the endocrine glands, she is likely to have 
recurrences of this condition throughout her life. Sometimes 
such patients do not menstruate for months, to again begin for 
a period or two, and then stop again. Whatever the other 
treatment is, whether ovarian extract, ovarian residue, or 
corpus luteum, thyroid extract is always of great value. Some- 
times an iodide is all that the patient requires. The value 
of thyroxin for these patients has yet to be determined. 

When the menopause develops in women, weight is always 
added, and if the secretion of the thyroid is too greatly deficient 
at this time, weight is added rapidly, and more or less symptoms 
of hypothyroidism occur. Thyroid extract is the treatment for 



THYROID GLAND 



437 



this condition. The dose required is generally not large, often 
best associated with an iodide. The pulse is always slow in 
these sub thyroid cases, the skin dry, aod there is pufBness under 
the eyes, on the hands, or on the feet v^athout any actual edema, 
i.e., there are symptoms of mild myxedema. 

If myxedema is really in evidence, the eye- lids are swollen, 
the teeth decay, the hair falls, hearing becomes impaired, men- 
tality sluggish J the blood -pressure low, the pulse-rate slow, and 
there are more or less digestive disturbances. Thyroid is the 
treatment, and it is curative. The dose of thyroid is always 
less when an iodide is added to it, and thyroxin may be found 
to be a most successful treatment. The dose of thyroid extract 
should be suflicient to cause improvement, and after improve- 
ment is in evidence the dose should be diminished, aod then con- 
tinued at the amount required to keep the patient normal. 

Although there are many causes for obesity that occurs before 
the age of forty-five or that occurs as an indi\ddual condition 
in a family that is not prone to stoutness, endocrine disturb- 
ance is generally at the bottom of the condition. Thyroid 
feeding for this kind of obesity has often been carried to excess, 
and has often caused very undesirable symptoms; but associated 
with the proper diet and the proper amount of exercise, some 
th>Toid treatment is generally advisable, perhaps associated 
with other glandular extracts. It should always be remembered 
that with patients who do not show other signs of subthyroid 
secretion, thyroid treatment may precipitate hyperthyroidism. 
On this account, many of the so-called obesity cures are danger- 
ous, and the sale of thyroid extract should be subject to the 
same restrictions as are the narcotics. 

Thyroid extract has been given in some of the toxemias, and 
j>articularly in the vomiting of pregnancy, and many times it is 
successful in this condition, although corpus luteum is now sug- 
gested for that disturbance; but certainly normal thyroid secre- 
tion IS necessary for the health of the mother during pregnancy, 
and if that gland is subsecrcting, thyroid should be administered 
in small doses. Puerperal eclampsia, in which the urine gives 
no evidence of insufficiency of the kidneys, has been attributed 
to thyroid disturbance, and certainly in these cases thyroid ex- 





438 THE PRINCIPLES OF THERAPEUTICS 

tract in very large doses has been successful in preventing and 
stopping convulsions. Also, large doses of thyroid will at times 
prevent the convulsions of uremia. But thyroid is only a small 
part of the treatment of the serious condition of either puerperal 
eclampsia or of uremia, and is only mentioned here to state that 
all these patients in this serious condition are improved by the 
administration of thyroid associated with other proper treat- 
ment. The dose in these conditions should be 10, 20 or even 
30 grains of the extract in the first six hours, and then repeated 
only as indicated, depending on the results and the symptoms of 
its action. 

At times epileptic attacks are associated with subthyroid 
secretion, esi>ecially the epilepsies which occur at the time of 
the menopause. Many of these cases may have their actual 
cause in mouth infection, which has irritated not only the brain, 
but the thyroid and parathyroid glands. It is possible that 
the parathyroids are always disturbed in an epileptic attack. 
Suffice it to say in this connection that cleaning the mouth 
and throat of infection, the administration of thyroid extract 
and of calcium salts will always ameliorate and sometimes cure 
this type of epilepsy. Also, the epilepsies that are aggravated 
at the time of puberty, or are aggravated during pregnancy 
should be managed on this same plan. More or less bromides 
should, of course, be given while the system is righting itself and 
the irritating substances, or the causes are being eliminated, but 
to perpetuate the detoxication of the system, unless there is 
contraindication against it, thyroid should be given with alka- 
line salts, and especially the calcium salts. All intestinal fer- 
mentation and putrefaction should be prevented in these cases, 
and generally the patients are better without animal proteins. 
The dose of thyroid in epilepsy cases need not be large, perhaps 
0.05 Gm. a day, and if this causes increased heart action the dose 
should be reduced. 

In some forms of digestive disturbances ^ especially in spastic 
constipation, small doses of thyroid are beneficial provided such 
a condition is associated with other signs of subthyroid secre- 
tion. Quite probably very small occasional doses of thyroxin 
will be found to be of great benefit in these conditions, but it 



THYROID GLAND 



439 



should be emphasized that thyroxin is very potent^ and as it 
is urged that thyroid extract should be given with the greatest 
of care, it should be more strenuously urged that thyroxin 
should be given vdth still greater care. 

In increasing blood-pressure as age advances, smaE doses of 
thyroid, given daily, or less frequently, especially if the skin is 
dry and there is tendency to chronic eczema, and the pulse is 
slow, are of very great benefit- Thyroid secretion is generally 
what the patient has begun to lack at this age. This evidence 
of lack of thyroid secretion may occur earlier in life, depending 
upon what the thyroid has had to do* If it is a woman and she 
has had many pregnancies, or if it is an indi\adual who has had 
many serious iUnesses, or has had some chronic disease that has 
caused more or less over-action and finally lessened action of the 
thyroid gland, thyroid extract is indicated and will be of benefit. 

Not infrequently the asthma which occurs in old age is pre- 
vented by thyroid, perhaps because it aids in properly combat- 
ing the irritations from mal-nitrogenous metaboUsm. At any 
rate, with high blood -pressure associated \\ith asthma, thyroid 
is of benefit. Perhaps at times the reason that iodides have 
been very successful in certain forms of asthma is because they 
increase thyroid activity. 

\\Tiile theoretically thyroid extract is contraindicated in pro- 
fuse Iwm&rrfiageSf as it generally increases such hemorrhages, 
occasionally in hemophilia thyroid has been curative, but 
generally it has been a failure. However, in the peculiar 
hemorrhages seen at the time of the menopause in women, 
thyroid extract is sometimes a specific. The dose for this 
condition should be large, for a few days, and then it should be 
given in daily smaller doses. Sometimes this treatment is 
successful after all other treatments have failed, it causing 
cessation of hemorrhage, even when the bleeding has been 
from the bladder, rectum, mouth, nose, and many other parts 
of the body. 

Thyroid treatment is caniraindicated when there are symp- 
toms of hypersecretion of the thyroid, when there are toxic 
symptoms from hj^erthyroidism, when there is sleeplessness, 
■delirium, or any cerebral excitation, when there is a rapid heart 



440 THE PRINCIPLES OF THEKAPEUTICS 

or any irritability of the heart, generally when there are acute 
inflammations of the skin, and when there is progressive loss of 
weight. 

PARATHYROID GLANDS 

The parathyroids are small, kidney shaped, reddish bodies, 
four in number, two upper and two lower, which are more or less 
closely associated with the thyroid gland on its posterior aspect. 
There may be supernumerary parathyroids as there may be a 
supernumerary thyroid. 

Many of the symptoms after thyroid extirpation, long 
attributed to removal of that gland, are now known to have 
been due to the coincident extirpation of the parathyroids. 
Such symptoms are mostly of the convulsive type, and if more 
than two of the four parathyroids are removed, these symptoms 
develop and are quickly fatal. The symptoms from parathy- 
roid extirpation are tremors and muscle contractions, more or 
less tetanic in type. It has been shown that the tetany and 
cerebral irritations caused by such extirpation are probably 
due to a deficiency of the calcium in the blood, and the injection of 
parathyroid extracts or the administration of caldmn will pre- 
vent or stop the muscular spasms. 

Macleod states that Noel Paton's investigations seem to 
show that the symptoms after parathyroidectomy are due to 
intoxication by guanidine, and therefore that one of the activi- 
ties of the parathyroid glands is to prevent the development of 
this muscle-irritating substance in the body in undue amount. 
Macleod then draws the conclusion that idiopathic tetany is 
probably due to an insufficiency of the parathyroid glands. 

After partial extirpation of the parathyroids in animals, not 
sufficient to cause tetany, there is loss of weight, dryness of the 
skin, eczema and loss of hair. 

The close association of the parathyroids with the thyroid 
would suggest their physiologic relationship to each other, and, 
though they have been found abnormal in thyroid disease they 
cannot assume the functions of the thyroid, however closely 
they may be associated with it in certain chemical relations. 
It would seem that the different forms of tetany and some of 



PARATHYROro GLANDS 



441 



the peculiar muscle irritabilitjes seen in certain nervous diseases 
are due to disturbances of, or injuries to, the parathyroid glands, 
and in certain conditions they have been found suffering from 
hemorrhagic disturbances, 

MacCaUum and his associates showed that the serious 
symptoms caused by parathyroidectomy were almost instantly 
cured by the intravenous injection of a solution of a calcium 
salt, five per cent, of either the acetate or lactate of calcium. 
When the solution was given by the mouth it was as efiFective, 
only it acted more slowly. The beneficial action lasted for 
twenty-four hours, when tetany w^ould again occur, and again 
disappear on another injection or administration of the calcium. 
They found the potassium salts aggravated the symptoms of 
the tetany. There would seem to be no question that the 
parathyroids have, as one function at least, control of calcium 
metabolism or of calcium absorption and assimilation. When 
there has been great calcium loss, and nervous irritability is 
the consequence, as sometimes occurs with too frequent preg- 
nancies, and with the cerebral excitement (spasmophilia) that 
occurs in serious illness, and that often occurs in hyperthyroid- 
ism the administration of calcium is sedative to the whole 
nervous system. Probably in these conditions the parathy- 
roids have either been overworked and have become insuflS- 
cient, or they are not functioning properly. 

KendalP suggests that an important function of the para- 
thyroids is to convert ammonium carbonate of the protein 
metabolism of the body into urea, and urea may be formed in 
various parts of the body, 

Halsted" showed that parathyroid tissue could be success- 
fully transplanted into the thyroid gland and into the rectus 
muscle of the abdomen in 61 per cent, of the cases, provided 
there was deficiency of parathyroid in the animal, in other 
words, that more than one-half of the parathyroid tissue had 
been removed. If there was no deficiency the parathyroid 
transplant was not a success. Therefore it would seem wise 
when, in the human subject, the parathyroid glands must be, 

* Journal A. M. A., March ir, 1916, p. 811. 
'Journal of Experimental Medicine, No. i, 1909. 



442 THE PRINCIPLES OF THERAPEUTICS 

or have been inadvertently, removed, that parathyroid tissue 
should be transplanted, especially as Halsted showed the 
tissue could survive and prevent tetany for months. One para- 
thyroid gland embedded in the rectus muscle seems to be 
sufficient. Unfortimately more recent attempts at trans- 
plantation of these glands have caused only temporary success. 

Underbill has shown that these glands are concerned in carbo- 
hydrate metabolism; also they have seemed to have something 
to do with the calcification of bone in growing animals. 

Infantile tetany would seem to be due to parathyroid dis- 
turbance, the symptoms being somewhat similar to parathyroid 
extirpation, and Noel Paton and his associates, of Glasgow 
University, conclude that idiopathic tetany and the tetany 
following extirpation of the parathyroid glands are similar, the 
symptoms being due to such chemical mistakes as cause poison- 
ing from guanidine or its derivatives. 

Howland and Marriott, of Johns Hopkins, have foimd a 
diminution of caldimi in the blood serum in cases of tetany. 
This bears out the clinical fact that the administration of 
calcium inhibits or prevents tetany, although, if symptoms of 
tetany are present, it is advisable to give sedatives, and prob- 
ably bromides are the best, imtil the blood has become again 
saturated with caldimi. 

As a quieter of the nervous system calcium and alkalies have 
long been known to be efficient, and the relation of hyper- 
acidity, or acidosis, to irritation of the central nervous system 
is of course well known. Consequently, the suggestion is not 
surprising that irritation of the parathyroids, which glands are 
so closely related to calcium metabolism, might be a cause or an 
associated cause of epileptic convulsions. The saturation of 
the body with alkalies, and especially with calcium, always more 
or less diminishes the frequency of epileptic attacks. The 
convulsions of eclampsia and of uremia are probably also 
associated with more or less acidosis and possibly more or less 
disturbance of calcium metabolism. Of course profoimd 
acidosis causes stupor and coma, but alkalies are always seda- 
tive to the nervous system, and more or less combat the serious 
nervous symp];oms of acidosis. 



PARATHYROID GLANDS 



443 



Quite the reverse of this condition was shown by Wilson* 
and by McCann^^ that extirpation of the parathyroids causes a 
condition of alkalosis due to a disturbance of the relations 
between the adds and bases. These experimenters agree that 
tetany is due to a condition of alkalosis. 

It is possible that while complete parathyroidectomy causes 
alkalosis of the system, dysfunction or hyperf unction of these 
glands might cause an acidosis, each condition corrected by 
chemical substances. If tetany is due to an alkalosis it seems 
rather paradoxical that calcium salts should cure it; however, 
perhaps no more paradoxical than that frequently hj^eraddity 
of the stomach is cured by the administration of dilute hydro- 
chloric add, which seems to prevent the developement of abnor- 
mal adds. Therefore the success of ciilcium salts in tetany may 
be due to the substitution of normally rdated alkaline salts for 
abnormal alkaline salts. 

Assodated with the caldum function of the parathyroids is 
also the caldum function of the thyroid, ovaries, and testicles, 
and all of these glands play some part in the most interesting 
story of calcium. 

Winteraitz has suggested that there is a disturbance of the 
caldum metabolism in tuberculosis, and it has been recognized 
that the more caldum given the tuberculous patient the better; 
ix.j plenty of milk and the administration of calcium salts. 
Tuberculous lesions are cured by local deposits of caldum salts. 

The amount of calcium used in the body is very small, and 
it has been estimated that only about o.oi per cent, of the cal- 
dum of the body is in the soft tissues; it is practically all in the 
bones. There is more caldum relatively in the brains and 
bodies of children than in adults, consequently any diminution 
of the caldum makes them more likely to have tetany or convul- 
sions, Caldum is retained by infants and children longer than 
by adults, and when an excess of caldum is administered, it is 
very slowly excreted. An increased excretion of caldum is 
generally assodated with an increase excretion of magnesium, 

^ Joum. Eiolog. Chem.f iif iQiSf p* 169; and Joum. Biolog. Chem., No. 35, 
igiSi p. 89. 
* Joum* Biolog. Cbcm,, No. sSt ipjS, p. 553, 



444 THE PRINCIPLES OF THERAPEUTICS 

and they appear in the urine as phosphates. ButL. B. Mendel 
has shown that the administration of hydrochloric acid increases 
the excretion of caldum moire than that of magnesium. 

The heart muscle, in certain weak conditions, is strengthened 
by the administration of caldum, and as above suggested, tuber- 
culous patients need an excess of caldum. Too frequent preg- 
nandes, or at times any pregnancy, may deplete the mother 
of her caldimi, in order to properly nourish her fetus and for the 
fetus to properly grow. If she is so depleted, fatty degenera- 
tions may occur, espedally of the liver, also her bones may 
soften. 

The parathyroids have been found diseased and to have had 
hemorrhages into their tissues in some cases of tetany, but they 
have not been often found pathologic in gastric tetany. Al- 
though on account of the musde irritability which is present 
in paralysis agitans the parathyroids have been thought to be 
in trouble in this nervous condition, this has not yet been proved, 
and they have been found normal in such cases. Parathyroid 
disturbance has been suggested as a cause of cataract, but there 
is no proof of this relationship. These glands have been found 
abnormal in the insane. 

Spasmophilia in acute infections may be due to a disturbance 
of the parathyroids. If there has been much loss of caldxun 
from any cause, however, such caldimi privation would account 
for the spasmophilic condition, and certainly in all serious infec- 
tions an extra amount of caldum should be given as soon as 
there is the least sign of cerebral irritation. It is well to give 
extra amounts of calcium in the last months of pregnancy, es- 
pedally if the mother has loss of hair, brittle nails, and decay 
of the teeth. 

It is possible that some of the paroxysms of whooping cough 
may be due to parathyroid irritation, and it has been suggested 
that hemorrhages into the parathyroids may be a cause of sud- 
den convulsions and death in infants. 

We may condude that the parathyroids are dosely associated 
with caldum metabolism; dosely assodated chemically with the 
substance guanidine that may cause muscle irritations; and, 
therefore, that these glands may be disturbed in all conditions 



PITIHTARY GLAND 



445 



that cause nervous irritation and con\iilsions. It is a fact that 
removal of the parathyroids will cause tetany, and that tetany 
is probably not alone due to a loss of calcium, but to some poison 
circulating in the blood or to an alkalosis, due to the removal of 
the parathyroid glands, and therefore to the absence of para- 
thyroid function. 

Parathyroid extracts, given hypodermatically, are always of 
value after parathyroid extirpation, but ordinarily the adminii- 
tration of calcium is as efficient. 

We may sum up the uses of parathyroid extracts by stating 
that small doses of parathyroid may be of benefit in all cases of 
muscle irritability. The dose should be very small, and the fre- 
quency of its repetition or the length of time it should be given 
depends upon the condition for which it is used. Preparations 
of the glands may be obtained in the form of a powder or as 
tablets^ the dose is about 0.006 Gm. (Jfo g^^^^)? once or twice 
a day. However, it has not been shown that in such a condi- 
tion as paralysis agitans this extract is of any more value than 
is the administration of calcium, and in such serious conditions 
as eclampsia better treatment is large doses of thyroid combined 
with large doses of calcium and sodium salts. In other words, 
it has not been shown that parathyroid glandular extracts 
should be much used in medidne. 



PITUITARY GLAND 
Hfpophysis Cerebri 

Description. — The pituitary body, or hypophysis, is located at 
the base of the brain in the sella turcica, and consists of tw^o 
lobes; the anterior larger lobe is oblong in form, and the pos- 
terior smaller lobe is round. The pituitary body varies greatly 
in size, having an average weight, in the adult, of perhaps half a 
gram, and is relatively larger in the child than in the full-grown 
individual. There is a communication termed the infundibu- 
lum, more or less patulous, that connects the posterior lobe with 
the third ventricle. The anterior lobe is distinctly glandular in 
structure, resembling somewhat the thyroid, while the posterior 
lobe is composed largely of nervous tissue and some glandular 



446 THE PRINCIPLES OF THERAPEUTICS 

cells. Sometimes the posterior lobe is termed the infundibular 
portion of the gland. The cleft (pars intermedia) between the 
two lobes of the pituitary body frequently contains a thick 
colloid material. Neither Gushing nor Goetsch have found the 
colloid of the pituitary body to contain demonstrable active 
principles. 

An active principle has been found in the anterior lobe which 
is termed tethelin, and this seems to represent the growth- 
producing element of this lobe. An active blood-pressure-rais- 
ing principle was long ago discovered in the posterior lobe and in 
the infundibular part of the gland, and extracts prepared from 
this portion of the gland stimulate smooth musde fiber. 

Function. — While the pituitary body has long been recognized 
and named, its pathology was not noted until first described by 
Marie, in 1886, who first showed the relation of this gland to 
acromegaly. The activities of the gland in the last few years 
have been carefully studied and demonstrated by Harvey Gush- 
ing and his co-workers. It has been found that the activity of 
the anterior lobe of the hypophysis is entirely distinct from the 
activity of the posterior lobe and the infundibular portion, and 
that the infundibular structure and activities are similar to the 
posterior lobe structure and activities. It has been shown that 
the anterior lobe is essential to life; the whole of it cannot be 
removed without causing the animal's death. If a part is 
removed, though death is not caused, structural changes develop, 
such as abnormal deposits of fat, loss of hair, loss of sexual 
power, and atrophy of ovaries and testicles. There is also dis- 
turbance of the urinary secretion, sometimes polyuria, some- 
times glycosuria. There is often associated with such operative 
interference with the gland an hypertrophy of the thyroid, and 
in the various pathologic conditions of the pituitary the thyroid 
has been found hypertrophied, or at least its function is dis- 
turbed. Also if either gland is removed the other hypertro- 
phies, and after thyroidectomy it is the anterior lobe of the 
pituitary that enlarges. It has been shown that the posterior 
lobe and infundibular portion of the pituitary body may be 
removed without any very definite changes in the body and 
without causing death. 



PITUITARY GLAND 



447 



Cushing and his co-workers Crowe and Homans, showed that 
separation of the hj*pophyseal stalk from the base of the brain, 
i.e,, separating the gland from the body, acted similarly to com- 
plete removal of the gland, and when the whole gland is 
extirpated the symptoms are lowered temperature, lowered 
blood-pressm-e, feeble pulse, slowed respirations, tremblings, 
twitchings, and finally death. 

Extracts prepared from the posterior lobe contain a blood- 
pressure-raising substance, and these extracts will cause con- 
tractions of the muscles, especially of smooth muscle fiber. It 
has, in the last few years, been demonstrated tliat this extract 
has a specific activity on the uterus, causing active contractions, 
especially when it is dilated. It has also been shown that this 
extract is an active stimulant to the muscular coat of the in- 
testine and promotes peristalsis. 

Cushing and his co-workers have shown that the posterior 
lobe is actively concerned in sugar metabolism; if this lobe hy- 
persecretes glycosuria may be caused; il it under-secretes great 
tolerance to sugar develops, and if its secretion is absent the 
tolerance to sugar is excessive. The activity of this part of the 
pituitary body may be demonstrated by testing the indi- 
viduaFs tolerance to large amounts of sugar. If 200 grams of 
sugar, which ordinarily causes glycosuria, does not cause that 
condition, a subsecretion of the posterior lobe of the pituitaryt 
may be considered as demonstrated, and sometimes the toler- 
ance to sugar is very great. 

It has also been found that extract from this posterior lobe is 
an active diuretic, perhaps only, however, because it raises the 
blood-pressure. This rise in pressure is not as 'rapid as that 
caused by suprarenal extracts, but it lasts longer* The pulse is 
slowed and the heart is strengthened by this extract. The 
slowing of the heart seems to be due to action on the vagus, and 
the strengthening of the heart to action on the heart muscle; 
the whole acti\4ty on the heart is not very dissimilar to that of 
digitalis. If much nerv^ous tissue extract is included in the 
posterior lobe extract a secondarj" effect of vasodilatation is 
likely to occur. Operations in the region of the posterior lobe 
or any nervous disturbance in that region often causes polyuria 



448 THE principi.es of therapeutics 

from the irritation, but a tumor growth of this lobe causes 
diabetes insipidus. 

Recently Houssay^ and Leschke* seem to have shown that 
diabetes insipidus or polyuria is not due to deficiency of the 
posterior lobe or to decreased activity of the pars intermedia, 
but is due to disturbance, perhaps from pressure from these 
glands, of the tuber dnereum. However, it has been rq>eated]y 
clinically demonstrated that in diabetes insipidus hypodermatic 
injections of posterior lobe extract will almost inmiediatdy stc^ 
the polyuria and prevent the thirst, though this treatment must 
be frequently repeated and does not cure the condition. Conse- 
quently it seems demonstrated that hyposecretion of the 
posterior lobe of the hypophysis from any cause may produce 
such cerebral disturbance somewhere as to cause diabetes 
insipidus, and the administration of extracts of this gland 
temporarily cures the condition. 

After removal of the anterior lobe, injections of anterior 
lobe extracts will prolong life. After removal of a part of 
the anterior lobe of the pituitary the growth of animals and 
their sexual development is interfered with, but feeding anterior 
lobe or posterior lobe preparations, or both, to children who do 
not grow does not seem to increase their growth. 

Gushing has shown that the colloid secretion of the pars 
intermedia is discharged into the posterior lobe which is largely 
composed of nervous elements, and the combined secretions 
from these two parts of the pituitary pass on into the infun- 
dibular cavity and then into the third ventricle and from there 
into the cerebrospinal fluids. 

Macleod states that the posterior lobe furnishes an antacoid 
which stimulates the utilization of sugar in the body, and any 
irritation of the brain that could stimulate this part of the 
gland may cause a glycosuria, and injections of post-pituitary 
extracts cause a lowering of sugar tolerance. Also any irrita- 
tion of the posterior lobe may cause diabetes insipidus. 

Abel and Kubota have found histamin in the hypophysis 
cerebri which substance stimulates smooth muscle tissue even 

^ Endocrinology, 191 8, No. 2, p. 94. 
'Zeitschr. f. klin. med., 1919, No. 87, p. 201. 



PITUITARY GLAND 



449 



in minute doses. This seems to be the substance of the poste- 
rior lobe that causes contractions of the muscles and acts on the 
uterus. This substance depresses the circulation and in large 
doses causes shock, and it may be this substance that causes 
the lowered b!ood*pressure when large doses of pituitarj^ extract 
have been injected, WhOe histamin is ingested more or less 
with our food, severe muscle injuries may cause a large amount 
of it to be absorbed, and the above investigators suggest that 
it may be one of the causes of traumatic shock. 

Weed and CusMng believe that extracts of the posterior lobe 
increase the circulatory activity of the choroid plexuses and 
hence increase the amount of cerebrospinal fluid. 

The pituitary gland is enlarged during pregnancy much as is 
the thyroidj and Gushing has found that repeated pregnancies 
may so enlarge this gland as to cause transient bi-teniporal 
hemianopsia which is caused by the pressure of the gland on the 
optic commissure. This gland also is more or less enlarged 
before or during menstrua tion^ and such enlargement or the 
disturbed secretion is a frequent cause of so-called menstrual 
headaches, and, if the disturbed secretion or the enlargement 
I>ersists, more or less permanent headache is caused. Such 
headache does not seem to be due to a hypersecretion, as 
the administration of w^hole pituitar}^ gland preparation very 
generally stops or prevents the headache. 

An increased secretion or disturbed secretion from this gland 
may be a cause of dysmenorrhea and of profuse uterine hemor- 
rhage, and, as one of the functions of this gland seems to be to 
promote uterine contractions during parturition, it is quite 
possible that its increased secretion could cause sterility, 
miscarriage, or at least premature labor. 

The part of the gland that seems to be normally hyper- 

trophied throughout pregnancy is the anterior lobe, and if this 

lobe does not enlarge or increase its actiinty disturbances of 

metabolism may occur, such as puffing of the hands and feet 

and deposits of fat, and there may be disturbances of the 

calcium metabolism as shown by imperfect bone development 

of the fetus, and loss of teeth, brittle nails and loss of hair in 

the mother. Such pituitary disturbance is likely to be associ- 
ate 



4SO THE PRINCIPLES OF THERAPEUTICS 

ated with thyroid insufficiency and perhaps with parathyroid 
• dysfunction. As far as the mother's pituitary secretion sheets 
the child, however, it should be noted that McCord^ found that 
both the pituitary and the suprarenal glands develop early in 
fetal calves, and he thinks that probably the fetus in utero is 
early under the influence of its own glands. 

Hypersecretion. — If the anterior lobe of the pituitary hyper- 
secretes in childhood and youth the individual grows abnor- 
mally large, and if the condition persists he becomes a giant. 
If he lives long enough, sooner or later the giant will become 
acromegalic in type on account of the secretion of the pituitary 
becoming abnormal; or the gland sooner or later, in txunor 
growths, hyposecretes. Hypersecretion of the anterior lobe 
after the individual is twenty years of age when the epiphyses 
of the bones are united will produce the acromegalic type of 
growth, namely, instead of the shafts of the bones growing 
excessively as in giantism (when the disease starts in childhood 
and youth) deposits occur at the ends of the bones, and some 
cartilage and tendons become bony. The irregular bone de- 
posits in the cartilages of the spine throw the alignment out of 
adjustment, and all kinds of spinal deformities occur, princi- 
pally kyphosis. The lower jaw is elongated by deposits of bone 
in the glenoid fossae, and prognathism occurs. There is an 
increased growth of hair on the body, warty growths may 
develop on any part of the body especially on the back, the skin 
becomes thickened and develops into folds, with deep furrows 
on the forehead, and the soft parts of the nose, face, and palms 
of the hands hypertrophy. As the disease progresses the thy- 
roid becomes disturbed, often subsecretes, and more or less 
myxedematous symptoms appear, with lowered blood-pressure 
and weakness of the heart; there is impotence in the male and 
amenorrhea in the female. 

More or less headache is always present, the intensity depend- 
ing upon the pressure from the enlarging pituitary body and 
possibly from its disturbed secretions. Possibly stimulation of 
the pars intermedia and the posterior lobe may cause increased 
cerebral pressure, due to an increased secretion from the choroid 
^ Joum. of Biolog. Chem., Baltimore, Dec., 1915. 



PITUITARY GLAND 



451 



plexuses and hence to an increased amount of cerebrospinal 
fluid. 

Very commonly pressure from the enlarged pituitary body or 
from tumor growth in this region on the optic commissure 
causes disturbances of the eye with narrowing of the visual fields. 

If the degeneration of, or the growth of the pituitary pro- 
gresses, various cerebral disturbances can occur, from epileptic 
convulsions to insanity; also cerebral symptoms from pressure 
may occur. 

Sooner or later, with the disturbance that probably started 
in the anterior lobe, the posterior lobe is disturbed, and if it 
hypersecretes glycosuria is Ukely to be a symptom, and if it 
hyposecretes there is increased tolerance to carbohydrates, more 
or less polyuria, and many digestive disturbances occur. 

Not every case of tumor growth in the sella turcica causes 
acromegalic symptoms, but in every case of acromegaly the 
pituitary gland is diseased. 

For a detailed description of the disease of acromegaly the 
reader is referred to the author's article in Buck's Handbook of 
the Medical Sciences, Vol, i. A description of the third case 
of acromegaly reported in America and the eighth in literature 
will be found in the author's article in the Transactions of the 
Association of American Physicians for 1897* An elaborate 
literature on the subject of pituitary diseases will be found in 
the book and articles published by Harvey Gushing. 

The treatment of this disease which generally has a duration 
of many years (unless the disease is due to a rapidly growing 
tumor) is not very satisfactory. There is no drug that will in- 
hibit the increased secretion of the pituitary, and if it is caused 
by a cystic growth, a sarcoma or other malignant tumor, it will 
rapidly progress to a fatal termination. If the disease is not 
caused by a malignant growth, and death is not caused by 
some intercurrent acute illness, the patient dies asthenic, 
with very low blood-pressure and failing heart. In the be- 
ginning of giantism and of acromegaly the operation to remove 
a portion of the anterior lobe would seem justifiable, espedaUy 
as the splendid technique offered by Gushing has made the 
operation possible. Recently radiotherapy has been tried on 



45^ 1^2 PRINCIPLES OF THERAPEUTICS 

pituitary growths, and this may be a successful method of 
treating the condition. It certainly should be tried before oper- 
ation is deemed advisable. 

In the more or less advanced stages of acrcnn^aly the anterior 
portion of the pituitary is probably not hypersecreting, but may 
even be subsecreting, and the posterior lobe is generally not 
secreting normally, as shown by low blood-pressure and an in- 
creased tolerance to sugar. In this condition the administra- 
tion of whole pituitary gland extracts improves the patient, may 
relieve the headache, increase the blood-pressure and heart tone 
and the muscle strength. If severe headache and cerebral 
symptoms are caused by cerebral pressure decompression may be 
done, or more radical surgical procedures would seem advisable. 

As previously stated, many of the symptoms of acromegaly 
are due to associated disturbances of other endocrine glands, 
eq>ecially the thyroid and the gonads, probably frequently the 
parathyroids and the suprarenals, and not infrequently the 
thymus has enlarged and renewed its activity. As in all dis- 
turbances of the central nervous system and eq>ecially in dis- 
turbances of calcium metabolism, the administration of an 
extra amoimt of calcium in the form of milk or the lactate or 
glycerophosphate of caldum diminishes the nervous irritability. 

Hyposecretion. — ^When the anterior lobe secretion is deficient 
in young children infantilism occurs, i.e., bone growth is inter- 
fered with, and the child remains small. If this secretion is in- 
suflSicient at the adolescent period the hair does not grow in the 
axillae and on the pubis, the genitals remain infantile, and the 
child does not develop. Also there is more or less pigmentation 
likely to occur on the body which is probably due to coincident 
suprarenal disturbance. In these conditions although small 
doses may stimulate growth somewhat, treatment with pitui- 
tary extracts is not very satisfactory, and Goetsch has shown 
that large doses of pituitary fed to animals will inhibit growth, 
and feeding posterior lobe extract retards the development of 
the sexual glands. With hyposecretion of the pituitary there 
is testicular atrophy, and males assume the feminine type, and 
after castration eunuchs grow large and fat, showing an associ- 
ated disturbance of the pituitary secretion. 



PITUITARY GLAND 



453 



Hydrocephalus may accompany hypopituitarism, and as- 
sociated with it there may be adiposity and sometimes genital 
abnormalities. So-called juvenile obesity is due to hj^po- 
secretion of the pituitary, and these children are large, fat, 
have protuberant abdomens, scanty development of hair, small 
genitals, sometimes dry skin, and frequently are not mentally 
bright. 

Hyposecretion of the posterior portion of the pituitary in 
older indi\'iduals may cause an abnormal development of fat 
deposited on the parts that are typical of Dercum 's disease, 
adiposis dolorosa. This condition is probably caused by an 
associated disturbance of the thyroid gland. 

Gushing thinks that the increase in weight in subhypophy- 
seal secretion may be due to the coincident disturbance of the 
testicles or ovaries, and he also thinks that the islands of Langer- 
hans in the pancreas may be disturbed and be a cause of the 
glycosuria sometimes seen in these subpituitary cases. 

In the cases of slightly lessened secretion of the pituitary- 
there often are symptoms not much dissimilar to those caused by 
a large amount of adenoid tissue in the nasopharynx, and fre- 
quently it has been noted that when these adenoids are re- 
moved the child begins to normally grow. Hence it is suggested 
that the adenoids in the nasopharynx may have something to 
do with the disturbance of the pituitary. In old age this gland, 
as many other glands, seems to atrophy. 

There may be a hyposecretion of one part of the pituitary 
and at the same time a hypersecretion of the other part of the 
gland; or both portions may have a disturbed secretion. There 
may even be acromegaly from dysfunction without enlarge- 
ment of the gland* Hence the function of the pituitary cannot 
be determined by an x-ray picture outlining the size of the sella 
turcica, and a smaU sella turcica does not necessarily show that 
the pituitary is insufficient. Also it should be noted that grow^ths 
or disturbances in other parts of the brain may cause dysfunc- 
tion of the pittiitarj" without any sella turcica evidence. 

The typical evidences of subsecretion of the hypophysis, 
termed Frohlich's syndrome (dystrophy adiposogenitalis) are 
deposits of fat on the hips, on the sides of the thorax, over the 



454 THE PRINCIPLES OF THERAPEUTICS 

pubis, scanty growth of hair everywhere except on the scalp, 
small genitals, in girls and women after maturity absence of 
menstruation, lack of sexual desire in both sexes, soft skin, 
lowered temperature and sometimes polyuria and thirsL There 
may be headache, drowsiness, loss of memory, and even more 
serious cerebral disturbances. Sometimes fat is deposited on 
the hips, thighs, and abdomen, and occasionally in women there 
is an increased amount of hair growth. 

There is Ukly to be digestive disturbances, subnormal tem- 
perature, low blood-pressure, and, as Plmmner has shown, a 
lowered basal metabolism. Sometimes these patients develop a 
cachexia and die asthenic, as in acromegaly. 

Sometimes dysfimction of the pituitary causes hypertension, 
a slow pulse, and some exophthalmos, but it should be constant- 
ly borne in mind that it is very rare that the symptoms present 
are due to disturbance of only one of the endocrine glands, as the 
interrelations are so close that the disturbance of one causes 
dysfunction of others. 

Uses. — The administration of pituitary extracts for disturb- 
ances of the secretions of the gland have not been very success- 
ful. Not infrequently, however, pituitary headache is cured by 
the administration of extract from the whole gland. If the 
patient is stout and is a woman, and amenorrhea is also a symp- 
tom, the combination of thyroid and pituitary treatment is very 
successful, imless the headache is due to a tmnor. It has been 
stated that posterior lobe extracts would increase the mammary 
secretion, but this has not stood the proof of test. When 
administered by the mouth, instead ot increasing the blood- 
pressure, it may occasionally cause some depression, loss of 
heart strength, and if long given, emaciation. These symptoms 
may develop because these extracts are likely to contain 
large amoimts of extracts of nervous tissue or histamin. Abel 
and Nagayama^ have f oimd considerable histamin in conmierdal 
post-pituitary extracts. 

The administration of anterior pituitary has its greatest 
value in dystrophy adiposogenitalis, but such treatment is 
more successful if combined with appropriate thyroid treatment, 

^ Joum. Pharm. and Exp. Theni., Baltimore, June 1920, p. 40Z. 



PITUITARY GLAND 



455 



and probably it is well in females to add ovarian extracts and in 
males testicular extracts to the treatment. 

The most important use of extract made from the posterior 
lobe (often termed infundibular extract) is in obstetrics. For 
this purpose it is always given hypodermatically in doses of H 
to I mil. The drug has been used too frequently, as it may 
cause asphyxia of the child or rupture of the uterus. It should 
never be used unless the cervix is completely dilated and there 
is no obstmctioa to the free passage of the child through the 
pelvisj and it may always be advisable to administer an anesthet- 
ic as the head of the child is passing over the perineum , if the 
contractions of the uterus have been increased by the pituitary 
injected. Infundibular extracts should not be used in normal 
labor, and perhaps never should be used in a primlpara, and the 
dose should be small in a midtipara. Under its action the 
uterine contractions are brisk and frequent, and unless the child 
is rapidly bom it becomes asph^^dated from interference with 
the placental circulation. In post-partum hemorrhage this 
preparation is not as valuable as is ergot. 

Pituitary extracts administered by the mouth have some- 
times been given in menorrhagia or metrorrhagia, but they are 
not as efficient as ergot unless pituitary disturbance is a cause 
of the bleeding. If there is no evident cause for menorrhagia 
or for too frequent menstruation in young girls, mammary 
extract represents the best treatment, although if the girl shows 
signs of pituitarj^ disturbance a combination of these two 
glandular extracts will be of greater value. 

In conditions of cardiac failure and in shock with low blood- 
pressure and whenever there is dangerous low blood-pressure 
extracts of the posterior lobe given hypodermatically in i mil 
doses is of benefit. It acts less rapidly than epinephrine 
preparations, but its action is much more prolonged. It also 
has an advantage in these conditions of promoting activity of 
the kidneys. 

After abdominal operations when normal intestinal peristalsis 
is not present and there is a tendency to tympanites pituitary 
extracts given h3rpodermaticaUy are of great value. One mil 
may be injected hypodermatically every twenty-four hours 



456 THE PRINCIPLES OF THERAPEUTICS 

for two or three days, and then less frequently until normal 
tonicity of the intestine has returned. If from the paralysis 
of the intestines gas is pressing on the diaphragm and interfering 
with the heart, a second dose of the hypophysis prq)aration may 
be given within a few hours after the first. 

If after a laparotomy or after parturition the bladder does 
not act and is semi-paralyzed, pituitary injections are of 
benefit. It is also of value, both when given hypodermatically 
and by the mouth, in incontinence of urine both in adults and in 
children, and it sometimes acts very satisfactorily in nocturnal 
incontinence. 

In diabetes insipidus which seems so frequently due to hy- 
pophysis disturbance, hypodermatic injection of posterior lobe 
extracts often act almost as a specific, causing the output of 
urine to be decreased, the urine to be of higher specific gravity, 
and thirst to be stopped, and at the same time the headache 
which so frequently accompanies this condition ceases. This 
preparation or any preparation of the pituitary will not have 
this satisfactory action if given by the mouth. Also this 
treatment, even hypodermatically, does not cure the condition 
unless the pituitary becomes normal in its activity; con- 
sequently the injections must be repeated. 

Some vasomotor disturbances may be due to dysfunction of 
the pituitary, and neuralgias, weariness and muscular weakness 
may be due to such a condition, and may be helped by adminis- 
tering by the mouth extracts of the whole gland. When the 
mother, after parturition, does not gain her strength and is 
weak and miserable, there may be pituitary deficiency, and 
pituitary feeding, associated with other proper treatment will 
benefit her. 

It is possible that some cases of epilepsy, especially in child- 
ren and youth, are due to dysfunction of the pituitary, probably 
associated with disturbed function of other glands, perhaps 
more especially of the parathyroids. In appropriate cases 
administration of preparations of the whole gland should be 
tried. 

Even when pituitary preparations seem positively indicated, 
if extracts of the whole gland are long given there is likely to 



PITUITARY GLANB 



457 



be an increase in the formation of uric acid, and joint pains may 
occur. Consequently the results of such treatment should be 
carefully watched. 

The exact cause of rickets is still not known, although it is 
apparently a mistake of nutrition, but probably not entirely one 
of privation. It has not been shown that disturbance of the 
thymus gland is related to rickets. It also has not been shown 
that disturbance of the anterior lobe of the pituitary body is a 
cause of rickets, but it is a fact that this portion of the gland is 
closely related to the formation of solid bone* Consequently, 
in the disease of rickets, besides administering cod liver oil and 
phosphates and good nutritious food, anterior pituitary extract 
should be tried. 

Administration.^ — The official Hypophysis Sicca is prepared 
from the posterior lobe of the pituitary body of cattle. It 
occurs as a yellowish or grayish powder, which is only partially 
soluble in water, and the dose is 0.03 Cm. Qi grain). The 
official preparation Liquor Hypophysis is a solution containing 
the water soluble principle or principles of the fresh posterior 
lobe of the pituitary body of cattle. It occurs as a transparent 
liquid, the dose of which is i mil (15 minims). As hypophysis 
solutions are generally used hypodermaticallyonly, this prepara- 
tion is hardly necessary, as sterile ampules are better. These 
ampules are made in two strengths, and contain }% mil or i mil of 
diluted posterior lobe extract* Tablets made from the posterior 
lobe may be obtained, each representing 3io ^^ ^ grain of its 
active principles. When administering these posterior lobe 
preparadons s>'Tnptoms of depression may develop. Conse- 
quently the patient should be carefully watched during such 
treatment. 

Preparations of the whole gland may be obtained, also prep- 
arations of the anterior lobe. Tablets of the anterior lobe 
represent 2 grains of the gland, and tablets of the whole gland 
may be obtained that represent i grain. These preparations 
also may be obtained in powder form. The frequency of the 
dose of any of these preparations depends upon the rapidity of 
the action desired. Generally the condition is chronic, and 
one or at most two daily doses are sufficient, and when the 



4S8 THE PRINCIPLES OF THERAPEUTICS 

minute amount of the secretion of this gland that circulates in 
the blood daily is considered, it will be seen that the dose to be 
administered should be small. 

SUPRARENAL GLANDS 

Descrq)tion. — Besides the adrenal glands, which are situated 
over the kidneys, there is likely to be small supernumerary 
suprarenal tissue scattered along the spermatic vessels in the 
male, on the broad ligaments in the female, and in various 
parts of the abdomen. Just how active this supernumerary 
suprarenal tissue may become after the adrenal glands have 
been destroyed has not been determined, although they may 
hypertrophy. 

The adrenal gland is composed of the cortex and the medulla. 
The cortex is embryologically related to the genital system and 
as far as its function is imderstood, this portion of the adrenal 
glands is closely related to the development of the sexual organs. 
Macleod notes that the evidence of such relationship is 
shown by the fact that with sexual precocity there is hyper- 
trophy of the adrenal cortex, that it is hypertrophied during 
pregnancy, and that it is poorly developed in sexual defi- 
ciency. The medullary portion is composed of masses of cells 
richly surroimded by blood. In these cells are character- 
istic granules which stain readily with chromic acid and are 
termed chromaflin cells. The medullary portion of the adrenal 
is embryologically related to the sympathetic nervous system. 

Function. — Animals may survive without the medullary 
portion of the glands, but complete extirpation of the adrenal 
glands is fatal to most animals. The symptoms begin on the 
second day after extirpation, and are weakness, both of the 
muscles and of the circulation; lowered temperature; dyspnea; 
and finally convulsions and death. If one-eighth of the total 
amount of the gland is retained the animal may survive, but 
transplants of adrenal tissue and the feeding of suprarenal 
extracts are not life-saving, according to Macleod. 

Shafer and Oliver first showed that there was a blood- 
pressure-raising principle furnished by the suprarenals. This 
principle is produced in the medullary portion of the gland, and 



SUPRAIUBNAL GLANDS 459 

is variously known as epinephrine (Abel's name) suprarenin, 
adrenin, and adrenalin. This prindple has been obtained in 
crystalline form, and chemically is closely related to tyrosine. 
Epinephrine is chemically an amino acid derivative, and may be 
made synthetically. Injection of minute doses of epinephrine 
will cause a rise in blood-pressure, due to the constriction of the 
arterioles, and will slow the pulse, due to action on the vagus 
center. The vessels of the splanchnic area are most influenced 
by epinephrine, but the large vessels near the heart are not 
much affected on accoimt of the absence of muscular tissue, and 
the coronary vessels have been thought not to be contracted in 
most animals. With large doses dilatation of the vessels instead 
of contraction is caused, and dilatation at times rapidly follows 
constriction and may be dangerous. There may be a slight 
dilatation of the pupils when an epinephrine solution is applied 
to the eye. The salivary glands and the mucous glands of the 
mouth and pharynx are stimulated by it, and epinephrine, when 
injected, disturbs the glycogen fimction of the liver so that 
hjrperglycemia and glycosuria occur. 

Herter and Richards were the first to note the relationship 
of the suprarenals to glycosuria, and from their investigations 
and those of others we must conclude that perfect glycogenic 
fimction depends upon the proper relation between the secretion 
of the suprarenals, the secretion of the pancreas, and the fimction 
of the liver, and if any one of these three organs is disturbed, 
sugar may appear in the urine. If too much epinephrine secrcr 
tion reaches the blood, glycosuria is likely to occur, appar- 
ently due to a stimulation of the liver to increase its output 
of glycogen. 

An extra amount of glycogen in the blood (if not too much) 
is a stimulant to muscle energy, and the whole body is stimu- 
lated. The glycogen function of the suprarenals is largely under 
the control of the nervous system and is related to the pituitary 
secretion. Stimulation of the thyroid may cause a stimulation 
of the adrenal glands, the reason that so frequently in Graves' 
disease there are evidences of hyperadrenalism. 

The suprarenal glands are seriously affected in toxemias, 
whether the toxemia is caused by inf ecton or by the absorption 



460 THE PRINCIPLES OF THERAPEUTICS 

of poisons from some focus within the body. Prolonged infec- 
tion exhausts the suprarenals and causes the depression and 
shock so frequently seen in serious iUness, and repeated toxemias 
completely prostrate, so to speak, the adrenal glands. On this 
accoimt coal-tar or other depressant drugs should not be given 
in prolonged illness, and not at all in a condition that soon 
leads to depression. This is tjrpically true in influenza, and 
many a patient is seriously, if not fatally, injured by adding 
coal-tar or aspirin depressants to the prostrating infection of 
the influenza germ. Pneumococdc infection and the toxins of 
diphtheria are also depressant to the adrenals. Insufficient 
adrenals at any time cause the patient to have a weakened de- 
fense against any infection. 

Although it has lately been concluded that a continuous dis- 
charge of epinephrine from the adrenal glands is not necessary 
for the maintenance of normal blood-pressure, still when neces- 
sity calls for an extra rise in blood-pressure and extra energy, the 
adrenals immediately furnish the needed extra secretion which 
for a time causes contraction of the abdominal vessels and raises 
the blood-pressure. 

Meek^ suggests that the cortex of the adrenals may supply a 
hormone necessary for life by virtue of its maintaining muscular 
and vascular tonus, and that the medullary portion supplies a 
particularly active pressor substance, epinephrine, to be used in 
times of emergency, and as a general body stimulant. In the 
vasomotor disturbances there is generally suprarenal insuffi- 
ciency, and a patient who faints easily has an insufficient epi- 
nephrine secretion. This tjrpe of patient is readily shocked. 

Sergent's test of adrenal sufficiency, by noting the color by 
gently stroking different parts of the body, is difficult to read in 
border-line cases, and as the color varies so in different parts of 
the body, it is not a test of any great importance, especially as 
it depends so much upon the character of the skin, the method 
of stroking, and whether, or not, there is a tendency to urticaria. 

Pigmentations on the body tend to show that the suprarenals 
are in trouble, and that they will soon become insufficient, unless 
the cause of their irritation is removed. Lowered suprarenal 

* Endocrinology, July-Sept., 191 7, p. 305. 



SLTPRARENAL GLANDS 



461 



activity may cause hyperchlorhydria, with heart-burn and pyro- 
sis. This condition is often seen in low blood-pressure, in cases 
of depression, and in old age. 

It has been thought that the adrenals assist in rendering 
harmless some of the products of muscular activity, and when 
these glands are insufhdentj toxemias more readily occur. 
This detoxicating function seems to be present in several of the 
internal secreting glands, especially in the thyroid and parathy- 
roids, andj if these glands are not properly functioning, certain 
metabolic substances may cause serious symptoms, though 
while they properly function these same substances are inocuous 
and harmless. 

In 1855 Addison first pointed out the relation between the 
disease characterized by darkening and bronzing of the skin, 
anemia, digestive disturbances, and a pathologic condition 
of the suprarenal glands, since which time it has been recognized 
that the cause of so-called Addison *s disease is a disturbance of 
the suprarenal glands tHat prevents their normal function, per- 
haps most generaUy a tuberculous condition. 

Lately it has been shown by Voegtlin and Macht that a pres- 
sor substance, not the epinephrine substance of the medulla, can 
be obtained from the suprarenal cortex. This may be the 
substance that is needed to maintain normal blood-pressure 
while the more active pressor stuff of the medulla is reserved 
for emergencies. Also in the cortex there is a large amount of 
lipoids. 

Hyperadrenalism, — ^Reasoning from analog)^ as the thyroid 
is known to hyper- and hj'po-secrete and cause consequent con- 
ditions, we can but presuppose that the adrenal glands, next 
in importance to the thyroid, must hyper- and h>'po-secrete, 
and, also have various modifications of secretion and dys- 
function. 

There can hardly be a doubt that certain individuals have 
continually a hypersecretion of these glands. Just what rela- 
tion hyperadrenalism has to abnormally high blood-pressure, 
the opposite condition seems to be a fact, namely, that sub- 
secretion of the adrenals causes low blood-pressure. Drugs 
that are known to stimulate the adrenals, as strychnine, raise 



462 THE PRINCIPLES OF THERAPEUTICS 

the blood-pressure. Repeated exertion and properly graded 
athletics raise the blood-pressure, especially the systolic pres- 
sure. Also from increased muscular activity more or less 
hypertrophy of the heart is caused. But an individual cannot 
be strong and sturdy and full of energy and muscular activity 
without sufficient adrenals, and very strong individuals who are 
well balanced mentally and can withstand pain, shock, blood- 
letting, injuries, infections and toxemias, all have a sufficiency 
of adrenal secretion, if not an increased amoimt. 

An abnormal secretion of the adrenals may have something 
to do with the unknown pathogenesis of gout, as in this disease 
there is some disturbance of the nitrogen metabolism, though 
various organs may partake in the causation of that disease. 
An increased suprarenal activity seems to be associated with an 
increased uric acid output. 

Hyper-function of the adrenals may be one of the causes of 
large appetite, good digestion, and splendid alimentation. 
Certainly, deficiency of the adrenals causes a disturbance of the 
secretions of the gastrointestinal tract, imperfect peristalsis, 
and imperfect sexuality. 

If there is hypersecretion of the adrenals early in life there 
is likely to be an early development of puberty; a girl may 
develop menstrual flow and have pubic and axillary hair, even 
when four or five years of age, and a boy of the same age may 
show the sexual development of full puberty, have hair on the 
body, have a mustache, and a masculine voice. If the hyper- 
adrenalism continues in the case of the female, the girl may show 
masculine characteristics. 

Thyroid hyperactivity increases the kinetic drive, so termed 
by Crile, and this, added to the present age of nervous, restless 
push, causes brain tire and heart tire. Also, as Crile states, 
emotion, energy and excitement increase the secretion of 
epinephrine, and that substance activates the muscles and 
increases the circulatory tone. If this stimulation persists, 
there can be only ultimate suprarenal tire and suprarenal 
insufficiency, and with this insufficiency must come weakness 
and debility. 

Chronic focal infection can at first irritate the suprarenals 



SUPRARENAL GLANDS 



463 



and stimulate them to extra secretion, to be followed later by 
subsecredon. On the other hand, toxins from certain germs not 
only of the acute infections, such as diphtheria, influenza and 
pneumonia, but from some chronic focal infections, can inhibit 
the secretion of the suprarenals from the start. These toxins 
can affect the suprarenals, either to stimulate or to inhibit 
their acti^dties, whether the infection is in the abdomen or in 
the mouth. Tonsillar infection and tooth infection can cause 
increased or decreased blood-pressure, and removal of such 
infection can correct the condition. Glycosuria may be caused 
by mouth Infection. Whether such infection stimulates the 
adrenals to an extra output of epinephrine, which in turn urges 
the liver to elaborate too much glycogen, or whether the 
infection disturbs the thyroid or the pituitary or the pancreas, 
or all of these glands, nevertheless glycosuria is sometimes the 
result, and the removal of the focal infection will very many 
times cure the glycosuria and prevent the development of 
diabetes mellitus. 

Mental depression, sorrow, and melancholia all inhibit the 
efficiency of the suprarenals, while, as Crile says, joy and 
hope seem to be a stimulant to these glands* Also insufficiency 
of the thyroid with the depression that goes with that condition, 
can but, at times, inhibit the suprarenals. The suprarenals are 
inhibited in their acti\^ty by acute pain though lasting but a 
short time, by subacute pain lasting a longer time, and by chronic 
pain lasting a still longer time, as evidenced by lowered blood- 
pressure, weakened heart action, and more or less shock. 

The necessity for suprarenal secretion directly reaching 
the blood is shown by death being caused by tying of the veins 
of the adrenal glands, although death will not occur as rapidly 
as after extirpation of the glands, 

Hypoadreiifllism*^There are all grades of subsecretion of the 
adrenals, from complete absence of secretion from destruction 
of the adrenal glands (as occurs in the final stages of tuber- 
culosis of these glands in Addison's disease) to an almost 
unrecognizable subsecretion, A mild form of hyposecretion is 
shown by lack of muscle tone, low blood -pressure, cold extremi- 
ties, proneness to infections, slow recovery from acute disease, 



464 THE PRINCIPLES OF THERAPEUTICS 

weak heart action, poor digestion, poor appetite, constipation^ 
lack of sexual tone, weariness, and the condition termed 
neurasthenia. Some of these conditions may be prominently 
present and others may be only slightly in evidence, but they 
all show more or less insufficiency of the suprarenal glands. 

Still greater insufficiency of the adrenals is shown by diarrhea, 
nausea, vomiting, and slight pigmentation of the skin. Small 
pigmentations developing at any time, or especially as age ad- 
vances, probably shows adrenal insufficiency. Brown spots on 
the body, not due to liver distiurbances, will disappear under the 
administration of suprarenal extracts. 

When Addison's disease is in evidence the patient may die of 
the acute disease within a short time without any pigmentation 
whatever, but in chronic, slowly developing Addison's, pig- 
mentation of the body occurs, sometimes bronzing to the extent 
of changing a white person to a black one, so that he could not 
be distinguished from a negro by his color. Even the mucous 
membranes are pigmented, the mouth, the tongue, the nostrils, 
and, in the case of women, the vagina. There may remain 
white patches on certain parts of the body, but in some cases 
this pigmentation may cover practically the whole body, and it 
is a fact that the administration of suprarenal extracts fre- 
quently will remove this pigmentation, even if it does not save 
life. Patients with Addison's syndrome are anemic; have a 
very low systolic blood-pressure, even to 95; have very weak 
heart action with consequent dyspnea; have complete insuffici- 
ency of the digestive glands, and many times abdominal pain. 

Occasionally Addison's disease has not shown apparent 
disease of the adrenals, but there probably has always been 
some nervous disturbance or some circulatory disturbance of 
the adrenal glands; but there is probably no doubt that with 
these symptoms, namely, bronzing, anemia, low blood-pressure, 
and digestive symptoms, the adrenals are always subsecreting. 
The cases in which the adrenal glands are not permanently 
diseased and have only lost their function are probably the ones 
that are more or less permanently benefited by the feeding of 
adrenal gland tissue or extracts. If both glands are tuberculous 
and not sufficient healthy tissue remains to be stimulated or to 



SUPRARENAL GLANDS 



46s 



cause suprarenal function, or if there are not supernumerary 
glands that can assume such function, feeding of suprarenal 
extracts may help, but will not save the patient. 

Hemorrhage into the suprarenals has caused sudden death, 
similar to shock. Also the adrenal glands can develop an 
acute inflammation, probably not recognizable. Occasionally 
cancer or sarcoma will afifect a suprarenal gland^ and sometimes 
both glands. 

Disturbance of the suprarenals sometimes causes asthmatic 
attacks, frequently associated with other signs of protein 
poisoningj and these patients are benefited by the administra- 
tion of suprarenal. 

Disturbances of the suprarenals are at times the cause of 
mental peculiarities* A hypersecretion may cause the indivi- 
dual to be aggressive, and women to assume a more or less 
masculine type. Subsecretion may make the individual cranky, 
dissatisfied with everything, probably because he always feels 
below par and ineflScient, and never feels normally fit. 

tJses.^Charies E. DeM. Sajous,* who has done so much re- 
search on the adrenal glands, rightly asserts that some of the 
sudden deaths seen in soldiers after violent exertion, without 
apparent heart lesion, is due to hypoadrenia; and it has been 
shown that although the heart may be normal and even en- 
larged and ready to do extra work, very small adrenals prevent 
the possibility of severe muscular strain, and such indi\'iduals 
fall, faint, are prostrated, or may even suddenly die after hard 
exertion. Sajous states, as has long been known, that digitalis 
is of no benefit in this kind of circulatory weakness, while supra- 
renal gland is at times of benefit, and, if 0,001 Gm. (^ j^y grain) 
of epinephrine, dissolved in physiologic saline solution, is in- 
jected hj^odermatically, it may save life in these shocked cases. 
Later suprarenal gland extracts may be given by mouth, daily, 
with benefit. 

Sajous also emphasizes what Crile has also stated, that pro- 
longed excitement, fear, rage, and the general strenuosity to 
which a soldier in active w^arfare is subjected may use up his 
reserve adrenal secretions, and the medullary portion of the 

^ Pemi. Med, Joum., Jan., 191 9, p, 315. 




466 THE PRINCIPLES OF THERAPEUTICS 

adrenals become insufficient, and lie suddenly becomes weak- 
ened or shocked. This probably represents an important cause 
of the "shocking" of soldiers, and explains the considerable 
length of time necessary for them to build up their reserve 
secretion and become again physically fit. 

In all shocked conditions from injury, in prostrating acute 
infections such as dysentery, typhoid fever, and especially in 
diphtheria, pneumonia and influenza, the adrenals have become 
insufficient, and from infections they may become actually 
pathologically disturbed. There may be hemorrhages into the 
glands. In all these cases suprarenal extracts should be given, 
but in not too large doses, as a secondary fall of pressure may 
occur; also large doses have caused death. Rest, heat, suprare- 
nal feeding, and strychnine in not too large doses is the treat- 
ment. Of course the blood-pressure-raising properties of 
caffeine and atropine may be needed to tide over the condition, 
but the cure is brought about by the administration of suprare- 
nal, or by the return of the adrenals to normal secretion. 

While part of the neuro-drculatory asthenia of enlisted men 
is due to thyroid hyperactivity, part is also due to suprarenal 
insufficiency. Rather typical of adrenal insufficiency are cold 
hands and feet, and bluing of the lips on the least exertion. 
Although it has been shown that epinephrine secretion does not 
seem necessary for the maintenance of normal blood-pressure, it 
is very necessary to develop an increased blood-pressure when 
the pressure is subnormal and the circulation insufficient. 

The rise in blood-pressure after the administration of epineph- 
rine, when given on the tongue or hypodermatically, or when 
it is absorbed from mucous membranes other than the stomach, 
quickly occurs, but it does not last long. This action is not, 
however, the action that causes the greatest help; it is the stimu- 
lation that it causes to the suprarenal glands. A blood-pressure 
raising treatment that lasts such a short time could be of only 
momentary help, consequently, as soon as the emergency is past, 
after administering epinephrine hypodermatically or on the 
tongue (though such treatment may be repeated a few times, 
especially on the tongue), the greatest advantage from supra- 
renal treatment is obtained by giving the whole gland extracts 



SUPRARENAL GLAKDS 



467 



by the mouth. When given in tablet, the tablet should be 
crushed and swallowed with water* The blood-pressure-raising 
substance seems to be changed chemically in the stomachy so 
that it does not cause the usual rise of arterial pressure, but the 
rest of the gland seems to stimulate and help a depressed circu- 
latory condition. Also, as above stated^ in Addison's disease 
with pigmentation administering the chromaffin part of the 
glandulax substance either directly causes a diminution of the 
surface pigmentation, or else it stimulates the adrenal glands 
to furnish the substance which is lacking. The gland by the 
mouth is active, as the author has seen pigmentation disappear 
and a blackened skin become white, when the suprarenal glands 
were later found, after death, to be riddled with tuberculous 
disease. 

Too much epinephrine given hypodermatically or on the 
tongue, may cause a low blood-pressure and a serious disturb- 
ance of the respiratory center, The treatment of such over- 
action would seem to be atropine and caffeine hypodermatically, 
and artilidal respiration. Suprarenal extracts often stimulate 
the heart to better activity. After injection of epinephrine the 
first rise in blood*pressure may be soon followed by a fall to, 
often, be foUowed by a second slight rise. 

Development of the genitalia, especially of the testes, may 
be stimulated by the administration of suprarenal, and at times 
sexual precocity in young children has been shown to be asso- 
ciated with disturbances causing hypersecretion of the adrenal 
cortex. In these young children who have this abnormal 
sexual development it has been generally found that there was 
a growth of the adrenal cortex, most frequently, perhaps, a 
hypernephroma. In milder forms of hypersecretion of the 
adrenal cortex in children there is a more rapid development 
than normal of the pubic hair and of the external sexual organs. 
This condition more frequently occurs with females than with 
males. 

It is impossible to decide what relation the suprarenal glands 
have to high blood-pressure which is so much in evidence to-day. 
There is no justification for removing the suprarenal glands for 
such a condition at the present time, because the exact relation 



468 THE PRINCIPLES OF THERAPEUTICS 

of constant high pressure to the suprarenals has not been 
proved. X-ray treatment of these glands has been suggested, 
but such treatment seems of doubtful value, as it would be im- 
possible to treat these glands without treating other parts of 
the abdomen or back, probably to the disadvantage of other 
organs. 

Serious bums of the body have sometimes caused adrenal 
insufficiency and hemorrhage into the tissues of the glands. 
Seriously burned, as well as other shocked patients, therefore, 
should receive suprarenal extracts. 

It has been shown that patients who have the morphine habit 
have insufficiency of the suprarenals, and that they are also 
more susceptible to all kinds of poisoning. It has also been 
experimentally shown that any insufficiency of the suprarenals 
increases the susceptibility to poisoning. 

Chloroform and ether anesthesia more or less inhibit the 
output of the suprarenals, and depression following anesthesia 
is well treated by suprarenal and pituitary extracts. 

Associated with Bright's disease there may be stimulation of 
the suprarenals, and this may be a cause of the increase of 
blood-pressure besides what is caused by the abnormal amount 
of irritants in the blood. 

Just what is the relationship of tobacco to the suprarenals has 
not been determined, especially as nicotine has been shown by 
Stewart and Rogoff^ to inhibit the epinephrine output of the 
suprarenals. Certainly, men who are used to smoking have 
their blood-pressure raised by tobacco, but the excessive use of 
tobacco does cause low blood-pressure and weakening of the 
circulation. This has been supposed to be due to action on the 
heart muscle, but as these experimenters state, it may also be 
due to inhibition of the epinephrine output, and therefore to a 
lack of tone of the splanchnic vessels. 

In any condition of low blood-pressure, depression and cir- 
culatory weakness whether suprarenal will be of benefit, or not, 
cannot always be determined before the clinical trial. If there 
are other symptoms of adrenal insufficiency, suprarenal feeding 
is often of value, but in ordinary fatigue and in low blood- 

^Joum. of Phann. and Exp. Thera., June, 1919, p. 183. 



SUPRARENAL GLANDS 



469 



pressure from many conditions, the treatment is very dis- 
appointing. 

Many times with indigestion of a fiinctional type suprarenal 
helps the patient and corrects the condition. It has not been 
determined why hypersecretion and hyposecretion of the thy- 
roid cause so many gastrointestinal disturbances, but the in- 
terrelations of the endocrine glands should always be kept in 
mind. Certain it is that sufficient suprarenal secretion seems 
necessary for normal gastrointestinal digestion, and adrenal 
extracts are sometimes especially valuable in weak muscle 
activity of the stomach and intestines. 

In Addison's disease there may be periods of intermission, 
therefore when suprarenal extracts have been given and im- 
provement occurs such improvement may not be due to the 
treatment* However^ it seems to be a fact when the suprarenal 
glands are not too seriously injured that there is some improve- 
ment from feeding suprarenal extract, and naturally the whole 
gland must be given, the administration of epinephrine rep- 
resenting only a small part of the acdvdties of the adrenals. It 
should be given for a long time, a small dose once a day. Al- 
though some symptoms are improved by such treatment, 
especially the pigmentation on the skin and mucous membranes, 
if the adrenal glands are seriously diseased this treatment cannot 
save life. Pituitary extracts in small doses may be added to the 
suprarenal treatment, as pituitary extract is known to stimu- 
late the adrenals. If the patient is benefited by these glandu- 
lar treatments, there is a rise in blood-pressure, a better dr- 
culation, and an improvement in digestion and nutrition, and, 
as just stated, the pigmentation disappears. 

The value of suprarenal and especially of epinephrine in 
asthma has now long been noted. An epinephrine tablet 
crushed with the tteth and allowed to absorb from the mouth, 
or 5 to 10 drops of an epinephrine solution of i part to looo, will 
usually stop an asthmatic attack. Also, the solution has been 
sprayed directly into the larynx with success. Large doses of 
epinephrine intravenously or hypodermaticaUy have caused 
death. Not every patient, however, is helped by epinephrine 
treatment, some patients are more benefited by nitroglycerin. 



470 THE PRINCIPLES OF THERAPEUTICS 

It is not always possible to foretell which patient will be im- 
proved by which method of treatment, as the two treatments 
are opposed to one another. Theoretically, if the blood-pres- 
sure is high, nitroglycerin would be the treataient; if the blood- 
pressure is low, adrenal or epinephrine preparations would be 
the treatment. There has seemed to be some relation between 
disturbances of the suprarenal glands and asthma, and perhaps 
the adrenals are disturbed in various anaphylactic reactions, 
especially in those that are associated with shock, and asthma 
many times represents an anaphylactic reaction. Rarely, 
however, is suprarenal treatment a cure for asthma, even if it is 
successful in stopping the paroxysms. The cause of the asthma 
must be sought and treated. 

It has been suggested that a dose of epinephrine, to be ab- 
sorbed from the mouth, should be given before the intravenous 
injection of arsphenamine, as tending to prevent some of the 
unpleasant symptoms that may follow such an injection. The 
dose should be given an hour before the injection, and then per- 
haps another dose just before the intravenous injection is given. 

Auer and Meltzer^ have shown experimentally that there is a 
more lasting blood-pressure-raising eflfect from epinephrine if it 
is given intraspinally. This would seem to be a valuable sug- 
gestion for trial in every shocked condition that did not react 
to other methods of treatment. Sajous^ advises that in acute 
shock and in heart failure (acute adrenal failure he terms it) 
during an acute infection hypodermic injections be given of lo 
minims of a i to looo epinephrine solution, in a syringeful of 
saline solution, every two hours for three doses, and then four 
times daily, if needed. 

In morphine and opiimi poisomng when artificial respiration 
is apparently saving life, many times death is finally due to 
heart failure. Therefore, if the pulse is not good, or at any 
time becomes feeble in such poisomng, epinephrine solutions 
on the tongue, hypodermatically or intraspinally, should be 
considered. 

Suprarenal sprays and snuffs have been used frequently in 

^Amer. Joum. of Physiol., Dec. 1918, p. 286. 
*Journ. Med. Soc. of N. J., No. 15, 1918, p. 109. 



SUPRARENAL GLANDS 



471 



hay fever, and in the eye in certain inflammations, and locally 
to cause blanching of a part to prevent hemorrhage before minor 
operations; it has^ also, been sprayed into the throat or larynx, 
or swabbed over irritated regions of the tonsils or phari^nx, to 
control acute congestions. The relief from shrinking of the 
tissues and a din\inution of the swelling is very great, but unless 
used repeatedlyj there is likely to be renewed swelling and, 
sometimes, a greater congestion than before. Occasionally a 
patient has considerable irritation from suprarenal sprays in 
the nose or mouth, such as serious sneezing and even pain. 
There is no habit formed from the use of suprarenal extracts. 

Epinephrine is added to different preparations of cocaine 
for local anesthesia, and renders the anesthesia more lasting, 
and the bleeding during the operation less. There may be a 
considerable rise in the blood-pressure from the use of epineph- 
rine solutions on the mucous membranes, but it should be 
remembered that the blood-pressure-raising substance is 
destroyed when the solution, tablets, or powders are taken into 
the stomach. 

The value of suprarenal in hemorrhagic conditions and 
puq}ura is not very great. Occasionally it has seemed to have 
been of some value, but other treatments are better. 

With patients who are neurasthenic and always have a low 
type of circulation, suprarenal may be of benefit, but it must be 
given for a long period, and unless there is good suprarenal 
tissue to be stimulated, any permanent success is doubtful. 
There seems to be no question that there are individuals who 
always have an insufficient secretion from the adrenals. 

Administration.^ — The official Suprarcnalum Siccum (desic- 
cated suprarenal glands) is prepared from the glands of animals, 
and should contain about 0.5 per cent, of epinephrine. It 
occurs as a yellowish powder, partially soluble in water and the 
watery solutions contain the active principle, epinephrine, and, 
therefore, are active locally in contracting blood-vessels. The 
Pharmacopocial dose of the powder is 0,25 Gm. (4 grains), but 
this dose is too large if the preparation is to be frequently 
repeated. However, the exact dose of suprarenal when 
administered by the mouth has not been determined. It 



470 THE PRINCIPLES OF THERAPEUTICS 

It is not always possible to foretell which patient will be im- 
proved by which method of treatment, as the two treatments 
are opposed to one another. Theoretically, if the blood-pres- 
sure is high, nitroglycerin would be the treataient; if the blood- 
pressure is low, adrenal or epinephrine preparations would be 
the treatment. There has seemed to be some relation between 
disturbances of the suprarenal glands and asthma, and perhaps 
the adrenals are disturbed in various anaphylactic reactions, 
especially in those that are associated with shock, and asthma 
many times represents an anaphylactic reaction. Rarely, 
however, is suprarenal treatment a cure for asthma, even if it is 
successful in stopping the paroxysms. The cause of the asthma 
must be sought and treated. 

It has been suggested that a dose of epinephrine, to be ab- 
sorbed from the mouth, should be given before the intravenous 
injection of arsphenamine, as tending to prevent some of the 
unpleasant symptoms that may follow such an injection. The 
dose should be given an hour before the injection, and then per- 
haps another dose just before the intravenous injection is given. 

Auer and Meltzer^ have shown experimentally that there is a 
more lasting blood-pressure-raising eflfect from epinephrine if it 
is given intraspinally. This would seem to be a valuable sug- 
gestion for trial in every shocked condition that did not react 
to other methods of treatment. Sajous^ advises that in acute 
shock and in heart failure (acute adrenal failure he terms it) 
during an acute infection hypodermic injections be given of lo 
minims of a i to looo epinephrine solution, in a syringeful of 
saline solution, every two hours for three doses, and then four 
times daily, if needed. 

In morphine and opiimi poisoning when artificial respiration 
is apparently saving life, many times death is finally due to 
heart failure. Therefore, if the pulse is not good, or at any 
time becomes feeble in such poisoning, epinephrine solutions 
on the tongue, hypodermatically or intraspinally, should be 
considered. 

Suprarenal sprays and snuffs have been used frequently in 

^Amer. Joum. of Physiol., Dec. 1918, p. 286. 
*Joum. Med. Soc. of N. J., No. 15, 1918, p. 109. 




SUPRAHENAL GLANDS 



471 



F 



hay fever, and in the eye in certain inflammations, and locally 
to cause blanching of a part to prevent hemorrhage before minor 
operations; it has, also, been sprayed into the throat or larynx, 
or swabbed over irritated regions of the tonsils or phar/nx, to 
control acute congestions. The relief from shrinking of the 
tissues and a dimtinution of the swelling is very great, but unless 
used repeatedly, there is likely to be renewed swelling and, 
sometimes, a greater congestion than before. Occasionally a 
patient has considerable irritation from suprarenal spraj^ in 
the nose or mouth, such as serious sneezing and even pain. 
There is no habit formed from the use of suprarenal extracts. 

Epinephrine is added to different preparations of cocaine 
for local anesthesia, and renders the anesthesia more lasting, 
and the bleeding during the operation less. There may be a 
considerable rise in the blood-pressure from the use of epineph- 
rine solutions on the mucous membranes, but it should be 
remembered that the blood-pressure-raising substance is 
destroyed when the solution, tablets, or powders are taken into 
the stomach. 

The value of suprarenal in hemorrhagic conditions and 
purpura is not very great. Occasionally it has seemed to have 
been of some value, but other treatments are better. 

With patients who are neurasthenic and always have a low 
type of circulation, suprarenal may be of benefit, but it must be 
given for a long period, and unless there is good suprarenal 
tissue to be stimulated, any permanent success is doubtful. 
There seems to be no question that there arc individuals who 
always have an insufficient secretion from the adrenals, 

Adniimstration, — ^The official Suprarcfiahwi Siccum (desic- 
cated suprarenal glands) is prepared from the glands of animals, 
and should contain about 0.5 per cent, of epinephrine. It 
occurs as a yeUowish powder, partially soluble in water and the 
watery solutions contain the active principle, epinephrine, and, 
therefore, are active locally in contracting blood-vessels. The 
Pharmacopoeial dose of the powder is 0,25 Gm. (4 grains), but 
this dose is too large if the preparation is to be frequently 
repeated. However, the exact dose of suprarenal when 
administered by the mouth has not been determined. It 



472 THE PRINCIPLES OF THERAPEUTICS 

should not be taken on any empty stomach, as it may cause 
nausea. 

There are no good S3rmptoms of over-administration such 
as are' so readily noted when thyroid is administered, but an 
increase in blood-pressure, unpleasant thumping of the heart, 
and headache, indicate that too much has been given. If 
the patient is pregnant, suprarenal may cause uterine pains, 
hence if suprarenal is given for low blood-pressure during 
pregnancy its action should be carefuUy watched. 

Prolonged use of epinephrine has been thought to cause 
atheroma, but this occurrence must be very rare, as the drug is 
but seldom used for any great length of time, except in Addison's 
disease. 

Various epinephrine preparations may be obtained. The i to 
looo solution is the most useful for administering it by the 
mouth and for use on mucous membranes. The action of these 
preparations is only on the circulation and is not suprarenal 
action. Ampules representing i part in 10,000 may be obtained 
for hypodermatic use. The dose of a i to 1000 solution on the 
tongue is 5 to 10 drops, diluted with only an equal number of 
drops of water, so that absorption will surely take place from 
the mouth, or a tablet may be crushed and dissolved in the 
mouth. Adrenalin tablets are oflfered which contain o.ooi Gm. 
per tablet. 

All solutions made from the dried gland or from the powder 
soon deteriorate unless some antiseptic is added. The ad- 
renalin chloride solutions contain a small portion of chloretone. 
There are various adrenalin ointments, inhalants, and tablets; 
also there are various epinephrine preparations and suprarenin 
preparations. When epinephrine solutions are used as a spray, 
the strength should be i part to 10 or 15 thousand, or even 
weaker. 

Tyramine Hydrochloride, — Tyramine has been isolated from 
ergot, and also is made synthetically. Tyramine hydrochloride 
occurs as a whitish crystalline powder, is soluble in water, and 
may be used in a i to 10,000 solution. Its action is similar to 
that of epinephrine, but less powerful and less persistent. It 
produces a rise in blood-pressure, and may be used in shock and 



CORPUS LIJTEUH 



473 



collapse^ or as a local hemostatic. As, like ergot, it contracts 
the uterus, it has been suggested for uterine hemorrhage. It is 
not as active a uterine contractor as is pituitary extract^ hence 
perhaps safer in parturition. The dose of tyramine hydro- 
chloride is about 0.02 Gm. (H grain) given in solution. 

CORPUS LUTEUM 

Descriptioii,^ — This small glandular structure named corpus 
luteum by Malphigi, has a distinct function although it is part of 
another gland, the ovary . Its acti\a ties are very positive and very 
distinct from the acti\'ities of ovarian substance before the cor- 
pora lutea develop and from ovarian substance minus the corpora 
lutea, ovarian residue. This glandular tissue does not occur until 
just prior to menstruation, and before puberty the interstitial 
cells of the ovaries furnish all the gonadal secretion that the 
female child requires. At puberty the ovule, Graafian foUicJe, 
ripens and ruptures, and the corpus luteum is a consequence, 

Function-^There is a general consensus of opinion that one of 
the functions of the corpus luteum is to sensitize the uterus to 
make it ready for pregnancy and for the growth of the placenta. 
It is also thought that it determines menstruation, and it prob- 
ably is a promotor of sexual impulses and sexual desires. This 
little gland grows for about two and a half weeks after ovula- 
tion and then gradually degenerates, provided conception has 
not occurred. If the female becomes pregnant, the corpus 
luteum persists at full activity, apparently, for about two 
months and then begins to degenerate. Just what causes the 
degeneration of this body at this time is not known* 

The relation of the corpus luteum to menstruation has not 
been determined, but some hormone must stimulate or by its 
absence cease to inhibit, the development of the next ovule 
and the new corpus luteum, and it would seem that thislitUe 
gland being so closely associated with the rhythm of menstruation 
must be the tissue that controls this function. On the other 
hand, something must inhibit ovulation during pregnancy and 
during lactation, and it has been suggested that the placenta in 
the first instance and the mammary glands in the second instance 
may furnish such hormones. 



474 THE PRINCIPLES OF THERAPEUTICS 

Abnormal persistency and disease of the corpus luteum seem 
to prevent the next menstruation^ and an abnormal function of 
several corpora lutea seems to be the cause of irregular and 
abnormal menstruation and of sterility. 

It has been suggested that the cessation of the nausea of 
pregnancy at about the beginning of the third month is due to 
the secretion from the corpus luteum of pregnancy, which at 
about the end of the second month begins to degenerate and 
^possibly furnishes substances for absorption into the blood, 
[.while previous to that time when it was developing it did not 
furnish such a secretion; therefore the nausea. Some obste- 
tricians therefore believe in feeding this gland during the nausea 
of early pregnancy, and, it has been claimed, with some success. 
Such an action of this gland, however, would seem almost 
paradoxical. Certainly, a substance that is known to be a 
gland and known to have function, and known to increase in 
size during early pregnancy, must have increased fimctional 
activity. Therefore such an interpretation of the cause of 
nausea and then its cessation does not seem logical. It should 
be noted that very many women after pregnancy are in better 
health than ever before, probably due to normal stimulation of 
the endocrine glands. 

It should be recognized that irritations and infection in the 
pelvic region may cause disturbances of the ovaries and corpora 
lutea similar to the disturbance caused other glands closely 
associated with infections. With the many abnormal conditions 
that can occur in the pelvic region of women, it is not surprising 
that various disturbances of the ovaries, of ovulation, and, there- 
fore, of the corpora lutea, ocoir, and cause all kinds of over-secre- 
tion and imder-secretion of these glands as evidenced by mental 
disturbances, by irregular, scanty or profuse menstruation, and 
by local pain. 

Just what relation the secretion of the corpus luteiun of pr^- 
nancy and the secretion of the placenta have to the growth of the 
breasts during pregnancy cannot be stated, but some hormones 
from some source cause the breasts to become ready for lactation. 
Sometimes the administration of corpus luteum extracts stops !*• 
pain in the breasts that occurs before and with menstruatk 



CORPUS LUTEUM 



475 



The relation of the ovaries and of the coq^ora lutea to the 
development of mammary cancer is of sufficient importance 
to deserve a most careful study. Mammary cancer is very 
frequent and generally develops at, or soon after, the menopause^ 
i,€,f at the time when the corpora lutea have ceased their func* 
tion and the ovaries are diminishing their secretion . Sometimes 
the removal of ovaries has stopped the growth of mammary 
cancer. There probably is some polyglandular disturbance at 
the period of the menopause which readily allows the mammary 
gland to become infected (if there is a germ of cancer) or to 
become stimulated to the production of small cellsj if the growth 
is due only to rapid cell proliferation. 

The close relation of the mammary gland to menstruation 
and the corpus luteum function must be recognized, as the 
breasts always hypertrophy more or less just before and during 
every menstruation. It has also been suggested that perhaps 
the atrophy of the uterus at the time of the menopause furnishes 
some hormone that irritates the breasts. Although none of 
these questions can be answered, still the positive relationship 
is there, and the fact remains to be explained as to why the most 
frequent location of cancer in the female is in the breast, and 
the most frequent period of such a growth is after the 
menopause. 

Uses. — Corpus luteum extracts have been used with success 
in the delayed menstruation of young girls and in amenorrhea* 
If, however, it is thought that the ovarian secretion is insuffi- 
cient in young girls just prior to the age of puberty, ovarian 
extract, or perhaps better, ovarian residue, should apparently 
be the treatment. At the time when puberty should develop, 
and in amenorrhea after young girls have menstruated several 
times, extracts of corpus luteum may be indicated, although 
generally in such patients there is a subthyroid secretion^ and 
small doses of thyroid are more efficient. U these young girls 
are anemic, and in unhygienic surroundings, and are over-worfc- 
^y and mentaUy, all such undesirahJe conditions 
'ented,i.e., the mere matter of amenor- 
^ is unimportant; certainly corpus 
case. Id older girls and young 




476 THE PRINCIPLES OF THERAPEUTICS 

women with amenorrhea there is generally associated hypothy- 
roidism, and treatment directed toward that gland is more effi- 
cient than is treatment aimed only at ovarian insufficiency. 
Some patients are most benefited by a combination of thyroid, 
corpus luteimi, and pituitary extracts. 

Women who alwa)rs have their menstruation delayed a few 
days, sometimes a week, and suffer in consequence more or less 
nervous irritability, may have it become normal in time by tak- 
ing thyroid or corpus luteum extract, some best with one gland 
treatment and some best with the other, and some with a com- 
bination of both. The physician must recognize that whenever 
a thyroid or corpus luteum extract is given a patient, the treat- 
ment is potent, and may cause harm, and neither should be 
given for more than short periods without supervision. 

In conditions of overweight with amenorrhea, or with increas- 
ing weight at the menopause, the whole glandular symptom 
complex should be studied, and the organ extracts that are indi- 
cated given. Corpus luteum for a time may be advisable, 
especially if the blood-pressure is high, which it often is at the 
time of the menopause. 

Sometimes the blood-pressure is excessively high without 
evident arteriosclerosis and without kidney insufficiency, and 
for such patients corpus luteum is often a very efficient treat- 
ment. It should be recognized that long continued and large 
doses will cause serious loss of blood-pressure, palpitation, 
nausea, vomiting, and depression, and when given for high 
blood-pressure a fall of 15 or 20 mm. should cause the treatment 
to be stopped for a time, and if the systolic blood-pressure is 
below 120 mm. and the extract is indicated, it should not be 
given longer than to lower the pressure 5 mm., and when the 
systolic pressure is lower than no mm. it should not be used at 
all. Sometimes the pressure falls suddenly much lower and 
causes faintness. Corpus luteum will often prevent some of the 
toxic conditions of the menopause. 

If pelvic pain occurs from delayed menstruation, or there 
are uterine pains with insufficient flow and then clot formation, 
corpus luteum extract many times causes such a flow to be- 
come normal. Before resort is had to glandular extracts, how- 



CORPUS LUTEITM 



477 



ever, tJie pelx'ic conditiOB must be studied from the physical 
standpoint, lest disturbances that could be corrected surgically 
be omitted. 

The relation of the corpus luteum of pregnancy to the vomit- 
ing of pregnancy has already been discussed. Although the 
administration of this gland extract to prevent the nausea does 
not seem logical, practically, there is a great deal of testimony 
to show that it is of value, and it should probably be tried, and 
best in the form of aseptic preparations, which may be obtained 
in ampules^ for intramuscular injections. This method of 
administration is also probably the best for high blood-pressure. 

The majority of clinicians use corpus luteum. extract in pref- 
erence to ovarian extract because it has tangible activities 
which ovarian extract does not have, but though ovarian extract 
acdvity is more intangible, many times it is as positive. In 
dysmenorrhea large doses of corpus luteum are sometimes given, 
even from i to 2 Gm. (15 to 30 grains) a day, by the mouth. If 
the drug was to be given for more than a few days such dosage 
would be too large. It should not be given when the blood- 
pressure is very low. 

In delayed menstruation and in amenorrhea the administra- 
tion of extracts of this gland is probably more successful when 
a corpus luteum is present in an ovary but not sufficiently 
functioning. It has not been shown that when the ovaries are 
degenerated corpus luteum can of itself cause menstruation. 
When there is great psychic disturbance just before men- 
struation, it may be tried, perhaps best by intramuscular 
injections. 

Adinimstration.— Corpus luteum extract is best prepared 
from the glands of the sow, and probably for clinical purposes 
the mixed preparations from both pregnant and non-pregnant 
animals are satisfactory. Even if the preparations were made 
from glands of pregnant animals only, they would be more 
active and hence the dose would be smaller; the difference is 
probably only in the dosage. The substance can be obtained 
in powder, in capsules and in tablets. Five grain tablets arc too 
large, and i or 2 grain tablets are better. 

In very high blood-pressure at the menopause, and in the 



478 THE PRINCIPLES OF THERAPEUTICS 

nausea of pregnancy, it is best given intramuscularly, and can be 
obtained for this purpose in ampules, each ampule containing i 
mil, which represents a soluble extract of 0.20 Gm. of the dried 
substance. In a mild case of nausea and vomiting the contents 
of one ampule every other day may be injected; or in severe 
cases, every day. 

The most frequent signs of intolerance to this gland treatment 
are indigestion and headache. The ampules of course have 
better keeping properties than the dried powder or tablets, 
and deterioration may be a cause of these unpleasant symptoms 
from its administration. 

OVARIES 

Function. — ^At just what embryonic age the ovaries begin to 
furnish their specific hormones has not been determined, but 
the growth of the external anatomical sexual characteristics of 
the female are not entirely due to the secretion from these 
glands. If for any reason the ovaries are removed in the 
young female child, the pelvis does not grow to the usual female 
size, the breasts do not normally develop, more or less hair 
appears on the face, the voice is low pitched, the legs are longer, 
and the mentality may be sluggish, i.e., a castrated female 
takes on the male type, much as the castrated male takes on the 
female type. 

It has long been noted that the earlier the girl menstruates 
the shorter, ordinarily, will be her legs, and the later before 
she develops this fimction, the longer the legs. Although there 
may be exceptions to this nde, ordinarily the girl ceases to 
grow tall at puberty. Sexual precocity in girls may be due to 
early and more rapid development of the fimction of the 
ovaries, or may be due to an insufficiency of the pineal gland, 
this gland being supposed to control the gradual sexual develop- 
ment. An increased secretion from the anterior lobe of the 
pituitary may cause an increased and rapid skeletal growth, 
and an imder-secretion of the posterior lobe of the pituitary 
may cause the girl to become large, fat, and to develop more 
rapidly external sexual characteristics, but later with such 
pituitary dysfunction the sexual activities may remain infantile. 



OVARIES 



479 



In disturbance of the pituitary as occurs in acromegaly in 
females there is generally amenorrhea, and with this ovarian 
disturbance there is likely to be some development of the 
masculine type. In subthyroid conditions, although the 
uterus and ovaries may be apparently normal, menstruation 
may not occur, and in real thyroid insufficienc)' the patient 
becomes obese and the skin is dry, while in pituitaiy disturb- 
ances the skin is moist and soft* 

The dose relationship of the thyroid to the sexual life of 
the female, namely, to the ovarian and to the corpus luteum 
secretions and to menstruation and pregnane}'- should be 
constantly borne in mind. The thyroid nonnally hypersecretes 
at each menstrual epoch and during pregnancy, and if it does 
not perform this increased function, the menstruation is not 
normal and may not occur, and the period of pregnancy may 
have serious metabolic or toxic disturbances. The effect of 
ovarian and corpus luteum secretion on the breasts is positive, 
and ovarian removal has even favorably affected inoperable 
cancer of the breast. 

The relation of the thymus gland to the sexual growth of the 
female has been denied, but if the thymus is large and h>T>er- 
secreting puberty is likely to be precocious and the growth of 
the girl diminished. Anything that stimulates the ovaries to 
increased secretion causes an early development of the girl and, 
after puberty, increases sexual desire. An increase of sexual 
desire also often occurs at the menopause, due to ovarian 
irritability. On the other hand, a too rapid cessation of 
ovarian activity at the time of the menopause may cause 
physical debility, mental depression, and even melancholia. 

Ovarian function is studied by ascertaining the activity 
of extracts of the whole gland including the corpora lutea, of 
extracts of the corpora lutea alone, and of extracts of the 
mature ovaries with the corpora lutea carefully removed, so- 
called ovarian residue. It must logically be admitted that the 
ovaries have an important function before puberty, i.e., before 
the corpus luteum appears. Also it is not rational to consider 
that as soon as the activities of the corpora lutea appear the 
remaining part of the ovaries, the ovarian residue, has no func- 



480 THE PRINCIPLES OF THERAPEUTICS 

tion whatever, though the corpora lutea have been shown to 
have very positive functions. 

X-ray radiations directed toward the pelvis may inhibit more 
or less the activities of the ovaries and the corpora lutea, and 
may, for a time at least, prevent menstruation. 

Menstruation. — The American girl matures, or first men- 
struates, on the average, at about the fourteenth year, but she 
may menstruate as early as twelve years of age, and rarely 
several years later than fourteen. Earlier menstruation is at 
the present time becoming more frequent because this age is one 
of excitement and nerve tension even for girls. Anything that 
increases the thyroid secretion in young girls may hasten pu- 
berty, and thyroid secretion is increased by anything that causes 
sexual excitement. Profuse menstruation in young girls is 
often due to hyperthyroidism, while amenorrhea may be due to 
a subsecretion of the pituitary or of the thyroid, and the con- 
dition of chlorosis often requires th3n:oid medication. Ill 
health delays puberty. 

It may seem to be a function of the corpus luteum gland to pro- 
mote menstruation, but it has not been determined what decides 
the day and hour of the flow. On the average, about six ounces 
of blood is lost. Although it has been thought that with the 
menstrual blood considerable amounts of calcium, phosphorus, 
and other salts were lost, still it has*been more recently shown 
that, though the amoimts lost vary at different times, as a rule 
the need for calciimi and phosphorus by women who menstruate 
is not greater than the need of men or of women who do not 
menstruate. 

Menstrual blood does not normally clot; if uterine dots occur, 
the bleeding is abnormal perhaps because the thyroid does not 
normally secrete. Profuse bleeding, or too frequent menstrua- 
tion certainly weakens the individual, but more loss of blood 
can be sustained without causing symptoms through men- 
struation than by hemorrhage from any other part of the body. 
Too frequent, or too profuse, or too prolonged menstruation can 
but deplete the blood, as evidenced by anemia and by the loss of 
some element that is concerned in the health of the bones, 
teeth and hair. If this valuable element that is lost is not cal- 



OVAKIES 



4«i 



dum, it must be pretty close to it. Also many times pregnan- 
cies cause the mother to lose her teeth and her hair^ and too 
frequent pregnancies may cause sufficient loss of calcium (used 
for the growth of her children) to cause osteomalacia. Also 
if a nursing mother begins to menstruate the milk is soon an 
insufficient food for her child. 

Uterine pains in dysmenorrhea may be caused by an excessive 
corpus luteum or a disturbed ovarian acti\nty, and it has been 
suggested that the influence of the developing placenta in 
pregnancy may prevent menstruation, and it has also been 
suggested that the absence of menstruation during lactation 
may be due to some mammar^^ hormone preventing ovulation. 
Directly after menstruation is the time the woman is likely 
to become pregnant. 

Women castrated during menstrual life generally rapidly add 
weighty not only because of the sudden loss of the menstrual 
flow, but also because of the loss of ovarian secretion. There 
is coincident with this loss of ovarian activity more or less thy- 
roid subsecretion and perhaps pituitarj^ subsecretioUj as the 
pituitary also takes part in the regular periodic menstrual cycle 
of the woman. If the thyroid should h^-persecrete after either 
artificial or normal menopause, weight will not be added, and 
there is likely to be loss of weight, and the vasomotor irregulari- 
ties which are tj'pical of the menopause. 

At the normal menopause which occurs on the average at 
about forty -eight years of age, if the thyroid begins to diminish 
its secretion coincidently and synchronously with the ovarian 
decreased activity and with the cessation of corpus luteum 
acti\^ty, very few symptoms occur. If, however, the thyroid 
does not cease its activity but rather continues its cycUcal hy- 
persecretion, more or less hot flashes, restlessness, irritability, 
sweatings, and many other associated disturbances occur, more 
aggravated every four weeks. Associated with this disturbed 
nervous condition is likely to be hysteria and many other neurotic 
symptoms. If, on the other hand, the thyroid too rapidly sub- 
secretes at the time of the cessation of menstruation, the woman 
rapidly adds weight, has digestive disturbances, is depressed, 
may be melancholic, and may have symptoms of mild m>Tc- 

31 



482 THE PRINCIPLES OF THERAPEUTICS 

edema. The most frequent age for myxedema is from forty to 
fifty, and at least 80 per cent, of all cases, if not 90 per cent., 
occurs in women. 

Profuse menstruation in young girls may be stopped by feed- 
ing pituitary extracts, and by feeding mammary gland extracts. 
Profuse uterine hemorrhage may occur without fibroids or 
other serious local disturbance, and be caused by pathologic 
ovaries, especially by cystic ovaries. Also quite possibly 
hypertrophy of the mucous membrane of the uterus may be 
caused by hypersecretion of the ovaries. Submucous fibroids 
however, are a frequent cause of venous bleeding, and menor- 
rhagia is frequent just before the menopause, at which time the 
cause must be carefully sought lest malignancy be overlooked. 

W. J. Mayo^ says "hysterectomy is seldom necessary for 
benign myoma in a woman under thirty-five, and demands an 
excellent reason in a woman under thirty. At forty-five hys- 
terectomy is probably the best procedure. Sutton has shown 
that ID per cent, of women who require hysterectomy for fibroids 
after fifty have coincident malignant disease." 

Disturbances of the ovaries which may not necessarily cause 
profuse menstruation may cause abnormal mental conditions, 
from simple girlish coquettishness and the desire for male com- 
panions to actual sexual perversion, and even to forms of insanity. 
When the history of such a sequence of symptoms has occurred, 
extirpation of at least one, and perhaps one and a half ovaries 
is certainly justifiable, and may cure the mental condition. 
Sexual intercourse may correct dysmenorrhea and irregular 
menstruation, and cystic ovaries are more frequent in the im- 
married than in the married woman. 

Osteomalacia is probably due to disturbances of several 
endocrine glands, but is largely due to dysfunction or over-func- 
tion of the ovaries, as it is rare after the menopause. It has 
been said to occur in men, but it is rare in males. There is 
always a disturbance of the caldimi metabolism, hence probably 
a disturbed function of the parathyroid glands. 

The proper treatment of osteomalacia is as follows: to stop 
lactation; prevent pregnancy; push nutrition, especially give 
^ Journal A. M. A., June