*■■.'■ V*--- v *-\n ** .♦»\<* "*&V ft.'*." " J?" / •V. .'"*« . ■ ' '* •-v- , Tjr •> a V,' ^J^ { V VL- tf* \P ^ ✓" ,^ ? t* V" Ay .41 \j6" &> - Zt J1 v' - ^ 0 \rC it* !£f >*> r.^ > ^,tV .^ «'*0 / ' v> NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland 1 f much that is contained in his observations on general pathology in the former Treatise, to which, therefore, he would respectfully invite the attention of the reader, if desirous of information on the subject. Vlii PREFACE^ Finally, it is proper to state that, on a comparison of this work with the Treatise on the Practice, upon the one hand, and the U. S. Dispensatory on the other, there will be found not a little that is common to it and one or both of the others; but this overlapping, at the borders, of Treatises on closely allied subjects is absolutely essential to a full and consistent view of each, and is nothing more than is found in all conterminous sciences, not only in the great complex science of medicine, but throughout the whole circle of human knowledge. This is probably the last professional Treatise of the author; as, with its publication, he will have exhausted what he has had to communicate in those departments of medicine to which he has given a special attention; and advancing years warn him that the time is fast approaching, when a failure of faculties, or the termi- nation of life, will render labour in any new field impracticable. He asks for it only the same kindly consideration which he has had occasion to acknowledge for his other works, and which has bound him to the profession by the strong ties of gratitude, in addition to those of duty and affection. Philadelphia, August, 1856. TABLE OE CONTENTS. PART I. GENERAL THERAPEUTICS AND PHARMACOLOGY. CHAPTER I. OPERATION OF MEDICINES. Section I. PRIMARY OPERATION OF MEDICINES. Subsection I. PRIMARY OPERATION THROUGH THE CIRCULATION, OR BY ABSORPTION. Subsection II. PRIMARY OPERATION THROUGH THE NERVES. Subsection III. PRIMARY LOCAL OPERATION. Subsection IV. MODES OF PRIMARY OPERATION. 1. Mechanical or Physical;—2. Chemical; — 3. Physiological, Vital, or Dynamic. Section II. SECONDARY OPERATION OF MEDICINES. 1. By Depression after Excitement. — 2. By Reaction following Depression. — 3. Through Dependence of Functio^fc4. Through Sympathy, or Nervous Transmission. — 5. Through Revumon, or Derivation. — G. Through the Repair of Injuries. — 7. Through the Removal of the Cause. CHAPTER II. EFB'ECTS OF MEDICINES. Section I. ESTIMATION OF THEIR POWERS OR EFFECTS. 1. Tlirough their Sensible Properties.—2. Tlirough their Chemical Relations.—3. Tlirough their Botanical Affinities. — 4. By Experiments and Observations on the Lower Animals. — 5. By Observations of their Effects on Man. Section II. WHETHER THE EFFECTS ARE ORGANIC OR FUNCTIONAL. Section III. CHARACTERISTIC EFFECTS OF MEDICINES. X TABLE OF CONTENTS. Section IV. INFLUENCES MODIFYING THE EFFECTS OF MEDICINES. 1. Age. —2. Sex. —3. Temperament. — 4. Idiosyncrasy. — 5. Disease. — 6. Cli- mate.—7. Habit. —8. Modes of Living. —9. Mental Action. CHAPTER III. APPLICATION OF MEDICINES. Section I. MODES OF THERAPEUTIC ACTION, OR THERAPEUTIC PROCESSES. 1. Depletion. —2. Repletion.—3. Dilution.—4. Elimination. — 5. Stimulation.— (>. Sedation or Depression. — 7. Revulsion, Derivation, and Counter-irrita- tion.— 8. Supersession. — 9. Alteration. —10. Anticausation.—11. Chemi- cal Influence. —12. Mechanical Influence. Section II. FORMS IN WHICH MEDICINES ARE USED. Subsection I. SOLID FORMS. 1. Powders. — 2. Electuaries. — 3. Conserves.—4. Pills. — 5. Lozenges. — 6. Cata- plasms.— 7. Ointments, Cerates, and Plasters. — 8. Extracts. Subsection II. LIQUID FORMS. 1. Mixtures.—2. Solutions.—3. Infusions.—4. Decoctions. — 5. Tinctures. — (i. Spirits. — 7. Wines.—8. Vinegars. — 9. Syrups. —10. Honeys. —11. Oxy- mels. —12. Fluid Extracts. Subsection III. IN THE AERIFORM STATE. Section III. PARTS TO WHICH MEDICINES ARE^APPLIED, AND MODES OP APPLICATON. SMmction I. TO THE ALIMENTARY CANAL. 1. To the Stomach.—2. To the Rectum. Subsection II. TO THE EXTERNAL SURFACE OF THE BODY. 1. By Contact with the Sound Skin.—2. By Friction. — 3. Endennic Application. Subsection III TO THE LUNGS. Subsection IV. TO VARIOUS OTHER SURFACES. 1. The Eyes. —2. Nostrils. —3. Mouth and Fauces. —4. Blood-vessels. CHAPTER IV CLASSIFICATION OF MEDICINES. 1. Uses of Classification. —2. Plan of Classification. TABLE OF CONTENTS. XI PART II. SPECIAL THERAPEUTICS AND PHARMACOLOGY. Division I. SYSTEMIC REMEDIES. Subdivision I. GENERAL REMEDIES. CHAPTER I. GENERAL STIMULANTS. Section I. PERMANENT STIMULANTS. CLASS I. Astringents. I. General Observations, including the consideration of Cold as an Astringent. II. Vegetable Astringents—Galls with Tannic and Gallic Acids; Oak Barks; Kino; Catechu with Gambir; Rhatany; Logwood; Cranesbill; Blackberry and Dewberry Roots ; L'ra Ursi; Pipsissewa ; Red Roses ; Tormentil; Water Avens; Hardhack; Pomegranate Rind; Bistort; Alum Root; Marsh Rose- mary; and Persimmon. III. Mineral Astringents — Alum; Lead and its Preparations; Sulphates of Iron, Zinc, and Copper, and other salts of the same metals; and various other mineral substances, as Nitrate of Silver, Corrosive Sublimate, Sulphuric Acid, and Lime with its Carbonate. CLASS II. Tonics. I. General Observations, including the consideration of Diet, Exercise, Pure Air, Mental Influence, Travelling, Cold, af^fTransfusion of Blood, as tonic agencies. II. Tonics of Animal Origin, of which ovS^^>d-liver Oil is treated of. III. Vegetable Tonics, subdivided into 1. Pure or Simple Bitters, comprising Quas- sia, Gentian, Chiretta, American and European Centaury, American Columbo, Columbo, Goldthread, and Yd low Root; 2. Peculiar Bitters, comprising Peru- vian Bark with Quinia and its other preparations, Hops, Dogwood, Willow Bark, Wild Cherry Bark, Chamomile, Eupatorium, Serpentaria, Myrrh, Angus- tura Bark, Cascarilla, Contrayerva, Wormwood, Tansy, and Uorehound; and 3. Aromatics, comprising Orange-peel, Lemon-peel, Bergamot Oil, Cinnamon, Canella, Winter's Bark, Cloves, Nutmeg, Black Pepptr, Cubebs, Pimento, Matico, Cardamom, Fennel-seed, Caraway, Coriander, Anise, Star Aniseed, Lavender, Rosemary, Peppermint, Sj>tarmint, European and American Pennyroyal, Horse- mint, Marjoram, Thyme, Sage, Balm, Partridge Berry, Ginger, Zedoary, Tur- meric, Calamus, and Wild Ginger. IV. Mineral Tomcs, subdivided into, 1. Those acting specially on the Stomach and Bowels, to which belong the Mineral Acids, comprising the Sulphuric, Nitric, Muriatic, Nitromuriatic, Phosphoric, and Carbonic Acids; 2. Those operating on the System generally through its Vital Properties, comprising the Prepara- XU TABLE OF CONTENTS. tions of Silver, Copper, Zinc, and Bismuth; and 3. The Reconstructive Tomes, to which belong Iron and its Preparations. Soi ion II. DIFFUSIBLE STIMULANTS. 1. General Observations. — 2. Division of these Stimulants into the Arterial, Ner- vous, Cerebral, and Spinal. —3. Consideration of Heat and Electricity as Diffusible Stimulants. CLASS I. Arterial Stimulants. 1. Cayenne Pepper.—2. Oil of Turpentine.—3. Carbonate of Ammonia with, the Solution, Spirit, and Aromatic Spirit of Ammonia. —4. Phosphorus. CLASS II. Nervous Stimulants. I. General Observations, with the consideration of Emotional and Sensational Iit- fluences, including those of Cold and Electricity, as Nervous Stimulants. II. Medicinal Nervous Stimulants — Musk, Castor, Assafetida, Sagapenum, Galba- num, Ammoniac, Valerian, Garlic, Coffee, Tea, Rectified Oil of Amber, and Dracontium. CLASS III. Cerebral, Stimulants. I. General Observations. II. Individual Cerebral Stimulants — Alcohol and its Preparations, Ether, Camphor, » Opium, Hemp, Hyoscyamus, Belladonna, and Stramonium. CLASS IV. Spinal Stimulants. Nux Vomica and Bean of St. Ignatius. CHAPTER II. GENERAL SEDATIVES. General Observations, with the consecution of Cold, Water, and Depletion, direct and indirect, as sedative agents.~W CLASS I. Arterial Sedatives, or Refrigerants. 1. Preparations of Antimony, including Tartar Emetic, Oxysulphuret of Antimony, and Oxide of Antimony.—2. Refrigerant Salts, with a particular account of Nitrate of Potassa.—Z. Vegetable Acids, comprising the Citric, Acetic, and Tartaric Acids. CLASS II. Nervous Sedatives. 1. Digitalis.-2. Tobacco.-Z. Lobelia. -4. Aconite.—*. American Hellebore - 6. Veratna, with White Hellebore and Cevadilla.-I. Black Snakeroot or Cimicifuga. CLASS III. Cerebral Sedatives. I. General Observations, with the consideration of M.ntal Influence, including Arti- ficial Somnambulism, as a Cerebral Sedative. TABLE OF CONTENTS. Xlll II. Medicinal Cerebral Sedatives — 1. Hydrocyanic Acid, with Bitter Almonds, Cherry Laurel Leaves, and Cyanuret of Potassium; 2. Chloroform; 3. Co- nium, or Hemlock; and 4. Lactucarium. CHAPTER III. ALTERATIVES. I. General Observations. II. M< miry and its Preparations. III. Preparations of Arsenic. IV. Iodine and its Preparations. V. Chlorine and its Preparations, comprising Gaseous Chlorine, Solution of Chlorine, Chlorinated Lime, Solution of Chlorinated Soda, Solution of Chloride of Cal- cium, Solution of Chloride of Barium, Chloride of Sodium or Common Salt, Muriate of Ammonia, and Chlorate of Potassa. VI. Sulphur and its Preparations— Washed Sulphur and Precipitated Sulphur, Sul- phurous Acid, Hydrosulphuric Acid, and Sulphuret of Potassium. VII. Vegetable Alteratives— Colchicum, Sarsaparilla, Guaiacum, Mezereon, Sas- safras, and Bittersweet or Dulcamara. Subdivision II. LOCAL REMEDIES. CHAPTER I. LOCAL REMEDIES AFFECTING THE FUNCTIONS. CLASS I. Emetics. I. General Observations on Emetics. II. Vegetable Emetics—Ipecacuanha, Gillenia, Bloodroot, Euphorbia Ipecacuanha and Corollata, Lobelia, Mustard, Squill, and Tobacco. • III. Mineral Emetics— Tartar Emetic, Sulphate of Zinc, Sulphate of Copper, and Turpeth Mineral. ' CLASjyi. CatharVbs. 1. General Observations, with the division into Laxatives, Purges, and Drastic Purges. II. Laxatives, subdivided into, 1. those which operate physically, as White Mus- tard Sothers that might be mentioned. .hel rerf„tgy' r; a?efore stated treats °f *»*<*>»* * *» dtir c n; h :n!,of crse their appiicati°n to *• e™ of disease, has nothrog to do with remedies not medicinal- whereas Therapeut.cs, which treats of all remedies in their ' J„T capacity, leaves out of view the properties of medic ne'V? t.ally belonging to them as such; their natural and eSSe°" history, for esampk, their sensible and ehem eal l^T^l their various forms of officinal preparation. IW S^Z' ^ therefore, n combining the two sciences in one ireZf^^ supphes the deficiencies of the other, and both comb h^ SS <*eh all desirable information in relation to the olTo , .C°nVe^ uses of remedies. gln' qualities, and In the present treatise, however, though some notice wil, be INTRODUCTORY OBSERVATIONS. 3 taken of those branches of the subject peculiar to Pharmacology, yet, as the United States Dispensatory, in the preparation of which the author participated, is especially devoted to Jfiat science, and treats in sufficient detail of almost everything exclusively belong- ing to it, he proposes to devote a more particular attention to thera- peutics, which is but partially treated of in the Dispensatory, and in many important points has been quite overlooked. Indeed, the work which he now submits to the medical public, may be looked on as, in some measure, supplementary to the U. S. Dispensatory, affording by its arrangement a convenient plan for the perusal and study of that work, supplying its therapeutical deficiencies, and noticing those relations and properties of medicines having no im- mediate connexion with therapeutics, only so far as may be essential to the practical physician; reference being made to the Dispensatory for information of general or pharmaceutical interest, and for minute detail on all exclusively pharmacological points. The work will consist of two parts. As there are many subjects, both in Therapeutics and Pharmacology, which are of a general nature, and cannot without inconvenience of arrangement, or the necessity for constant repetition, be considered in connexion with special remedies, or even classes of remedies, it is proposed to treat of these preliminarily under the heading of General Therapeutics and Pharmacology, which will, therefore, constitute the first part of the work. The second part, much more extensive than the first, and forming, indeed, the main body of the treatise, will be devoted to the subordinate divisions and specialties of the two sciences, under the name of Special Therapeutics and Pharmacology. • PART I. GENERAL THERAPEUTICS AND PHARMACOLOGY. CHAPTER I. Operation of Medicines. The operation of medicines is either primary or secondary ; the primary operation being that which results from their immediate influence on the system; the secondary, that which follows their original and characteristic impression, in consequence of certain physiological laws. Thus, purgation is the primary operation of a cathartic; derivation of blood from the head, with the attendant relief of any existing cerebral congestion, is a secondary operation, and a simple consequence of the first, just as the same result would follow an equal amount of intestinal irritation with diarrhoea from other causes. SECTION I. Primary Operation of Medicines. One of three events must occur when a medicine is applied with effect to any part of the body. Either it must enter the circula- tion, and be carried with the blood throughout the system, acting upon such parts as may be susceptible to its influence; or the local impression, first produced by it, must be conveyed through nervous communication to the parts more or less distant in which its effects are to be displayed; or, finally, it must act exclusively in the vicinity of its application. Each of these modes of operation requires to be considered. 6 OPERATION OF MEDICINES. [PART SUBSECTION I. Primary Operation through the Circulation.—Absorption. It was at one time thought by many that medicines never entered the circulation. The absorbents were supposed to afford the only avenue of foreign bodies into the system. Substances incapable of being assimilated to the blood, were believed to pene- trate no further than the absorbent glands, which were so many sentinels placed to guard the system against the intrusion of nox- ious agents. This notion was purely theoretical; and, even at the time when it was most strenuously maintained, was opposed by known facts which prevented its universal adoption. Subsequent experiments and observations, extremely numerous, and diversified in almost every conceivable manner, have established the conclu- sion, beyond all possible doubt or cavil, that medicines are very frequently absorbed, and, entering the blood-vessels, are circulated with the blood throughout the body. The following proofs of this truth may be adduced. 1. When medicines are applied directly to any surface of the body, and produce their characteristic effects elsewhere, it may often be noticed that portions of them have disappeared, without any possibility of accounting for their disappearance except by their absorption, or at least their entrance into the system. 2. The sensible properties of the medicine, its odour, taste, and colour, are frequently perceptible, either unchanged, or somewhat modified, in the breath, the secretions, and even in the various solid tissues. The effect of garlic in diffusing its odour and taste is universally kno.wn; rhubarb gives to the urine the property of staining linen yellow; and madder not unfrequently imparts its red colour to the bones. 3. The peculiar medicinal or poisonous effects of certain sub- stances, are occasionally produced by taking into the stomach the liquid secretions of individuals under the influence of these sub- stances. Thus, medicines given to the mother not unfrequently operate on the suckling; and numerous other illustrations of a similar kind might be adduced. 4. Effects produced by medicines in distant parts, may be pre- vented by ligatures around the blood-vessels proceeding from the part with which the medicine is brought into immediate contact. 5. In many instances the characteristic effects of medicines CHAP. I.] PRIMARY OPERATION OF MEDICINES. 7 exhibited in the ordinary way, may be obtained by injecting them into the blood-vessels. 6. But the most irresistible evidence is that afforded by chemical investigation, which has in almost innumerable instances detected medicinal substances taken into the stomach, or applied to other parts of the body, not only in the perspiration, saliva, urine, and other secretions, and in various solid tissues, but in the blood itself. Indeed, the list of substances which have thus been proved to have been circulated through the system, is so large as to authorize the inference, that all medicines capable of extending a direct action beyond the original surface of contact, may be absorbed and carried with the blood to the part or organ which they affect. It has been said that the effects of some medicines and poisons are so rapid, as to preclude the idea that they could have been absorbed, and conveyed to the seat of their action by the ordinary route of the circulation. But comparatively recent experiments, by proving the extreme rapidity with which the blood makes a complete circuit in the body, have invalidated that objection. Professor Hering, of Stuttgard, found that ferrocyanuret of potas- sium, injected into the jugular vein of a horse, might be detected in the opposite jugular vein in a period of time varying from twenty to thirty seconds (Zeittschrift fiir Pkysiologie, iii. 122); and Dr. James Blake, formerly Professor of Anatomy in the Saint Louis University, has proved that " the time required for the blood to pass from the jugular vein, and to be circulated through the body, was, in the horse sixteen seconds, in the dog twelve seconds, in the fowl six seconds, and in the rabbit four seconds." (Am. tloum. Med. Sci, N. S., xviii. 100.) The latter experimenter also found that the most rapidly fatal poisons, introduced into the veins of the animals referred to, gave rise to no signs of their action within less than the periods of time mentioned as occupied in the several animals by one round of the circulation. (Ibid., p. 101.) Having introduced some hydrocyanic acid into the mouth of a rabbit, Dr. Blake noticed that its first effects on the system were evinced in two seconds and a half, and death followed in five seconds. (Ibid., p. 106.) It is scarcely possible that any medicine can act more speedily than this; and, considering that the acid probably acted through the lungs, and, by entering the pulmonary veins, might reach the left side of the heart by a route much shorter than that of the general circulation, it is not too much to infer, that the time mentioned was sufficient for it to arrive at the 8 OPERATION OF MEDICINES. [PART I. brain through the medium of the blood. From these facts the conclusion may be fairly deduced, that no medicine acts with such rapidity as to preclude the possibility of its having reached the part affected through the circulation; and, the accuracy of the statements being admitted, the objection urged upon this ground against the universality of the mode of operation through the blood must be abandoned. Medicines are absorbed from mucous membranes, the areolar tissue, the skin, and probably from any other part of the body to which they may be applied. The rapidity of their absorption is proportionate to the thinness and delicacy of the tissue intervening between them and the blood-vessels. Hence, of all the surfaces with which they are practically brought into contact, that of the pulmonary air-cells affords them the most speedy entrance into the circulation. Every one knows the great rapidity with which ether and chloroform act when inhaled. Next to the air-cells in this respect is probably the alimentary mucous membrane, and especially that of the stomach, which, as a general rule, admits the entrance of medicines more readily than that of the rectum. Absorption takes place most slowly from the skin. This might be inferred from the firmness and thickness of the epidermis. It has indeed been maintained that fhis tissue is impermeable by medicines in its healthy state. But experiments have satisfactorily shown that they do enter the system through the epidermis; and the consti- tutional impression sometimes resulting from the wearing of a mercurial plaster is of itself a sufficient proof. There can be no doubt, however, that the epidermis opposes a great impediment to absorption; and, without such a protection, the system would be constantly exposed to the most deleterious influences from without. The impediment may be much diminished by softening the tissue with water, or by mechanically deranging it; and hence medicines applied to the surface by a local or general bath, or in the form of cataplasm, or by means of friction, may often be made to act very efficiently on the system. Deprived of its epidermis, the skin admits the entrance of medicines with great facility, though even in this state, somewhat less readily than the gastric mucous mem- brane, probably because it is less vascular. Means of Absorption. The lymphatics and lacteals were formerly supposed to be the exclusive agents of absorption. Magendie proved that foreign substances are also received from without directly into the blood-vessels; and multiplied experiments have CHAP. I.] PRIMARY OPERATION OF MEDICINES. 9 since shown that most medicines enter the system in this way. It is probable that the capillaries, in consequence of the extreme delicacy of their walls, are chiefly concerned in the process; and that medicines enter them upon the same principles of endosmose by which liquids pass through dead membrane out of the body. Attempts have even been made to establish the conditions, based on the rules of physical endosmose, upon which medicines in con- tact with the capillaries will either enter the blood-vessels, or cause the extravasation of the liquid contents of the vessels them- selves, and thus to explain the effects of a medicine, if not in- deed to deduce d priori its probable operation from its physical qualities. But, admitting to a certain extent this principle of operation in medicines, there are so many circumstances, physical, chemical, and vital, which modify the result, that no previous con- clusions can be relied on; and even explanations upon this basis must be received with great caution, lest they may lead into serious error. It must be remembered that the condition of a living mem- brane is very different from that of the same membrane out of the body; and there can be little doubt that the vital forces have such a control over the tissues, as greatly to modify their endosmotic relations to the fluids on opposite sides of them. For example, in a certain condition of vital influence the membrane may be con- tracted and firm, in another relaxed and loose; and it is impossible to say that some modifying power may not be exerted on the fluids themselves, in and around it, by the life-forces, as we know that the electric forces modify chemical conditions out of the body. In the present state of our knowledge, therefore, it is quite premature to attempt to explain the phenomena of medicinal absorption in every case, or to anticipate the results in any particular case, on simple physical principles. After the entrance of the medicine into the capillaries, it is carried forward in the course of the circulation, and sooner or later mingles with the blood in the heart, with which it is transmitted over the whole system, and consequently reaches the part on which it is des- tined to act. But it may be asked whether medicines are not also taken up by the absorbents, and conveyed by them into the blood. It would seem to be the legitimate function of these vessels, to select from the alimentary liquid in the bowels, and from the disintegrating tissues throughout the body, those principles which may assimilate with the blood, and thus contribute to the sustenance of that fluid 10 OPERATION OF MEDICINES. [PART in its requisite state and quantity. In order that this function may not be interfered with, they have the power to reject in great measure noxious substances, and medicines among others. Tiede- mann and Gmelin found that, of numerous colouring and odor- ous substances given to animals with their food, a large propor- tion imparted their colour and odour to the blood of the portal veins, but not one to the chyle. Of a number of salts tried in the same manner, though many could be detected in the veins, but a few only had entered the thoracic duct. Drs. Lawrence and Coates, of Philadelphia, in a series of carefully conducted experiments, proved that ferrocyanuret of potassium was taken up from the bowels both by the radicles of the vena portae and by the lacteals. (Philad. Journ. of Med. and Phys. Sci, v. 327.) It has been subsequently shown, in repeated instances, that poisons introduced into the ali- mentary canal, fail to produce their effects on the system when the vena portae is tied. (Pereira, Elem.ofMat. Med, 3rded., i. 103.) From these statements it is fairly inferrible that, though the absorbents are capable of taking up a few saline substances, probably not alto- gether incongruous with the blood, they are not the ordinary agents by which medicines are introduced into the circulation. Circumstances affecting Absorption. 'Various circumstances more or less affect the facility or rapidity of absorption. Reference has already been made to the influence, in this respect, of the nature of the surface to which the medicine is applied. The following are other modifying influences. 1. In relation to the blood-vessels, it is highly probable that the varying condition of their coats, under varying nervous influence, or different degrees of vital force, may considerably modify the pro- cess ; but too little is precisely known on this subject to justify any definite statements. 2. The condition of the blood as to density may not be without effect, upon the principles of endosmose, in favouring or opposing the entrance of fluids from without. 3. The fact has been abundantly proved, that fulness of the blood- vessels is opposed to absorption; and hence, in a plethoric state of the circulation, medicines sometimes act with difficulty, because not readily taken into the system. It is well known that, in a state of high febrile excitement, the abstraction of blood very much favours the action of diaphoretics and diuretics, probably in part at least by removing an impediment to their absorption. Substances too which act powerfully as local irritants, by causing congestion of the CHAP. I.] PRIMARY OPERATION OF MEDICINES. 11 blood-vessels in the part, impede their own absorption, and thus fail to act on the system; while, if applied in a dilute state, so as not to irritate, they may find a ready entrance. On the contrary, when the blood-vessels are relatively empty, absorption is promoted. Hence medicines act more powerfully after fasting, and in reduced states of the system generally, than in its ordinary condition. 4. The character and state of the medicine itself have also great influence. Allusion has been already made to the influence of den- sity in opposing the absorption of medicines. Volatility appears in general to have an opposite effect; the most volatile medicines, for the most part, operating with greatest rapidity. Hence in part probably the very speedy effect of ether, chloroform, and hydro- cyanic acid. 5. Greater or less affinity between the medicine and the blood appears also to affect the facility of absorption; and substances which unite with that fluid with difficulty, are scarcely admitted into the system. Castor oil may be cited as an example. 6. The fluid form is usually considered essential to absorption, and consequently to medicinal activity, so far at least as the general system is concerned. It is true that many solid substances, nearly or quite insoluble in water, are powerful medicines. But they must undergo changes which bring them into the liquid state, before they can gain access into the blood-vessels. Such changes are often effected by the liquids of the alimentary canal. Thus, metals, in themselves insoluble and inert, often act energetically in conse- quence of oxidation, and union with an acid in the stomach and bowels. But some recent experiments would seem to show that this principle is less universal than has been imagined. Rabbits were fed on finely powdered wood charcoal; and fine particles of this substance were afterwards found abundantly in the blood, the liver, and the lungs. Starch mixed with charcoal was given to frogs; and the corpuscles of the former were observed in the blood of the mesenteric veins, by the aid of the microscope, having their characteristic form, and exhibiting their characteristic reaction with iodine. Similar results, though less decisive, were obtained with mercury and sulphur, both taken into the stomach, and applied by friction to the surface of dogs and rabbits.* It is conceivable that * These experiments were made chiefly in Germany. Begun by Oesterlein, they wore repeated and varied by Eberhard, Kolliker, Meyer, Donders, and Mensonides, all with more or less confirmatory results.—(London Med. Times and Gazette, March 13, 1852, p. 270.) 12 OPERATION OF MEDICINES. [PART I. mercury, being liquid, though insoluble, should be able to pene- trate the tissues; but it is impossible, with our present views of the capillaries, that solid visible particles should enter them with- out some solution of continuity in their coats. It is not improba- ble that such particles, passing mechanically between the epithelial or epidermic cells, and thus separated from the blood of the capil- laries only by the extremely tenuous coats of these vessels, and the equally tenuous basement membrane, may, by their contact with this delicate tissue, cause minute openings in it, so as to admit their passage, by a sort of physiological action such as that which causes two cells in contact to communicate together; and these openings, after the entrance of the particles, may close under the influence of the same vital law. 7. Another modifying influence, exerted over the absorption of medicines, is probably their own power of altering the condition of the intervening membrane, either by a physiological or chemical action upon it. Thus, it may be readily conceived that the con- traction produced by tannic acid, and the chemical reaction with solution of nitrate of silver, might interfere with the absorption of these medicines in an unchanged state. Changes in Medicines before and after Absorption, and their Elimina- tion. Of the organic medicinal substances none are probably taken into the system in the exact state in which they are furnished by nature. It is only certain proximate principles contained in them that are absorbed, such as the volatile oils, vegetable alkaloids, bitter and colouring principles, &c.; the residue being left behind when they are applied externally, and either digested, or thrown off by the bowels, when they are swallowed. Thus, in the instance of garlic, the gum, starch, sugar, and albumen are probably digested, the lignin passes off with the feces, and the volatile oil alone is absorbed. In like manner, Peruvian bark probably yields its quinia, cinchonia, and quinidia, rhubarb its colouring matter, and aloes its bitter purgative principle to the blood; while the remaining con- stituents are evacuated or destroyed. A great number of medicines undergo various changes in the stomach and bowels before absorption, in consequence of the chemical reaction between them and the acids, salts, and various animal principles, introduced or secreted, which abound in those passages. Alkalies, alkaline earths, and many metallic oxides are neutralized by acids; metals are oxidized and form salts; metallic salts form combinations with albumen or other proximate organic CHAP. I.] PRIMARY OPERATIONS OF MEDICINES. 13 principles, or undergo decomposition with sulphuretted hydrogen or other acids, or by reaction with other saline compounds; carbonates are decomposed with the extrication of carbonic acid in the stomach and bowels; salts with vegetable acids yield their acid constituent to the digestive process, while their bases appear to enter the circu- lation as carbonates; acids often combine with bases and form salts; iodine and chlorine become acidified and then neutralized ; and by some one of the above, or by other chemical reactions, insoluble substances are rendered soluble, and consequently more capable of absorption. Some medicines appear to be absorbed unchanged, as ether, alco- hol, chloroform, hydrocyanic acid, various proximate organic prin- ciples previously isolated, as the volatile oils and vegetable alkaloids, and many saline bodies in aqueous solution. After entering the circulation, many medicines undergo chemical change, through the agency either of principles they meet with in the blood, or of the constituents of the various tissues with which they come in contact. The character of these changes is not well understood, and for the most part is merely conjectural. It is pos- sible that some soluble substances may become insoluble, and by a mechanical operation modify the state of the capillaries. It would seem that certain metallic compounds are reduced; as mercury and silver are asserted to have been found in the metallic state in the tissues. Some medicinal substances, as alcohol, probably serve in part the purpose of nutrition or respiration; being, in the latter case, oxidized and thrown off from the lungs, in the form of water and carbonic acid. Sooner or later almost all the substances absorbed are eliminated from the system, either unchanged, or variously decomposed; the change being produced either in the circulation, or in the process of elimination. Examples of such change we have in the oil of tur- pentine, which imparts not its own, but a violaceous odour to the urine, and in benzoic acid, which, when taken into the stomach, is eliminated by the kidneys in the form of hippuric acid. The elimi- nation is usually effected, for solid or non-volatile matters, by the great secreting organs, especially the kidneys and the skin; and so frequently are the former emunctories the avenue of escape, that, when evidence is required of the absorption of any medicine, it is almost always sought for in the urine. Volatile substances escape not only by these organs, but in general abundantly also by the lungs. 14 OPERATION OF MEDICINES. [PART I. The period required for elimination is very various with different substances. With some the process begins almost immediately, and is completed in a short time; with others, it is in various degrees pro- tracted; and with a few, many months elapse before the system is entirely freed from them. Thus, A. F. Orfila, having administered bichloride of mercury, sulphate of copper, acetate of lead, and ni- trate of silver to dogs, for a sufficient length of time to impregnate their systems with those metallic poisons, found, upon killing the dogs, and submitting their bodies to a rigid chemical examination, that mercury disappeared from their systems in a period of from eight to eighteen days, silver sometimes so early as six weeks, but in other instances not until the expiration of six months; while lead and copper were found in the liver eight months after they had ceased to be administered. (Gazette des Hopitaux, Jan. 24,1852.) With perhaps the single exception of silver, it has not been de- monstrated that any substance given medicinally remains perma- nently in the system, and in reference to this, only in a few rare instances, in which it has been given in large quantities, and for a long time. Under such circumstances, it sometimes leaves a perma- nent dark stain of the skin, probably from the deposition of its oxide in the substance of the cutis vera. SUBSECTION II. Primary Operation through the Nerves. Less than half a century ago, it was a prevalent belief that medicines operated on parts distant from the seat of their applica- tion by means of sympathy; in other words, by the transmission of their local impression through afferent nerves to the nervous centres in the encephalon, spinal marrow, or ganglia, and its radi- ation thence to the part or parts affected. In favour of this opinion was, in the first place, the want of proof, in relation to the great ma- jority of medicines, that they ever penetrated into the system be- yond the original surface of contact; and, secondly, the great ra- pidity with which some of them produced their effects, which was supposed entirely to preclude the possibility of their actual convey- ance to the seat of these effects. But since it has been discovered that almost all medicines are capable of being absorbed into the circulation, and that perhaps in no instance are their effects felt in a time shorter than that required for their conveyance with the blood to the part acted on, the explanation of their operation bv CHAP. I.] PRIMARY OPERATION OF MEDICINES. 15 sympathy, or through the medium of the nerves, has become unnecessary, and, in reference to most medicines, is, I think, quite untenable. It is true that many medicines produce local impressions, which are followed by effects in parts more or less distant, that cannot be explained upon the supposition of the transfer of the medicines themselves, and must, therefore, be brought about through nervous agency. Thus, tobacco and ammonia, applied to the mucous mem- brane of the nostrils, occasion sneezing, undoubtedly through the intervention of the nerves and the nervous centres; and in the same way we must account for such effects as the sweat and feeling of coldness in the forehead, sometimes following the application of com- mon salt to the tongue, and the flow of tears and saliva resulting from horseradish in the mouth. But it will be observed that these are secondary effects, dependent on mere irritation of the part first impressed, and which might equally result from any other cause capable of producing an equal amount of irritation. They are not the primary or characteristic action of the medicines, which alone we are now considering. To fulfil the conditions of the theory of nervous transmission, it is necessary that the first impression on the surface of application should be conveyed unchanged, or merely modified; or at least that the remote effect should be of a charac- teristic nature, and not the same as that which any irritant might produce. Yet it cannot be denied that there are facts tending to show that, in some instances, medicines do propagate their primary and pecu- liar influence through the nerves. Thus, certain fetid substances, which act efficiently as antispasmodics when introduced into the stomach or rectum, seem, by their mere impression on the olfactory nerves, to give rise to the same effects; and tobacco and lobelia occasion, by their presence in the fauces, nauseating impressions very similar to those produced by them when swallowed. I think every practitioner in the habit of administering opiates by enema, for the relief of nephritic and uterine pains, strangury, &c, must have witnessed a greater and more speedy effect from them thus given, than when taken into the stomach. This can be accounted for only by the transmission of their anodyne influence through the neighbouring nervous centres; as, if absorbed into the circula- tion, they would reach the seat of action no sooner than if absorbed from the stomach, and, indeed, less speedily and efficiently; as medicines administered by the rectum are well known to affect the 16 OPERATION OF MEDICINES. [PART I. system less readily than when swallowed. It is, therefore, I think, premature to reject altogether this mode of medicinal operation; and, indeed, it is not impossible that some substances may operate in both ways, giving rise to an impression through nervous trans- mission, which may be afterwards strengthened, and perhaps modi- fied, by the immediate action of the medicine through the circu- lation. SUBSECTION III. Primary Local Operation. By the expression, local action, is here meant that exerted on the part, or in the immediate neighbourhood of th& part, to which the medicine is originally applied. Some medicines are exclusively local in their operation. Such are those applied directly to any surface, with a view to some mechanical, physical, or chemical influence on that surface. It is probable that certain medicines which act physiologically, that is, through the vital properties of the system, are also exclusively local. Medicines incapable of being absorbed, if there be any, would belong to this category. An example of this kind, I am inclined to think, we have in castor oil. Many medicines are, under certain circumstances, local in their action, which, under others, may enter the system, and operate on distant parts. Thus, substances capable of violently irritating or in- flaming the surface to which they may be applied, when employed so as to produce this effect, are little apt to be absorbed, in con- sequence probably of the distension of the capillaries; whereas, if previously diluted so as not to irritate, they may find a ready entrance into the circulation. Other medicines both act locally, and, entering the circulation, produce the same or dissimilar effects on distant parts. Thus, opium and chloroform operate as anodynes on the nerves of the part to which they are applied, and subsequently produce the same effect throughout the system by acting upon the nervous centres ; while tartar emetic is irritant in its local operation, but sedative when acting through the circulation upon the heart. Medicines of this kind are often used in reference to their local effects. In most cases of local action, the influence of the medicine extends more or less beyond the original surface of contact. Thus the anodyne influence of chloroform, applied to the skin, often CHAP. I.] PRIMARY OPERATION OF MEDICINES. 17 penetrates through this tissue to parts beneath it, and the same may be said of opium, camphor, aconite, and other medicines of the kind. Castor oil, applied to the inner surface of the alimentary mucous membrane, calls the muscular coat into action. An irritant substance often extends its effects both deeply into the tissues, and to a considerable distance superficially beyond the surface of con- tact. How is this result to be accounted for ? In some instances, probably, by the penetration of the neighbouring tissues, to a certain extent, either on the principle of the diffusion of liquids, or on that of capillary attraction, or of both. In others, the effect may be propagated by what Mr. Hunter denominates contin- uous sympathy; spreading along the course of the tissue affected, with a gradual diminution, until quite lost. Again, it is not im- possible that the influence may be extended to neighbouring parts through common nervous centres in the vicinity; as when the extract of belladonna, rubbed upon the eyelids, produces dilatation of the pupil, or opium in the rectum relieves pain in the ureters; in neither of which instances can the result be fairly ascribed to the circulation, as the effect should in this case be, what it is known not to be, equally great and rapid to whatever part of the body the medicine may be applied, supposing it to be equally distant from the heart, and to afford equal facilities for absorption. Finally, the effect may be secondary, as'in the instance of castor oil, which directly irritates the mucous membrane, and, as any other similar irritant would do, indirectly excites the peristaltic movement, through the agency of the physiological law which determines the latter result as a necessary consequence of the former. SUBSECTION IV. Modes of Primary Operation. Hitherto we have been considering rather the seat of the opera- tion of medicines, and their manner of reaching it, than the mode in which they produce their effects. The latter point must now receive attention. 1. Mechanical or Physical Methods. The operation of medicines may, in some instances, be purely mechanical or physical. Thus, they may act by excluding the atmospheric air, as in the instance of collodion applied to the skin in cutaneous affections; by min- gling with and obtunding the acrimony of various acrid substances, as in the operation of demulcents; by the influence of gravity, as VOL. I.—2 18 OPERATION OF MEDICINES. [PART I. illustrated by the laxative effects of metallic mercury; or by their shape and bulk, as when bran, mustard seed, small shot, &c, operate on the bowels by a mechanical irritation of the mucous membrane. Endosmose and Exosmose. Another physical mode of action has recently been suggested, which, though not yet satisfactorily esta- blished, is not without a certain amount of plausibility. Refer- ence has already been made to the entrance of medicines into the blood-vessels on the principle of endosmose. Poiseuille and others have demonstrated that, if the serum of the blood be placed on one side of an animal membrane out of the body, and certain strong saline solutions, or other concentrated liquids on the other side, a current of the.serum is made to set through the membrane towards the denser liquid; while, if the solution be very weak, the current is established in a contrary direction. Hence, it has been suggested that strong solutions of certain salts in the stomach and bowels may act as cathartics, by producing an extravasation of the serum , from the blood-vessels; while weak solutions of the same may enter the vessels, and thus act on the system generally. This principle has been extensively applied to the explanation of the action of medicines; the general rule being, that a liquid denser than the blood will produce exosmose of the serum, and thus operate as an evacuant* But the principle is not reconcilable with many facts which might be adduced, and is wholly insufficient to explain many others. To mention only a single example. Chloroform taken internally, or applied to the surface of the body, produces effects on the system which can scarcely be referred to any other cause than its presence in the circulation. It must, therefore, enter the blood- vessels, though vastly denser than the serum of the blood and fails to produce the extravasation, which ought to take place upon the principle of exosmose referred to. Still, this physical property may be received as one of the probable agencies through which medi- eines operate, though, in the present state of our knowledge it cannot be admitted as of universal or even general application The supposed agency of endosmose and exosmose has been car ried much further than to the explanation of the action of medicines on exposed surfaces. Thus, it may be exerted in thP „• itself, causing the character of tb/red corpuscle to var^T varying relative density of the serum without, anl thV^J^ * See experiments of Poiseuille (Comptes rendus, xix. 944 A D 10„, Cogswell (Lond. Med. Times and Gaz., Jan. 3, 1352, p. 23)? U)' and of Dr" CHAP. I.] PRIMARY OPERATION OF MEDICINES. 19 the corpuscles; so that whatever increases the specific gravity of the serum, as certain salts, for example, shall cause an exosmose of the corpuscular contents, and a shrinking of those bodies, and whatever diminishes its density, as water, shall occasion an endos- mose into them, and their consequent distension or rupture. Still further, it is thought that the relative density of the serum of the blood in the capillaries, and of the moisture without them, may be one of the controlling influences in the operation of medi- cines which act through the circulation. If the nature of the medicine be such as to increase the density of the serum, it would tend to promote absorption from the tissues, if to lessen it, to favour extravasation into them; and the same explanation ought to apply also to the influence of medicines within the circulation upon the various secretions. At present, however, all this is merely hypothesis or conjecture; and must be placed upon the same basis of admissibility with that theory of the operation of medicines, which ascribes it to the mechanical influence of the shape of their ultimate particles upon the tissues with which they come into contact. 2. Chemical Methods. Reference is not had, in this place, to the chemical changes which medicines undergo in the alimentary canal preparatory to absorption, nor even to those which may take place in the course of the circulation or elimination of the medicines, so far as relates exclusively to the medicines themselves. But, when these chemical changes of the medicine in the circulation result from reactions between them and the constituents of the blood or the tissues, it cannot but happen that physiological alterations must take place, which may possibly be more or less remedial; and the consideration of such changes belongs strictly to this section. Some medicines have so strong an affinity for the constituents of the tissues, that, when in contact with them in a concentrated state they overcome their vital resistance, and cause the decomposition and consequently the death of the part. In this way many caustic substances act. In a dilute state, this affinity is more than counter- balanced by the vital forces, and no chemical change ensues. As medicines never extend, in this state of concentration, far beyond their original surface of contact, it is obvious that similar decom- position of the tissues cannot result from their operation on the system, either by the circulation, or through the medium of the nerves. It is highly probable, however, that many medicines produce 20 OPERATION OF MEDICINES. [PART I. chemical changes in the blood, which enter into their remedial action. The blood consists of certain vitalized, and certain un- vitalized constituents, the latter of which are probably merely held in solution, and are subject to the same chemical reactions as if dissolved in a fluid out of the body. Thus, an acid medicine, absorbed into the blood, may prove remedial by neutralizing a morbid excess of alkalinity; and, conversely, an alkaline medicine, by correcting any morbid acidity of that fluid. It is highly proba- ble that many analogous changes may take place; and to some of these there will hereafter be occasion to allude in the account of particular medicines, or classes of medicines. It is even possible that the normal condition of the blood may be so far modified by such a chemical agency, exerted for example upon its albumen, its fibrin, its salts, &c, as to alter materially the influence of that fluid upon the tissues and functions, and thus to give rise to systemic actions or conditions, which, though in fact only the secondary effects of the medicine, are usually regarded as the results of its direct and characteristic operation. But these changes can be traced only conjecturally; and there are very few, if any, which can be truly said to have been experimentally demonstrated. Another mode in which a medicine may act chemically, after absorption, is at the time of elimination by the secretory functions; when, coming in contact with the products of secretion, it, or one of its constituents, or some compound which may have been formed by chemical reactions with it in the course of the circulation may materially modify these products. Thus, alkaline medicines elimi- nated by the kidneys, render soluble the uric acid, or insoluble urates, which may have been deposited from the urine after its secretion. It is not impossible that the peculiar effects of medicines on the system, may sometimes result from chemical reaction between the medicines and the tissues with which they are brought into contact while in the blood. Combinations may be formed between the medi- cine, or one of its constituents, with some one or more of the con- stituents of the tissues, at the moment of their physiological dis- integration; and these compounds, retained in the organs perhaps within the organic cells, perhaps in the interstices of the tis'sue, may modify the functions in a manner that may prove remedial Th s I repeals possible; but it has not been proved posit'velv that medicines do really produce their peculiar effects in th s wav in any one instance; and it is altogether premature to explain as CHAP. I.] PRIMARY OPERATION OF MEDICINES. 21 some are disposed to do, the whole agency of medicines upon this principle. The only well ascertained fact which can be adduced in support of the hypothesis is, that certain medicines, particularly the metallic, may be detected in the substance of the organs, often for a considerable time after they have been taken. 3. Physiological, Vital, or Dynamic Methods. Most medicines pro- bably produce their peculiar effects by operating on the vital pro- perties of the system, or of the part affected. Of the nature of this action we are quite ignorant, and must remain so until the nature of life itself is better understood. In the present state of our know- ledge, all that we can say is, that living structure is endowed with certain susceptibilities, and medicines with certain properties, or powers, through which, when the two are brought together, certain changes of condition or action take place in the former. The medi- cine is said to act, and the living structure to be acted on, because it is in the latter that the changes are most obvious, and most interesting. This kind of operation is called physiological, or vital, in reference to the character of the effects produced in the system, and dynamic, in reference to the supposed possession of an active power by the medicine. We may speculatively ascribe the results to physical or chemical reaction; but this explanation is, in the great majority of instances, destitute of the shadow of proof, and is indeed altogether insufficient, with our existing knowledge of physics and chemistry, to account for many of the phenomena. Until, there- fore, further light is obtained, it is safest to be content with the mere statement of the fact. When medicines are introduced into the system, they generally show a tendency to act on some one part, or set of parts, preferably to others, and not unfrequently act on these parts exclusively. Thus, some medicines operate more especially on the brain, others on the heart, others on the stomach and bowels, and others again on some one or more of the secretory organs, though equally in contact with the parts unaffected as with those upon which they act. This ten- dency is ascribable to the peculiar constitution of the several parts of the system, giving them peculiar susceptibilities; just as the eye alone is sensible to light, and the organs of smell and taste to odours and sapid substances. A medicine, therefore, entering the circulation, and reaching all parts of the system, acts on such parts only as are so constituted as to be susceptible to its influence; as light, though falling on the whole surface of the body, produces its characteristic impression only upon the eye. The chemists explain 22 OPERATION OF MEDICINES. [PART I. this peculiar direction of medicines by the supposition, that it is only in the organs affected that they find affinities capable of being disturbed by their presence. It is not impossible that some medicines may act upon the blood through its vital properties, modifying the condition of the living corpuscles and fibrin, in the same manner as others act upon the living solid tissues. Such medicines may operate exclusively on the blood, producing effects upon the various functions simply through the change effected in that fluid; or they may operate at the same time directly upon the organs. The probability, however, is, that, in the great majority of instances, medicines are merely conveyed by the blood to the part in which their effects are expe- rienced; for otherwise these effects would be more frequently universal, as any change in the blood itself must be felt more or less in all the organs and functions. SECTION II. Secondary Operation of Medicines. The secondary operation of medicines has been already defined to be that which follows their original and characteristic impression, in consequence of certain physiological laws. Without treating in this place of the resulting effects, it will be proper to explain, in a general way, the several modes in which they are produced. 1. By the Depression following Excitement. It is a general physio- logical law, that excessive excitement of any function must be fol- lowed by a corresponding degree of depression, upon the removal of the cause. When, therefore, an excitant medicine ceases to act, its original and characteristic operation is succeeded not only by a subsidence of the excitement, but by a reduction of the actions of the part affected below the standard of health. This depression is often experienced even before the complete elimination of the medi- cine from the system; for the excitability may have been so far exhausted by the excess, that the influence of the excitant ceases to be felt, and the healthy vital stimuli have no longer their ordinary influence. The prostration which follows a debauch is often ob- servable, while yet the breath smells of the alcohol. 2. By the Reaction following Depression. When any of the functions are depressed by an agency which simply restrains action, without impairing the vital forces or deranging the organization, there is a CHAP. I.] SECONDARY OPERATION OF MEDICINES. 23 tendency, upon the cessation of the depressing influence, to an ele- vation of the function beyond its medium state. This depends upon the principle, that excitability is recruited by rest. The re- sulting elevation of function is usually denominated reaction. It is, however, much less frequently noticed as a consequence of depress- ing medicines, than the contrary condition of depression after ex- citants; probably because sedative medicines usually impair power, as well as reduce action. But a fine example of it is afforded in the reaction which follows the depressing influence of cold. 3. Through the Dependence of Function. Most of the functions of our system are more or less mutually dependent, so that any con- siderable derangement of one will in some degree affect the others. A disturbance, therefore, of one of the more influential functions, produced by a medicine acting primarily upon the organs of that function, will be followed by disorder in all the rest; and this dis- order will obviously be a secondary effect of the medicine. Thus, alcohol, opium, and quiuia, largely taken, occasion so much excite- ment and active congestion of the nervous centres in the brain, as to disqualify them from transmitting their usual influence to the various organic functions, as those of respiration, circulation, and secretion, which consequently become much depressed; and general prostration ensues. The active cerebral congestion is a primary, the general prostration a secondary effect of the medicine. This is a highly important principle, and of very extensive application. A due attention to it is essential to the practitioner. Suppose that it should be disregarded in the cases just stated, and the prostration considered as the result of the direct and characteristic action of the medicine. A powerful stimulant to the brain might thus be mis- taken for a really sedative medicine, and administered with the most serious results in cases of cerebral disease. In like manner, a medicine, powerfully depressing in its action upon the cerebral centres, would be followed by great general pros- tration ; and this would really be, as well as in the former instance, a secondary effect: but there is not the same necessity for making the distinction; because the secondary is of the same character with the primary effect, and no mistake could occur of the nature of that above referred to. The results of what is denominated the shock, are another exam- ple of the secondary operation of medicines belonging to the same category. Any sudden and violent impression, as from a fall, a blow, a surgical operation, or some strong emotion, primarily over- 24 OPERATION OF MEDICINES. [PART I. whelms and paralyzes the cerebral centres, and secondarily occasions general prostration. Now certain medicines of great violence, as for example the corrosive poisons taken largely into the stomach, may produce a similar shock upon the nervous centres, followed by a similar general depression, which, without a knowledge of this principle, might be mistaken for the result of a directly depressing agency, and treated as such with very serious consequences. The operation upon the system at large of medicines which act by changing the character of the blood, is another example of the same kind. The general effects result from the state of the blood, and not from the immediate influence of the medicine, and are, there- fore, secondary effects of the latter. 4. Through the Principle of Sympathy, or Nervous Transmission. Though it is not probable that special or peculiar impressions of medicines are, to any considerable extent, conveyed from the part impressed through the nerves to the nervous centres, and thence transmitted to other parts, yet mere excitative impressions, or those consisting in pure irritation or inflammation, are undoubtedly thus conveyed. What is special in the influence of the medicine is, therefore, mainly limited to its surface of contact; while it is only the pure irritation, such as may result from any irritating cause whatever, that is conveyed away, and propagated through the nerves. This transmission of irritation arises from a general physiological law, and is, therefore, a secondary effect of the medicine. Thus, a rubefacient or epispastic may excite so much local inflammation as, through the nervous centres, to bring many of the organs into sym- pathy, and in this way to produce general excitement, and even fever. The increased frequency of pulse, heat of skin, cerebral disturbance, &c, which enter into this excitement, are secondary effects of the rubefacient or epispastic, the primary action of which is limited to the portion of skin to which it was applied. This principle is also of extensive application in explaining the effects of medicines. 5. Through the Principle of Revulsion or Derivation. There is in the system but a limited amount of blood, and of nervous power. When these are concentrated, or accumulated in undue amount, by the in- fluence of a local irritant or otherwise, in some one part or or^an, they must be deficient elsewhere; and a depression must ensue in those functions which are not irritated by sympathy with the part or organ originally affected. Supposing the local accumulation of blood and nervous power to be the result of the action of a medi- cinal agent, the depression produced elsewhere is a secondary effect CHAP. I.] SECONDARY OPERATION*OF MEDICINES. 25 of that agent. Now it may have happened that the parts de- pressed were previously in a state of morbid excitement, which has thus been diminished, and perhaps entirely removed by the direc- tion given towards the seat of the primary influence. The name of revulsion or derivation has been given to this forced transfer of morbid action; and we frequently avail ourselves of the principle in the treatment of disease. It is upon this principle that a blister relieves internal inflammation. It is upon this, also, in part, that a cathartic, by producing a moderate irritation along the whole course of the intestine, draws off morbid excitement from other organs, and especially from the brain. Indeed, whatever remedy occasions a local irritation may thus prove the means of unseating irritation elsewhere. It is quite obvious that the diversion of disease, thus effected, is a secondary operation of the remedy. Upon the same principle exactly, operating reversely, a depres- sion of any part or organ, by diminishing the blood and nervous power in the part affected, must cause their accumulation elsewhere; and thus, depressing or sedative medicines, acting locally, may, throtfgh a secondary operation, cause irritation in some other posi- tion. For example, lead-water applied to a gouty foot, by dimin- ishing the inflammatory excitement there, may secondarily occasion inflammation of the stomach. Medicines are not often employed in reference to such effects; but this mode of secondary action should be understood, if on no other account, at least in order that its injurious effects may be guarded against. 6. Through the Efforts of Nature to Repcdr Injuries. It may be con- sidered as a general law of the animal economy, that, when any injurious influence is exerted upon the system, actions are induced with the object, and frequently with the effect, of obviating the injury, or repairing the damage inflicted. It is probable that many diseases are nothing more than the struggles of the system to free itself from some noxious agent, or to counteract its influence. The abnormal impressions made by medicines are often, no doubt, upon this principle, followed by resisting or corrective efforts of nature, which must rank among the secondary effects of the medicine, and may sometimes be taken advantage of for remedial purposes. Thus, the death of a part produced by an escharotic is the primary effect of the medicine; the subsequent inflammation, ulceration, sloughing, and suppurative discharge, are secondary effects, in- tended for the repair of the injury, and useful in reference to pre-existing disease, upon the principles of revulsion and depletion. 26 OPERATION OF MEDICINES. [PART I. 7. Through the Removal of the Cause. Very many of the morbid actions or states of the system are secondary, depending upon the existence of some other action or condition, upon the removal of which, the effect also ceases. It is obvious that a medicine, which by its primary operation removes the cause, and thus cures the disease, acts secondarily in relation to the latter effect. Thus, acid in the stomach often occasions severe headache, which is cured by an antacid, or an emetic. The neutralization or evacuation of the offending agent is the primary operation of the medicine, the cessa- tion of the headache a secondary effect. This is a very extensive remedial principle. It is very often difficult to determine which are primary and which secondary effects of medicines; and the decision of the ques- tion will often rest on the view which may be entertained of the mode of action of the remedy. In the instance, for example, of a sedative depressing the cerebral functions, the question of its pri- mary or secondary action on the brain will be determined by our opinion upon the point, whether it is merely carried by the blood to the brain, or operates on that organ exclusively through changes first produced in the blood, incapacitating that fluid from the per- formance of its proper functions. In the latter case, the character- istic sedative operation of the medicine must be considered as secondary. But it is the safest rule to consider the obvious effects of a remedy as primary, unless some intermediate stage in its ope- ration can be positively demonstrated, or rendered extremely proba- ble by observed facts. CHAP. II.] EFFECTS OF MEDICINES. 27 CHAPTER II. Effects of Medicines. SECTION I. Estimation of their Powers or Effects. In treating of the effects of medicines, the first point which offers itself for consideration is the method by which they can be ascer- tained. Is it possible to determine, before trying a medicine upon the human system, what will be its effects? Do its sensible or chemical properties, its botanical relations, or its action upon in- ferior animals, afford us any facilities in this respect? 1. Through their Sensible Properties. Much importance has been attached by some to the sensible properties of colour, taste, and smell. In relation to the first, it is probably altogether useless. The times are long past, when a correspondence between the colour of a medicine, and that of the fluids or solids of the body, was con- sidered as indicative of a therapeutic relation; when, for example, dragon's blood was thought useful in hemorrhage because it was red, and turmeric in jaundice because it was yellow. The smell and taste, however, are more significative; substances resembling each other in these respects, having in many instances a similarity of medicinal effect. Thus, aromatics are usually excitant, carmina- tive, and antiemetic; fetid substances, often antispasmodic; sweet substances, demulcent; those having an astringent taste, styptic; and bitters, tonic: but, in such general statements, allowance must be made for so many exceptions as to deprive them, in a great measure, of practical value. 2. Through their Chemical Relations. Analogy in chemical con- stitution is also not unfrequently attended with similarity in medical virtues. The preparations of any one of the ordinary metals have a remarkable correspondence in their effects upon the system; and there are several metals which greatly resemble one another. The mineral acids, the vegetable acids, the inorganic alkalies, and the 28 EFFECTS OF MEDICINES. [PART I. neutral salts of the alkalies, constitute groups, of which one indi- vidual may often be substituted for another without disadvantage. But in this respect, as well as in relation to sensible properties, there is so much uncertainty, that no practical conclusion in refer- ence to the properties of any particular medicine should be relied on without careful trial. 3. Through their Botanical Affinities. The same may be said of botanical affinities; though more importance has perhaps been attached to these than to either of the preceding grounds of judg- ment. It might indeed be inferred, that the similarity in internal constitution, which gives to plants those resemblances in obvious structure which serve as the basis of their arrangement into natural families, would also give them a certain identity in other respects, and among the rest, in their operation upon the system; and observation has, to a considerable extent, confirmed the truth of the inference. Plants belonging to the same genus yield very fre- quently not only similar, but identical medical products. Thus, the oaks yield tannic acid, the pines oil of turpentine, the cinchonas quinia and cinchonia, the different species of strychnos strychnia and brucia, the gentians gentian in, the poppies morphia, and the garlics a characteristic volatile oil. This resemblance extends also very frequently to much larger groups; and many of the natural orders of plants have great similarity in medical virtue. Examples of this we have in the Malvacese, which are demulcent, the Gentian- acese tonic, the Convolvulacese purgative, the Solanacese narcotic, the Euphorbiacese emeto-cathartic and acrid, the Pinacese stimulant, the Brassicacese stimulant, pungent, and acrid. Yet in almost every family there are instances, and, in some, very striking instances, in which not only are the characteristic medical properties wanting, but others wholly different, and even in some measure opposite are possessed; while similar and even identical medical virtues belong to plants having no botanical affinity whatever. Thus, in the Convolvidacese above mentioned, there are some species wholly des- titute of purgative properties, as the esculent sweet potato; and among the Solanacese is capsicum, which is simply stimulant, without being in the least narcotic. Among the Ranuncuhcese is Hepatica, which is slightly astringent, tonic, and demulcent; Helleborus powerfully purgative; Zanthorrhiza and Coptic, simply tonic; Aconi- tum, acrid, sedative, and narcotic; and Cimicifuga, chiefly nervine. Of medicines having analogous properties, yet derived from differ- ent families, we have examples in the volatile oil of Pimpinella CHAP. II.] EFFECTS OF MEDICINES. 29 anisum belonging to the Umbelliferse, and that of lllicium anisatum, belonging to the Anonacese; in the oil of turpentine proceeding from the Pinacese, and from Pistacea Terebinthus of the Anacardiacese ; in the aromatic products of the Umbelliferse, Myristicacese, Myrtacese, and Zingiberacese; in the astringent roots and juices of plants be- longing to the Fabacese, Polygonaceee, Cinchonacese, Geraniacese, and many other families; and in the simple bitter tonics obtained from the Gentianacese, Simarubacese, Ranunculacese, and Menispermacese. But in reference to each of the analogies above alluded to, the sensible, the chemical, and the botanical, though none should be relied on in estimating the virtues of a medicine, yet each may be frequently suggestive, and, in relation to any new subject of inquiry, may be valuable by giving a proper direction to experimental inves- tigation. 4. By Experiment or Observation on Inferior Animals. The effects produced on the inferior animals are more to be relied on, and will generally be a safe guide to the employment of medicine in man; but even this rule is not without exceptions. It is well known, for example, that sheep, goats, and cows eat with impunity the leaves of Hyoscyamus niger, which are highly narcotic, and in large quantities poisonous to the human subject. 5. By Observation of their Effects on Man. The only certain means, therefore, of judging of the effects of medicines, is to observe care- fully their operation in man; and, even in this mode, multiplied observation under diversified circumstances, and a most cautious comparison of results, are necessary in order to arrive at the truth. From the want of these precautions, many errors in relation to the action of medicines have originated, and been handed down from writer to writer for many years; and, even at the present time, there are medicines long in use, upon the precise virtues of which opinion is yet unsettled. SECTION II. Whether the Effects are Organic or Functional. The effects of medicines, in other words, the changes produced by them in the system, must be either organic or functional; that is, must consist in an alteration, either of the organization or structure, or of the function or actions of the body, or of some one or more of its parts. Some have denied that there can be any 30 EFFECTS OF MEDICINES. [PART I. change of action, or any action whatever, in the system, without change of structure, and consequently that the effects of medicines can ever be exclusively functional. This denial is founded upon the assumption that, in every operation of a living system, there is necessarily a chemical action, an oxidation perhaps of some por- tion, however minute, of the part or tissue acting, by which it becomes disintegrated and thrown off; while its place, in the healthy state, is supplied with new structure. This may be true, but it has not been proved; and, in the mean time, cannot be received as the basis of a general theory of the action of medicines. But, even admitting its truth, it does not follow that in all cases of physio- logical action there must be an alteration of structure. Sup- pose an organ to be secreting. The general opinion now is that the function is performed by the agency of cells, which, abstracting the material of the secretion from the blood, elaborate it when elaboration is necessary, and then, breaking up themselves, are thrown off with the secreted matter; their place being supplied by new cells. There has not been necessarily in this case any change of structure. One or more cells have disappeared, and their place has been supplied by one or more new cells of the same- character exactly. The organ is precisely as before. There has been change of matter, but no change of structure or organization. Now it may be readily conceived that a medicine, affecting the secretory function of an organ, shall act simply by increasing or diminishing the rapidity of the cell-action ; that, in the time required in health for the throwing off and replacing of a certain number of cells, twice tfce number may undergo the same process in the one case, or only half the number in the other; and yet the organ shall remain precisely as in health, and in no degree altered; the only appreciable difference, even in its condition, being the. greater or less amount of blood contained within it, or passing through it in a given time, and the greater or less amount of the secreted pro- duct. Medicines may, therefore, change the action of an organ, as regards the degree of rapidity, without altering its structure; and the same may be said of the nature of the action, as indicated for example, by the character of the secretion; for a cell may elaborate different secretory products, according to the quality of the blood, or of the foreign materials brought with it, without differino- in the least in its characteristic form or structure from the normal cell. But, throwing aside this refinement of discussion, we may assume as functional effects all that are not attended with appreciable struc- CHAP. II.] EFFECTS OF MEDICINES. 31 tural change; and as organic, all that are attended with such change; and this is the meaning which I attach to these terms, as employed in the present work. In the sense just referred to, the effects of the great majority of medicines, as ordinarily used, are exclusively functional; and it is chiefly those employed externally, to inflame, vesicate, or cauterize, that can be said to operate essentially by a change of structure. SECTION III. Characteristic Effects of Medicines. Medicines either increase, lessen, or alter the healthy functions; and, in reference to these several effects, are called stimulants, seda- tives, and alteratives; the effects themselves being distinguished by the names of stimulation, sedation, and alteration. It has been main- tained that, from the very nature of the vital functions, medicines can affect them in no other way than either by increasing or diminishing them, and that they differ from each other only in the degree in which they produce these effects respectively, or in the seat of their action. But this doctrine is purely hypothetical, and is opposed, apparently at least, by numerous facts. Nothing is more common than to witness peculiar effects from different medi- cines, without any observable increase or diminution of the vital functions; and this difference may often be observed in medicines acting on the same part. Besides, in relation to those which are essentially either stimulant or sedative, we observe characteristic peculiarities which cannot be ascribed either to the degree or direc- tion of their action. Thus, in relation to medicines the effects of which are visible, we have intense redness with comparatively little tendency to vesication from mustard, a less degree of redness with large vesication from cantharides, a copious vesicular eruption from croton oil, a peculiar pustular eruption from tartar emetic, and the production of urticarious wheals from the nettle, all acting on the same portion of the surface, and all excitant in their operation. Now it is possible that, in these and similar cases, the result may be owing to the direction of the action of the irritants severally to some distinct constituent of the skin; but this has not been proved; and, in reference to a great number of the peculiar effects of medi- cines, such a direction to distinct constituents of the structure is altogether insusceptible of proof. In the present state of know- 32 EFFECTS OF MEDICINES. [PART I. ledge, therefore, it is best to admit, as the result of observation, that medicines do materially differ in the nature of their effects, independently of degree and position; and to leave to further investigation the determination of the precise nature of the causes which occasion such difference. Another opinion denies the existence of directly sedative or alterative medicines, maintaining that all substances which act on the system are essentially stimulant, and that whatever sedative effects may be produced are purely secondary. According to one view, medicines operate on the vital excitability, producing primarily an elevation of action, which is followed by secondary depression in consequence of the exhaustion of the excitability; and whenever a direct depression takes place, it is in consequence of the diminution of the ordinary healthy excitants, as through the influence of cold, abstinence, &c. According to a second view, medicines operate as foreign bodies, offensive to the economy, in which, consequently, an excess of action is induced in order to rid it of the offending cause; in other words, all medicines operate by calling forth vital reaction, as inflammation is induced in a part by the presence of a foreign body, in order either to isolate it by a coating of coagulable lymph, or to throw it off through the agency of suppuration and ulceration. But in opposition to all such purely hypothetical views is the simple fact, that certain medicines, when brought into contact with certain parts or organs of the body, are immediately followed by a depression of function in those parts or organs, without any other discoverable intervening derangement; just as, under similar circumstances, certain other medicines are followed by immediate increase of function; and the obvious ex- planation is, that the susceptibilities of the parts are such that the presence of a body constituted in one mode occasions depression, that of another, differently constituted, excess of excitement. But, admitting that some medicines are stimulant, others seda- tive, and others again alterative, we are not called on to believe that any one medicine is essentially one or the other under all circumstances. Much and very unnecessary discussion has taken place in relation to particular medicines, whether they were stimu- lant or sedative. It might all have been spared by the admission of the simple truth, that the same medicine may be stimulant or sedative according to the part upon which it acts, or the state of the system, or parts of the system, at the time of its action. Thus, tartar emetic is stimulant to the skin or mucous coat of the stomach, CHAP. II.] EFFECTS OF MEDICINES. 33 but sedative to the heart; digitalis, which depresses directly the circulation and nervous system, excites the kidneys; and opium, at the same time that it stimulates the heart and brain, diminishes secretion. These different primary effects of the same medicine are dependent on the different susceptibilities of the parts affected, rendering them liable to opposite impressions from the same cause; and, as these susceptibilities are often different in disease and health, the same medicine may produce opposite effects in these two states. Thus, Cayenne pepper, which produces in the healthy fauces red- ness and burning pain, acts as a sedative in the sore-throat of scarlet fever. A mere difference in the mode in which a medicine is em- ployed may cause it to be either stimulant or sedative. A concen- trated solution of acetate of lead applied to the skin denuded of its epidermis, or to a mucous membrane, acts as an irritant; while the same solution, very much diluted, will operate as a sedative through the peculiar powers of the medicine. This principle is of great importance in therapeutics, as will be hereafter more particularly shown. The consideration of the special phenomena, whether of stimula- tion, depression, or alteration, produced by particular medicines or classes of medicines in the several functions, belongs to the depart- ment of special therapeutics. It is obvious that they must be extremely diversified, from the difference in the degree and nature of the action of the medicine, from its direction to one or to several functions at the same time, and from the great diversity in the character of the functions affected. SECTION IV. Influences Modifying the Effects of Medicines. The circumstances which are calculated to modify the ordinary and characteristic action of medicines should always be taken into account by the physician. These may be divided into such as relate especially to the medicines, and such as relate to the system. The former will be more conveniently treated of in the third part of the work, after the medicines themselves have been considered. A few general remarks, in relation to the latter, will be appropriate in the present place. To enter into minute particulars would be quite impossible; as there is scarcely a change, whether consequent upon the healthy progress of the body from birth to old age, or upon the operation of morbid causes, which does not in some vol. I.—3 34 EFFECTS OF MEDICINES. [PART I. measure influence the effects produced by medicines. Many of these influences will be referred to in connection with the several medicines or remedies described; but much, in practice, must always be left to the observation, experience, and judgment of the physician. The modifying influences may be such as are essentially con- nected with our bodily constitution in health, or such as are more or less accidental. The first may be ranked under the heads of age, sex, temperament, and idiosyncrasy; the second under disease, climate, habit, modes of life, and mental action. 1. Age. It is a general, though not universal law of nature, that susceptibility to the influence of medicine is inversely proportionate to the size of the animal. This probably results chiefly from the greater amount of a medicine required to give a certain degree of impregnation to the blood of the larger animal than the smaller. The medicine acts on different bodies, not in proportion to its abso- lute quantity in the blood, but to the quantity of it which is brought to bear upon each point acted on, in other words, to the strength of its solution in the blood. Under the rule here referred to, the child should be more susceptible to the influence of medicines than the adult, and should consequently be affected by smaller quantities. But there is another reason, also, for the greater susceptibility of early life. In the growing state, greater impressibility and mobility are essential, in order that there may be a more rapid assimilation of external material, and a due arrangement of the organism. The higher susceptibility to impression must extend to medicines, as well as to all other impressing agents. Still another cause of differ- ence, in this respect, between the young and the old, is the absence or less degree, in the former, of the influence of habit in diminish- ing susceptibility. I do not here allude to the habit of using medicines; for the cause operates though no medicine may ever have been taken. The general impressibility of the system di- minishes by time under the necessary influence of external agents- and this law holds good even in relation to particular agents to which the system may never have been exposed, though it would be less operative in reference to these than to others. It is impossible to give any precise rule for proportioning the dose to the age; because different individuals exhibit a great difference in this respect; and there is a remarkable diversity in reference to medicines; some, as opium, producing in children more than the mean proportionate effect; others, as castor oil and calomel, much CHAP. II.] EFFECTS OF MEDICINES. 35 less. It may be said, in general terms, that the dose for an indi- vidual under maturity should be proportioned to the years of his age. This holds good in relation to all ages between 12 and 24, at the latter of which periods of life the full dose may be given. From the age of twelve downwards to two years, the rule of Dr. Young is perhaps as good as any that can be given; namely, that the dose proper for an adult should be diminished, for a child, in the proportion of the age increased by twelve to the age. Thus, the age being three years, and the dose for an adult 20 grains, the diminution must be in the proportion of 3 + 12=15 to 3; or, the quantities being reduced to their lowest terms, of 5 to 1; that is, the dose for the child must be one-fifth of that for the adult, or in the present instance 4 grains. At one year the dose may be one- ninth; at nine months, one-tenth; at six months, one-twelfth; at three months, one-fifteenth; at one month, one-twentieth; but it must be admitted that these numbers are nothing more than safe approximations. From full maturity to the commencement of declining life, that is, from about twenty-four to forty-eight, the dose may remain unchanged; but, after the latter period, it should be somewhat diminished with the increasing age, not because the system becomes more susceptible; for, as a general rule, it is less so; but because it is less able to sustain, without injury, a given impres- sion from medicines than in the full vigour of life. 2. Sex. It is necessary to say but little under this head. There are certain conditions in the female which require attention in the prescription of medicines, which, however, cannot be said to exert any materially modifying influence over their effects, and do not, therefore, require particular attention in this place. Such is preg- nancy, which demands especial caution in the use of all medicines having a direct influence on the womb, and which, in its advanced stages, contraindicates the use of any medicine whatever of a power- fully perturbating character. Such, too, is the menstrual state, in which care is required, in the employment of remedies, to guard against any interference with the uterine function. Another im- portant point, of a similar bearing, is the caution requisite, in the cases of nursing women, not to use medicines which might injure the suckling; and a similar caution may be very properly extended to pregnancy, in which, while prescribing for the female, we should always bear in mind that there is another being to be affected by the remedy employed. So far as concerns the modifying influence of sex upon the 36 EFFECTS OF MEDICINES. [PART effects of medicines, the only circumstance of importance is, that women, being smaller, more delicately organised, and in general more susceptible than men, require a smaller amount to produce a given effect. The dose for females should, therefore, be somewhat reduced. From one-sixth to one-quarter maybe deducted for them from the dose proper for the male at the same age. 3. Temperament. Temperament should receive some attention in the administration of medicines; but the judicious physician will probably be influenced in relation to it more by his general principles than by any special precepts. The sanguine tempera- ment obviously demands caution in the administration of stimu- lants, and the nervous in that of evacuants; while the phlegmatic, being characterized by a general deficiency of susceptibility, admits and requires a freer use of medicines in reference to a given effect. 4. Idiosyncrasy. Individual peculiarity, technically denominated idiosyncrasy, is of much greater importance, and can scarcely receive from the physician a too careful attention. In very many indi- viduals, perhaps it may be said in nearly all, there is some peculiar- ity, in relation to the effects of a particular medicine, or possibly of more than one, which, if unknown or neglected, may lead to serious inconvenience or injury, and even to fatal results. This peculiarity sometimes consists merely in an excessive susceptibility, or in an abnormal insusceptibility to the action of the medicine or medicines; so that an ordinary dose might, in the former case, act with danger- ous violence, and in the latter not act at all. This is strongly illustrated in the not unfrequently unexpected results from the use of the mercurial preparations. In more than one instance that might be adduced, a moderate dose of calomel or other mercurial has acted so powerfully, in consequence of a remarkable constitu- tional susceptibility to its influence, as to occasion death; and every experienced practitioner, who has used this medicine habitually, must have witnessed instances of unexpected violence in its action; while, in other cases, from defective susceptibility, it is quite im- possible to bring about its peculiar effects on the system by any quantity that can be given, with any regard to prudence. The instance of mercury has been brought forward simply as a striking example; but there is scarcely an efficient article of the materia medica, in relation to which there does not exist, in some one or more persons, a similar excess or deficiency of susceptibility. But the idiosyncrasy is not unfrequently also of such a nature as to render the effects of a medicine altogether different from those CHAP. II.] EFFECTS OF MEDICINES. 37 which it ordinarily produces. The well-known and often cited example of ipecacuanha, in causing by its mere smell an asthmatic paroxysm in certain persons, is strikingly illustrative of this fact. Other examples are offered in the cutaneous eruption produced in some individuals by copaiba and the turpentines, the irregular and very inconvenient effects sometimes resulting from opium, and the occasional peculiar and poisonous operation of mercury, altogether different from its proper action. I have known so innocent a me- dicine as pipsissewa (Chimaphila umbellata), given in the form of decoction, in the dose of a wineglassful, to cause a most violent attack of erythematous inflammation of the mouth and face. These idiosyncrasies are sometimes also developed by disease, so as to render individuals susceptible to effects from medicines quite different from those expected, and sometimes even directly opposite. Whether original or acquired, they should claim the careful at- tention of the practitioner, who should never neglect information in reference to such peculiarities that may be volunteered by the patient, and should lay up in his memory, for future use, all that he may witness in his own experience or observation. A physi- cian thoroughly acquainted, from habitual attendance, with all the constitutional peculiarities of his patient in reference to the effects of medicines, often has great advantages in treatment over others without any experience of the kind. 5. Disease. Reference has already been more than once made to the influence of disease in modifying the effects of medicines. Not only is the susceptibility to their influence greatly increased in some instances, and greatly diminished in others, but new sus- ceptibilities are occasionally awakened, and effects wholly abnormal, or at least apparently so, are experienced. Thus, inflammation of the stomach so much increases the susceptibility to the influence of emetics, that a minute fraction of the ordinary dose will often ope- rate ; while, in certain nervous affections, as delirium tremens for example, there is an almost equal diminution of susceptibility, and, in some instances, enormous doses are required to produce vomit- ing. In certain morbid conditions of the brain, a little opium will excite to phrensy; in others, it is with the utmost difficulty that the medicine can be brought to operate, as in tetanus and certain forms of mania. In diarrhoea, opium often checks the evacua- tions, in colic, on the contrary, favours the action of cathartic medi- cine. But in this place all that is necessary is simply to notice the 38 EFFECTS OF MEDICINES. [PART I. modifying influence of disease, and to impress on the mind of the student the indispensable necessity of attending to it. The pecu- liarities in this respect of different morbid states, must be studied along with the several diseases in which, or the several medicines in reference to which, they are displayed. 6. Climate. Climate acts by altering the state of the system. Sometimes the change is so great as to amount to disease; and then the influence of this modifying cause is merged in that of the one last considered. But climate also affects the functions in a manner which can scarcely be considered pathological; as the result is ex- perienced more or less by the whole community; and, though the state of system under any particular climatic influence, may be less vigorous, or less perfectly balanced, than under more favourable circumstances, it is nevertheless the health of that region where the influence prevails. The following may be mentioned as examples of the modifying influence of climate over the effects of medicine. In cold climates the susceptibility to alcoholic stimulants is much less than in the hot; probably because, in the former, much of the stimulant is consumed in the lungs for the production of heat, and thus thrown off from the system; while in the latter, in which heat is already in superfluity, none of the alcohol is consumed in the lungs, and more of it is consequently retained to act upon the brain. In hot climates calomel acts less energetically on the liver than in cold, probably from the diminished general susceptibility of that organ, consequent upon its habitual over-excitement. In miasma- tic districts, bloodletting and other evacuant measures are, in gene- ral, not so well borne as in regions exempt from malarial influence; while quinia may be given with a freedom which elsewhere might be hazardous. But the modifications produced by climate in the operation of medicines have not been investigated with sufficient accuracy and precision, to justify anything more than very general statements upon the subject. 7. Habit. This is a powerful agency. Its effect is almost uni- formly to lessen the susceptibility to the influence of medicines, and thus to require an increase of their dose for the production of a certain amount of impression. In relation to medicines which are purely functional in their operation, this augmentation of the dose, under the influence of habit, may be carried on almost inde- finitely. The quantities of alcohol and of opium to which the system may become accustomed, with present impunity, are enor- mous. It is not exactly the same with medicines of powerful che- CHAP. II.] EFFECTS OF MEDICINES. 39 mical action, corrosive mineral substances for example; for, though the quantity may, through the agency of habit, be very considera- bly increased beyond what could be borne without its aid, yet, at a certain point, the chemical forces necessarily overcome the vital resistance of the tissues, and decomposition must take place. The mineral acids, therefore, the caustic alkalies, and the corrosive me- tallic salts, such as nitrate of silver, corrosive sublimate, and sul- phate of copper, cannot be indefinitely increased without the dan- ger of great organic mischief. But it must be remembered that, even with those acting functionally, the ultimate effects are in the highest degree injurious, either through chronic inflammation in- duced at length by the constant irritation sustained, or by the failure of susceptibility to the ordinary vital stimuli, and the con- sequent loss of all power of action. The rule in relation to the effect of habit in diminishing suscepti- bility is probably universal. There are, it is true, some apparent exceptions; as in the case of emetic substances, which often operate, on successive occasions, in successively diminishing doses; but the exception is only apparent; for the result in this case is ascribable not directly to the medicine, but to a diseased state of irritation produced by it, which itself is sufficient to induce vomiting. If an emetic substance is given at first in a small dose, and afterwards gradually increased, the stomach becomes accustomed to it, and very large quantities may be given without provoking vomiting. The practical inferences from this effect of habit are, 1. that when it is desirable to maintain for a long time a given medicinal im- pression, the dose should be gradually, but at the same time cau- tiously increased, so as not too rapidly to wear out the susceptibility; 2. that when one medicine has been given so long as materially to impair its powers, another of analogous mode of action, but exert- ing its influence on a different tissue or part, should be substituted, until the susceptibility to the first returns; and 3. that, in omitting a medicine which has been long given in gradually increasing quantities, it should be withdrawn gradually, or its place should be supplied for a time with another of similar but feebler powers, lest the system or part should suffer from the want of an influence to which it had become habituated, and which might be essential to the performance of its proper functions. 8. Modes of Living. The occupation and mode of life of an indi- vidual modify the action of medicines, in so far as they affect the condition of his system. But it would be quite impossible, in the 10 EFFECTS OF MEDICINES. [PART I. present place, to follow out this influence into all its results. Little more can be done here than to call attention to its existence. One consideration, however, is worthy of notice, as it has a general bearing, and can be brought forward nowhere else so appropriately. Firm and vigorous health affords the strongest resistance to all disturbing influences, and consequently to the action of medicines, which must, therefore, be given more freely, to produce a certain effect, than in conditions of the system either above or below that standard. This is true in relation not only to medicines which stimulate, but to those also which depress or alter the vital func- tions. Thus, persons in full health will bear both the stimulant influence of alcohol, and the sedative operation of digitalis, better than the plethoric or the feeble. But it must be remembered that full health does not consist in that richness and abundance of blood, and that high activity of the functions, which are sometimes mis- taken for it. This is indeed a condition, if not itself morbid, at least closely bordering on disease, and capable of being excited into positive disease by slight causes. The system is most healthy when all its parts, and all its functions are in due relation; when the quantity and quality of the blood are in exact accordance with the offices it has to perform in the economy; when the nervous system has no higher nor lower activity than is sufficient to maintain every function in its just vigour and subordination; and when no one organ or apparatus is excessively or deficiently developed. It is in this "condition of system that medicines are best borne, and that, upon the occurrence of disease, vigorous treatment may be most safely adopted. Modes of life, therefore, which tend to produce an over-elevated condition of system on the one hand, or a debilitated condition on the other, render peculiar caution advisable as to the quantity of medicines employed, and the energy of the treatment in general. 9. Mental Action. The influence of the mind over the operation of medicines is often very considerable. As a general rule, they will act with greater certainty when their legitimate effects are known and expected. An emetic will be more likely to vomit, if the patient anticipate this effect from it. The co-operation of faith with the medicine will often favour its action. This is more espe- cially true when the nervous system is prominently concerned. The full belief in the efficacy of quinia in intermittent diseases aids considerably in the prevention of the paroxysm. But mental causes sometimes interfere with the regular operation of a medicine. CHAP. II.] EFFECTS OF MEDICINES. 41 When this is given to procure sleep, especially in divided doses, at certain intervals, if the patient is made acquainted with the object, his anxiety for the result may tend to prevent it. I have noticed, when I have directed, with the knowledge of the patient, a certain dose of opium to be given at bedtime, and repeated, at intervals of an hour, until sleep is produced or a certain number of doses have been exhibited, that the whole quantity prescribed is generally taken. The nervous disturbance occasioned by the expectation of the next dose, and the watchfulness for the appointed time, tend to keep the patient awake. Hence, in prescribing an anodyne in this way, I now invariably take particular care that the patient shall not know that the dose is to be repeated if requisite. It is to mental influence that empiricism is partly indebted for its seeming triumphs, especially in nervous diseases; and regular practitioners sometimes employ bread pills, with the happiest effect, in accom- plishing certain results which the patient has been previously taught to expect. 42 APPLICATION OF MEDICINES. [PART I. CHAPTER III. Application of Medicines. Medicines have hitherto been considered, not so much in rela- tion to their application to the cure of disease, as to their modes of affecting the system in health. It now remains to consider them more especially in the former capacity; and, in doing this, it will be convenient to treat first of the several modes in which they may operate in the cure of disease, secondly of the forms in which they may be applied, and thirdly of the parts through which, and the means by which they may be introduced into the system. The remarks which follow apply not only to medicines strictly so called, but to all other remedies. SECTION I. Modes of Therapeutic Action, or Therapeutic Processes* These may be arranged under the heads of 1. depletion; 2. reple- tion; 3. dilution; 4. elimination; 5. stimulation; 6. sedation; 7. revul- sion; 8. supersession; 9. alteration; 10. anti-causation; 11. chemical action: and 12. mechanical action. SUBSECTION I. Depletion. 1. Nature of Depletion. By this term is here meant diminution of the blood, in relation either to the whole mass, or to some one * The reader who may be familiar with my work on the Practice of Medicine will recognize, in the observations which follow, many things which are to be met with in that work. These have not been introduced into the present treatise inadvertently. They essentially belong to it, and could not be omitted without leaving the treatise imperfect. Their insertion here, however, will give me the opportunity, should the work on the Practice ever come to another edition of dropping in the revision the subjects here treated of, and supplying the space thus gained with new matter of a practical nature, which is ever in the course of dis- covery and accumulation. CHAP. III.] APPLICATION OF MEDICINES. 43 or more of its constituents. As it is these constituents of the blood to which, both through the material they furnish, and the stimulus they apply, all the vital functions owe their support, and the organs their due nutrition, the abstraction of them must necessarily occa- sion, in the ordinary state of the system, a depression of action and reduction of strength. It is not only, however, by diminishing the quantity of blood that depletion operates, but also by altering its quality. When a portion of the blood is abstracted, the place of the solid constituents withdrawn is rapidly supplied by the process of absorption, so that its former volume is soon restored; but, as water is absorbed in much greater proportion relatively than the solid ingredients, the blood becomes diluted, and is, therefore, less capable of performing its due office in the economy. Depletion depresses especially the force of the heart, and of the whole circu- latory system. It diminishes also digestion, respiration, secretion, nutrition, calorification, and the functions of animal life. This last effect is rendered obvious when the depletion is carried far. Lan- guor, impaired sensation, deficient emotional and intellectual ener- gy, muscular weakness, even faintness, and positive syncope, result from the failure of the due influence of the blood upon the brain. But, with this general diminution of the vital powers and actions, there is one function which depletion promotes, that, namely, of absorption. To supply the loss of blood, the liquids and solid tis- sues of the body are taken up with more than the usual rapidity, and water is copiously absorbed from the contents of the alimentary canal, and perhaps also from the external air. Notwithstanding what has just been stated, depletion is not always purely sedative; and this is a very important therapeutical fact. The general rule may be considered as holding true, when- ever the blood is in excess as regards its animalized or vital consti- tuents; and, in the ordinary state of the blood, so far as concerns the immediate effects of depletion, and even in its ultimate effects when it is moderately used and properly guarded. But excessive depletion may act as an excitant instead of a depressing agent to certain functions, and especially those of the circulatory and nervous systems. The functions of the system generally, feeling the want of their ordinary support from the blood, make this want known to the nervous centres, which then transmit a stimulant influence to the heart, while, at the same time, they give evidence of their own disturbance by various irregular nervous phenomena. Under no circumstances, is the heart thrown into more violent commotion 44 APPLICATION OF MEDICINES. [PART I. than, .sometimes, through an impoverished condition of the blood. Depletion, therefore, especially the more direct and powerful kinds of it, should be employed with reserve in anemic states of the cir- culation, even though strongly indicated by other considerations. Another important rule is that, when a purely sedative effect is desired from this remedial measure, all the functions should be kept as quiescent as possible; so that, consuming little blood, they may not, from a feeling of deficiency, excite the nervous centres and throusrh them the heart into a state of irritation. Rest should be enjoined, the food diminished, and strong mental action or emotion avoided; so that the muscles, the digestive organs, and the brain may be content with less than the ordinary supply of their essential pabulum. 2. Applications of Depletion. The therapeutic applications of de- pletion are obvious. It is the great remedy in plethora, and in an excess of vascular excitement, whether that excess amount to irritation merely, or to inflammation. Sanguineous determination and active congestion, hemorrhage, morbidly increased secretion, and other derangements of function, so far as these disorders are the result of vascular irritation, are to be corrected by it. In the treatment of inflammation it is invaluable, not only lessening the force with which the blood is driven into the inflamed part, but impairing those qualities of the vital fluid which most powerfully support that morbid process. Another application of depletion, dependent on its influence over the absorbent process, is to the treatment of morbid effusions; the different forms of dropsy, for example, in which it is often employed with great efficacy, though requiring caution. Upon the same principle, it may be used in polysarca or morbid obesity. 3. Means of Depletion. Depletion maybe effected either directly, by taking blood or promoting secretion, or indirectly, by diminish- ing the supplies through which the natural losses of that fluid are repaired. Direct Depletion. Beyond all comparison the most efficient of the measures for direct depletion is general and heal bleeding. The character of this remedy, its peculiar applications in disease, and the methods of employing it, will be fully considered in the second part of this work. Another important mode of direct depletion is increased secretion. It not only unloads the circulation in general, but, in some cases, has the advantage over bleeding, of directly depleting from the CHAP. III.] APPLICATION OF MEDICINES. 45 diseased vessels themselves, and thus imitating a very frequent process of nature in the relief of irritation and inflammation. Thus, cathartics relieve mucous enteritis, expectorants bronchitis, and diuretics nephritis. It is not merely the watery parts of the blood that are thus evacuated, but its animalized constituents also, though the red corpuscles seldom pass. Upon the whole, this mode of depletion is much less efficacious than bleeding, in the relief of plethora and vascular excitement. But, for the purpose of pro- moting the absorption of effused fluids, it is even more efficacious; as a much larger amount of liquid may be safely abstracted from the blood-vessels by increased secretions than by bleeding, and consequently a greater amount of absorption produced. The remedies most efficaciously employed with reference to depletion, upon this principle, are cathartics, diuretics, and diapho- retics. But all that increase secretion are occasionally useful, including expectorants, emmenagogues, sialagogues, errhines, epis- pastics, issues, and setons. It is upon this principle, in part, that the warm, hot, and vapour baths act usefully in certain inflamma- tory affections. In the application of these various remedies there is much room for discrimination; some being better adapted to one condition, others to another, and some being positively injurious where others are highly useful. This, however, is not the proper place to discuss their properties; and the reader is referred to the second part of the work. It may be proper to mention here, that such as are employed for the reduction of plethora, or inflam- matory excitement, should be destitute of general stimulating pro- perties, and that the most efficient are those which unite a sedative influence over the circulation with the power of increasing secretion. Such especially are the saline cathartics, and the antimonial diapho- retics and expectorants. A general rule applicable to all these medicines is, that, in cases of high vascular excitement, when the pulse is full and strong, and bleeding is otherwise indicated, they should be preceded by that remedy. Secretion is often checked by excess of excitement in the secreting organ, and favoured by a reduction of the excitement. Besides, medicines are not easily absorbed when the blood-vessels are full to distension. If the object be to reduce active congestion or inflammation by promoting secretion from the part or organ affected, preference should always be given, at least in the earlier stage, to those stimulants of the secretory function which are least irritant in their action. Thus, sulphate of magnesia should be preferred in dysentery to gamboge, 46 APPLICATION OF MEDICINES. [PART I. scammony, or elaterium; tartar emetic or ipecacuanha to squill or seneka in the earlier stage of bronchitis; and cream of tartar to oil of turpentine in acute nephritis. Indirect Depletion. This is effected by whatever prevents the usual amount of solid organic material from entering the circula- tion. Emetics and cathartics act in this way, by discharging the partially digested food from the alimentary canal before it has entered the lacteals. Still more efficacious is a temporary ab- stinence from food, or a reduction of its quantity and quality. But the subject of diet as a means of indirect depletion belongs to special therapeutics, and will be considered hereafter. SUBSECTION II. Repletion. This term is here employed, rather in reference to its origin than in accordance with its accepted meaning, to signify an increase in the quantity of the blood in general, or of its solid animalized in- gredients. The circumstances of disease under which this remedial process is desirable are the opposite of those requiring depletion; namely, general debility, a too scanty blood, and a condition of that fluid in which, though its bulk may be sufficient, there is an undue proportion of the watery ingredient. The means by which it may be accomplished are the free employment of a highly nutri- tious diet, and the use of remedies calculated to invierorate di^es- tion and sanguification, such as moderate exercise, tonic and stimu- lant medicines, frictions, and the cold bath. SUBSECTION III. Dilution. By this is meant the copious internal use of water, whereby the liquids of the body are diluted, and rendered less excitant. The contents of the stomach are first diluted, then the blood in conse- quence of the absorption of the water, and, lastly, the secretions, especially those of the skin and kidneys, in consequence of its passing out through these emunctories. The therapeutic effect is to relieve irritation or inflammation of the surface with which the diluted fluid may be in contact, as the mucous membrane of the stomach, and that of the urinary passages, and to moderate general excitement by attenuating the blood. CHAP. III.] APPLICATION OF MEDICINES. 47 SUBSECTION IV. Elimination. It is well known that, in the course of various diseases, matters accumulate in the blood, either altogether foreign to that fluid, or existing in it during health only in almost inappreciable quantities, and in the course of spontaneous elimination from the system. Thus, urea and uric acid, which are the results of the disintegration of the tissues, or the superfluous residue of the food in its conver- sion into blood, are, in the healthy state, present in the circulation only until they can be thrown off by the kidneys; and the same may be said of the colouring matter of the bile, which is separated and excreted by the liver. These accumulate abnormally in the blood, when their respective emunctories fail in their office of ex- cretion, and become sources of inconvenience and danger. It is highly probable that other noxious principles, not well understood, in like manner vitiate the blood, either forming special diseases, or complicating those resulting from other causes. In febrile com- plaints, a sour odour is often observable in the breath and perspi- ration, arising from the escape of acid matters from the blood. In typhus fever, smallpox, and many cases of disordered digestion and obstinate constipation, the breath and other secretions have an offensive odour, indicating, no doubt, an impure condition of the circulating fluid. Now the existence of such morbid matters in the blood affords a well-grounded indication for the use of reme- dies calculated to effect their elimination ; and there can be no doubt that this is not unfrequently a very useful therapeutic process. The remedies alluded to are such as stimulate the several emunctories; and cathartics, diuretics, diaphoretics, and cholagogues, or medicines having the property of exciting the secretory function of the liver add this mode of action to their other beneficial influences in disease. There is another mode of elimination which has recently beo-un to attract attention, and which may possibly hereafter prove a highly important method of cure. It has been shown that certain substances, having a noxious influence upon the health, are some- times incorporated with the tissue of the organs, and probably thus impair their efficiency by a constant unhealthful influence. Such are various metallic poisons, as the preparations of arsenic, lead, 48 APPLICATION OF MEDICINES. [PART I. copper, and mercury. To separate these from their seat in the tissues is an important indication; and there is reason to believe that this may sometimes be fulfilled, not only by medicines calcu- lated to promote absorption and secretion, or to alter the nutrition of the organ, but also by others which modify the condition of the foreign matter, so as to render it soluble in the blood, and thus capable of being eliminated from the system. It is believed, for example, that lead is thus displaced, when producing colica picto- num or paralysis, by the exhibition of iodide of potassium. More will be said on this subject under the head of the several remedies employed on the principle referred to. SUBSECTION V. Stimulation. Stimulation, as here understood, is the exaltation of any or of all the vital functions above the state in which they may happen to exist, at the time when the stimulating measures are resorted to. There is a vast diversity in this process. It differs in direction, degree, duration, and character. Perhaps the most convenient pri- mary division of it is into general and local; the former being felt, to a greater or less extent, throughout the body, the latter confined originally to a particular part or organ. A property common to all stimulation is, that it is followed, in the ordinary state of the system, by a degree of depression bearing some proportion to the previous excitement. There may be con- ditions of temporary prostration, in which stimulation may put the system in the power of resuming its ordinary grade of action without subsequent depression; but these do not come within the general rule. The depression is dependent upon the temporary diminution of excitability, resulting from excessive action. If the stimulant influence be continued, it follows, as a consequence of the diminished excitability, that a greater amount of the stimulant agent must be employed to produce the same effect, and the excita- bility is thus still further diminished; until, in the end, the system refuses entirely to respond to the ordinary healthy excitants and morbid and often fatal debility results. This is an evil a^inst which it is necessary to be constantly on our guard, in the use of stimulant measures. Another, scarcely less important, is the pro duction of inflammation by the excessive or repeated excitement to which the stimulated organ or system is exposed. CHAP. III.] APPLICATION OF MEDICINES. 49 1. General Stimulation. It is barely possible that stimulation should be absolutely universal. In whatever degree the functions generally may be excited, there is almost always some one or more that become depressed, or remain quiescent. Stimulation may be considered general, when any one of the vital properties or functions which belong to all parts of the frame is exalted, as contractility or nutrition; or when one of the anatomical systems which pervade the whole body is excited into increased action, as the circulatory or nervous. In such cases, the excitement is felt throughout the frame, though not in every function. The lowest grade of general stimulation is that produced by astringents, which operate on the organic contractility, and produce a general condensation or shrinking of the tissues. Tubes and ori- fices are thus contracted, the flesh becomes firmer, and the pulse somewhat more tense. The therapeutic applications of this power of astringency, with the requisite cautions, will be hereafter fully considered. Somewhat higher in the scale of general stimulation is the action usually denominated tonic. This is a moderate increase of the vital functions generally, produced rather slowly, and lasting for a con- siderable time. It is of vast importance in the treatment of mode- rate or chronic debility. For an account of its special applications, the reader is referred to the second part of the work. Among the agents by which it is effected is a class of medicines denominated tonics, which may act directly on the whole system, or especially on the digestive function, thereby enriching the blood, and making that fluid the immediate excitant. Some medicines probably also give tonic power to the blood by a direct action on that fluid. Such are the chalybeates. But there are other very important tonic agents besides medicines. Cold operates in this way secondarily, through the reaction which follows its direct depressing influence. A wholesome and nourishing diet, succeeding an impoverished one, and pure fresh air with those who have been confined to a close and vitiated atmosphere, have a powerful tonic operation. So also has moderate physical exercise, under similar circumstances of previous deprivation. Gentle electrical excitation may be placed in the same category. Mental influences, moreover, have great effect. No tonic is, under many circumstances, more efficient than the cheering influ- ence of social pleasures, domestic enjoyment, and a gentle exercise of the intellectual faculties, and all the kindlier emotions. A quicker, and more rapid stimulation is sometimes distinguished vol. I.—4 50 application of medicines. [part I. by the name of diffusible. It usually affects more or less, at the same time, the functions both of organic and animal life; though, as proceeding from one cause it may be more especially felt in the circulation and its dependent functions, from another, in the nerv- ous system. This special direction is sometimes so far exclusive as \o justify the division of diffusible stimulants into those operating more particularly on the circulation, and those upon the cerebro- spinal functions. It will be found, hereafter, that this distinction serves as the basis of an arrangement in the plan of classification which I have adopted. For want of a better name, the medicines acting on the circulation especially, with little tendency to the nervous system, may be denominated arterial stimulants. Stimulants which act chiefly on the nervous system may diffuse an apparently equable action over the whole of that system, or may concentrate their influence especially on the brain. The former may be called nervous stimulants, though more commonly designated as antispasmodics; the latter I propose to call cerebral stimulants, pre- ferring this title to that of narcotics, which has reference to the property of stupefying, that belongs also to medicines of wholly different powers. It will be perceived hereafter that the above arrangement of stimulant medicines is not only natural, in relation to their physiological effects, but has also an important practical bearing. Other influences besides those properly medicinal are susceptible of very useful employment in reference to general stimulation. Heat and electro-magnetism are agencies of this kind; and stimu- lating food is yet more important. These will be fully treated of under Special Therapeutics. 2. Local Stimulation. Local stimulation may have the effect of merely irritating or inflaming a part; or of exciting it to an in- creased performance of its peculiar function. In the former case, the object is usually to act revulsively, or to produce general stimulation through the sympathy of the system with the part affected. The agents employed for either purpose, so far as the external surface is concerned, are the rubefacients, epis- pastics, and escharotics. Occasionally, however, the object is entirely local. The vessels of a part may become relaxed and congested with blood, and, in consequence, an imperfect sort of inflammation may be sustained; or there may be ulceration, and the surface too feeble to take on the action necessary for the healing process. In either case, local stimulation sometimes answers an excellent pur- pose in removing the evil. CHAP. III.] APPLICATION OF MEDICINES. 51 But still more frequently this remedial process is employed for the increase of function. The surface may be pale, dry, and in- active; the muscles may be enfeebled to paralysis; the senses of smell, taste, and touch may be imperfect from weakness; digestion may be feeble, and the bowels costive from deficient secretion, or want of due peristaltic movement; the liver, kidneys, or other secretory glands may be inert. The means used to restore the weakened functions are medicines, and other remedies, having a special influence over the functions severally. Hence the use of friction to the surface; the hot bath; the cold bath used with a view to reaction; diaphoretics; errhines; masticatories; gastric stimulants, such as bitters, aromatics, and the mineral acids; emet- ics; cathartics; diuretics; expectorants; emmenagogues; and cho- lagogues to excite the liver, as mercury and nitromuriatic acid. Hence the employment of ergot to stimulate the uterus to con- traction. Sometimes a local stimulant is employed to produce general de- pression; as in the case of the hydragogue cathartics, which, though they stimulate the bowels, depress the system in consequence of the depletion they produce. SUBSECTION VI. Sedation or Depression. This implies a diminution of action. Like stimulation it may be general or local. General sedation may affect especially either the circulation and its dependent functions, or the nervous system. The agents which produce the former effect I denominate arterial sedatives. They are the refrigerants of other writers; as they re- duce temperature along with vascular action. Those operating upon the nervous system may produce their depressing effect in two ways; in one, by directly affecting the functions of the nervous tissue wherever they encounter it; in the other, by acting primarily on the brain, and through the cerebral centres depressing the de- pendent nervous functions. The former may be called simply nervous sedatives, the latter may be distinguished by the title of cerebral sedatives. It is important to understand, that general nerv- ous sedation may result even from the cerebral stimulants, through this dependence of function. In this case, the nervous centres are overwhelmed by an active congestion, which cripples their power both of receiving impressions and transmitting influence; and sensi- 52 APPLICATION OF MEDICINES. [PART I. bility, muscular motion, and in fact all the functions which derive a necessary support from the brain are more or less impaired. This distinction is of great practical value. Thus, hydrocyanic acid, tobacco, and acetate of lead might be used as sedatives, when it might not be altogether safe to employ alcohol or opium. The agents of sedation will be enumerated and described here- after. It is here sufficient to say that, besides sedative medicines, we are in possession of two powerful remedies of this kind; viz. cold, in relation to its primary effects, and water. Local sedation may affect all the constituent tissues of a part, or more especially the nervous. In the former relation it is employed to repress inflammation, or vascular irritation as shown in morbid secretion, hemorrhage, or simply congestion; in the latter, to relieve neuralgic pain, and allay spasm. Many of the general sedatives may be employed locally for these purposes. SUBSECTION VII. Revulsion. Derivation. Counter-irritation. Revulsion consists in the diversion of disease from one part of the system, by the production of inflammation or irritation in an- other part. The term derivation is applied to the same process, but may be extended also to cases in which the diversion is effected by a degree of excitement, which may still be within the limits of health. Counter-irritation, strictly defined, applies to the revulsive impression rather than to the revulsion itself. The system has only a certain capacity of nervous action, and a certain amount of blood. When either the former or the latter is strongly directed to a particular part of the body, there is a tendency to its diminu- tion elsewhere. This is absolutely necessary of the blood; and it is true, to a great extent, in relation to nervous action. Such a direction is given by the application of irritants of any kind. Hence, in order to relieve inflammation, any of the forms of vas- cular irritation, or mere nervous disorder as indicated by pain or spasm, in any particular part of the body, we apply irritants, which under these circumstances are called revulsives, to some other part. This principle is of very extensive applicability to the cure of disease. It often comes into play as an auxiliary force, in cases in which the remedy is used for other purposes. Thus, while emetics are employed to relieve spasmodic affections of the air-passages, in CHAP. III.] APPLICATION OF MEDICINES. 53 consequence of the relaxation they produce, they are probably also useful by a revulsive influence towards the stomach. Cathartics act very powerfully, upon this principle, in the relief of inflammations and active congestions, though they may be employed chiefly in reference to their depleting power. There is no remedy whatever, allowing it to have the power of producing excitement in any part of the body, which may not act as a revulsive. But the remedies usually employed, in special reference to this principle of action, are external irritants, such as hot water, rubefacients, epispastics, and caustics. Derivation may often be advantageously effected by exercise, calling off undue excitement from internal organs to the exterior, or from one part of the body to another, and thus pro- ducing an equilibrium of the vital actions. The application of the principle of revulsion requires discrimi- nation. When the local affection consists rather in a determination of blood to the part affected than in inflammation, as in cases of vertigo threatening apoplexy, and of frequently recurring epistaxis or hasmoptysis, the indication is to divert the general current of ex- citement, and of the blood, towards the most distant parts of the body. Hence the use of strongly stimulating pediluvia, and of sinapisms to the legs, in cases of cerebral affection of the character just alluded to. But, when the disease is fixed in a part in the form of inflammation, it is necessary to bring the revulsive impression into nearer contiguity with the diseased part, though it may be proper also to employ remote revulsion as an adjuvant. Hence, in inflammation of the lining membrane, or of the contents of the great cavities, the revulsive remedy is most advantageously ap- plied over the outer surface of the walls of those cavities, as over the abdomen in cases of peritonitis or enteritis, the chest in cases of pleurisy or pneumonia, and the scalp in those of encephalic inflammation. The revulsive influence of remedies is peculiarly indicated in cases of metastasis, or of diseases which are especially liable to assume the metastatic form. In these cases, the agent should be applied to a portion of the body towards which there is a natural tendency of the morbid action to flow, and in which it would be safe; as, in gouty cases, to the feet, and in cases of retrocedent eruption, to the part of the surface from which the retrocession has taken place. Another important principle is not to employ a highly irritative revulsive agent, in inflammatory cases, during the greatest violence 54 APPLICATION OF MEDICINES. [PART I. of the disease. A strong impression upon the surface may some- times prove useful in a commencing inflammation, before any febrile action has been excited, and in the declining stages, when the fever has in some measure yielded to depletion, or subsided spontaneously. But, during the existence of high constitutional excitement, the revulsive agent is not sufficient to unseat the inflammation, and, if itself very irritant, as in the instances of the more powerful rubefacients and of blisters, may add to the existing excitement by the sympathy of the system with the superficial inflammation they produce. But, when the revulsive impression is conjoined with copious depletion, as in the case of the saline hydragogue cathartics, which produce a revulsion towards the whole lining membrane of the bowels, while they evacuate the contents of the blood-vessels, it may be resorted to in the greatest height of the inflammation. The copious secretion prevents the production of an intestinal irritation sufficient to bring the consti- tution into sympathy. When the local affection to be remedied is a mere nervous irrita- tion, such as spasm or neuralgic pain, it is generally best to produce a quick, powerful, and transient revulsion; when inflammatory, especially when the inflammation is severe, to sustain a more moderate impression for a longer time. Hence, the more active rubefacients, such as mustard and ammonia, are applicable in the former case, and epispastics in the latter. SUBSECTION VIII. Supersession. By this process is meant the displacing or prevention of one affection by the establishment of another in the seat of it. It is a general, though by no means universal pathological law, that two powerful diseases, or forms of abnormal action, cannot exist in the whole system, or in any one part of it at the same time. If, there- fore, we can produce a new disease, or new mode of abnormal action, in the exact position of one that may be existing or expected, we may possibly supersede the latter; and, if the new disorder subside spontaneously without injury, we cure our patient. The operation of numerous remedial agents may be explained in this way. It is thus, for instance, that mercury has been supposed to cure syphilis. But we have better examples in the powerful influence of certain antiperiodic remedies, such as quinia and CHAP. III.] APPLICATION OF MEDICINES. 55 arsenic, in the cure of intermittent diseases. They establish their own morbid impression in the absence of the paroxysm; and the system, being thus occupied at the moment when the disease was to return, is incapable of admitting it. In the same way may be explained the effects of blisters, opiates, emetics, or indeed any violent impression from any source, in the cure of paroxysmal diseases, if caused to be in full action at the time of the expected recurrence of the paroxysm. Mental influences are sometimes very powerful in the supersed- ing not only of intermittent diseases, but of continued disease also, when of a merely functional character. The excitement of any strong emotion may have this effect; and the pre-occupation of the nervous system resulting from a strong faith has often exhibited a wonderful influence. The same law holds in cases of purely local disease. It is prob- able that many cutaneous eruptions, and diseases of the mucous membrane of the alimentary canal and urinary passages, yield, upon this principle of supersession, to certain applications made to them directly, or, in the case of urinary diseases, through the route of the circulation. SUBSECTION IX. A Iteration. This name may be given to that operation of medicines by which they change existing morbid actions or states, without any observable effect on the system to which the result could be ascribed. The medicines are usually called alteratives. They may produce their effects by changing the character of the blood, or the condition of the solids. Their precise mode of action is unknown, or at best conjectural. It will be perceived that the employment of the term is merely a convenient mode of classifying certain unin- telligible results, which depend altogether for their acceptance upon the evidence of observation. In certain states of disease we administer certain remedies, without other observable effect than a cure. It is often very difficult, in such cases, to decide whether the result has proceeded from the remedy, or has happened in the ordi- nary course of the disease. It is at least highly probable that a great many medicines have acquired a credit as alteratives, which was due exclusively to nature. Among the most striking illustrations of this operation of medi- 56 APPLICATION OF MEDICINES. [PART I. cines is that of mercury in the cure of inflammation. After due depletion, or when depletion is not indicated, no remedy has so powerful an antiphlogistic influence as mercury, urged to the point of affecting the system. Other examples are offered by iodine in scrofula, sarsaparilla in venereal disease, colchicum in gout, &c. It is apparent that supersession and alteration may often lay claim to the same results. Thus, does mercury cure syphilis and inflammation by the substitution of its own transitory morbid effects for the existing disease, or does it merely alter the morbid into healthy action ? Upon the solution of this question it de- pends, whether the remedy is to be looked upon as a supersedent or an alterative. SUBSECTION X. Anti-causation. I use this term to express that operation of a remedy which consists in the cure of a disease by the removal of its cause. It very often happens that one morbid state depends upon another; and the cure of the latter, by any process Avhatever, results in the cure of the former. This is not, however, the influence to which allusion is here made. To bring any case under the present head, the cause must not itself be a disease, and the remedy removing it must do so by a special agency. Thus, antacids cure headache by neutralizing acid in the stomach, which produces the headache. Anthelmintics cure various disorders, dependent on worms in the bowels, by destroying or expelling the worms. An emetic will cure spasm of the stomach caused by indigestible food by evacu- ating the offending matter, and cathartics often relieve colic on a similar principle. In like manner, an alkaline carbonate will relieve irritation of the urinary passages dependent on the precipi- tation of uric acid, and certain acids the same condition produced by the presence of undissolved phosphates; each operating on the offending cause by neutralizing it, or rendering it soluble. SUBSECTION XI. Chemical Influence. This might, perhaps, be included in some one or more of the processes already referred to. Substances may be employed thera- peutically, in reference to their chemical influence, for three pur- CHAP. III.] APPLICATION OF MEDICINES. 57 poses; first, for the destruction of the tissues, as in the formation of issues, the removal of morbid ulcerated surfaces, &c; secondly, for the neutralization, or other chemical change of substances con- tained within the body, but not forming an essential part of it, as when excess of acid in the primae vias, the blood, or the urine, is obviated by alkalies, or an insoluble metallic combination in the tissues is rendered soluble by the chemical agent administered; and, thirdly, through their reaction with the constituents of the blood or of the tissues, to produce changes in them favourable to the removal of disease. But their influence in all these methods of action may be resolved either into anti-causation, elimination, or alteration ; except in the formation of issues, in which instance the chemical action is not in itself curative, but simply operates by setting on foot certain physiological processes which constitute the real remedy in the case. In relation to the process of alteration, it is highly, probable that, in many instances, it is purely the result of chemical reactions set on foot by the remedy in the interior of the system; but we have little positive knowledge upon the sub- ject, and theoretical speculations can lead to little practical good, except in so far as they may serve as a guide to inquiry and experi- ment. They should not be allowed to serve as the basis of curative methods, until the chemical reactions have been experimentally traced out, and demonstrated beyond reasonable doubt. SUBSECTION XII. Mechanical Influence. This is often very important in the treatment of disease. Upon careful examination, however, of its effects, it will be found in general to act upon some one or more of the principles already considered. The following are the different modes in which this kind of influence can be brought to bear upon disease. Position may be made to favour or counteract, through the agency of gravitation, the entrance of blood into a part. Thus, when fainting is threatened from a want of the due pressure of the blood upon the brain, by placing the patient in a horizontal posture, the pressure is favoured, and the apprehended result prevented. Much more frequently, however, the object is to diminish conges- tion or inflammation in a part, by diminishing the access of blood; and this is accomplished by elevating the part affected above its usual position. Thus, in an inflamed limb, the extremity should be 58 APPLICATION OF MEDICINES. [PART I. raised, instead of being allowed to retain its ordinary dependent position of health. It is clear that the remedy operates, in the latter of these cases, upon the principle of local depletion, and in the former, upon that of local repletion. Compression is another useful mechanical process, which may be made to diminish or increase the quantity of blood in a particular part of the body, and thus to accomplish in some degree the same object as the former remedy. Thus, the access of blood to a part may be lessened or cut off by pressure upon the arterial trunks which supply it; or the capillaries themselves may be emptied by direct and equable pressure made upon them. In the latter mode especially, much good is often done in obstinate inflammation and passive congestion. An accumulation of blood may be produced by pressure upon the veins, and not upon the arteries, as when the tourniquet is applied not very tightly. This process may some- times be useful by abstracting temporarily a quantity of blood from the general circulation, without its ultimate loss. It is a mode of general depletion. Other advantageous effects of com- pression are to promote absorption, and to afford mechanical sup- port to relaxed parts, as in varicose veins of the legs, and to the abdomen after the operation of tapping. Distention sometimes also operates usefully by stimulating a part to increased action; as when large fluid injections are thrown up the bowels. It may, however, be carried so far as to produce paralysis of the muscular fibres, and thus to prevent all contrac- tion. This is an important therapeutical fact. Friction may be considered as a mechanical remedy. It acts partly by compression, partly by stimulation. Employed for the latter effect, it is often a powerful agent in rousing and supporting the system in low disease, and in exciting the part itself when en- feebled ; but it is more frequently and usefully employed for its effect in producing revulsion from within outwardly. The covering of surfaces, so as to protect them against irritating substances, and the contact of the air, is another useful mechanical process. Thus, demulcents protect inflamed mucous surfaces; and collodion, cataplasms, plasters, cerates, and thin layers of gutta percha and caoutchouc, are applied for the same purpose to the skin. It is not improbable that the effect of nitrate of silver and iodine, in subverting superficial inflammation, may be partly owing to a chemical change in the epidermis, rendering it less pervious to the air. How the exclusion of the air proves useful it is not easy CHAP. III.] APPLICATION OF MEDICINES. 59 to determine. Perhaps it may be partly by maintaining the mois- ture which would otherwise be evaporated; perhaps, as suggested by Dr. Latour, by diminishing calorification to which the presence of the air may contribute, if it be not essential. (Archives Gen., 4e sen, xxvii. 237.) SECTION II. Forms in which Medicines are Applied. Medicines are used in the solid, liquid, and aeriform state. In the solid state, they are employed, internally, in the several shapes of powder, electuary, conserve, pill or bolus, and lozenge; and ex- ternally, of cataplasm, ointment, cerate, and plaster. In the liquid state, they are either originally liquid, or rendered so by mixture or solution. In the aeriform state they have the form either of gas or of vapour. For ample details upon each of these forms the reader is referred to the U. S. Dispensatory. It will be sufficient, in this place, to make a few general observations, calculated to facilitate to the learner the study of the practical application of medicines which is to follow. SUBSECTION I. Solid Forms. 1. Powders (pulveres) are medicines finely comminuted by the process of pounding, grinding, levigation, elutriation, precipita- tion, &c. This is a convenient form for the administration of in- soluble substances, not very disagreeable to the taste. It is unsuit- able for deliquescent substances, as carbonate of potassa, and for combinations consisting of ingredients which become liquid or semiliquid by chemical reaction, as is the case when acetate of lead is mixed with sulphate of zinc. Light powders, readily miscible with water, may be given diffused in that liquid, either pure, or rendered more agreeable to the taste by sugar and aromatics. Resinous powders, in order to be diffused, require that the water should be rendered somewhat viscid by saccharine or gummy addi- tions. Heavy powders, as the metallic, are more conveniently ex- hibited in the form of electuary. 2. Electuaries (electuaria) are preparations in which the medi- cine is brought into the condition of a soft solid, and may be con- 60 APPLICATION OF MEDICINES. [PART I. veniently made by mixing powders, extracts, &c, with syrup, molasses, or honey. They are included among the confections in the U. S. Pharmacopoeia. Liquids may be brought into the same form by admixture with sugar and gum. Any medicine may be ex- hibited in this form which is not too bulky, or too offensive to the taste. In forming powders into electuaries, the proportion of the semi-liquid vehicle must vary with the nature of the article used. Thus, dry vegetable powders usually require twice their weight of syrup, gummy and resinous powders an equal weight, and the me- tallic a still smaller proportion. In the last case, it is well to add a small quantity of some conserve; as the tenacity of syrup or honey alone is scarcely sufficient to prevent a separation, by the subsidence of the heavier ingredients. 3. Conserves (conservse) are preparations in which fresh vege- table substances are beat up with sugar, as well for the sake of preservation, as for convenience of administration. They are in- cluded, along with electuaries, under the confections of the U. S. Pharmacopoeia. Very few medicines are exhibited in this way. 4. Pills (pilulse) are small, spherical, solid bodies, of a con- venient size for swallowing. Medicines of which the dose is small, and the taste disagreeable, may be appropriately given in this form; but it is not suitable for deliquescent substances, nor, indeed, for those which are copiously efflorescent, unless previously de- prived of their water of crystallization. Hence, when carbonate of soda or sulphate of iron is given in pill, the dried salt, from which the water of crystallization has been driven off by heat, should be preferred. Care should be taken, in prescribing a substance in this form, that the adjuncts should be such as not to render it too hard, and of difficult solubility in the liquors of the stomach. As a general rule, pills recently made are preferable to the old, as being softer and more soluble; but occasionally, when the object is that the medicine should act very slowly, and consequently that it should be slowly dissolved, old and hard pills may be advantageously ad- ministered. The weight of the pill, if composed of vegetable sub- stances, should not generally exceed three or four grains, if of metallic ingredients, it may be from four to eight grains. It will sometimes be useful, when the ingredients of the pill are very offensive to the smell or taste, to give it a coating of some tasteless material which may be readily dissolved in the stomach. Gelatin answers this purpose very well, and is easily applied. Gold leaf, formerly employed, is objectionable from its insolubility. CHAx. III.] APPLICATION OF MEDICINES. 61 Boluses are preparations similar to pills, but larger, and may be preferably used where the dose is large, and the patient can swallow them without difficulty. Their size is limited only by the patient's capacity of deglutition. 5. Lozenges, or Troches (trochisci), are solid masses of various shape and size, which may be conveniently held in the mouth, and there allowed slowly to dissolve. They are adapted for the adminis- tration of medicines not disagreeable to the taste, or of which the taste can be qualified or covered by agreeable additions. They should be made with materials which, without being wholly insolu- ble, are dissolved slowly by the saliva. Demulcent medicines are often administered in this form; and it is convenient in all cases in which the object is to sustain a slight impression steadily on the interior of the mouth and fauces. 6. Cataplasms, or Poultices (cataplasmata), are intended only for external use. They should be soft and moist, somewhat tenacious, and of such a consistence as to accommodate themselves accurately to the part to which they are applied, without being disposed to spread, or to adhere firmly to the skin. They may be employed solely in reference to the sedative influence of the water they con- tain, or for the purpose of producing the peculiar impression of a medicine either on the surface, or, through the medium of absorp- tion, upon the system. 7. Ointments (unguenta), Cerates (ceratd), and Plasters (emplas- tra) are preparations also intended exclusively for external use. As the terms will be frequently used, the student should have a precise idea of their meaning at the outset. Ointments are soft solids, always containing fatty or oily matter, and capable of being applied by gentle rubbing, or, to use an appropriate phrase, by inunction. Cerates are of a firmer consistence, generally contain wax (cera), from which they derive their name, and are capable of being spread by means of a spatula, at common temperatures, upon suitable dress- ings, in which state they are usually applied. Plasters differ from cerates in possessing a still firmer consistence, requiring heat in order that they may be spread, and, though quite firm and brittle at common temperatures, becoming softish, tenacious, and adhesive at the temperature of the skin. Either of these preparations may be employed exclusively for local effect, or with a view to act upon the system. For the latter purpose, the ointments are preferable when the cuticle remains; as, by the friction with which their appli- cation is often accompanied, they may be foreed between the epi- 62 APPLICATION OF MEDICINES. [PART I. dermic scales, and thus brought more completely within reach of absorption. 8. Extracts (extracta) are rather modes of pharmaceutical pre- paration, than forms for administration. They consist of the active ingredients of complex medicinal substances, extracted by water, alcohol, or acetic acid, or by expressing the juice of plants, and then evaporating to the solid consistence. Some of them are so dry that they may be readily reduced to powder, and given in this state. All of them may be administered in the form of officinal mixture. But the most common method of exhibition is in the form of pill, to which they are often very readily brought, in con- sequence of their soft, somewhat cohesive consistence. SUBSECTION II. Liquid Forms. In the liquid form medicines may be given internally, or ap- plied to the surface. In the former case, if taken in any considera- ble quantity, they receive the name of potion (potio), or draught (haustus); the former being sometimes applied to a quantity of liquid which may be taken in divided doses, the latter exclusively to a single dose. Applied to the surface, they receive the name of lotion (lotio) when thin and watery, and of liniment (linimentum) when of a soft oleaginous consistence, fitted for application by gentle friction with the hand. One of our officinal liniments (Lini- mentum Saponis Camphoratum, U. S.) is of the consistence of a soft solid when cold, but becomes quite liquid at the temperature of the body. Some medicines are essentially liquid, as castor oil, glycerin, &c.; others are brought to the liquid form by admixture and sus- pension, or by solution. The following are forms of officinal liquid preparations. 1. Mixtures (misturse), in the sense of the term as employed in the U. S. Pharmacopoeia, are preparations in which a medicine, insoluble in water, is suspended in that fluid, pure or variously medicated, by means of viscid soluble substances, as gum arabic, sugar, and the yolk of eggs. The term julep embraces both these preparations, and others in which the mixed substances may be dissolved. The form of mixture is one of the most common and convenient for the administration of insoluble medicines. As a general rule, the medicine is so proportioned in the mixture as to render the dose a tablespoonful (fass) for an adult. CHAP. III.] APPLICATION OF MEDICINES. 63 2. Solutions (liquores) are preparations in which the medicine or its active principle is dissolved in water or other menstruum. In relation to medicines which are wholly soluble, the process is ex- tremely simple; and the only rule requiring attention is not to mix, in the same solution, substances which will undergo mutual decomposition, so as to form an insoluble precipitate. But, under the head of solutions may be considered various officinal prepara- tions, in which the soluble and active principles of a medicine are extracted, leaving behind the insoluble and inert. Such are the infusions, decoctions, tinctures, wines, vinegars, syrups, honeys, oxymels, and fluid extracts of the Pharmacopoeias. 3. Infusions (infusd) are aqueous solutions made by treating with water, without boiling, medicines containing principles soluble in water, with others insoluble. They are either cold or hot, the former being prepared with water at ordinary temperatures, the latter with the same liquid previously heated to the boiling point. Hot water acts more rapidly than cold under circumstances other- wise the same, and may, therefore, be preferred when speedy action is desirable. But it is sometimes objectionable in consequence of dissolving starchy matters, which are insoluble in cold water, and the presence of which may render the infusion more liable to speedy change. On the contrary, cold water is liable to the same objec- tion in reference to vegetable albumen, which it dissolves, while hot water coagulates instead of dissolving it. Heat injuriously affects the virtues of certain medicines, and should not, therefore, be employed in preparing them. These considerations should be allowed some weight in the choice between cold and hot infusion. The infusions are most elegantly and efficiently prepared by the process of percolation or displacement. (See U. S. Dispensatory.) 4. Decoctions (decocta) differ from infusions simply in the cir- cumstance that boiling is used in preparing them. They are liable to the same objections as the hot infusions in a still greater degree, but are convenient when haste is requisite, and the active princi- ples of the medicine are not likely to be materially injured by the heat. As the access of atmospheric air, at a high temperature, is liable to act injuriously on various vegetable principles, the process should be performed in a covered vessel, and should not be con- tinued longer than is necessary to the end in view. Hard, tough, fibrous substances are often most conveniently treated in this way; but the process is altogether inapplicable to those medicines whose 1 64 APPLICATION OF MEDICINES. [PART I. activity depends upon a volatile principle, as, for example, upon a volatile oil. 5. Tinctures (tincturse) are alcoholic solutions of medicinal prin- ciples. As, in consequence of the preservative influence of the alcohol, they may generally be kept, in well closed bottles, an inde- finite length of time, they are almost always prepared by the phar- maceutist, and very seldom extemporaneously. It should be re- membered that some of them are prepared with officinal alcohol (sp. gr. .835), and others with diluted alcohol, made by mixing equal measures of the officinal alcohol and water. The former are of course more stimulating than the latter, so far as concerns the menstruum; and this circumstance may be occasionally of practical importance. The officinal tinctures (U. S. Pharmacopoeia) of the pure resins, gum resins, balsams, volatile oils, camphor, aconite root, nux vomica, ginger, castor, and iodine are made with the stronger alcohol; almost all others, including those of the roots, barks, leaves, and fruits of plants, with the diluted. This set of preparations is applicable only when some degree of stimulation is admissible, or when the active principle dissolved in the alcohol is so powerful as to render the amount of the menstruum employed in each dose insignificant, as in the instances of tinctures of aconite root and opium. They are especially adapted as adjuvants to other forms of preparation, when it is desirable to render these somewhat more stimulating. Thus, tincture of Peruvian bark" may, in low forms of disease, be very appropriately added to the infusion or decoction, or to the solution of sulphate of quinia. In relation to the long-continued employment of tinctures, the practitioner should be aware of the danger of establishing a habit of intemperance, and should be on his guard accordingly. The resinous and cam- phorous tinctures become turbid on the addition of water, in conse- quence of the precipitation of the resin or camphor, and should therefore be given with a viscid liquid, as mucilage, syrup, or some- times milk, or, if diluted with water alone, should be taken imme- diately after admixture. 6. Spirits (spiritus) are closely analogous to tinctures, being like them solutions of medicinal principles in alcohol, but differing in being prepared by distillation. Thus an alcoholic solution of oil of peppermint would be called spirit of peppermint if prepared by distilling alcohol either from the oil or the plant;. whereas, when made simply by dissolving the oil in the menstruum, it is denomi- nated in our Pharmacopoeia tincture of oil of peppermint. CHAP. III.] APPLICATION OF MEDICINES. 65 7. Wines (vina) differ from the tinctures simply in being pre- pared with wine as the menstruum, instead of alcohol or diluted alcohol. These are also usually the subjects of officinal preparation. The advantages of wine, in the cases to which it is applicable, are that it is less stimulant than alcohol, while it is more effectual than water in counteracting the tendency of the organic medicinal prin- ciples to decomposition, and, in consequence of the alcohol it con- tains, is sometimes more effective as a solvent. For the purposes of a medicinal solvent, the stronger wines are preferred to the weaker; as the latter are apt to contain principles incompatible with the substance dissolved. Thus, Madeira, sherry, or Teneriffe should be preferred to claret or the Rhine wines. Port wine is seldom proper, on account of the tendency of the tannic acid it contains to form insoluble compounds with other bodies. 8. Vinegars (aceta) are simply infusions made with cold distilled vinegar, or diluted acetic acid. Very few of them are used; and these more in the preparation of other forms of medicine, than for direct administration. Thus, vinegar of squill is much used as an ingredient in the syrup of squill, seldom alone. This class of preparations is based on the fact, that in certain cases acetic acid favours the solvent property of water, while it also has a preserv- ative effect, though in this respect much less efficient than alcohol. 9. Syrups (syrupi) are aqueous solutions of sugar impregnated with medicinal principles. When the term syrup (syrupus) is used singly, it implies, officinally, a simple solution of sugar in water, of a certain recognized strength, which, according to the U.S. Pharma- copoeia, is two and a half pounds of sugar to a pint of water. The medicated syrups are designated by the name of their chief medi- cinal ingredient, as syrup of rhubarb, syrup of ginger, &c. The mode in which the medicinal impregnation is effected varies much with the character of the medicine. The syrups are generally sub- jects of officinal direction, and are kept ready made in the shops. Their advantages are that the sugar serves to cover the disagree- able taste of the medicine, and at the same time prevents its spontaneous decomposition. They are favourite preparations in infantile cases; but, in their use, the physician should bear in mind the frequently injurious effect of much sugar in a feeble stomach. 10. Honeys (mellita) differ from the syrups only in the substi- tution of honey for sugar. They are at present little used; honey, in consequence of its impurities, being inferior to sugar as a pre- servative. vol. I.—5 66 APPLICATION OF MEDICINES. [PART I. 11. Oxymels are preparations in which the menstruum consists of honey and vinegar combined. They are now almost out of use. 12. Fluid Extracts (extracta fluida) are highly concentrated solu- tions of the active constituents of medicines, or the active constitu- ents themselves extracted in the liquid state; and are often very convenient and efficient preparations. They have been introduced into use at a comparatively recent date, and are at present much employed. There are two kinds of them. In one, the active principles of the medicine are extracted by diluted alcohol, sugar is added as a preservative, and to improve the flavour, and the alcohol is afterwards evaporated. These are concentrated aqueous solutions, with a little alcohol remaining. The other kind consist mainly of volatile oil and resinous matter, extracted by ether from the medicine, and subsequently freed from the solvent by evapo- ration. SUBSECTION III. Aeriform State. This may be a state either of gas or vapour. Gases are aeri- form fluids which retain their condition at common temperatures. Vapours are likewise aeriform fluids, but require an elevated tem- perature, under the ordinary degree of atmospheric pressure, to enable them to retain that state, and, upon the diminution of their temperature, become liquid or solid. Both gases and vapours are employed as medicinal agents, the former seldom, the latter very frequently. Gases are used almost exclusively by inhalation; vapours both in this manner, and by application to the external surface of the body. More will be said on this subject hereafter. (See page 76.) SECTION III. Parts to which Medicines are Applied, and Modes of Application. The parts to which medicines are applied, in order to affect the ■system, are chiefly 1. the alimentary canal, 2. the skin, and 3. the bronchial tubes and pulmonary air-cells. When applied to other surfaces, it is generally with a view to local effect. CHAP. III.] APPLICATION OF MEDICINES. 67 SUBSECTION I. Alimentary Canal. Medicines are applied to the two opposite extremities of the ali- mentary canal; to the stomach, namely, and to the rectum. 1. The Stomach. This is the most convenient, generally the most effective, and by far the most frequently employed avenue for medi- cines into the system. To this, as to any other part, they may be applied with the view exclusively to a local effect; but much more frequently the object is to act on the system at large, or on some distant part, for which the stomach affords great facilities, both by the readiness with which absorption takes place from its inner surface, and the sympathies which connect it, beyond any other accessible organ, with all parts of the body. The forms in which medicines are introduced into the stomach have been already re- ferred to. The modes of administering them are in general too obvious to require notice. Two or three remarks, however, upon this point will not be irrelevant. 1. Sometimes patients are coma- tose, and cannot voluntarily swallow medicines. In these cases, there is sometimes danger of the medicine passing into the glottis, and producing embarrassment of respiration. Substances, however, which act in small doses, as croton oil, may be placed .upon the tongue towards its further extremity, where they excite the reflex action of deglutition, and are often swallowed. 2. Children not unfrequently refuse to take medicine into their mouth, and cannot be prevailed on by any persuasion. They can generally be made to swallow, without great difficulty, by taking them in the lap, clos- ing the nostrils so as to compel them to open the mouth, and then introducing the medicine by a teaspoon. 3. In the cases of adults who, from insanity or the purpose of suicide, will not, or from paralysis or insensibility, cannot take medicine, the physician may sometimes be justified, in order to save life, in forcibly injecting it into the stomach by means of the stomach-tube and a syringe. 2. The Rectum. Medicines are employed by the rectum with two distinct objects; one to evacuate the bowels by simply irritating the part, the other to produce their peculiar and characteristic im- pression either on the rectum itself, or, through absorption or sym- pathy, upon other parts, or the whole system. These two objects are often incompatible; and it is necessary, therefore, when the latter effcci is desired, to administer the medicine in such a manner as not 68 APPLICATION OF MEDICINES. [PART I. to produce the former. But, in either case, the patient should be directed to resist the immediate impulse to evacuate the bowels; as, even when the cathartic effect is aimed at, time should be allowed for the action of the medicine to be extended or propagated to the higher portions of the large intestines, which might otherwise not be affected, and the rectum only emptied. Medicines may be ad- * ministered by the rectum either in the liquid or solid form. In the former case, they are called enemata, injections, or clysters, in the latter, suppositories. In either of the forms mentioned, the dose of the medicine, when given in reference to its peculiar effects, may be about three times that given by the mouth. But, when the medicine is very active/ as in the instances of the poisonous alkaloids, it would be a safer course to administer a somewhat smaller dose, and increase after- wards if necessary. There is another important consideration in regard to the relative dose by the stomach and rectum. When an individual has become habituated to very large quantities of the more active medicines by the mouth, as opium, for example, it might be very dangerous to triple the quantity, when administering it per anum. Though, undoubtedly, the loss of susceptibility is mainly in the nervous centres, it is very probable that the stomach experiences the loss in a greater degree than other organs, and that, applied to another part, the medicine might be found to exercise a much greater proportionate influence. It would be best, therefore, in such cases, not only not to triple the dose, but not to increase it at all, and at first even to administer the medicine in much smaller quantity by the rectum than the stomach, until the relative suscepti- bility of the two parts, or the relative facility of absorption from them, shall have been tested by trial. The circumstances under which medicines may be administered by the rectum are the following; 1. when the stomach is unable to retain them, or from any cause they may be thought injurious to that organ; 2. when it is desirable to produce a very rapid or pow- erful impression on the system, and thus to seek an entrance into it by every avenue; 3. when, from the long continuance of the indication for the use of any medicine, it is advisable to vary the surface of application, in order to avoid wearing out the suscepti- bility of the stomach, and thus to prolong the period during which the effects of the medicine may be sustained; 4. when the seat of disease is in parts neighbouring to the rectum, and the disease itself is of such a character as to be relieved by impressions made in its CHAP. III.] APPLICATION OF MEDICINES. 69 vicinity more speedily and effectually than through the system at large, as in painful affections of the urinary and genital organs; and 5. when the indication is to produce the effects of the medicine upon the rectum itself,-as in neuralgia or spasm of that bowel, and chronic inflammation and ulceration of its lining membrane. Medi- cines are also exhibited in this way, in order to weaken or destroy the thread-worm which infests the rectum. Enemata. When intended to evacuate the bowels, the enema should measure for an adult a pint or somewhat less, for a youth of twelve years about half the quantity, for a child one or two years old two fluidounces, and for an infant at birth one fluidounce. Too great a quantity, if used habitually, may injuriously distend the rectum, and diminish its power of contraction. Upon the subject of cathartic enemata more will be said under the head of cathartics. When the object is to obtain any characteristic effect from medi- cines, other than purgation, the bulk should be small, say from one to four fluidounces, and the vehicle very bland, consisting of pure water, or of some mucilaginous or starchy fluid; and, when there is danger of its being rejected, from twenty to forty drops of laud- anum, or an equivalent quantity of some other liquid preparation of opium should be added, in order to control the irritability of the rectum. The most convenient instrument for the administration of ene- mata is on the whole a good metallic syringe, which may vary in capacity, according to the bulk to be thrown up, from a pint to two fluidounces. The old-fashioned pipe and bladder may be resorted to, in the absence of this instrument. The gum-elastic bottle with a tube is still more convenient. Another instrument, sometimes used in France, is a long slender, water-proof, tube-like bag, three or four feet long, two or three inches in diameter at the larger end, and gradually diminishing to the smaller, to which an ivory pipe is attached for insertion into the rectum. When employed, the pipe is introduced, the larger extremity of the bag held up as high as it will extend, and the liquid poured in. This either enters the rectum by its own specific gravity, or may be gently forced in by running the fingers, pressing the bag between them, from the upper gradu- ally down towards the lower end. The self-injecting apparatus, which is a kind of forcing pump, is very useful when an individual wishes to administer an enema to himself, and also when the object is to throw an indefinite quantity of liquid into the bowels, with the 70 APPLICATION OF MEDICINES. [PART I. view of overcoming obstruction. Whatever instrument is em- ployed, the liquid injected, as well as the instrument itself, should be at about the temperature of the interior of the body; and, after the injection, the operator, in cases where there is any disposition to a premature discharge of the liquid, should aid the efforts of the patient to retain it by pressing a warm folded towel against the fundament, until the first irritant effect shall have passed away. Great care should be taken not to wound the mucous membrane by entangling the end of the pipe in its folds, or pressing it against the membrane too strongly. Severe pain is sometimes produced by a neglect of this caution. In relation to the medicine injected, it should, if solid, or a liquid not soluble in, water, be thoroughly and equably incorporated with the liquid vehicle by means of some suspending substance. When an irritating substance, such as oil of turpentine, is injected, the yolk of eggs is an excellent intermedium. Suppositories. Like enemata, these may be' used simply to eva- cuate the bowels by irritating the rectum, or to produce the pecu- liar effect of the medicine employed. For the former purpose, they may be of a cylindrical or oval form, an inch or two in length by about half an inch in diameter, and made of some softish material, like soap. For the latter, they should be used in the pilular form, and as small as is consistent with due effect; the object being that they should irritate as little as possible. Opium is not unfrequently employed in this way. Gaseous Injection. Aeriform substances have sometimes been in- jected into the rectum, though this method of medication is rare. Atmospheric air thrown up largely has been found useful in over- coming obstruction of the bowels; tobacco smoke has been em- ployed to produce relaxation; and carbonic acid gas has been recommended in certain morbid states of the rectum. Electric action may also be developed in the rectum, either by introducing a complete metallic galvanic arrangement in a compact form, or by passing a wire connected with one pole into the bowel, and applying the other at some point on the back or ab- domen. SUBSECTION II. The Skin. Next to the alimentary canal, the skin is most frequently resorted to for the application of medicines. The object may be either to CHAP. III.] APPLICATION OF MEDICINES. 71 affect the system or some unconnected part through absorption, sympathy, depletion, revulsion, &c, or to act exclusively on the skin itself. The modes of application are various, both in relation to the state of the skin and the substance employed. Thus, the skin may remain undisturbed, the medicine being merely brought into contact with it; or the epidermic scales may be disturbed by friction at the time of application; or the epidermis may be re- moved, and the medicine placed upon the denuded cutis. The substance employed may be solid, semiliquid, liquid, or aeriform, and, if solid, may be of different degrees of consistence. 1. Simple Application to the Sound Skin. Of such application we have examples, with reference to solids, in cataplasms, cerates, and plasters; with reference to liquids, in lotions, fomentations, general baths, local baths, the douche, affusion, and sponging; and, with re- ference to aeriform substances, in the hot air bath, the general and local vapour bath, and the vapour douche. Of the different solid forms mentioned, as well as of lotions, enough has been already said. Fomentations or stupes are heated liquids, applied by means of flannels or other cloths saturated with, or wrung out of them. They are usually employed to obtain the effects of water and heat, but sometimes also for the specific effects of medicines, as when the decoction of poppy-heads, or infusion of tobacco is ap-' plied. Baths consist in the direct application of water either pure or medicinally impregnated, more or less extensively to the surface; the general bath being applied to the whole surface, the head per- haps excepted, the semicupium or half bath to the lower half of the body, the coxseluvium or hip-bath to the pelvis and upper part of the thighs, the pediluvium or foot-bath to the feet and legs, and the maniluvium or hand-bath to the hands and forearms. When the water is made to fall upon the body generally from above, in minute currents or streams, as through a colander, the application is called a shower bath; when a single stream of greater or less size is directed upon one part with greater or less force, it is named, from the French, the douche. In all these, the water may be cold, warm, or hot; and we thus have the cold bath, the warm bath, and the hot bath, which are very .different in their effects, and employed for a great diversity of purposes. Of the principles of operation, and of the applications of the different forms of baths, I shall have occasion to treat, at some length, under the different classes of re- medies to which they respectively belong. It is sufficient here to 72 APPLICATION OF MEDICINES. [PART I. state that the bath, when below 75°, may be called a cold bath; when between 85° and 98°, a warm bath, and from 98° to 112°, a hot bath. Some make a distinction between the tepid and warm baths, the former being of a somewhat lower temperature than the latter. The douche acts not only by the temperature of the water, but also by the shock and pressure, consequent upon the force with which the liquid falls. A\rhen continued long, or from a considera- ble height, say ten or twelve feet, it becomes after a time extremely painful, so as to be quite intolerable; and, on this account, has been employed as an instrument of fear or punishment to criminals and maniacs. So far as it acts mechanically, it is primarily excitant, and secondarily depressing. Affusion consists in the pouring of water, at various temperatures, from pitchers, buckets, &c, more or less extensively over the body. It differs from the douche in being more diffused, and in falling with less force upon the surface. It has been highly recommended in certain febrile and inflammatory diseases, but requires caution in its use, of which more will be said hereafter. Sponging is a term sufficiently expressive without definition. It may be employed locally or generally, with water, spirit, or other liquid, at different temperatures. It is often extremely useful. Heated atmospheric air has been employed as a remedial agent, in the form of a warm or hot air bath. When the object is that the patient shall breathe the heated air, as well as experience its effects externally, it may be most conveniently accomplished by simply placing him naked in a confined apartment, raised by the introduc- tion of hot air to the required temperature, which may vary from 90° to 150°. More frequently the application is made to the ex- ternal surface alone, while the patient is allowed to breathe air at ordinary temperatures. This may be done by inclosing the body in a cell, box, or closet of suitable dimensions, so arranged that the head shall project through an opening, which is accurately closed around the neck, while the confined air is heated by any conve- nient plan. An extemporaneous bath of this kind may be pre- pared, by supporting the bed-coverings, over the patient in bed, upon two or three pairs of crossed half hoops, so as to form a vacant space around him; and then either introducing heated air, by means of a tube, from some exterior source, or heating that around the patient by hot bricks, bottles filled with hot water, or bags filled with heated salt, oats, or other suitable material. Medicated hot air baths may be applied, in the same way, by im- CHAP. III.] APPLICATION OF MEDICINES. 73 pregnating the air with gaseous bodies, as chlorine and sulphurous acid, or with the vapours of volatile solids, as cinnabar, iodine, &c. The vapour bath, like the hot air bath, may be so employed that the patient shall or shall not breathe the vapour. In the former case, the heating effect upon the body is greater from a certain temperature of the bath than in the latter; for the natural refrige- rating effect of the pulmonary exhalation is prevented. The bath is much more frequently employed in reference to the external surface alone. Various modes of obtaining the effects of the vapour bath have been practised. One of the most simple is to make a space around the patient in bed, by elevating the coverings by means of crossed half hoops, in the manner above mentioned, and tucking them well in at the sides of the bed or mattrass, and then to introduce into this space bricks previously heated, immersed in water, and covered with flannel, taking care that they do not touch the body of the patient. The vapour from the heated bricks soon fills the empty space. Another mode of introducing vapour is by means of Jennings' apparatus, which consists of a tin tube, much broader at one extremity than the other, curved so that the smaller end may be inserted into the space around the patient, while the larger end may be supported on a stool without the bed. A lighted spirit lamp is placed within the broad end of the tube, at the side of which an opening is left for the entrance of air. As the spirit burns, a current of heated air, with the aqueous vapour and carbonic aid resulting from the combustion, passes through the tube, and envelopes the body. A different mode of accomplishing the same end, is to seat the patient on a stool or in a chair, placed either over or in a tub or bucket containing hot water, and then by blankets descending from his shoulders to the floor, to enclose together his body and the whole apparatus. The heat of the water may be increased by introducing into the tub or bucket heated bricks, as they may be required. Caution, however, is requisite not to scald the patient. A case occurred in Philadel- phia, under the care of an empiric, in which a child, subjected to a vapour bath of this kind, was scalded to death. Where convenience permits, a better vapour bath may be arranged, by making a frame of wood-work, and covering this with cloth impervious to vapour, so as to enclose a space within which the patient may conveniently sit upon a stool or chair, while the vapour is introduced into the lower part of the enclosure, by means of a tube proceeding from a kettle of boiling water. The 74 APPLICATION OF MEDICINES. [PART I. heat of the vapour may vary from 100° to 150°; and has been increased with impunity beyond this latter temperature ; but it is better, in this respect, to err on the side of caution. Medicated vapour baths may be formed by introducing volatile substances into the water evaporated, so that their vapour may rise with that of the water. The vapour douche is a stream of vapour directed with some force upon a particular part of the body. 2. Application with Friction. The friction here alluded to is em- ployed not to excite the surface, but, by deranging the epidermic scales, to force an entrance for medicinal substances to the absorb- ent tissues beneath. It is made by the hand protected by a leather glove, or by means of a piece of flannel, or of coarse linen. Sub- stances applied in this way are most frequently in the unctuous form, as in the case of the mercurial and iodine ointments ; but olea- ginous, aqueous, and spirituous medicines and solutions are also not unfrequently used. The medicine employed, if insoluble, should be brought to the finest possible state of division. The parts usually selected for the application are those in which the cuticle is most delicate, as the inside of the upper and lower limbs, especially the inner surface of the thighs; but reference should be had to the special object in view; and, when a particular organ or part is to be acted on, or a tumour to be dispersed, it is usually deemed best to apply the medicine as nearly as may be over the seat of disease. In affections of the absorbent glands, the portion of sur- face from which lymphatics run through the diseased glands should be preferred. This mode of using medicines is uncertain in its results, and, in consequence of the irritation produced in the skin, is often incon- venient. But it may be resorted to in aid of internal medication, or when from circumstances this cannot be employed; and it is often very efficient in the cure of local affections, as of neuralgic pains, for example, and tumefactions of various kinds. 3. The Endermic Method of Application. In this mode of employ- ing medicines, the epidermis is first removed, and the medicine then applied to the denuded surface. It is by far the most efficient external method. Medicines are rapidly absorbed; and produce their effects in some instances as quickly as when taken by the mouth, or even more so. In cases of great irritability or phlo- gosis of the stomach, and when the patient cannot or will not take medicines by the mouth, it is an invaluable resource. Other in- CHAP. III.] APPLICATION OF MEDICINES. 75 dications for its use are afforded by insusceptibility of the stomach arising from a long continued or excessive employment of the medicine, the necessity in urgent cases of introducing medicines by every practicable avenue, and the existence of serious local affec- tions, which have refused to yield to remedies addressed to the constitution. The last indication is often very agreeably fulfilled by endermic medication. I have known, for example, vomiting which had resisted all other means, yield to a salt of morphia sprinkled upon a blistered surface in the epigastrium. This method of medication had long been partially employed, as exemplified in the frequent application of mercurial ointment to blistered surfaces; but it was first systematized by Dr. A. Lembert, of France, whose experiments were repeated and extended by Dr. Gerhard, of Philadelphia, by whose essay on the subject the attention of the profession in this country was first extensively called to it, as a useful mode of employing a great number of medicines. (V. Am. Med. and Surg. Journ., ix. 392, A. D. 1830.) Almost all medicines, the dose of which is not very large, or which do not irritate severely, or corrode the surface to which they are applied, may be employed in this way; but it is especially appropriate to the organic alkalies, and to the other more active proximate vegetable principles. Per- haps no medicine acts more efficiently by the endermic plan than the salts of morphia. The dose of medicines administered in this way may be twice or thrice that given by the mouth. There is less danger here from an over-dose; as what remains of the offending material may be readily removed, should serious consequences be threatened. Some- times the medicine will be found to act as efficiently as by the stomach in the, same dose. The part best adapted for the application of the medicine, when some local affection does not call for a special direction, is the epi- gastrium ; but any portion of the anterior surface of the body, or the inner surface of the thighs and arms will answer well. A denuded surface for the purpose is most conveniently obtained by means of a blister of cantharides; though, in cases of great urgency, the more rapid action of the stronger solution of ammonia may be resorted to. Upon the average, the blistered surface may be about three or four inches square. It is not necessary to detach the cuticle immediately. The medicine may be first applied over the raised epidermis, which, if cut freely, will come off with the first dressing. 76 APPLICATION OF MEDICINES. [PART I. The medicine should be reduced to the state of a very fine powder, and, if irritant, should be diluted with pulverized gum Arabic, or other bland substance, and then sprinkled equably over the surface, or applied upon dressings of simple cerate. If so soft that it cannot be powdered, it may be rubbed up with solutions of gelatin, mucilage, lard, or cerate, and applied upon pledgets of lint; and substances originally liquid may be applied in the same way. Care should be taken to avoid irritation as far as possible. Active congestion and inflammation, independently of the pain and inconvenience, interfere with the operation of the medicine by offering an impediment to absorption. Sometimes sloughing re- sults from the incautious use of an irritant medicine, and a per- manent scar is left. I have known this to follow the application of sulphate of quinia undiluted. In cases of excessive constitutional action from the medicine, it may sometimes be advantageously followed, after removal, by a counter-agent. Thus, unpleasant symptoms from strychnia or digitalis, might possibly be relieved by morphia applied to the blistered surface; and the effects of morphia are said to have been neutralized by musk. SUBSECTION III. The Lungs. The bronchial mucous membrane, and the surface of the pul- monary air-cells, afford not unfrequently a ready entrance of medi- cines into the system, in consequence of the great facility of absorption through their delicate tissue. Indeed, some volatile medicines act much more rapidly and powerfully in this way than when taken into the stomach. The effects, for example, of ether and chloroform are familiar to every one. But the practical use of this avenue into the system is very much limited by the inconvenience, and even danger, of administering most medicines in that way. Some, it is true, have proposed to throw fine medi- cinal powders into the lungs by loading with them the respired air; but when the hazard is considered of exciting inflammation by such means in this delicate tissue, it must I think be admitted to outweigh any probable advantages. The substances to which this method is applicable are gases and vapours. Of these, some have been employed to act locally on the bronchial passages, as chlorine gas, the vapours of tar and iodine, and the fumes of burn- CHAP. III.] APPLICATION OF MEDICINES. i I ing rosin in chronic bronchitis, and ethereal vapour, the smoke of stramonium and tobacco, and the gas evolved by the burning of paper impregnated with nitre, in the asthmatic paroxysm. At present, however, attention is much more than formerly directed to constitutional impression; and various volatile substances have been employed for their exhilarating or anaesthetic effect. Aque- ous vapour has been long and much employed by inhalation. Inhalation may be effected in various ways. One of the simplest is to impregnate the air of the apartment in which the patient is confined with the gas or vapour. In this way a steady effect may be sustained, for a great length of time, by proper attention to the degree of impregnation, so as not to oppress the breathing. Even when the patient is not confined to the house during the day, much advantage will often accrue from medicating the air of his sleeping chamber. Chlorine and the vapour of tar may be thus administered; and I have witnessed the happiest effects from the latter remedy, continued for months, in very threatening chronic pulmonary disease. A convenient method, in the case of tar and other liquids but moderately volatilizable, is to employ a common tin apparatus called the nurse-lamp, in which a cup, containing the material to be evaporated, is placed in a small water-bath over a spirit lamp. Another mode, applicable to very volatile liquids, such as ether- and chloroform, intended for temporary use, is to place them upon a large sponge, or piece of linen cloth, a handkerchief or towel for example, and apply this, fully charged, over the mouth and nostrils, so that the patient may inhale their vapour along with the atmo- spheric air. Sometimes the saturated sponge is enclosed in an apparatus, so arranged that all the vapour which escapes from the liquid shall be inhaled, and thus unnecessary loss be prevented, while a due supply of atmospheric air is insured. In the exhibi- tion of the narcotic vapours, it is of the utmost importance, in order that the most serious consequences be avoided, to attend strictly to this latter caution. The patient, rendered more or less unconscious by the medicine, is not sensible of the want of air, and does not, therefore, give warning to the operators of his danger, as he would do under other circumstances. There can be little doubt, that death has sometimes resulted from an insufficient supply of atmospheric air, in this method of using anaesthetic agents. The pure gases, and the vapours of very volatile substances, such as ether, may also be inhaled by means of an air-tight bag, supplied 78 APPLICATION OF MEDICINES. [PART I. with a mouth-piece and stop-cock, so as to regulate the escape of the confined gas or vapour. The patient is made to breathe into and out of the bag; but it is obvious that, unless there be a large admixture of atmospheric air or oxygen, life could be sustained but a very short time during such a process, which, therefore, should be of short continuance, and always carefully watched. The vapour of water, pure or impregnated with various volatile matters, may be inhaled by means of an instrument called the inhaler. Mudge's inhaler, which has been much used for this pur- pose, consists of a pewter quart mug, with a metallic removable covering, in which is a small opening to admit the air, and another larger one to which a flexible tube with a mouth-piece is affixed. Water, alone or variously impregnated, is introduced into the in- strument, which may then be placed in a vessel containing water, heated to whatever point may be necessary sufficiently to vola- tilize the confined liquid, the vapours of which are inhaled by the patient, along with the air admitted through the small opening. A better apparatus for the same purpose may be made from a Wolfe's bottle, with three tubulures at top, into one of which is fitted a flexible tube with a mouth-piece, into a second a glass tube extend- ing from the air without to a point beneath the surface of the liquid in the bottle, and into the third a glass stopper, to be removed when there is occasion to pour liquid into the bottle. It is obvious that, when the patient inspires, the air from without must pass through the liquid, and thus become more thoroughly loaded with the vapour than it would be likely to be in Mudge's inhaler. An extemporaneous inhaler may be made, as formerly suggested by Dr. Physick, by fitting a cork into any broad mouthed common bottle, making three openings through the cork, and supplying these with tubes in the manner mentioned in reference to the Wolfe's bottle, only that the breathing tube may be straight, and, if glass is not at hand, common pipe stems, or pieces of goose's quill, lengthened sufficiently by insertion into one another, may be substituted. As in the Mudge's inhaler, a proper temperature of the contained liquid may be maintained, if necessary, by setting the bottle in a water-bath. Finally, certain fumes and vapours may be inhaled through a common smoking pipe, as those of stramonium and camphor for example, the former being set on fire in the bulb, the latter volatil- ized in the same position by the current of air passing through it. CHAP. III.] APPLICATION OF MEDICINES. 79 SUBSECTION IV. Other Surfaces of Application. There is no surface attainable from without, to which medicinal applications have not been made, with reference to a curative in- fluence on the surface itself. The conjunctiva, the nasal duct, the nostrils and various cavities communicating with them, the mouth and fauces, the pharynx and oesophagus, the internal auditory mea- tus, the Eustachian tube, the urethra and bladder, the vagina and uterus, have all been the seats of such applications. Particular names have been given to certain medicines thus employed. Thus, liquid applications to the eye are called collyria or eye-waters ; sub- stances applied to the nostrils, errhines and sternutatories ; liquids to the fauces, gargarismata, collutorea, or gargles ; solid bodies intended to be chewed, masticatories; and those applied to the urino-genital passages, if liquids, simply injections. Of all these surfaces, those of the nostrils and mouth are the only ones to which medicines are applied in reference to any other than a local effect. In consequence of the strong sympathies of the nasal passages with the brain, errhines and sternutatories are not unfrequently employed to rouse the nervous centres, and some- times also to agitate the respiratory organs by the act of sneezing. Both to the Schneiderian and buccal mucous membrane, medicines are occasionally applied with a view to their revulsive impression, and to the latter occasionally in order to affect the system, as for example by rubbing the medicine upon the gums. It must be con- fessed, however, that this latter method cannot be looked on as peculiarly efficient; and it is probable that, when any considerable effect has been experienced, it has been the result rather of the portion of the medicine swallowed, than of that absorbed from the mucous membrane of the mouth. Even to the serous membranes, applications are sometimes made with a view to some alterative effect on these tissues. Thus, injec- tions are thrown into the tunica vaginalis for the cure of hydrocele; and attempts have been successfully made, in a few instances, to cure dropsy by stimulant liquids thrown into the cavities of the pleura and peritoneum; but this practice is too hazardous for gene- ral adoption. Blood-vessels. Many medicines, when injected into the veins, produce the same effects as when taken into the stomach, but gene- 80 APPLICATION OF MEDICINES. [PART I. rally operate more powerfully. Hence it was long since proposed to administer medicines in this way; and the method has been frequently tried. In some instances it has appeared to do -good; but the general experience of its results has by no means been such as to counterbalance its obvious disadvantages; and it is only under the most urgent circumstances, and in cases otherwise desperate, that it would, in my estimation, be justifiable. When medicines are absorbed into the circulation, they frequently undergo preliminary changes which probably better adapt them for admixture with the blood. Being taken up gradually, they enter the circulation in extremely minute quantities at one time, so that the whole blood becomes equably impregnated, and the least possi- ble shock is produced either on the blood, the vessels, or the system. When injected into the veins, it is impossible to introduce them thus gradually and cautiously, and, if the attempt were made, the time consumed would greatly aggravate the danger of the ope- ration. The blood, therefore, at the point of injection becomes too strongly impregnated, and must produce on the tissues more than the desired effect, while it is scarcely possible to calculate what in- jurious influence maybe exercised on its own qualities or constitu- tion. We are too little acquainted with the chemical and vital reactions which take place, under such circumstances, to be able to infer a priori what results would ensue; and experiments have not yet been sufficiently numerous and varied to supply this deficiency. The most violent effects have sometimes been produced by sub- stances which, in other modes of application, are quite bland and innocuous. Besides, there are the dangers of injecting air into the veins along with the medicine, and of giving rise to phlebitis by the injury of the vein. Inoculation has recently been proposed as another and safer me- thod of introducing medicines into the blood-vessels; but I cannot conceive of any advantage it possesses over the endermic method, while it is liable to the great disadvantage that the medicine, to produce any effect on the system, must enter the blood in a highly concentrated state, and thus endanger too strong a local impression. CHAP. IV.] CLASSIFICATION OF MEDICINES. 81 CHAPTER IV. Classification of Medicines. The use of classification is to facilitate the work both of the author or teacher, and of the student. To the former it is highly advantageous by affording him the opportunity of presenting, in one view, and in a comparatively few words, all the common pro- perties and uses of any number of bodies; so that, in the subsequent description of these bodies severally, he may omit whatever is not peculiar to each, and thus spare himself a vast amount of repetition. To the latter it is almost essential; as, by fixing in his mind the properties of classes, and thus serving to recal these properties in relation to any individual, upon the recollection simply that it belongs to the class, it aids his memory beyond all other con- trivance, and enables him to gather and retain an amount of know- ledge, which would be quite unattainable were he to study each object in an isolated state. The only kind of works in which classi- fication is unnecessary are those intended, not for continuous study, but for occasional reference, when information is desired upon some particular name or object, such as dictionaries, encyclopedias, and, to a certain extent, dispensatories, in all of which an alphabetical arrangement is most convenient. The advantages and even necessity of classification being ad- mitted, the next point for consideration is the plan to be adopted. Now it may be asserted, without fear of contradiction, that no plan is faultless. Every mode of classification which has been proposed in relation to remedies has its disadvantages; and it is therefore, no valid objection to any particular one which may be suggested that it is not perfect. That one, it appears to me, is the best, which best promotes the great object of all classi- fication ; the facilitating, namely, of the acquisition of knowledge. As different kinds of knowledge are required of the same bodies by different sets of students, it follows that the classification should be different also; for, to be productive of the most good, it must be VI)L. i.—6 82 CLASSIFICATION OF MEDICINES. [PART I. based upon the relation of the bodies to one another in those pro- perties which are the special object of study. Thus, in reference to medicines, the intention may be to study them as objects either of natural history, or pharmaceutical management, or of therapeutic use; and they should be arranged accordingly. Their classification, therefore, should be based, for the general student, upon their geo- logical, botanical, or mineralogical relations; for the pharmaceutist, either upon their chemical properties, or their resemblance in modes of preparation; for the therapeutist, undoubtedly upon their effects on the system, through which they become applicable to the cure of disease. It is in the last mentioned capacity that they are im- portant to the physician, and in this especially he should be taught, from the earliest period of his studies, to regard them. As, there- fore, the present work is devoted more especially to the therapeutic consideration of medicines, I have, without hesitation, adopted a system of classification, founded upon their relations to one another in their modes of affecting the human system. The question now occurs, admitting the effects of medicines to afford the true basis of classification, whether it is their physiologi- cal or therapeutical effects to which we should have recourse. At the first glance it might be supposed that the latter should be pre- ferred. But a little consideration will decide against them. For- merly, when the notion prevailed that there were specific remedies for particular diseases, or classes of disease, an arrangement of medicines based on this principle was to a certain extent naturally adopted. Hence the terms antiphlogistics, febrifuges, antispasmodics, antiscorbutics, antisyphilitics, antilithics, &c. But the fact is, that there is no specific, strictly speaking; that is, there is no remedy which is especially adapted to one disease, and one only, and no curable disease which will yield only to one remedy; and, in rela- tion to classes of disease, such as inflammations, fevers, and spas- modic affections, there is no one which does not require, in differ- ent stages, and under different circumstances, the same medicines which are found useful in the others; so that classes founded on this basis, would be constantly clashing, each containing the individuals embraced by the others; and thus, all the advantages of classifica- tion would be lost. For example, in the treatment of the three sets of diseases above mentioned, in one or another of their stages or varieties, we employ bleeding, cathartics, emetics, narcotics, tonics, stimulants, revulsives, &c. The physiological effects must, therefore, be resorted to; and, happily, it will be found that, to one • CHAP. IV.] CLASSIFICATION OF MEDICINES. 83 well acquainted with pathology, these very effects, and consequently the medicines producing them, are suggested by the therapeutic indications. It will be perceived that, in the following plan, all the old classes founded on the therapeutic basis, as antispasmodics and antilithics, have been abandoned, and, except in the instances of the antacids, and anthelmintics, in which the remedy does not act on the system itself, but on extraneous matters accidentally con- tained within it, and operating as causes of disease, all the classes have a purely physiological relation. I wish it to be specially noticed that, in distributing remedies in the following classes, I am fully aware that the members of one class often possess properties which characterize another; and that, in deciding in which to place them, I have been in many instances influenced by their practical use, giving them a position in accordance with those properties which, if not always most striking, are those which constitute their chief value as medicines, or at least for which they are most employed. Plan of Classification. Remedies are divided primarily into those which operate upon the system, and those upon extraneous bodies accidentally con- tained within the system. The former division embraces the great body of remedies; the latter includes only two small classes, which are retained for the sake of practical convenience; as it is desirable that the physician should have the medicines belonging to them associated together in his memory. I. SYSTEMIC REMEDIES. Some remedies extend their action throughout the whole living system; others, operating upon one or more of those functions, as the circulatory and nervous, which pervade the body, are appa- rently felt in all parts of it, though not strictly universal in their direct influence. All these may be denominated general remedies. Another large division act specially on some one part or organ, or, if they affect the general system, do so only indirectly or second- arily. These may be called local remedies; and thus we have the basis of the first subdivision. 84 CLASSIFICATION OF MEDICINES. [PART I. I. GENERAL REMEDIES. The general remedies are necessarily, as before stated, either stimulant, sedative, or alterative; that is, either elevate, depress, or alter the systemic actions. These three sets constitute the second subdivision. 1. General Stimulants. If the operation of stimulant substances be closely observed, it will be noticed that, while some are slow, moderate, and lasting, others are, on the contrary, quick, energetic, and proportionably brief in their action ; though the two sets run together by almost insensible gradations. This difference of operation was made by Dr. Murray, of Edinburgh, the basis of a division of the general stimulants into two distinct sets, which he named respectively per- manent and diffusible stimulants. Though these terms are neither of them very accurately expressive of the distinctive characters of the two divisions; yet it may not be easy to find better, and it is advisable not to adopt new names unless upon some real ground of preference. I have, therefore, admitted this division with the no- menclature. 1. Permanent Stimulants. There is a very striking distinction between the permanent stimulants; one section confining their direct influence to the vital function of organic contractility, the other operating upon the vital functions generally. The first division is very appropriately denominated astringents, the second less appropriately tonics. They constitute two of the ultimate classes of remedies. 1. Astringents are medicines which produce contraction of the living tissues. 2. Tonics are characterized by their general stimulating influ- ence over the functions, operating slowly, moderately, and some- what durably, either directly through the circulation, or secondarily through the digestive function. 2. Diffusible Stimulants. Some of these appear to be universal, such as heat and electricity; but the greater portion, and perhaps all which come strictly under CHAP. IV.] CLASSIFICATION OF MEDICINES. 85 the denomination of medicines, exhibit a special tendency to one or the other of the two great pervading systems or apparatuses of the body, the circulatory, namely, and the nervous. As those which have a tendency to the circulation operate directly rather upon the arterial than the venous side of it, I name them arterial stimulants. Those acting specially on the nervous system may be called cerebro- spinal stimulants. 1. Arterial Stimulants are scarcely susceptible of further profitable subdivision, and therefore constitute one of the ultimate classes. They are characterized especially by their property of in- creasing the action of the heart and arteries, and, along with this effect, and probably consequent upon it, of causing an elevation of the animal temperature. 2. Cerebro-spinal Stimulants. I do not wish, by the use of this term, to intimate that the remedies so called act exclusively on the brain and spinal marrow; they may possibly, and probably do, in some instances, affect the ganglionic system, and, indeed, the whole nervous substance wherever they may meet with it. There is a marked difference between the members of this subdivision. Whilst some appear to operate equably upon the whole nervous system of relation, showing no special influence over the proper cerebral functions; others act with great energy on the brain, as evinced by their power of deranging sensation, voluntary motion, consciousness, and the various intellectual and emotional functions. The former I denominate nervous stimulants, the latter cerebral stimu- lants. Besides these two sets of cerebro-spinal stimulants, there is at least one medicine which acts especially and powerfully on the spinal marrow, and for which a distinct class may be formed under the name of spinal stimulants. These three are all ultimate classes. a. Nervous Stimulants, characterized by a special but equable influence over the nervous system, generally stimulate in some decree, though not necessarily, the circulation also. They are sometimes called nervines, and not unfrequently antispasmodics. b. Cerebral Stimulants, with more or less influence on the circu- lation, and sometimes a powerful influence, are peculiarly charac- terized by their control over the special cerebral functions. They are equivalent to the stimulant narcotics of other writers, and em- brace some of the most energetic articles of the materia medica, such as alcohol and opium. c. Spinal Stimulants act specially, so far as their operation is known, on the reflex motor function. 86 classification of medicines. [part I. 2. General Sedatives. These are remedies which directly depress the vital functions. While a few operate universally, as cold and water, most of them, like the corresponding stimulants, act especially or exclusively on one of the two great systems, the circulatory, namely, and the nerv- ous; some .prominently affecting the former, and therefore denomi- nated arterial sedatives, others the latter, and named cerebro-nervous sedatives. 1. Arterial Sedatives constitute one of the ultimate classes. They act mainly, if not exclusively, in their primary influence, upon the heart and arteries, without any direct effect on the cere- bro-spinal functions. As, among the results of the circulatory depression, is a reduction also of the temperature, they are fre- quently called refrigerants. 2. Cerebro-spinal Sedatives. These may be advantageously divided, like the corresponding subdivision of stimulants, into the nervous and cerebral, which form ultimate classes. a. Nervous Sedatives are such as reduce generally the nervous functions, without any special reference to the brain. They uni- formly, either by a conjoint primary action, or secondarily through their influence on the nerves, reduce the force of the circulation also. They are usually designated as sedative narcotics. b. Cerebral Sedatives are remedies which, while they depress the circulation either primarily or secondarily, exert a special and marked influence, of a sedative character, on the cerebral functions. Like the preceding class, they would rank with the medicines usually known as sedative narcotics. 3. General Alteratives. These are remedies which insensibly change the functions or organization, without any necessary elevation or depression of the vital actions, and the influence of which is mainly recognized by their effects in disease. They may be stimulant or sedative, and they may produce various local effects which would rank them in other classes; but it is not through these that the special curative effects are produced, which entitle them to the name by which they are distinguished. Knowing so little of their mode of action, we are not possessed of grounds for subdividing them, and they there- fore rank with the ultimate classes. CHAP. IV.] CLASSIFICATION OF MEDICINES. 87 II. LOCAL REMEDIES. I do not include in this class, in reference at least to their pecu- liar and characteristic properties, the general remedies which may sometimes be made to act locally by confining them to a particular part; as opium, for example, and belladonna, both of which are sometimes applied to the surface, with the view of affecting exclu- sively the neighbourhood of their application. The division in- cludes only remedies which either have a special direction to some particular organ or part of the body, to whatever portion of it they may be applied, or which, if possessed of general powers, are em- ployed locally for some effect different from the general; as when potassa, for instance, is used as an escharotic, cantharides for blis- tering, and mustard as a rubefacient, which effects are not incident to their internal use as medicines. With a very few exceptions, all the local remedies are more or less stimulant; and the possession, therefore, of this property, or that of depression, does not constitute a sufficient ground of dis- tinction between them. Consequently, some other basis of classifica- tion must be sought for; and it has appeared to me that they might be most conveniently arranged, according as they are employed to affect the functions, or to change the organization, or to act merely as mechanical agents. 1. Local Remedies acting on the Functions. The subdivisions of these are all ultimate classes of medicines, and are as follows; 1. Emetics, which operate on the stomach, producing vomiting; 2. Cathartics, which operate on the bowels, producing their evacuation downward; 3. Diuretics, which act on the kidneys, increasing the secretion of urine; 4. Diaphoretics, which act on the skin, causing perspiration; 5. Expectorants, which act on the lungs, causing expectoration; 6. Cholagogues, which act on the liver, increasing the secretion of bile; 7. Emmenagogues, which act on the uterus, exciting, increasing, or restoring the menses; 8. Uterine motor-stimulants, which favour uterine contraction; 88 classification of medicines. [part I. 9. SlALAGOGUES, which increase the secretion of saliva; and 10. Errhines or Sternutatories, which operate on the nostrils, causing an increased secretion, and sneezing. 2. Local Remedies affecting the Organization. The subdivisions of these are also ultimate classes, and are as follows; 1. Rubefacients, inflaming the skin; 2. Epispastics, producing blisters; and 3. Escharotics, destroying the life of the part, and producing a slough. 3. Local Remedies acting MechanicaUy. These include, besides the various measures enumerated under the head of "Mechanical Influence" (page 57), the following classes of medicines; 1. Demulcents, bland viscid liquids, which cover surfaces and protect them from irritation, or mingled with acrid substances ob- tund their acrimony; 2. Emollients, which soften and relax; 3. Diluents, which dilute the fluids of the body; and 4. Protectives, which operate by covering the surface, and pre- venting the contact of the air. II. NON-SYSTEMIC REMEDIES. These are remedies acting on bodies foreign to the system, but within it. They embrace the two ultimate classes of 1. Antacids, which neutralize acid in the stomach or elsewhere in the system; and 2. Anthelmintics, which favour the expulsion of worms from the bowels. The following is a tabular view of the foregoing classification. CHAP. IV.] CLASSIFICATION OF MEDICINES. 89 Systemic Remedies. General remedies. Stimulants. Permanent stimulants. Astringents. Tonics. Diffusible stimulants. Arterial stimulants. Cerebro-nervous stimulants. Nervous stimulants. Cerebral stimulants. Spinal stimulants. Sedatives. Arterial sedatives. Cerebro-nervous sedatives. Nervous sedatives. Cerebral sedatives. Alteratives. Local remedies. Affecting the functions. Emetics. Cathartics. Diuretics. Diaphoretics. Expectorants. Cholagogues. Emmenagogues. Uterine motor-stimulants. Sialagogues. Errhines. Affecting the organization. Rubefacients. Epispastics. Escharotics. Operating mechanically. Demulcents. Emollients. ■Diluents. Protectives. Non-systemic Remedies. Antacids. Anthelmintics. 90 CLASSIFICATION OF MEDICINES. [PART I. The plan of arrangement here presented does not claim to be perfect. It is, however, in the best judgment of the author, as little objectionable as any that has been proposed, and perhaps as nearly perfect as the present state of our knowledge on the subject permits. It is but partially original. In forming it, the author has preferred adopting what seemed to him best in preceding sys- tems of classification, and modifying where modification was called for by the progress of knowledge, to any presumptuous attempt to supersede, by crude novelties of his own, plans which have in their favour the matured observation of ages, and the judgment of the soundest thinkers of past times. The present plan is a classifi- cation of results, of facts well known and generally admitted, which must remain true whatever changes the progress of discovery may hereafter make in our views of the operation of remedies. It does not profess to explain the modes in which the results are produced. For a classification upon this principle we are not yet prepared. Our knowledge of the precise modes in which medi- cines act is yet too uncertain to admit of any system of arrange- ment, founded upon their resemblance in this respect; and it may be confidently predicted that any such system will prove unstable, as it must rest upon a fluctuating basis. The attention of the reader is particularly requested to a few considerations, which are necessary to a proper understanding of the scope of the present arrangement. I have said that the classi- fication is not perfect. In the first place, the remedies attached to the several classes, while they agree in the possession of the particular property which characterizes the class, often differ very much in other respects, and in some instances are applicable to very different purposes. The rule which I have adopted is to classify them, as far as possible, according to their most distinctive property, or that for which they are most valuable therapeutically, and then, in the description of each remedy, to refer to all its other remedial properties and applications, so that its individual character may be well understood. In many instances, the operation of the remedy is altogether peculiar, except in the single point in which it conforms with the other individuals of its class. Thus, while the salts of lead are astringent, they are in every other respect quite specific in their manner of affecting the system. Again, it not unfrequently happens that a remedy belonging to one class, has additional powers, which serve to rank it in another. In such cases, the remedy is considered in both classes; being CHAP. IV.] CLASSIFICATION OF MEDICINES. 91 treated of at large in that with which its most important therapeutic character would rank it, and in the other only so far as may con- cern its categorical position. Thus, digitalis is a powerful nervous sedative, and is more strongly characterized, and probably more used as such than in any other capacity; but it is also a very efficient diuretic. It is, therefore, treated of in general, among the nervous sedatives; while, among the diuretics, it is again referred to, but only in relation to the property which attaches it to that class. Indeed, there are some remedies which, in this manner, may be ranked in several classes; as the antimonials, for example, which, while they are chiefly arterial sedatives, belong also to the emetics, diaphoretics, and expectorants. Nor is there any incon- venience in considering medicines in this way. In therapeutics, it is not any particular medicinal substance or remedial agent that we have in our minds, but the condition of disease calling for cer- tain remedial influences; and it is important that our knowledge should be so arranged in the memory, as most readily to suggest what particular remedy may be best calculated to exert this influ- ence. This object will certainly be better attained by ranking all the remedies together calculated to meet each indication, and to have them thus associated in our minds, than by having the whole character of each body, in all its different relations and applications, impressed upon us in one exclusive view. Thus, it will be more useful practically, when we have occasion for an arterial sedative, emetic, expectorant, or diaphoretic, to have tartar emetic associated with each of these classes in our recollection, than to know it only as an antimonial, having a great diversity of properties, and thus to be compelled to think over it, along perhaps with a number of other bodies, in order to ascertain whether any one of these pro- perties may suit our present purpose. In reference to the modes of operating of the several remedies in producing the effects which serve to classify them, I shall offer and enforce those views which seem to me most in accordance with reason and experience, not omitting, however, to allude to others which may have been advanced, and wishing always to be under- stood as considering our knowledge upon this point to be in great measure provisional, and liable to be materially modified in the progress of discovery. PART II. SPECIAL THERAPEUTICS AND PHARMACOLOGY. Drofoton 2. SYSTEMIC REMEDIES. Subdivision 1. GENERAL REMEDIES. CHAPTER I. General Stimulants. SECTION FIRST. Permanent Stimulants. Class I. ASTRINGENTS. Astringents are remedies which produce contraction of the living tissues. I do not here refer to the visible contraction which takes place in muscles under the influence of the will, or other ex- citant agency; but to a certain shrinking or condensation of struc- ture, which is not attended with visible movement, but is never- theless very obvious in the result, as in that well-known state of the skin called goose-flesh, produced by exposure to cold. That astringents have this effect locally, is proved by the obvious dimi- nution of bulk in any part of the surface to which they may be applied, and by the strong puckering sensation occasioned by them when taken into the mouth. There can be no doubt that they operate upon the mucous membrane of the stomach and bowels, when brought into direct contact with it, in precisely the same manner as upon the mouth and skin. It has been denied that their operation extends beyond the surface of application; but the effects 94 GENERAL STIMULANTS. [PART II. obtained by their use in disease can be explained only by the ad- mission, that they exert upon the system at large their characteristic influence; though it must be allowed that their general are much less than their local effects. It is not impossible that a portion of the constitutional impression produced by them may be the result of sympathy or nervous communication; in like manner as the similar effect of cold upon the skin is transmitted to certain in- ternal parts. But this explanation is not necessary to account for the result. Experiment has satisfactorily proved that astringents are absorbed ; and the probability is that they are conveyed every- where with the blood, and thus act everywhere by direct contact. 1. MODE OF OPERATION. Dead animal structure, submitted to the action of astringent substances, especially to those of vegetable origin, has long been known to undergo condensation, in consequence of chemical com- bination between constituents of the tissue and the astringent substance. In relation to the vegetable astringents, their tannic acid unites with the albumen and gelatin of the animal product, to form insoluble tannates, as in the preparation of leather from hides; in relation to the mineral, the metallic salt or its oxide also combines with albumen, producing compounds insoluble in water. The chemical therapeutists suppose that this same reac- tion takes place between the astringent and the living tissue, and ascribe the effects of the medicine to this agency. But there is no proof whatever that such a combination takes place in life. It could not do so, to any considerable extent, without de- structively disorganizing the part affected. The force of life opposes these chemical reactions, and successfully so long as the medicine is moderately employed. If this be applied abundantly, it may first exhaust the vital forces by the excess of vital reaction it excites; and the chemical affinities may then triumph, with the effect of destroying the life of the part. But, under such circum- stances, it ceases to be a medicine, and becomes a poison. The rapidity, moreover, and amount of local astringent. effect are far greater than can be explained on the chemical principle. Every one knows how sudden and great is the contraction produced in all the tissues of the mouth by a very minute quantity of alum. It appears to me absurd,.ta^§jibe all this effect to chemical combi- nation. Even were^^wh»]e of the alum which can possibly be absorbed in such a%ree to combine chemically with the tissues, it could not produce an amount of contraction in any degree approach- CHAP. I.] ASTRINGENTS. 95 ing to that really experienced. Besides, the contraction, if chemical, would be much more permanent than it really is. The following appears to me to be the true explanation of the phenomena, so far as they are at present susceptible of explanation. All the living tissues have a certain degree of vital cohesion essential to the due performance of their functions; and this co- hesion probably depends on a property of organic contractility, which is called into action and sustained by the healthy stimulus of the blood and nervous influence. If these fail, the cohesion diminishes, and a condition of relaxation takes place. Now astrin- gent substances have the peculiar property of stimulating this organic contractility; and it is this property by which they are cha- racterized as a class of medicines. All that we know upon the subject is that, in consequence of the contact of these substances with the tissues, the contractility of the latter is called into action, and they shrink. The effect is in no degree more singular than that a similar shrinking should take place under the influence of cold. . It is a very singular mistake, which still prevails with some writers, that astringents act especially or peculiarly on the muscles. It is true that they do increase the vital cohesion of this structure, rendering the muscle firmer, but they also act equally on every other tissue capable of shrinking; as may be distinctly seen in their effects upon the skin, and felt in their effects on the mucous mem- brane of the mouth. 2. EFFECTS ON THE SYSTEM. The observable physiological effects of astringents are, beside the general condensation of tissue referred to, or rather as a part or result of it, shortening of fibres; diminished caliber of the arteries, veins, capillaries, absorbents, and ducts; diminished secre- tion, exhalation, and absorption; constipation of the bowels; and increased firmness along with contraction of the pulse. The blood becomes more coagulable, in consequence, probably, of the same influence exerted by them on the organized constitu- ents of this fluid as on the solids. It is supposed also to be less disposed to putrefaction after death. The astringents are said to increase the appetite, and invigorate digestion. This effect they undoubtedly have, in debilitated states of the function connected with relaxation of tissue. It is reasonable to suppose that, even in health, with a very moderate degree of their peculiar influence, they may produce some slight increase of the functions. Their 96 GENERAL STIMULANTS. [PART II. effect is to bring the molecules more closely together; which may thus be rendered capable of a more energetic vital reaction. But whatever may be the case with the perfectly pure astringents, it is certain that many of the medicines ranked in this class do exercise a tonic influence; and for this reason, that they unite positive tonic powers with their astringent property. Such is the case with the vegetable astringents, which, besides their characteristic ingredient, not unfrequently contain a bitter principle also, and with the pre- parations of iron, which are essentially and powerfully tonic, while they are in some degree astringent. It must be obvious, upon a little consideration, that, though astringents are stimulant to the organic contractility, they may really prove sedative to the healthy functions, when employed too freely or continued too long. The digestive function is necessarily impaired in consequence of the diminished secretion of gastric juice, the restrained peristaltic movement of the stomach and bowels, and the impeded absorption. As a result of this defective digestion, if from no other cause, the circulation is enfeebled; nu- trition suffers, emaciation takes place, and a general reduction is experienced in the forces and functions of the system. The above results flow from an excess of. the proper astringent influence. But a still greater abuse of this class of medicines leads to other and very different effects. When applied to delicate sur- faces in great excess, instead of acting simply as astringents, they become irritants. In the denuded skin they excite inflammation, and, taken into the stomach, cause gastric and intestinal pains, nausea, vomiting, and sometimes diarrhoea; their astringent in- fluence being either prevented or overwhelmed by the irritation. As already stated, some of them, in very great excess, overcome the vital resistance of the tissue to their chemical affinity for one or more of its constituents; and disorganization, with the death of the part, ensues. It is said that, under such circumstances, putre- faction does not readily take place, being prevented in part by the previous expulsion of the liquids, but probably in chief by a direct preservative or antiseptic effect, arising from the union of the astringent with the animal principles. 3. INDICATIONS, AND THERAPEUTIC APPLICATIONS. The indications for the use of astringents are such as might be inferred from their physiological effects. They are three in number; 1. to check morbid discharges, 2. to obviate morbid relaxation, and 3. to check inflammation in its earliest stage. For the first two CHAP. I.] ASTRINGENTS. 97 purposes they may be used either generally or locally, for the third they must be applied directly to the seat of the inflammation. It will be most convenient to treat first of their internal, and afterwards of their external use; including under the former head only what has reference to their entrance into the stomach, under the latter all their direct local applications from without. It must not, however, be forgotten that, in their operation upon the mucous membrane of the alimentary canal when taken into the stomach, they act as di- rectly as upon the external surfaces; the only difference being that they cannot be applied so freely to the former, in consequence of its greater sensitiveness, the greater danger of any excess of action, and the impossibility of limiting the extent of their application, or readily removing them if found to be injurious. a. Internal Use of Astringents. 1. To Chech Morbid Discharges. In fulfilling this indication, astrin- gents act by contracting the pores in the blood-vessels through which the discharge takes, place. Two distinct kinds of morbid discharges are affected by them ; the one consisting in excessive or deranged secretion or exhalation, the second in hemorrhage. In reference to their influence in checking the latter, the astringents are denominated styptics. In both, some cautions are required in their use. When the discharge depends upon some local or general dis- order which it is intended to relieve, as plethora, active congestion, inflammation, or the presence of noxious matters, in the blood, the astringents are as a general rule contra-indicated; and the same remark applies to what have been denominated critical discharges, though, strictly speaking, these belong in fact to one of the pre- ceding categories. As the astringents operate in general by merely closing the avenues by which the fluid escapes, and have no effect in removing the disorder which the discharge is intended to relieve, it is obvious that they may, under these circumstances, do much mischief. If they check the discharge, they may increase the real pathological condition; if they fail, their own irritative effect is superadded to that previously existing. Again, a discharge, though originally morbid, may have become habitual; and the processes of digestion and sanguification having taken on increased activity, the system may have accommodated itself to the drain. Astringents in such cases might disturb this balance, and give rise to dangerous local congestion, or general vol. i.—7 98 GENERAL STIMULANTS. [PART II. plethora. If resorted to, therefore, they should be applied cau- tiously and gradually, so as to permit the system to accommodate itself to the change; or the apprehended evil should be coun- teracted by other measures, as by cathartics, issues or setons, a regulated diet, and increased exercise, which may have the effect of consuming the excess of blood. Astringents are applicable when the discharge is purely local, and dependent on no coexisting disease; as, for example, in the hemorrhage consequent upon an accidental rupture of a blood- vessel, either from direct violence, or from a sudden and temporary congestion produced by straining, position, &c. They are also applicable when the affection depends upon debi- lity or relaxation of the coats of the bloodvessels, either original, or consequent upon previous excessive excitement, which has quite disappeared. This is a very common condition in the advanced stages of inflammation; and it is, perhaps, under such circumstances that astringents are upon the whole most useful. Another condition which sometimes imperiously calls for them, even under otherwise opposing indications, is when the discharge is so copious as itself to become the main source of danger. Thus, a hemorrhage from the rectum, intended as a relief to serious ple- thora or portal congestion, may be so frequent or abundant as to put life at risk; and, in this case, should be arrested without hesi- tation. It is not unfrequently necessary to choose between such opposite indications; and the prudent practitioner will always pre- fer what may seem to him the least of the two evils. The position, moreover, of the discharge may sometimes be such as to render this the greatest danger; as in a case of haemoptysis which threatens to overwhelm the lungs. Here astringents may be employed, though the hemorrhage might have been the result of a congestion, and may have a tendency to relieve it. In such cases, however, the use of the styptics should be accompanied with mea- sures, calculated, in a safer way, to accomplish the end for which the hemorrhage was intended. Finally, there are certain individuals of this class which, with their astringent property, unite others calculated to relieve the affection in which the discharge originated, and against which, therefore, the contra-indication above mentioned has less force than against the members of the class generally. Thus, acetate of lead, while powerfully astringent, is also antiphlogistic, and may some- times be advantageously employed to arrest morbid secretion from inflamed surfaces, when others would prove only injurious. CHAP. I.] ASTRINGENTS. 99 It is unnecessary to detail minutely all the diseases in which astringents may be useful, and the circumstances in each, which modify the indication for their employment. Guided by the above principles, the practitioner will judge for himself when the occasion may be offered. It will be sufficient, for the sake of illustration, to trace a single disease through its various therapeutic relations with astringents, in conformity with the foregoing rules, and after- wards simply to enumerate the other diseases in which they may be required, to meet the indication now in view. Diarrhoea is one of the complaints in which astringents are most frequently employed. But this affection often depends on inflam- mation of the bowels, or congestion of the liver and whole portal circulation, which it has the purpose and effect of relieving. Astringents, if they succeed in checking the increased secretion which is at once the agent of relief, and the cause of the diarrhoea, will act injuriously on the inflammation or congestion; if they fail, they will add their own irritation to that pre-existing. They are, therefore, as a general rule, improper under such circum- stances. In certain kidney affections, urea accumulates in the blood, and sometimes seeks an outlet through the bowels, producing diarrhoea, which thus protects the system, in some measure, against the fatal influence of that agent upon the brain. Diarrhoea is some- times critical; that is, occurs at the termination of certain diseases, such as idiopathic fever, and is probably one of the processes by which the system relieves itself of its morbid condition. In either of these cases, astringents might do serious injury. Lastly, the diarrhoea may have existed so long that the system has accommo- dated itself to the increased discharge, the sudden checking of which might occasion dangerous congestion of the liver, lungs, or brain, or perhaps dropsical effusion. Here, though astringents may not be altogether contra-indicated, they should be used with cau- tion, so as gradually to bring about the cure of the complaint; while, in the mean time, measures may be taken to obviate any threatened injury. There is reason to believe that diarrhoea sometimes results from a pure relaxation of the mucous membrane of the bowels, permit- ting the liquid parts of the blood to pass through the walls of the capillaries, almost as through dead membrane. Very frequently inflammation of the mucous coat ends in such a state of debility or relaxation. The vessels, dilated in the active stage of the dis- ease, with pores also probably enlarged so as to admit the passage 100 GENERAL STIMULANTS. [PART II. of the liquor sanguinis, retain this condition upon the cessation of the excitement; and the extravasation and consequent diarrhoea continue long after the occasion for them has ceased. It is under such circumstances that astringents prove most useful in this affection. Another very frequent occasion for their use in diarrhoea is when the discharge, no matter what may have been its origin, is so pro- fuse as to endanger the safety of the patient. Such is the case in epidemic cholera; and I have repeatedly known patients in danger of their life from copious white alvine evacuations, dependent on portal congestion from inertness of the capillaries of the liver. Here astringents are sometimes indispensable. In cases of diarrhoea connected with vascular irritation of the mucous membrane, perhaps with some degree of acute inflamma- tion, and very often in chronic inflammation, it may be proper, even though the discharge may not be immediately dangerous by its quantity, to employ astringent medicines, having along with their astringency a sedative or alterative property, which renders them useful in the treatment of the irritation or inflammation itself; and, when a very exhausting.discharge, originating in such causes, imperiously demands the employment of astringents, it is to this set of them that we should preferably have recourse. Acetate of lead is indicated in the more acute of these cases, and sulphate of zinc, sulphate of copper, or alum in the more chronic; the first from its sedative, the three latter from their alterative action upon inflamed surfaces. Dysentery is another complaint in which astringents are fre- quently recommended by writers. But a cautious discrimination is here necessary, in order to avoid the most serious consequences; and, in ordinary acute dysentery, in the earlier stages, it is I think best to avoid entirely their internal use, even that of acetate of lead, which has been commended by some. In the advanced stages, when the discharges have become more copious, the grade of the inflammatory excitement greatly reduced, and the patient's strength exhausted, they may sometimes be employed with benefit; though even under such circumstances caution should always be observed. In the chronic form of the disease they are not unfrequently useful, particularly in warm climates, where there is greater laxit}?- of system, and especially of the bowels, demanding the use of this class of remedies. The metallic alterative astringents are most efficacious in these cases, though the vegetable are also not unfre- quently employed. chap, i.] ASTRINGENTS. 101 Other morbid secretory affections, in which the internal use of astringents is called for, are diuresis or excessive secretion of urine, profuse and exhausting sweats, catarrh of the bladder, excessive bron- chial srcrelion, and sometimes possibly dropsical effusion dependent on relaxation of the tissues. In these complaints they are less obviously efficacious than in those of the bowels; because, in the latter, they are brought directly into contact with the diseased tissue, while, in the former, they must reach it through the medium of absorption. A rule in these cases is to select the particular astringent which experience has shown most readily to reach the seat of the discharge. Thus, uva ursi and chimaphila are especially useful in the affections of the urinary passages, from their well known quality of impregnating the urine. Hemorrhages often demand the use of astringents; and the gene- ral rules before given hold, in relation to this set of discharges, as well as to morbid secretions and exhalations. When active, and connected with plethora or local vascular irritation, unless alarming by their quantity, or injurious by their position, they should be treated hesitatingly with astringents; and, should this class of remedies be indispensable, those should be selected which are sedative as well as styptic, such as cold, and the preparations of lead. After the relief of the plethora or congestion, and a sufficient reduction of the active character of the hemorrhage, either by depletory measures, or in the course of the complaint, astringents may be employed without hesitation, and without any special refer- ence to their antiphlogistic properties. In passive hemorrhages no particular caution is requisite; the free use of astringents being almost always indicated in these. Besides the mere property of closing the bleeding orifices, it is probable that many of the astrin- gents exercise another power in arresting hemorrhage; that, namely, of increasing the coagulability and plasticity of the blood. 2. To Obviate Morbid Relaxation. In most instances morbid re- laxation is attended with morbid discharge, and the two indi- cations are answered at the same time. But occasionally there is an unhealthy laxity of the nonsecreting tissues; and even the secreting may be affected in the same way without increased extra- vasation. In scrofulous diseases, and other cachectic affections de- pendent on defective or depraved nutrition, this condition is not uncommon; and astringents have accordingly been much and advantageously used in their treatment. In the convalescence from febrile and other acute diseases, especially when somewhat protracted, 102 GENERAL STIMULANTS. [PART II. the same condition not unfrequently exists, calling for the same remedies. It is probable that sulphuric acid and the chalybeates, so much employed under these circumstances, may prove useful as well by their astringent as their tonic virtues. In chronic inflam- mation of the mucous membrane of the stomach and bowels, when all acuteness is passed, and the blood-vessels are merely passively dis- tended, or ulcerations exist, which, in consequence of the laxity and feebleness of their tissue, are unable to take on the healing process, there would appear to be an indication for astringency; and the fact is, that, among the most efficient remedies in such affections, are some of the mineral substances belonging to this class, as sulphate of iron and sulphate of copper. 3. To Check Inflammation. The indication for astringents in the early stage of inflammation, founded on their property of contracting the vessels, and thus excluding, in some measure, the blood neces- sary for the support of the inflammatory process, can seldom be fulfilled by their internal use. To answer this purpose, they must be brought to act upon the inflamed vessels in a more concentrated state than would be safe, or indeed possible, in the blood, through the medium of absorption; and they would consequently be wholly in- applicable to any inflammatory affection, the seat of which could be reached only through the circulation. Even in inflammations of the alimentary canal, there would be too much risk that, if used largely enough to have any powerful effect, they might act more disadvan- tageous^ as irritants to the sound parts, than usefully as astringents upon those inflamed, as it would be impossible to limit their application to the latter; and, besides, there is always difficulty in deciding, whether the inflammation has not passed the point at which any good could be expected from them. Hence, the astrin- gents can seldom be used internally, with the view of rendering commencing inflammation abortive; and it is only externally or topically, that, as a general rule, they can be beneficially applied upon this principle. b. External Use of Astringents. The same indications exist for the external or topical as for the internal use of astringents, and they are even more effectual by the former method than the latter. 1. For arresting morbid discharges they are employed in exces- sive secretion, resulting from advanced or chronic inflammation, or debility of the vessels, in the nostrils, conjunctiva, external auditory CHAP. I.] ASTRINGENTS. 103 meatus, mouth and fauces, urethra and bladder, vagina, and rectum. Hence their use in chronic coryza and ozsena, purulent ophthalmia, otirrhoza, stomatorrhcea, gonorrhoea and gleets, cystirrhcea, leucorrhcea, and mucous or purulent rectal discharges. Excessive sweating, and oedema of the limbs, may also be treated by them with advantage. They are the most effective remedies in hemorrhages from all these sources. The same caution should be observed, as in their internal use, not too hastily to arrest a discharge which is effecting some useful purpose. But they may sometimes be employed with pro- priety topically, where we might hesitate to administer them by the mouth, and almost always with much greater freedom. Any irrita- tion they may excite in external parts is much less hazardous than an equal amount in the stomach or bowels. Besides, we can in this topical method precisely limit their application, if deemed advis- able, and, should they act too powerfully, may remove them. They may, moreover, be used much more effectively than by the sto- mach, because in a more concentrated state. 2. For obviating relaxation, not essentially connected with exces- sive discharge, they are employed in a great variety of affections, as in the different forms of venous distension, including varicocele^ hemorrhoids, and varicose veins of the legs; in prolapsed anus, uvula, and uterus; in indolent, flabby, and fungous ulcers; and in various other conditions of local debility, attending or following advanced and chronic inflammation of the different surfaces mentioned in the preceding paragraph, and additionally in that of the larynx. 3. In the forming or early stage of inflammation, with the view of contracting the capillaries, the astringents are much and most usefully employed. When, however, that process is in full vigour, and sustained by a plethoric state of the blood, or some cause acting vigorously through the constitution; when, too, exudation has taken place in the tissue, and blood may have coagulated in some of the vessels, astringents will often fail to produce their characteristic effect, and may even increase the inflammation by acting as irritants. But, even under such circumstances, after the activity of the inflammation has been subdued by depletion, they may again be resorted to, and will now not unfrequently succeed where they had before failed. Hence, astringents are used locally in inflammation of the conjunctiva, of the mouth and fauces, of the rectum, of the mucous membrane of the genito-urinary passages, and of the skin. It is upon this principle, in part, that they operate so usefully in various cutaneous eruptions. But, in the 104 GENERAL STIMULANTS. [PART II. choice of astringents for these purposes, there is great occasion for the exercise of judgment. From their diversified powers, some are applicable where others might prove injurious. It is obvious that those which possess other antiphlogistic powers besides astrin- gency, must be more efficient in answering the indication than the pure astringents. Plence, the mineral are generally more efficacious than the vegetable substances belonging to the class. 4. DIVISION OF THE ASTRINGENTS. There is sufficient ground for arranging the astringents in two sections, one including the vegetable, and the other those of mineral origin. 1. The vegetable astringents are distinguished by a striking simi- larity of properties, which has been ascertained to depend on the presence of a peculiar proximate principle, or set of princi- ples, denominated tannin or tannic acid. Though this, as found in different products, has been ascertained to differ somewhat in chemical character, yet, both in this respect, and in its sensible and therapeutical properties, it is so nearly identical that, in relation to its medical uses, it may be considered as one substance. It is undoubtedly the main astringent principle. This rank was at one time claimed for gallic acid, which is associated with tannic acid in certain astringents; and there are some who seem disposed to revive this claim; but it is quite sufficient simply to taste the two principles, to be convinced that gallic acid is incomparably inferior in styptic power, and that little of the effects produced by astrin- gent vegetables can be justly ascribed to it. The fact would seem to be, that it is more readily absorbed than tannic acid, probably because it does not like this form insoluble compounds with albu- men and gelatin; and its constitutional effect is probably greater in proportion to its local than is the case with the more astringent substance; but, when it is understood that the vegetable astringents which have been most used internally, and in favour of which experience has spoken most decidedly, contain no gallic acid, as kino, catechu, and extract of rhatany, its claim to be considered the prominent astringent principle must be admitted to be ex- tremely feeble. Tannic acid seems to be purely astringent, and desti- tute of any other physiological property. The vegetables, therefore, which contain little or none of any other active principle than this, may be looked on as proper representatives of the class. But these are very few. Most of the vegetable astringents contain also a bitter CHAP. I.] COLD, AS AN ASTRINGENT. 105 principle, which somewhat modifies the influence of their tannic acid, and might entitle them to rank with the tonics, which they considerably resemble in their effects. But, so far as their mere astringency is concerned, they are essentially different from that class of medicines, resembling them only in this single point, that, in cases of debility connected with deficient vital cohesion of the tissues, they increase strength by restoring to the tissues the com- pactness necessary for the proper exercise of their functions. It is obvious that the bitter astringents are less applicable than tannic acid itself, or the pure astringents, to those cases in which it is de- sirable to stimulate, whether looally or generally, as little as possible. 2. The mineral astringents have in general nothing in common but their astringency. Each has peculiar properties of its own, which render it applicable to peculiar purposes. Thus, the pre- parations of lead are sedative, alum has an alterative influence, sulphuric acid is refrigerant and tonic, and the preparations of iron have remarkable tonic powers, and a peculiar power of modifying the blood. Between the sulphates of zinc and of copper, however, there is a remarkable coincidence of properties, though the latter is vastly more powerful than the former. COLD, AS AN ASTRINGENT. Cold is primarily sedative, and secondarily stimulant through reaction. Its astringent influence, in relation to which alone it is here considered, is merely incidental to the sedative. The effects are essentially the same as those already described as the result of the action of astringents generally, and need not be repeated. The cutis anserina, or goose-flesh, in which the roughness is owing to the shrinking of the skin around the prominent sebaceous and hair follicles, is even more striking than the similar effect from other astringents. There is also from cold a greater degree of stiff- ness or firmness in the contracting tissue. 1. Mode of Operation. The astringent effect of cold is partly phy- sical, and partly vital. It is a general law of heat, that bodies ex- pand with its increase and contract with its diminution; and the contraction produced in living structure by cold is in some mea- sure undoubtedly the result of this law. The peculiar density and stiffness of tissue may be ascribed, in part, to the solidification by cold of the oil globules of the adipose matter. But I am disposed to ascribe the diminution of bulk still more to the sedative influ- ence of the cold upon the vital forces of the part, and the conse- 106 GENERAL STIMULANTS. [PART II. quent inability of the capillaries to receive and carry forward the blood. According to this view, it is rather the part which shrinks, because the blood does not enter it in normal proportion, than the blood that is expelled, because the capillaries are contracted; though the two causes probably co-operate. It is not impossible that a diminution of heat may, in some unexplained manner, act as a sti- mulant to the organic contractility, exactly in the same mode as the medicinal astringents; but the former explanation is more ac- cordant with the received views of the sedative influence of cold, which would seem to be a necessary corollary to the stimulant action of heat. There can be no doubt that the astringent influ- ence of cold is transmitted, through nervous communication, from the external surface where it is applied, to certain internal surfaces, especially those of the respiratory and alimentary mucous mem- branes, and the lining tissue of the uterus. 2. Therapeutic Effects. The therapeutic effects of cold as an astrin- gent are, for the most part, the same as those of the class in gene- ral. It is, however, seldom resorted to with the view of checking morbid secretion. Sometimes it is used to moderate or arrest excessive sweating, but cautiously, and with much reserve. By far the most extensive and useful application of this agency of cold is to the suppression of hemorrhage. In this it exhibits extraordinary powers. The effect is generally ascribed to the closure of the bleeding orifices, and no doubt correctly in part; but I am inclined to think that still more is due to the depression of the local circu- lating forces through the sedative influence of the cold. The styptic effects of the remedy have also been attributed, in some1 measure, to an increased coagulability of the blood; but this is probably a mistake; as cold retards rather than hastens coagulation, and for a very good reason; for, otherwise, exposure to a very low tempe- rature might endanger coagulation of the blood, and consequent inevitable gangrene, in the most exposed parts. Blood may even be frozen without coagulating, and, upon thawing, may still retain the property. Hence, frozen parts may by proper management often be restored, which could not happen if the blood had all coagulated in the vessels. Almost all forms of hemorrhage may be treated advantageously by cold, unless the vital forces have been so much prostrated as to be able to bear no further reduction. This remedy is less applicable, than other astringent measures, to the treatment of simple relaxation; at least in reference to its direct and primary action. It may, however, sometimes be advan- CHAP. I.] COLD, AS AN ASTRINGENT. 107 tageously used in varicocele, and in hemorrhoidal and aneurismal tumours. It has been employed also to aid in the reduction of strangulated hernia, in which it is supposed to be useful by dimi- nishing the bulk of the contents of the sac, in greater degree than it contracts the hernial orifice, so as to favour the return of the former through the latter; but this is scarcely an example of the mode of operation here referred to. For fulfilling the third indication for the use of astringents, that, namely, of obviating early inflammation by emptying the vessels, cold is an admirable remedy; but it is still more useful in that affection as a sedative, and will be fully treated of, in relation to its antiphlogistic action, under the head of sedative remedies. 3. Modes of Application. Cold as an astringent may be applied by means of cold air, cold water, ice or snow, evaporating liquids, and frigorific mixtures. Cold water may be applied upon linen rags or towels, by means of the douche, or by affusion, and may vary in temperature from 32° to 60°, according to the amount of effect de- sired. Ice and snow may be' applied in bladders, or wrapped up in cloths; and the former may be used in larger or smaller fragments, or finely pounded. Ether is the liquid most frequently employed with a view to the production of cold by evaporation; and its effects in this way may be greatly increased by blowing on it, by means of a pair of bellows, as it is dropped upon the surface. The most convenient frigorific mixture, in the absence of cold water or ice, is made by mixing, in a pint of water, four ounces of sal ammoniac and the same quantity of nitre, which may be applied in a bladder. The following applications are made of cold in one or another of the above forms. Cold air is sometimes useful in arresting trau- matic hemorrhage, and checking profuse perspiration. In the same kind of hemorrhage, very cold water or ice may sometimes be ad- vantageously resorted to, when the bleeding vessels are too small to be tied, or not conveniently reached, as in some operations about the rectum, vagina, &c. In epistaxis the water or ice may be applied over the nose, to the back of the neck, to the genitals in obstinate cases, or by affu- sion to the head. The same application may be made, in very obstinate hsemopty- sis, to the breast or axilla; but in this variety of hemorrhage the remedy should be used with caution, from the danger of producing congestion in the pulmonary parenchyma. In Jucmatemesis, the most effectual method of employing this 108 GENERAL STIMULANTS. [PART II. remedy is to allow the patient to swallow small pieces of ice, which, by dissolving in the stomach, will keep up a constant frigorific effect on the organ. There might be danger, in the external use of cold in this affection, of producing congestion of the portal circle, which might more than counterbalance the sympathetic astringent effect on the mucous membrane. In hsematuria, uterine hemorrhage, and bleeding from the rectum, the applications may be made over the sacrum, to the perinaeum, and over the pubes; and the douche, falling from a considerable height upon the lower part of the abdomen, is often more efficient than the simple contact of the water or ice. Very cold water has sometimes been injected into the rectum and vagina, and even pieces of ice have been introduced into the same cavities, when a very strong impression was desired. In varicose swellings and aneurismcd tumours, one or another of the several modes of application mentioned may be employed, ac- cording to the situation of the part, or other circumstances affecting their convenience or efficiency. In strangulated hernia, recourse has been occasionally had to the evaporation of ether, as well as to other frigorific measures, especially to pounded ice or snow in cloths or bladders. But in all these cases, especially when ice or snow is employed, care should be taken not to allow so long a continuance of the appli- cation as to endanger the freezing and consequent mortification of the part; and, when ice is introduced either into the stomach or rectum, to guard with special caution against a too great depressing effect. —♦— I. GALLS. Galla, U.S., Lond.— Gallse, Ed., Dub. Origin. Galls are excrescences upon the young branches of Quercus infectoria, a small tree growing in Asia Minor, Syria, Persia, and other parts of central Asia. They result from punctures in the tender shoots, made by an insect, which deposits its egg in the puncture. They are brought from the Levant and India. Sensible Properties. Galls are spherical, varying in bulk from the size of a pea to that of a large cherry, studded with small tuberosi- ties, but smooth in the intervals; of a dark-bluish, greenish, gray, or yellowish-white colour; inodorous, and of a bitter, very astringent taste. CHAP. I.] ASTRINGENTS.— GALLS. 109 Varieties. There are two varieties, one denominated blue, green, or black galls, the other white galls. The former are smaller, harder, more compact, relatively heavier, and of a darker colour than the latter, and, having been gathered before the escape of the insect into which the deposited egg has become developed, have no hole leading to their interior. The white galls are large, light, frequently hollow in the centre, generally of a dirty yellowish-white colour, with a round perforating hole in their surface, through which the insect has escaped; and are much inferior in astringency to the other variety. Active Principles. These are tannic acid of the variety which forms bluish-black precipitates with the sesquisalts of iron; gallic acid; and probably a distinct bitter principle. It is the tannic acid upon which the virtues of the medicine chiefly depend. Galls im- part their active properties to water and alcohol. Incompatibles. A strong infusion yields precipitates with concen- trated muriatic and sulphuric acids; lime-water; the carbonates of potassa and ammonia; the soluble salts of iron, manganese, lead, and copper; the nitrates of silver and mercury; tartar emetic; the infusions of all vegetable substances which contain an organic alkali, as opium, ipecacuanha, Peruvian bark, &c, and of various other active vegetable medicines, as columbo and digitalis; and solutions of starch, albumen, and gelatin. Effects on the System. As galls contain a very large proportion of the astringent principle, they are among the most powerful medfcines belonging to the class. Their effects are those already described in the general observations on astringents; but they exercise also some tonic influence, probably connected with their bitterness. Therapeutic Application. Though not less efficacious than other astringents, in the diseases in which simple astringency is in- dicated, they are little used internally; and of late have been almost entirely superseded by the tannic acid extracted from them, which has their astringent virtues, in a concentrated state, without their bitterness. They are, however, occasionally used in diarrhoea; and may be advantageously employed in obstinate flatulence and tympanites, dependent upon an atonic state of the stomach and bowels. I have, in this affection, prescribed with great apparent benefit an infusion of galls and fennel-seed, made in the proportion of half an ounce of the former, and two drachms of the latter, to a pint of boiling water, and given in the dose of a small wineglassful three times a day. It probably acts, in the correction of flatulence, 110 GENERAL STIMULANTS. [PART II. in some degree, by constringing the capillaries, and preventing the evolution of gaseous matter from the blood. Galls have been recommended as an antidote to the vegetable alkaloids, and the medicines containing them, as opium, belladonna, stramonium, hyoscyamus, conium, and nux vomica, upon the sup- position that, the tannates of these principles being insoluble in wa- ter, they are rendered less active by the combination. But it has been shown that, in respect to one at least of these alkaloids, namely quinia, the tannate is scarcely if at all less efficacious than the soluble salts; and the same is probably true of all of them. Galls should not, therefore, be relied on as an antidote in any case of poisoning with these organic alkalies, whether isolated or in their native state of combination; and, if exhibited at all, should be used merely as adjuvants to measures calculated to evacuate the poison from the stomach and bowels. The same may be said of their pre- sumed efficacy in cases of poisoning from tartar emetic; at least this antimonial has been repeatedly known to vomit actively, when prescribed, in the ordinary emetic dose, in connexion with sub- stances containing tannic acid. Administration. The dose of powdered galls is from ten to twenty grains, which may be given three or four times a day. An infusion, made in the proportion of an ounce to a pint of boiling water, may be administered as often in the dose of a wineglassful. The Officinal Tincture (Tinctura Gall^e, U.S.) is more used as a chemical test than as a medicine, but may be given in the dose of from one to three fluidrachms. By time and exposure the tannic acid contained in it is apt to be converted into gallic acid; and its virtues, whether as a test or as a medicine, may be thus impaired. A powerfully astringent preparation was much used, in obstinate cases of diarrhoea, by the late Drs. Physick and Parrish, of this city, made by introducing into a cup two or three drachms of coarsely powdered galls, pouring over the powder three or four fluidounces of brandy, putting upon iron skewers placed near each other over the top of the cup several pieces of loaf sugar, then set- ting fire to the brandy, and allowing it to burn until the alcohol was so far consumed that it would burn no longer. The sugar was melted in the flames, and, falling into the liquid, made a rich syrup, which was carefully poured off from the dregs, and given in the dose of a fluidrachm. Externally galls are much and efficaciously employed. In the form of infusion, prepared as above mentioned, the medicine may be used as a gargle in chronic angina and relaxed uvula, as an in- CHAP. I.] ASTRINGENTS.—TANNIC ACID. Ill jection in gleet, leucorrhcea, and prolapsus of the ttterus and rectum; and as a lotion in piles and flabby ulcers. The Ointment of Galls (Unguentum Gallje, U. S.) is an excel- lent local application in piles, prolapsus ani, and flabby and in- dolent ulcers; and may be rendered still more efficacious, in the two former affections, particularly when in an irritated state, if combined with a little powdered opium, as in the compound ointment of the British Pharmacopoeias. Two officinal preparations considerably used are made from galls, namely, tannic and gallic acids. 1. TANNIC ACID. — Acidum Tannicum, U.S., Lond., Dub.— Tannin of Galls.—Gallo-tannic Acid. Origin. This is the variety of tannic acid which precipitates the sesquisalts of iron of a bluish-black colour. Besides galls, it is found in different products of the oak, and in various other vegetable astringents. Other varieties of tannic acid precipitate the salts of iron of a greenish-black or grayish-black colour, and are apt to be associated with a reddish or reddish-brown colour in the medicine containing them, as in kino, catechu, and rhatany. These all differ from that now under consideration, in not being convertible into gallic acid, upon exposure in the state of infusion to the atmo- spheric air. They probably differ among themselves, and may be distinguished from the tannic acid here referred to, and from one another, by designative epithets derived from the medicine. Thus, the variety derived from kino may be called kino-lannic acid, that from catechu, catechu-tannic acid, &c. Tannic acid is extracted from galls by means of ether containing a little water. The liquid is passed through powdered galls, and after passing separates into two layers, the lower of which holds the tannic acid in solution, and yields it on evaporation. Sensible and Chemical Properties. Gallo-tannic acid is solid, spongy, light, white with frequently a yellowish or greenish-yellow tint, inodorous, and of a strongly astringent taste, without bitter- ness. It is freely soluble in water, less so in alcohol and ether, and insoluble in the fixed and volatile oils. Its incompatibilities are the same with those of galls (see page 109), which owe their chemical relations with other substances chiefly to this principle. Exposed in solution to the air, it is slowly changed into gallic acid, with the escape of carbonic acid. Effects on the System. Tannic acid, being the peculiar active principle of the vegetable astringents, must affect the system in 112 GENERAL STIMULANTS. [PART II. the same manner as these medicines, so far as their astringency is concerned, with this difference only, that it exceeds them all greatly in power. In reference to topical effect alone, it is pro- bably the most energetic astringent known. In its general action, it is inferior to some of the mineral substances belonging to the class. In consequence of its strong affinity for some of the proximate constituents of the tissues and of the blood, as albumen, gelatin, and fibrin, with which it forms insoluble compounds, it is probably never taken unchanged into the circulation. Indeed, it could scarcely exist as tannic acid in the blood. Experiments with tannic acid upon dogs have shown that, when it is given freely to these animals, the urine becomes darker, and yields evi- dences, upon chemical examination, of the presence of gallic and pyrogallic acids. Into these acids, therefore, or into something intermediate between them and itself, the tannic acid is probably converted on entering the circulation. This presumption is ren- dered more plausible by the fact, that gallic acid does not, like the tannic, form insoluble compounds with the animal principles above mentioned. Now, as this acid is greatly less astringent than the tannic, we can readily account for the much greater power of the latter as a local than as a general astringent. Among its local effects are of course those which it produces in the bowels; for with the mucous membrane of these it is brought into as close contact as with the skin. In moderate doses, tannic acid is said to .produce warmth in the stomach, and somewhat to excite the appetite. It undoubtedly tends to diminish the number and quantity of the stools. Largely given, it causes a feeling of constriction in the epigastrium, not unfrequently nausea, and sometimes obstinate constipation. Therapeutic Application. When pure astringency is required, tan- nic acid is preferable to the crude medicines containing it, from its comparatively small dose, its less unpleasant taste, its less liability to offend the stomach, and from the circumstance that, not being associated with principles having a different action from its own, it can be given in cases in which the crude medicine, in conse- quence of containing such principles, may be contraindicated. 1. Internally, it may be used most advantageously in affections of the stomach and bowels, with the inner surface of which it comes into direct contact. In all cases of diarrhoea, and chronic dysentery, demanding the use of astringents, especially in the former of these diseases, it is very useful. It may even be employed in these affec- tions, in some instances, when the medicines containing it could not, CHAP. I.] ASTRINGENTS.—TANNIC ACID. 113 in consequence of associating too much of a tonic or stimulating property with their astringency. In cholera infantum it may fre- quently be associated usefully with the other medicines employed. It is asserted to have produced extraordinary effects in epidemic cholera, in which it may be given at any stage so long as copious evacuations continue. From the rapidity and violence of this dis- ease, it must be given more largely than in most other affections; from five to ten grains being required, to be repeated every half hour or hour until the discharges are checked. In hemorrhage from the stomach and bowels, not connected with high vascular irritation or acute inflammation, it is an excellent remedy, and per- haps, as a general rule, the most efficient of all the astringents excepting alum and acetate of lead. In hsematemesis it should be given preferably in solution, as it will thus act more promptly and equably upon the bleeding surface. In intestinal hemorrhage, on the contrary, the pilular form is to be preferred, because, in this state, the medicine will be more likely to pass through the stomach unaltered, and thus reach the seat of its destined action. In all these affections, it should generally be combined with opium, and often also with ipecacuanha, the proportions of which should vary to suit the particular circumstances of the case. Acetate of lead is generally indicated at the same time. Should this and the tannic acid have been employed separately without success, they may be given conjointly; for, though the tannate of lead would be formed, yet there is reason to suppose that this might prove more effica- cious, in certain cases, especially in the intestinal affection, than either of the two medicines alone. Though less efficacious in complaints the seat of which it cannot directly reach, tannic acid has yet been highly recommended, as an internal remedy, in various morbid discharges, whether secretory or hemorrhagic, proceeding from other sources than the alimentary canal. Profuse and exhausting expectoration, whether mucous or puru- lent, colliquative sweats, excessive diuresis, chronic catarrh of the blad- der, haemoptysis, hsematuria, and menorrhagia, are the affections of this kind in which it has been used. But in all of them I should prefer the mineral astringents; and the probability is that gallic acid might prove little less effective than the tannic. Dr. S. Scott Alison recommends the acid as an excellent remedy in dyspepsia, in which he states that it promotes the appetite,. relieves flatulence, and not unfrequently, instead of constipating, produces a healthy action of the bowels. It would probably prove vol. i.—8 114 GENERAL STIMULANTS. [PART II. not less efficacious than galls, in obstinate flatulence and tympanites dependent on relaxation of the bowel. It is asserted to have been very successful in the cure of intermittens, and has been given as an anthelmintic, in the dose for children of from five to ten grains. Tannic acid has also, like galls, been recommended as an antidote to the poisonous vegetable alkaloids, and certain metallic salts, especially tartar emetic; but, for reasons already mentioned, it should not be relied on to the exclusion of other measures. (See page 110.) Administration. The dose is from two to ten grains, to be repeated, in chronic cases, three or four times a day, in those requiring a speedy impression, every hour, two, or three hours. The medicine may be given in pill or solution. In the latter form, it is best ad- ministered in connection with syrup; which may be either simple, or medicated by the addition of some agreeable flavouring sub- stance, as one of the aromatic volatile oils or tinctures. Syrup of orange peel or of ginger may be used for the purpose. The strength of the solution should be such, that from one to four fluidrachms may contain the required dose of the medicine. 2. Externally, tannic acid may be used for all the purposes for which astringents are indicated, and will be found among the most effective of them. It has been specially recommended in the puru- lent ophthalmia of infants; in epistaxis and chronic coryza; in angina prolapsed uvula, ulcerous affections of the mouth and fauces, excessive sail. vation, bleeding and spongy gum.s, bleeding from the socket of an extracted tooth, &c; in gonorrhoea, gleet, leucorrhoza, and prolapsed uterus; in bleeding from the rectum, prolapsus ani, and hemorrhoidal affections generally; and, finally, in flabby and fungous ulcers, and various erup- tive affections. In these complaints it may be used in solution, pow- der, or ointment. For injection into the eye, the nostrils, the urethra or vagina, and the rectum, and for gargles, the form of solution should be used, the medium strength of which may be five grains to the fluidounce of water. A much stronger solution, containing one part of the acid to three of water, has been recommended in puru- lent ophthalmia, and for ulcers and specks on the cornea; while one considerably weaker, containing not more than a grain or two in the fluidounce, to begin with, should be used as a collyrium in commencing or retreating inflammation of the conjunctiva, of the catarrhal character. In the form of powder, the acid has been em- ployed in epistaxis, being snuffed up the nostril, or blown up through a quill; and as a remedy in spongy gums, and foul old and CHAP. I.] ASTRINGENTS.—GALLIC ACID. 115 bleeding ulcers, to which it may be applied by sprinkling or. dusting it over the surface. It has also been particularly recommended in chronic inflammation of the lachrymal sac; being applied, by means of a fine camel's-hair pencil, to the vicinity of the puncta lachry- malia, after the matter has been evacuated from the sac by pressure. An ointment may be made by rubbing two scruples first with twenty minims of water into a paste, and afterwards with an ounce of lard; and the preparation may be weakened by adding any de- sirable quantity of lard. In this form it may be used in piles, cuta- neous eruptions, sore nipples, and old ulcers. In the form of lozenges, each containing half a grain of the acid, it may be em- ployed in cases of chronic angina and relaxation of the uvula; the lozenge being held in the mouth, and swallowed as it slowly dis- solves. 2. GALLIC ACID.—Acidum Gallicum, U. S., Lond., Dub. Origin. Gallic acid is procured from galls, either through the gallic acid fermentation which these undergo when exposed, in the state of powder, to water and atmospheric air, or through the re- agency of sulphuric acid. Sensible and Chemical Properties. The acid is in delicate, .silky, acicular crystals, colourless when quite pure, somewhat brownish as commonly kept in the shops, inodorous, of an acidulous slightly astringent taste, sparingly soluble in cold, but freely in hot water, very soluble in alcohol, and slightly soluble in ether. It produces a deep bluish-black colour with solutions of the salts of sesqui- oxide of iron, but has no effect on that of the sulphate of the protoxide, and differs from tannic acid in not causing precipitates with gelatin, albumen, or salts of the organic alkalies. Effects on the System. In small doses, gallic acid produces no sensible effect when swallowed, and, in the largest ever given for medical purposes, is said to occasion only a feeling of internal heat. Externally applied, it produces little of the corrugating effects characteristic of the astringents. Therapeutic Application. This substance has but recently been employed as a medicine. Formerly supposed to be the active principle of the vegetable astringents, though not used in the iso- lated state, it lost this reputation almost entirely upon the discovery of the much greater astringency of tannic acid; and it is only within a few years, that it has partially recovered its original credit. There can be no doubt of its great inferiority to tannic acid in 116 GENERAL STIMULANTS. [PART II. affections of the skin, alimentary canal, and all those parts with which the medicine can be brought into direct contact. But, not having those chemical relations which render the absorption of tannic acid as such impossible, it may enter the circulation, and thus reach all parts of the system; and, as tannic acid may possibly be con- verted into gallic acid before being absorbed, and through this agent produce all its general effects upon the system at large, the inference is not unreasonable, that the latter medicine might, per- haps, be substituted for the former, without disadvantage, in all cases in which the effects are to be produced through admixture wi'th the blood. We might go further, and calculate upon results even more favourable from the gallic than the tannic acid; as, inde- pendently of its more ready entrance into the circulation, it is less apt to disturb the stomach and constipate the bowels, and thus to interfere with digestion. Experience, however, upon these points is not yet settled; and, though gallic acid has been of late much em- ployed, very different opinions have been given of its efficiency. These remarks on the relative efficiency of gallic and tannic acids, have reference only to the latter acid as it is procured from galls. The complaints in which it may be most advantageously given are the hemorrhages, and especially those proceeding from parts which are conveniently accessible only through the circulation, as haemoptysis, hsematuria, and menorrhagia or uterine hemorrhage. In the last mentioned affection it has proved peculiarly efficacious; and in haematuria it might reasonably be expected to be so, as it passes out of the system through the kidneys. In all these complaints, it has the great advantage of being quite destitute of irritant or gene- ral stimulant properties, at least in medicinal doses, and it is not improbable that it is somewhat sedative to the circulation, or refri- gerant, like many other vegetable acids. The power has been claimed for it of arresting, in some degree, the escape of albumen from the blood in cases of albuminous urine; and it has been em- ployed with supposed benefit in chronic mucous discharges from the urinary organs. It has been found, moreover, one of the most effective remedies in cases of chylo-serous or spontaneously coagulable urine. The dose is from five to twenty grains three times a day. It may be given in the form of pill, made with conserve of roses, or with syrup and powdered gum Arabic; in the form of powder; or in liquid mixture. CHAP. I.] ASTRINGENTS.—OAK BARK. 117 II. OAK BARK. Quercus Cortex, Ed.—Quercus, Lond., Dub. WHITE OAK BARK.—Quercus alba, U.S. BLACK OAK BARK—Quercus infectoria, U. S. The bark of most of the oaks is possessed of properties very nearly identical, so that one species may generally be substituted for another without great disadvantage. Q. Robur and Q. peduncu- lala, the latter of which is the common British oak, are the species most used in Europe; Q. alba or American white-oak, Q. prinus or white chestnut-oak, Q. montana or rock chestnut-oak, Q.falcata or Spanish oak, and other indigenous species, have been indifferently used in this country. Our Pharmacopoeia has adopted Q. alba or white-oak, as the representative of the oaks in general, being one of the most astringent, and Q. tinctoria, or black-oak, as possessing somewhat different properties, and requiring a separate consider ation. It is the inner bark, in all the species, which is principally efficacious, and which should, therefore, be employed to the exclusion of the epidermis, when this is readily separable. The bark is better from the young branches than the old, and gathered in the spring than at other seasons. Sensible Properties. The inner bark has a coarse, fibrous tex- ture; a light-brownish or reddish-brown colour; a slight pecu- liar odour, little perceptible in single pieces, but very obvious in mass; and a rough, astringent, bitterish taste. Active Principles. These are tannic acid of the kind found in galls, gallic acid, and a bitter crystallizable, neuter substance called quercin, which has been found in the bark of European oaks, and probably exists in most or all of the species. Of these principles, tannic acid is the most abundant and most important. They are all extracted by water and alcohol. Incompatibles. These are the same essentially as those of galls; but the bark of the British oak is said not to precipitate tartar emetic. Peculiarities of Q. tinctoria, or Black-oak Bark. This variety is more bitter than most of the others, and differs also in staining the saliva yellow when chewed. Besides the tannic and gallic acids, it contains a peculiar colouring principle, called quercitrin, which renders it valuable as a dye-stuff, in which capacity the 118 GENERAL STIMULANTS. [PART II. coarsely powdered bark is considerably used under the name of quercitron. *> Effects on the System. The effects of oak bark are those of a mild astringent and tonic. Experiments performed with it at the vete- rinary school of Lyons appear to show that, when largely taken, it renders the blood redder, thicker, and more viscid, and at the same time diminishes the putrefactive tendency after death. The blood of a horse, which was made to take twenty pounds of the bark in a month, was said, at the end of that time, to have undergone the change referred to; and the body of the animal, which was killed, remained two months without the least sign of putrefaction. Black-oak bark is said to differ from the other varieties in having some tendency to operate on the bowels. Therapeutic Application. Oak-bark has been used internally in chronic diarrhoea and dysentery, in passive hemorrhage from the bowels, and in intermittent fever; but it is little employed in this way. The inhalation of the odorous matter which exhales from large quantities in mass, has been thought to be advantageous in phthisis; because this disease has been observed to prevail less among tanners than with other classes of people; but more accu- rate and copious statistical details are wanted to establish the fact. The black oak bark, in consequence of its supposed irritant effects on the bowels, should not be given in cases of diarrhoea. The topical use of the bark is much greater than the internal. The decoction has been employed as a bath, especially in children, in marasmus, scrofula, chronic diarrhoea, cholera infantum, and inter- mittent fever. It has also been found useful as a gargle in pro- lapsus of the uvula and inflammation of the fauces, as an injection in leucorrhoea, prolapsus uteri, prolapsus ani, and dropsical cysts, and as a wash, or in the form of poultice, in piles, old and obsti- nate ulcers, edematous swellings of the limbs and joints, and even in the cure of reducible hernias, aided by the use of a truss. The powder made into a cataplasm is said to have been useful in ex- ternal gangrene; and the infusion taken from tanners' vats has been beneficially employed in old, flabby, and ill-conditioned ulcers. Administration. The dose is from thirty grains to a drachm. An extract made by boiling the decoction to dryness has been given in half the quantity. The decoction prepared by boiling an ounce in a pint and a half of water to a pint, is given in the dose of two fluidounces. In each instance, the dose may be repeated from three to six times in a day. For external use, the decoction may be made with twice the proportion of bark just mentioned. CHAP. I.] ASTRINGENTS.—KINO. 119 The fruit of the oak, or acorn, is more astringent and bitter than the bark, and has been considerably used in scrofulous affections. It is said to be more efficacious when previously roasted, in conse- quence of a supposed beneficial influence of the resulting empy- reumatic products upon the nervous system. The most agreeable form for use is that of an infusion or decoction, prepared from the roasted and ground fruit, exactly in the manner of coffee, and taken like that with sugar and cream. For an adult, half an ounce of acorns may thus be prepared for each morning and evening meal; for a child, from half a drachm to a drachm, with a conve- nient quantity of water. Acorns have been sometimes used as food in periods of famine; but they are said to produce for a time obstinate constipation, followed in the end by diarrhoea and cholera. III. KINO. U.S.,Lond.,Ed.,Dub. The name of kino was first conferred upon an astringent pro- duct, introduced into use by Dr. Fothergill of London, about the middle of the last century, and supposed to be the concrete juice of Pterocarpus erinaceus, a tree growing' on the western coast of Africa. But the same name has since been extended to similar products from other sources, and may now be considered as a generic title for various concrete juices, of a reddish-brown or blackish colour, an astringent taste, and existing either in the state of minute, shining, angular fragments, or of larger masses very readily breaking into such fragments. The varieties now in use are the E. India kino, the West India or Jamaica kino, and the South American or Caracas kino. The E. India variety is most em- ployed. 1. East India Kino is the inspissated juice of Pterocarpus Mar- supium, a large tree growing in the mountains upon the Malabar coast of Hindostan. It is in small, irregular, angular, brittle, glistening fragments, of a dark reddish-brown almost black colour, redder and lighter in powder, inodorous, of a bitterish strongly astringent taste followed by a sense of sweetness, softening in the mouth when chewed, adhering somewhat to the teeth, and staining the saliva blood-red. Water and alcohol dissolve all its active matter, receiving from it a deep-red colour. Its active principle is tannic acid of the variety which precipitates 120 GENERAL STIMULANTS. [PART II. the sesquisalts of iron of a greenish or olive black colour, called kmo-tannic acid. This differs also from the tannic acid of galls, in being converted, by exposure to the atmospheric air, into a brick- red, tasteless, and inert matter, instead of into gallic acid. Be- sides this principle, there is also extractive matter, upon which pos- sibly the bitterness may depend. Its chemical reactions are the same with those of the tannic acid of galls, except that the alkalies favor its solubility in water, while they destroy its astringency. 2. West India, or Jamaica Kino is said to be an extract of the wood and bark of Coccoloba uvifera, growing in the West Indies; but this origin is somewhat doubtful; and specimens which I have seen under that name, had the appearance of an inspissated juice, and probably were so; as, on chemical examination, they were found to contain a resinous ingredient. In sensible properties, in the characters of its active principle, in solubility, and general chemical reactions, it is not materially different from the preceding variety; except that, instead of being imported in minute fragments, it has been brought to this country in a com- pact mass in gourds, and breaks into rather larger and more rec- tangular fragments, less glistening, and not quite so dark. 3. South American, or Caracas Kino is brought from the northern coast of South America; but its botanical source is un- known. It is in large irregular masses, which, after importation, are broken up into small irregular fragments, less sharply angular, glistening, and dark-coloured than the E. India variety, and in these respects closely resembling that from the W. Indies. In taste and smell, solubility, the character of its active principle, and in general chemical relations, it resembles the preceding variety. Besides these varieties of kino, there is the Botany Bay kino, from Eucalyptus resinifera of New South Wales, and a product named Bulea gum from Butea frondosa of Hindostan, both of which have the general properties of this drug, but are scarcely used in the United States. (See U. S. Dispensatory) Effects on the System. So far as they have been investigated, the effects of kino are not essentially different from those of galls; but it is doubtful whether they exert an equal influence through the circulation; as their tannic acid is not capable, like that of galls and oak bark, of being converted into absorbable gallic acid, but passes, through the reagency of oxygen, into the state of a taste- less, insoluble, and inert matter. CHAP. I.] ASTRINGENTS.—KINO. 121 Therapeutic Application. Kino is one of the best of the vege- table astringents for internal use, on account of its purity, and general acceptability to the stomach. It is employed chiefly in diseases of the alimentary canal; and, though occasionally pre- scribed internally for haemoptysis, menorrhagia, and leucorrhcea, it probably, for reasons already given, exerts little influence in these complaints. In those forms of diarrhoea and advanced or chronic dysentery, in which astringents are indicated, it is a very useful remedy, and much employed in this country. It may also be sometimes used advantageously in epidemic cholera, in order to check the excessive evacuations. Pyrosis, hsematemesis, and intes- tinal hemorrhage are among the complaints in which good effects may be expected from it. In the last mentioned affection, occurring in the advanced stages of low fevers, it is an admirable remedy. I have seen it promptly check the most alarming hemorrhage at- tendant on typhoid fever; but it must be given very freely, much more so than under ordinary circumstances. In all these com- plaints it should generally be associated with opium. Locally, in the form of powder, it is sometimes efficacious in arresting hemorrhage from bleeding surfaces. In a bloody tumour of the roof of the mouth, which bled alarmingly upon being cut into, I once succeeded in checking the hemorrhage, after trying other means unsuccessfully, by filling the incision with the powder, and causing a piece of patent lint, on which the powder was thickly sprinkled, to be pressed firmly by the tongue against the tumour. In the same form, it may sometimes be sprinkled beneficially upon the surface of flabby ulcers. In the form of infusion also it is sometimes topically applied, as in cases of epistaxis, relaxation of the uvula, aphthae, leucorrhcea, and obstinate gonorrhoea; but its liability to stain everything which it touches is some objection to this mode of employment. Administration. The dose is from five to thirty grains, which may be repeated every two, three, or four hours in cases of urgency, and three or four times a day in the more chronic. In bowel com- plaints, it is frequently associated with prepared chalk or oyster shell, and one of the liquid preparations of opium, in the form of mixture, made by suspending the insoluble ingredients in some aro- matic water, by means of gum Arabic and loaf sugar. In the form of pill, kino may be given, combined with acetate of lead and opium, in cholera and diarrhoea. Though the salt of 122 GENERAL STIMULANTS. [PART II. lead is probably decomposed by the tannic acid, experience has proved the efficacy of the combination. Kino may also be prescribed in the form of an electuary, made by mixing the powder with syrup or molasses; and powdered cin- namon, powdered opium, and prepared chalk, one or all, may be added as circumstances may seem to require. A more elegant preparation is an infusion, made in the propor- tion of two drachms of kino and a drachm of powdered cinnamon to eight fluidounces of boiling water, and filtered when cold. Of this one or two tablespoonsful may be given for a dose, sweetened with loaf sugar, and mixed, in cases of diarrhoea, with a fluidrachm of camphorated tincture of opium, or an equivalent quantity of some other liquid preparation of that narcotic. If the effects of chalk are required, this antacid may be mixed with the infusion by the intervention of powdered gum and sugar. Tincture of Kino (Tinctura Kino, U. S.) is an officinal prepara- tion, and, in cases where the alcoholic menstruum is not objection- able, may be given, in the dose of one or two fluidrachms, added to cretaceous mixtures, or other liquid astringent preparation. It should, however, be used recently made; as it is apt to gelatinize by time, and to lose its astringency. ■♦■ IV. CATECHU. U. S., Lond., Ed., Dub. Origin and Properties. Catechu is an extract prepared from the inner wood of Acacia Catechu, a small tree growing in Hindostan, Pegu, and other parts of India. It is in masses or fragments of diversified shape and size, usually rusty-coloured externally, red- dish-brown internally, with a fracture generally smooth and some- what shining, but sometimes rough, inodorous, and of a bitterish very astringent taste, with a sweetish after-taste. It yields its vir- tues to water and alcohol. Active Principle. This is tannic acid, of the variety which yields with the sesquisalts of iron a greenish-black or olive-black precipi- tate, and may be called catechu-tannic acid. Another constituent, to which it probably owes its sweetness, is catechuic acid, which, how- ever, is not known to possess any medical virtues. Its chemical relations are the same as those of kino. Effects on the System. So far as the effects of catechu upon the system can be traced, they are almost precisely those of the medi- cine last described. CHAP. I.] ASTRINGENTS.—CATECHU.—RHATANY. 123 Therapeutic Application. Its therapeutic uses are also the same as those of kino, and need not, therefore, be repeated here. It is, however, I believe, less used internally in this country, probably because less elegant in appearance, and usually less pure. Some writers speak of it as specially advantageous in checking excessive expectoration; but I cannot think that it has much power of this kind. As a topical application, in the form of infusion, it has the advantage over kino of staining less. From its greater hardness, it is better adapted to the treatment of chronic angina, with relaxa- tion or elongation of the uvula, in which it sometimes proves very useful by being held in the mouth between the cheek and teeth, and allowed slowly to dissolve. Its solution in the saliva is thus brought constantly, as it is swallowed, into contact with the dis- eased parts, and keeps up a steady astringent action upon them. In the form of powder, it is also occasionally useful in spongy gums, to which it may be applied by means of a camel's-hair pen- cil. The tincture is preferable to that of kino, in consequence of being less liable to change by keeping. The dose of the powder is from ten to thirty grains, that of the Officinal Tincture (Tinctura Catechu, U Si), from thirty minims to three fluidrachms. The modes of administration are precisely the same as those already sufficiently described under kino. GAMBIR. This is probably the old terra Japonica. It is usually ranked with the varieties of catechu, which it closely resembles in vir- tues ; but it has a wholly different origin, being an extract from the leaves and young shoots of Nauclea Gambir (Uncaria Gambir, De Candolle), which is a native of Eastern India. It is in the form of cubes, of about an inch in size, light and porous, of a yellowish or reddish-brown colour, lighter within, an earthy fracture, and a strongly astringent, bitter, and sweetish taste. It is closely analo- gous in composition to catechu, and may be used for the same pur- poses, and in the same dose. V. RHATANY. KRAMERIA. U.S., Bond., Ed., Dub. Origin and Properties. Rhatany is the root of Krameria triandra, a shrub growing in Peru. It is usually in long, cylindrical pieces, 124 GENERAL STIMULANTS. [PART II. from the size of a straw, to half an inch or more in diameter, some- times in the form of radicles attached to a short, thick, common head. The root consists of a reddish-brown bark, in which the virtues chiefly reside, and of an interior lighter-coloured, but still reddish ligneous portion. It yields a reddish powder, is inodorous, but of a slight peculiar smell in decoction, and has a bitter, very astringent, and slightly sweetish taste. Its virtues are extracted by water and alcohol, but are impaired by boiling. The infusion and tincture are reddish-brown. Active Constituents. Its chief active principle is a variety of tannic acid, somewhat peculiar in properties, affording a deep grayish- brown precipitate with the sesquisalts of iron, and converted by oxidation, especially at an elevated temperature, into an inert apotheme. It contains, also, a bitter extractive which may have tonic virtues; and a peculiar acid called krameric, for which some influ-, ence over the system has been claimed, but of which little is known. Its chemical reactions are the same essentially as those of the other vegetable astringents in general. Effects on the System. Rhatany combines the effects of a powerful astringent with those of a gentle tonic, and does not, in these re- spects, differ observably from kino and catechu. Like these, also, it may operate less forcibly, through the route of the circula- tion, than the tannic acid of galls or the astringents containing it; because its active principle, instead of being converted by oxida- tion into gallic acid, which is at once absorbable and astringent, becomes under that process an insoluble and inert apothem. But this view of its action on the system must be considered as some- what theoretical. Tlierapeutic Application. Rhatany has been employed for all the purposes of the vegetable astringents generally, and may be considered as identical in its therapeutic application, both internal and external or topical, with kino and catechu. To mention, there- fore, in this place, the several affections for which it has been recommended would be mere repetition. There is one use of it, however, which requires special notice; as, though there can be little doubt that either of the astringents just mentioned would answer the same purpose, yet they have not been put so fully as rhatany to the test of experiment. The use referred to is in the cure of that most painful and obstinate affection, known by the name of fissure of the anus. M. Bretonneau found injections of krameria an almost certain remedy in that complaint; and his ex- CHAP. I.] ASTRINGENTS.—LOGWOOD. 125 perience has been confirmed by that of M. Trousseau. The injec- tion employed by him consisted of a drachm and a half of the extract of rhatany, dissolved in five fluidounces of water, to which about a fluidrachm of the tincture of rhatany was added. This was administered daily, the rectum having been previously cleared out by an enema of warm water, or some mucilaginous fluid. The patient usually experienced relief in the course of a week, and was effectually cured in two or three weeks. In the use of the remedy, the pains are at first sometimes aggravated; but this should not prevent a perseverance with it. Great care must be taken, after the cure, to keep the evacuations, by means of laxatives if neces- sary, in a soft state, so as to prevent a reproduction of the fissures. MM. Trousseau and Blache have employed the same remedy, with great benefit, in the treatment of fissures and excoriations of the nipple in nursing women. They first wash the part with a liquid consisting of 5 parts of the extract, 10 of the tincture, and 100 of water, and then introduce into the fissures the extract brought into a proper* consistence by means of the white of eggs. Administration. The dose of the powdered root might be from a scruple to a drachm; but the medicine is seldom used in this form. The most elegant preparation, and one of the most useful of all the vegetable astringents, is the Officinal Extract (Extractum Kra- mers, U. S.) prepared according to the directions of our national code. The dose of it is from ten to twenty grains. The Tincture of Rhatany (Tinctura Krameri^e, U. S.), and Syrup of Rhatany (Syrupus Krameri^;, U. S.), are also officinal preparations, the former of which is given in the dose of one or two fluidrachms, and the latter, which is especially adapted for children, in that of half a fluidounce for an adult, and twenty or thirty minims for a child a year or two old. VI. LOGWOOD. H^EMATOXYLON, U.S., Ed. — Hjematoxylum, Lond., Dub. Origin. This is the inner or heart-wood of Haematoxylon Cam- pechianum, a tree of medium size, growing in Campeachy, and on the shores of the Bay of Honduras, in the Peninsula of Yucatan, and in Jamaica and other West India Islands, into which it is said to have been introduced from the Continent. Sensible Properties. It comes in billets of various magnitude, 126 GENERAL STIMULANTS. [PART II. hard, compact, and heavy, of a red or yellowish-red colour, be- coming darker and almost black by exposure, of a peculiar not disagreeable odour, and a sweet somewhat astringent taste. As kept in the shops for use, it is in small chips, or in the form of a coarse powder produced by rasping. It yields its virtues, with a deep purplish-red colour, to water and alcohol. Active Principles. Its chief constituents are a variety of tannic acid in small proportion, in which its astringency resides, and a peculiar colouring principle called hsemaloxylin, to which it owes its colouring properties, and its sweetness. Chemical Reactions. The decoction of logwood produces precipi- tates with lime-water, acetate of lead, and alum, a deep-violet blue with the salts of sesquioxide of iron, and reddish curdy flakes with a solution of gelatin. Effects on the System. The effects of logwood on the system are those of a pure mild astringent, without bitterness, and without irritant properties. The colouring principle appears to be absorbed, as the urine is reddened by the internal use of the medicine. Therapeutic Application. This astringent is applicable to mild cases of diarrhoea and chronic dysentery, in which simple astrin- gency is required, and more irritating substances might be inju- rious. It is especially suited to the diarrhoea of children, and has been considerably employed in that form of it which succeeds cholera infantum, after the violence of the disease has been sub- dued. It may be used also for the general purposes of the vege- table astringents, but is too feeble for much effect, unless in cases of the kind above referred to. Administration. The only two forms in which it is used are those of the Decoction (Decoctum H^ematoxyli, U. S.) and Extract (Ex- tractum H^matoxyli, U. S.), both of which are officinal. In the preparation of the decoction, an ounce of the rasped wood is boiled with two pints of water to a pint, and two drachms of bruised cin- namon may sometimes be usefully added at the end of the boiling. The dose is two or three fluidounces for an adult, two or three fluidrachms for a child of two years, to be repeated three or four times a day, or more frequently if required. The dose of the ex- tract is from ten to thirty grains. It may be given in the form of pill or solution; but, if pills are preferred, they should be taken freshly prepared; as they are said to become so hard, by long keeping, as sometimes to pass through the bowels unchanged. CHAP. I.] ASTRINGENTS.—GERANIUM. 127 VII. CRANESBILL. GERANIUM. U.S. Origin and Properties. This name has been given to the root, or rather rhizoma of Geranium maculatum, a small, herbaceous, peren- nial plant, growing in woods throughout the United States. It is in pieces from one to three inches long, somewhat flattened, wrin- kled, tuberculated, compact, externally brown, internally reddish- gray, inodorous, and of a pure astringent taste, without bitterness, or other disagreeable quality. Active Principle. This is tannic acid, having the general properties of that principle, but of what precise character is yet undetermined; though, if it be true, as stated by some, that the root contains also gallic acid, it must be of the kind found in galls. We need, how- ever, a more accurate analysis of this medicine. Effects and Uses. Cranesbill has the effects on the system of an efficient but pure astringent. From its want of unpleasant taste, it is particularly suited to infants, and persons of delicate palate and stomach. It may be used for all the purposes of the vegetable astringents already detailed, whether external or internal; but has been most highly recommended, as an internal remedy, in chronic diarrhoea and dysentery, and, as a topical application, in cases of aphthous ulceration of the mouth and fauces. It is peculiarly appli- cable to the looseness of bowels following cholera infantum, in con- sequence of its exemption from irritant properties. Administration. The dose of the powdered root is from twenty to thirty grains. It is, however, more frequently given in the form of decoction, which may be prepared by boiling an ounce of the bruised root in a pint and a half of water to a pint, and given in the dose of one or two fluidounces, repeated three or four times a day. For infants the decoction in milk, in the proportion of an ounce to a pint, is an eligible preparation, and may be given to a child a year or two old in the dose of one or two fluidrachms, or more largely if required. An extract and tincture have been re- commended, but are little used. 128 GENERAL STIMULANTS. [PART II. VIII. BLACKBERRY ROOT.—Rubus Villosus. U.S., and DEWBERRY ROOT.—Rubus Trivialis. U. S. Origin. The blackberry and dewberry roots are those respect- ively of Rubus villosus and Rubus trivialis, indigenous briers, grow- ing in different parts of the United States. Properties. These roots are cylindrical or branching, with a brown or ash-coloured bark, and a central woody portion, the for- mer of which is of a bitter and strongly astringent taste, the latter is tasteless, and both are without smell. The woody part is inert; and either the smaller roots, or the bark only of the larger, should be employed. Water and alcohol extract all their virtues. Active Principles. These are tannic acid, and probably a peculiar bitter principle, which, however, has not yet been isolated. Effects on the System. There is no observable difference in the effects of these roots. Both are gentle tonics, and energetic astrin- gents. Therapeutic Application. Blackberry and dewberry root may be employed for the same purposes generally as the bitter vegetable astringents; but are seldom given except for bowel complaints, in which they are highly esteemed popular remedies. I have used them in diarrhoea with advantage. They are applicable only to chronic cases of this disease, or to such as are connected with intes- tinal debility; and shoulpl not be employed when there is general fever, or any acute inflammation of the mucous membrane of the bowels. They are a favourite domestic remedy in the diarrhoea which follows cholera infantum. Administration. They are usually given in the form of decoction, made by boiling an ounce of the bruised roots in a pint and a half of water to a pint, and administered in the dose of a wineglassful for an adult, a dessert-spoonful for a child two years old, three or four times a day, or more frequently. It may be well to add to the decoction, at the end of the boiling, half an ounce of bruised orange peel, or two drachms of bruised cinnamon, in order to qualify the flavour, and render the preparation more acceptable to the stomach. CHAP. I.] ASTRINGENTS.—UVA URSI. 129 IX. UVA URSI. U.S., Lond., Ed., Dub. Origin and Properties. Uva ursi consists of the leaves of Arcto- staphylos Uva Ursi, or bearberry, a low evergreen shrub, growing in the northern parts of Asia, Europe, and America, and extending in the United States as far south as New Jersey, where it is found abundantly. The leaves are from half an inch to an inch long, somewhat wedge-shaped, thick and coriaceous, with a smooth rounded margin, on the upper surface smooth, shining, and brown- ish-green, on the lower lighter coloured and reticulated, inodorous when fresh, of a hay-like smell when dried, and of a strongly astringent, bitterish, and ultimately sweetish taste. Water and officinal alcohol extract all their virtues. Active Principles. These are tannic acid of the kind found in galls, gallic acid, bitter extractive, and, according to Mr. Hughes, a peculiar crystallizable principle called by him ursin, which he found to be diuretic in the dose of a grain. (Am. Journ. of Pharm., xix. 90.) The incompatibilities of uva ursi are essentially the same as those of galls. Effects on the System. Uva ursi is astringent and gently tonic, with the property of slightly increasing the secretion of urine, and at the same time altering its colour. Its astringent principle is said to have been detected in the urine; but it was probably the gallic acid, not the tannic. In over-doses it is apt to produce nausea and vomiting. Therapeutic Application. This medicine is probably capable of producing, in a greater or less degree, all the effects of the vegetable astringents, but is less powerful than most of those already described. Towards the close of the last, and at the beginning of the present century, it was very highly esteemed and much employed in various affections of the urinary and genital apparatus, and even enjoyed some reputation in pulmonary consumption, which, however, it soon lost. It was used in chronic inflammation and ulceration of the kid- neys, gravel, diabetes, cystirrhoea, strangury and bloody urine, paralysis of the bladder, incontinence of urine, leucorrhcea, and menorrhagia • and was believed by many, if not to dissolve stone in the bladder at least greatly to relieve the symptoms of that affection. That its virtues were over-estimated there can be no doubt; but, in the natural reaction which has followed, it has appeared to me that the credit which it now enjoys is scarcely equal to its merits. The VOL. I.—9 130 GENERAL STIMULANTS. [PART II. circumstance that it changes the character of the urine would seem to show, that some one or more of its constituents passes out with that fluid; and it is not improbable that it thus directly exercises an astringent, somewhat corroborant, and perhaps alter- ative effect upon the surface of the mucous membrane, lining the pelvis of the kidney, the ureters, and the bladder. Experience has, I think, shown that it possesses this power; and it is probably to this alone that it owes any peculiar therapeutic efficacy which it may possess. No one now believes that it is capable of mate- rially modifying the symptoms of stone in the bladder, in any other way than by invigorating the kidneys when relaxed or debili- tated, or by relieving the attendant inflammation of the urinary passages; and any efficacy which it may possess in gravel must be ascribed to the same cause. It should not be employed in acute inflammation of these organs, as its excitant property, under such circumstances, could prove only injurious; but in chronic affections, when the membrane is relaxed, when atonic ulceration may be sus- pected, and the urine is loaded with pus or mucus in excess, it may be used with great propriety, and with reasonable hope of advantage. The complaints in which it has proved most efficacious, in my experience, are chronic inflammation of the pelvis of the kidney with purulent impregnation of the urine, and the similar affection of the bladder, known as catarrh of that organ, or cystirrhcea. In cases of this kind, persevered in for a long time continuously, for several months if necessary, I believe that it will occasionally effect cures even unaided, and will often prove a serviceable adjuvant to other measures. Though apparently indicated in atonic hsematuria, I have not found it equally efficacious. It sometimes appears to do good in spermatorrhoea, probably by an invigorating effect upon the mucous membrane at the neck of the bladder, or origin of the urethra; and, by a similar influence, extended sympathetically to the fibres of the sphincter, it is occasionally useful in nocturnal incontinence, though it must be confessed that it much more fre- quently fails. Administration. The dose of the powdered leaves is from a scruple to a drachm; but the Decoction (Decoctum Uvse Ursi, U.S.), made by boiling an ounce of the leaves in a pint and a quarter of water to a pint, is a more eligible preparation. It may be given in the dose of one or two fluidounces, three or four times daily. An extract is directed by the London College, the dose of which is from five to fifteen grains. CHAP. I.] ASTRINGENTS.—PIPSISSEWA. 131 X. PIPSISSEWA. CHIMAPHILA. U.S., Land. Origin and Properties. This consists of the leaves of Chimaphila umbellata, a low evergreen plant, growing in the northern parts of Asia, Europe, and America, and abundant in the United States. These leaves are about an inch and a half long, wedge-shaped, pointed at the end, notched on the border, coriaceous, shining and of a bright sap-green colour on the upper surface, paler beneath, of a peculiar odour when fresh and bruised, and of an astringent, bitter- ish, somewhat sweetish, and not disagreeable taste. Water and alcohol extract their virtues. Active Principles. These are tannic acid, and bitter extractive. It is probable that the matter indicated by the latter title is really complex, and that among its constituents is a peculiar principle, upon which all the virtues of the medicine, not connected with its astringency, depend. Effects on the System. The fresh leaves, bruised and applied to the skin, are said to be rubefacient and even vesicating. Internally, the medicine is mildly astringent and tonic, with the property of somewhat increasing the secretion of urine, to which they probably impart some degree of remediate power. It is, I think, scarcely doubtful that their peculiar active principle, through which they stimulate the kidneys, passes off, either changed or unchanged, with the urine. Therapeutic Application. Pipsissewa was much employed by the aborigines of this country, to whom it owes the name by which it is now generally designated. It is sometimes called winter green; but, as this name has also been applied to Gaultheria procumbens it should be abandoned for both. From the Indians the medicine passed into popular use, whence it was adopted by the profession. It was used chiefly in scrofula, rheumatism, and affections of the kid- neys and urinary passages. Its diuretic powers have recommended it in dropsy, and it has been employed with asserted advantage in cases of this disease attended with debility; but little reliance can be placed upon its efficacy; and at best it should be used only as an adjuvant to other more powerful diuretics. In scrofula, it is, I think, a valuable remedy. The late Dr. Joseph Parrish used it very extensively in this affection, and had 132 GENERAL STIMULANTS. [PART II. great confidence in is powers. I have myself been in the habit of employing it, in cases of external scrofula, during the whole period of my practice, and have found few remedies which have appeared to me more efficacious. Its mildly astringent and tonic properties adapt it admirably to the treatment of the scrofulous cachexia, in which a general laxity of the tissues, and debility of the functions, call for these two remedial influences; while the chronic character of the affection requires that the medication should be gentle, in order that it may be long sustained, without injury to the organs. In the earlier stages of the disease, I have been in the habit of directing, in connexion with its use, a saline laxative twice or three times a week, and in anemic cases have had recourse also to the chalybeates; but in many instances the pipsissewa has been the remedy mainly relied on. It has seemed to me to exercise a favourable alterative influence in scrofula, independently of its astringency and tonic power; but it is extremely difficult to dis- criminate, in affections of this kind, between the course of nature and the effects of remedies, so that it is proper to speak of the latter with some reserve. Fully aware of the necessity of this caution, I am still of opinion, as the result of considerable experi- ence, that pipsissewa deserves to rank next to cod-liver oil, and the preparations of iodine, in the treatment of scrofula; and may often be usefully combined with one or both of these remedies. In order that its full effects may be obtained, it should be long continued, with interruptions now and then, should any considerable degree of fever supervene. In cases attended with ulcers of an indolent or flabby character, it may be used with advantage in decoction as a wash, at the same time that is administered internally. The resemblance in properties between pipsissewa and uva ursi would suggest the employment of the former also in complaints of the urinary organs; but I have had little experience with it in these affections, and cannot, therefore, speak with confidence of its utility, though it has been recommended by others. Administration. The Decoction (Decoctum Chimaphiljb, U. S.), prepared by boiling an ounce of the bruised leaves in a pint and a Iialf of water to a pint, is the most eligible form for administration, .and may be taken in the dose of from two to four fluidounces four times a day. A pint may generally be taken by an adult in twenty- four hours without inconvenience. Some recommend the medicine :as an ordinary drink in scrofula, in the form of beer, which may ibe made by fermenting together sugar, water, and the bruised CHAP. I.] ASTRINGENTS.—PIPSISSEWA. 133 leaves, with the addition of yeast. An extract has also been recom- mended, and may be given in the dose of twenty or thirty grains. The vegetable astringents above described are those probably most used in the United States, and are numerous enough to afford all desirable latitude of choice to the physician. There are, how- ever, several others having similar virtues, and some not less efficient than the preceding, with a general notice of which I shall content myself, from the fear of needlessly embarrassing the memory of the student, referring him for a particular account of them to the United States Dispensatory. 1. RED ROSES (Rosa Gallica, U. S., Lond., Ed., Dub) are the unexpanded petals of Rosa Gallica, a European species of the rose, occasionally cultivated in our gardens as an ornamental plant. They are used chiefly in preparing a Confection (Confectio Ros^e, U.S.; Conserva RosiE, Ed) much employed as a vehicle for sub- stances made into pill, and one of the ingredients of the officinal mercurial pill; and the Compound Infusion of Roses (Infusum Rosjg Compositum, U.S., Lond), which consists of an infusion of the flowers made with the addition of a small proportion of sulphuric acid, and the virtues of which depend mainly on the latter ingredient. 2. TORMENTIL (ToRMENTlLLA, U.S., Lond., Ed) is the root or rhizoma of Potentilla Tormentilla, or septfoil, a European plant. This is a simple and powerful astringent, formerly much employed, but neglected since the general introduction of kino and rhatany into use. 3. WATER AVENS, the root of Geum rivale, indigenous in Europe and the United States, is tonic and powerfully astringent. 4. HARDHACK (SPIRAEA, U. S) is the root of Spiraea tomentosa, an indigenous shrub, all parts of which are bitter and astringent, though the root only is officinally recognized. 5. POMEGRANATE RIND (GRANATI FRUCTUS CORTEX, U.S.; Granatum, Lond) is the rind of the fruit of Punica Granatum, or pomegranate tree, indigenous in the warmer latitudes of the old con- tinent, and cultivated in the southern section of the United States. This is bitter and astringent, and is used chiefly as a gargle in sore-throat, in the form of decoction. 6. BISTORT, the root of Polygonum Bistorta, growing in Europe and Northern Asia, was formerly much more used than at present, and is now seldom imported. It is an efficient astringent. 134 GENERAL stimulants. [part II. 7. ALUM-ROOT (Heuchera, U S) is the root of Heuchera Americana, an indigenous plant, very strongly astringent. 8. MARSH ROSEMARY (Statice, U. S) is the root of Stalice Caroliniana, an indigenous maritime plant. It is an active astringent, and is used to a considerable extent in some parts of the United States. 9. PERSIMMON (Diospyros, U.S.) is the unripe fruit of Dios- pyros Virginiana, an abundant indigenous tree. This fruit, though sweet and edible when quite mature, is in the unripe state ex- ceedingly astringent, and may be beneficially employed whenever a simple vegetable astringent is indicated. XI. ALUM. ALUMEN. U.S., Lond., Ed., Dub. Origin. Alum is a double salt, composed, in the crystalline state, of one equivalent of sulphate of alumina, one of sulphate of potassa, and twenty-four of water; and denominated, chemically, sulphate of alumina and potassa. It is prepared either by the direct combi- nation of its constituents, or by various processes from certain minerals denominated alum ores, containing ingredients, by the mutual reaction of which, under favourable circumstances, and with necessary additions, the salt is generated. Sensible and Chemical Properties. This salt is in octohedral or more rarely cubic crystals, or, as it is usually found in commerce, in irregular crystalline masses or fragments, whitish and translu- cent, slightly efflorescent, inodorous, and of a strongly astringent, sweet, and acidulous taste. Exposed to heat, it first melts, then boils up, loses its water of crystallization, and becomes white and opaque, and readily reducible to powder. In this state it is called burnt alum, or, officinally, Dried Alum (Alumen Exsiccatum, U.S.). By a strong heat it is quite decomposed. In the crystalline state, it is soluble in about eighteen parts of cold, and three-quarters of its own weight of boiling water; is entirely insoluble in absolute alcohol, and very nearly so in proof spirit. It has an acid reaction with vegetable colours. Incompatibles. Alum is incompatible with alkalies and their carbonates, lime-water, magnesia and its carbonate, tartrate of potassa, phosphate of soda, and acetate and subacetate of lead, with all of which it produces precipitates. Those thrown down by the chap, l] astringents.—alum. 135 • alkalies are dissolved by an excess of alkali. It also precipitates solutions of albumen, gelatin, and many of the vegetable astrin- gents, and coagulates milk. Effects on the System. When applied externally, or taken inter- nally in such manner and quantity as not to excite irritation, alum acts, so far as can be observed, purely as an astringent, contracting the tissues, diminishing the caliber of the blood-vessels, and thus lessening the colour of the part, and diminishing secretion and exhalation. On the mucous membrane of the mouth and fauces its astringent effect is strong, and the impression which it leaves behind it durable. I have often observed that, when used as a gargle at bedtime, it so affects the tongue and palate that the sense of taste remains much blunted in the morning. Acting directly on the alimentary mucous membrane, it lessens the number and quantity of the stools. There can be no doubt that, when taken internally, it exerts its peculiar action also on the whole system, though its general is much less powerful than its local operation. The probability is that it is absorbed, as alumina has been found in the urine and viscera of animals to which it has been administered; but in what state precisely it enters the circulation has not been determined- Its effects upon the system at large are more observable in disease than in health; but dryness of the throat and fauces, with thirst, has been noticed as one of the results of its internal use. It is believed by some, and not, I think, without reason, to be somewhat refrigerant or sedative in its influence on the circula- tion. Some ascribe the astringent effects of alum to its chemical reac- tion upon the tissues. Considering how instantaneous and con- siderable is the shrinking of the mucous membrane of the mouth, when a strong solution is applied to it, I cannot conceive that the result is owing to a mere chemical change. Not only in this case, but in every other, I believe that it operates by calling the vital property of contractility into action. When used either outwardly or inwardly in large quantities, though primarily astringent, it becomes irritant after a time, and at length, if continued, may excite inflammation. This effect will follow the application even of small quantities to a very delicate or unprotected surface, as to the conjunctiva of the eye, or to the skin recently denuded of the epidermis. In such cases, its peculiar astringent effect is overwhelmed by the inflammatory action. Thus, when swallowed in the quantity of a drachm or more, it not unfre- 136 GENERAL STIMULANTS. [PART II. quently causes nausea and vomiting, and sometimes produces griping pains and purging. Devergie found about six drachms of dried alum, given to a dog, to produce death when the oesophagus was tied, so as to prevent vomiting. Under such circumstances, the mucous membrane of the stomach and bowels has been observed to be much inflamed. The same quantity, when the oesophagus is not tied, is discharged by vomiting without any permanent evil effects. Orfila found that seven drachms of powdered crystallized alum produced vomiting in dogs in from ten to thirty minutes. Dried alum, applied to a denuded surface, acts as a mild caustic, and is sometimes used with reference to this effect. When used for a considerable time, in doses insufficient to nau- seate, alum not unfrequently produces a sense of stricture in the epigastrium, precordial oppression, and other dyspeptic feelings, probably by interfering with the secretion of the gastric juice, and thus impairing digestion. Therapeutic Application. Alum is useful, as an internal remedy, in those forms and states of diarrhoea and chronic dysentery to which astringents are applicable, and in hemorrhage from the bowels under similar circumstances. It is not so well adapted to hemorrhage of the stomach, in consequence of its liability to produce nausea and vomiting; but might nevertheless be employed in this affection, in considerable doses, should other remedies fail, and the case be urgent. In the treatment of the bowel affections, it has not unfre- quently been associated with some of the vegetable astringents, such as tannic acid, kino, extract of rhatany, &c.; and, though it undergoes chemical change through reaction with these substances, yet it does not follow that the resulting products are inert; and experience has shown that the combination is often effectual. In the dose of ten or twelve grains three or four times a day, with an equal quantity of bitartrate of potassa, it has been found by Sir James Murray very useful in the chronic gastric affection, charac- terized by vomiting of glairy mucus. In comparing the remedial efficacy of alum with that of the ve- getable astringents, it will probably be found to be relatively more efficacious, when operating through the medium of the circulation, than directly upon the stomach and bowels. It is, indeed, some- times given very advantageously in menorrhagia or uterine hemor- rhage, and in cases of bloody urine. In obstinate haematuria con- nected with disease of the kidneys, I have known it apparently to produce the happiest results, after vain trials of other methods. CHAP. I.] ASTRINGENTS.—ALUM. 137 There would seem to be no reason why it should not prove equally serviceable in hsemoptysis; but it is less used in that affection; and I have myself so seldom employed it, that I should not be justified in giving an opinion, upon the ground of experience. In all the above affections, alum may be used in combination with small doses of opium, which generally co-operates to the same result, and may also serve to obviate, in some measure, its tendency to irritate the stomach. For the latter purpose, one of the aroma- tics is also not unfrequently conjoined with it, as nutmeg or cinna- mon, especially when it is given in powder. With reference to its astringent property, alum has also been given in dilatation of the heart, and aneurism of the aorta, and some- times, it has been thought, with advantage. Incontinence of urine from debility of the sphincter muscle of the bladder, spermatorrhoea, obstinate leucorrhcea, colliquative sweating, and diuresis, are other com- plaints in which it has been used with supposed benefit, and in which it would seem to be indicated. Little good can be expected from it in proper diabetes, in which it has, nevertheless, been re- commended. It was formerly supposed to possess febrifuge properties; and Cullen states that he succeeded with it in intermittent fever, given in connexion with nutmeg, in anticipation of the paroxysm. But it is not to be relied on, and is not now employed in that disease. Of much greater importance is it as a remedy in colica pictohum, or lead colic. So long ago as the middle of the last century, it was employed in that affection by Grashius, a physician of Holland, and afterwards by Dr.Thomas Percival of England; but it did not attract particular attention until, at a comparatively recent period, it was brought into notice by M. Kapeler, physician to one of the hospitals of Paris. Since that time, it has been extensively used, and experience has pronounced decidedly in its favour. I have myself employed it with the best results, even where the opiate and mercurial treatment had failed. Its mode of operating is quite unknown. Some suppose that it cures the disease by con- verting the poisonous preparation of lead, which may have caused it, into the insoluble and inert sulphate of that metal. But it is by no means always that lead-colic proceeds from a preparation of that metal swallowed. Quite as frequently it probably originates through the inhalation of the fumes of the metal, or of vapours impregnated with one of its salts; and there is in such cases no poison in the bowels to neutralize. Besides, even when the poison 138 GENERAL STIMULANTS. [PART II. has been swallowed, it probably acts much more through absorp- tion into the blood than by mere contact with the membrane. If alum, therefore, act merely as a chemical antidote, it must do so by entering into the circulation, and there producing the insoluble sulphate, which, in this position, would probably produce as much mischief mechanically as the poison had done physiologically. But, independently of these considerations, it is a sufficient refuta- tion of the notion of the chemical action of alum, that the same curative effect is not obtained from Epsom or Glauber's salt, or other soluble sulphate, or from sulphuric acid itself, which ought to be equally efficacious, if the chemical theory were true. All that we can say on the subject, in the present state of our know- ledge, is that, though alum and lead are both astringent, yet each has its own specific or peculiar mode of action, and that the influ- ence of the former is incompatible with that of the latter; in other words, alum cures the poison of lead on the principle, already suf- ficiently discussed, of supersession. (Seepage 54.) The remedy is asserted to have been found effectual in other forms of colic; and it may be employed, with hope of special bene- fit, in those cases of intestinal neuralgia which are occasionally met with, bearing a close resemblance in their symptoms to colica pic- tonum. In this disease, alum is given in doses larger than are thought appropriate in most other cases in which it is employed. From a scruple to a drachm or more may be administered every three or four hours, dissolved in some mucilaginous liquid, to which sulphate of morphia may be very advantageously added, in such quantities as may be necessary to allay the sufferings of the patient. Alum has been recommended in hooping-cough by Dr. Davies, editor of Underwood's treatise on the diseases of children. As an emetic, it has been advantageously employed in the treat- ment of pseudo-membranous croup, by the two Drs. Meigs, father and son, of Philadelphia. A teaspoonful of the powdered salt is given to the child every ten or fifteen minutes until it vomits. A second dose is seldom required to produce the effect. But it is topically that alum is most used. In arresting morbid discharges, it is probably the most effectual of the local remedies in our possession. Epistaxis very rarely fails to yield to a solution of the salt, containing fifteen or twenty grains to the fluidounce, in- jected up the nostril. When the bleeding proceeds from a readily accessible part of the membrane, the solution may be applied by CHAP. I.] ASTRINGENTS.—ALUM. 139 means of a piece of lint. In peculiarly obstinate cases, it has been recommended to snuff or blow up the powder; but the method is I believe less effective, as the remedy cannot be in this manner so thoroughly applied to the whole surface. The same solution is scarcely less effectual in the hemorrhoidal flux, and in hemorrhage proceeding from a point higher up the rectum. Three or four fluidounces of it should be injected at once, along with two or three fluidrachms of the solution of sulphate of morphia, of the U.S. Pharmacopoeia. It may also be used in hemorrhage from the mouth or throat, and to arrest bleeding from leech-bites. The latter is often extremely obsti- nate, and has even proved fatal. A method I have long used, with uniform success, is to make a saturated solution of alum in hot water, to impregnate a dossil of raw cotton with this before it begins to crystallize on cooling, and then to press the cotton upon the bite. In this way the salt is applied more effectually than it can be by any other method; as the saturated hot solution is vastly stronger than the cold, and still retains the alum, at a temperature at which it may be well tolerated by the skin. It is even better than the powder itself, which acts probably only so far as it is dissolved, and is less soluble in the blood than it is in hot water. The same appli- cation may be made, with prompt effect, in the bleeding from the socket of an extracted tooth, which it is sometimes very difficult to arrest. In severe uterine hemorrhage, recourse may also be had to the strong solution of alum as a local styptic; the liquid being injected, or applied by means of a sponge saturated with it, and introduced into the vagina. 3forbid secretions may sometimes be advantageously treated by the topical use of alum. Thus, its solution has been employed in leucorrhcea, gonorrhoea and gleets, profuse salivation, colliquative sweat- ing, and to check excessive suppuration from ulcerated surfaces, and in cases of purulent ophthalmia. To obviate relaxation of tissue, alum is locally used, commonly in solution, in flabby and fungous ulcers, and in prolapsus of the uvida, rectum, and uterus. It is employed also in aneurism from anastomosis, in order to produce contraction of the vessels. A cataplasm of alum-curd may sometimes be preferable, in the cases of ulcer and anastomotic aneurism. On the same principle of obviating relax- ation, may be explained the asserted advantage of alum gargles in some cases of loss or alteration of voice. (Bennati, Bullet, gen. de Therap., i. 256.) 140 GENERAL STIMULANTS. [PART II. In the earliest stage of inflammation, before any other change has taken place than mere congestion of the vessels, alum applied to the part sometimes arrests the disease, by diminishing the caliber of the capillaries, and thus excluding an excess of blood. For this purpose, it is much used in mucous inflammation of the fauces, or ordinary angina. A gargle made of alum, sage tea, and honey has long been a popular remedy for sore-throat. The remedial im- pression, however, is due to the alum alone; the other ingredients simply serving to qualify the taste. Some persons are very subject to these anginose attacks, which not unfrequently subject them to great inconvenience, and sometimes to danger, by extending to the larynx, bronchia, or even pulmonary tissue. The attack may often be warded off by proceeding immediately, upon the occurrence of the first symptoms, to gargle the throat with a strong solution of alum; taking at the same time a dose of sulphate of magnesia, and using an exclusive vegetable diet. But when the inflammation has become firmly established, the remedy will generally be useless or worse than useless, until the activity of the symptoms has subsided; when, if a relaxed state of the vessels remain, keeping up a slight chronic congestion, it may be again resorted to with advantage. In the pseudo-membranous form of angina and stomatitis, and in the same condition attending scarlet fever, a strong solution of alum, or the salt in powder, is sometimes very effectual. The powder may be applied by means of the finger, or more conveniently by introducing it into a tube, and through this blowing it into the fauces. This application of alum in modern times we owe to Bre- tonneau. It is generally made in cases of infants, who are most subject to the diphtheritic affection. It is usually followed by a copious salivation, and by efforts to vomit; but these cease after a few minutes. The remedy is equally effectual when applied to the diphtheritic affection, which, during the prevalence of an epidemic of the disease, is apt to attack other parts, as the nipple, mucous membrane of the generative organs, and ulcerated surfaces in any portion of the body. It may be used also in obstinate apthous in- crustations of the mouth. Painful caries of the teeth may sometimes be relieved by filling the cavity with a paste made of alum, ether, and a little mucilage, which may be repeated twice a day while the pain lasts. (Trousseau et Pidoux, 4e ed., i. 137.) In commencing ophthalmia, alum sometimes arrests the disease; but in this affection, the solution should be much weaker than when used CHAP. I.] ASTRINGENTS.—ALUM. 141 for the throat, or to arrest hemorrhage. When the inflammation is fixed, the remedy is no longer applicable; but it sometimes comes again into play when, in the advanced stage, the eye remains red, and perhaps blood-shot, from a passive distention of the vessels. Another mode of using alum in ophthalmia is in the form of alum- curd, which may be applied as a poultice over the closed eyelids, between pieces of soft linen or gauze. Other forms of inflammation, in which alum-curd may be em- ployed, are chilblain before the cuticle is broken, and the erythema tous redness which results from pressure, as in the cases of patients long confined to bed with diseases of debility. Administration. The dose of alum for ordinary purposes varies from 5 to 15 grains, which in chronic cases may be given three or four times a day, and in those more acute, every two or three hours. It may be taken either in powder or solution. In either case, it will often be desirable to make some aromatic addition, to obviate nausea. Five grains of pulverized nutmeg are often added to each dose of the powder; and an equal weight of white sugar may be mixed with it, in order to qualify the taste. Another form of administration is that of alum-whey. This is made by boiling two drachms of the powdered salt with a pint of milk, and straining after coagulation. The dose is from one to three tablespoonfuls. For external use, the curd remaining after straining the milk, in the preparation of the whey, may be employed in the form of cataplasm. Another mode of making an alum cataplasm, is to rub the white of egg with a piece of alum, in a saucer, until the albumen coagulates; or a drachm of powdered alum may be well shaken or beaten with the whites of two eggs. The curd thus prepared may be applied between folds of soft linen. The solution of alum for external use is of various strengths, according to the purpose for which it is employed. In commencing ophthalmia its strength should not at first exceed four or five grains to a fluidounce of water; for application to the urethra from five to ten grains. A much stronger solution, containing fifteen or twenty grains in the fluidounce, has been above recommended for various purposes. The uses of Dried Alum (Alumen Exsiccatum, U.S.) will be treated of under Escharotics. 142 GENERAL STIMULANTS. [PART II. XII. LEAD. PLUMBUM. The preparations of lead are here considered, because one of their most prominent properties, and that for which probably they are most employed, is their astringency; though, in other respects, they are quite peculiar, and different in their mode of action from all other medicines. In the metallic state, lead is believed to have no effect on the system. It is true that its introduction into the sto- mach has been followed by symptoms ascribable to its presence; but there can be little doubt that it underwent chemical change, under the influence of the gastric liquids, before these symptoms were experienced, at least any other than such as could be referred to a mere mechanical agency. The vapour arising from melted lead is capable of affecting the system through the lungs; but it is probably an oxide, and not the metal itself, which acts in this case. According to Mialhe, all the salts of lead, however insoluble in pure water, are in a greater or less degree soluble in the liquids of the alimentary canal, through the agency of the chloride of sodium or potassium there present. All of them, therefore, are capable of being absorbed, and of operating on the system. He does not except even the sulphate, which has usually been considered inert in consequence of its great insolubility. It is now generally be- lieved that none of the known combinations of lead are without some effect, excepting only the sulphuret. 1. Effects upon the System. The preparations of lead may act in two ways; first, by simply irritating the part with which they may come into contact; and secondly, by exercising their peculiar influence, through absorption, either on the part itself, or the system. To a certain extent, these influences are inconsistent with each other; for irritation in a part is well known to impede absorption; and, in proportion as the irri- tating substance is taken up, and removed from the point of appli- cation, is its power of irritating, in any given quantity, diminished. This fact has an important practical bearing. If the peculiar effect of lead is wanted, care must be taken that the preparation be as little irritant as possible. Thus, a quantity of acetate of lead, large enough to irritate the stomach, will be much more likely to operate CHAP. I.] ASTRINGENTS.—LEAD. 143 on the system, when administered in small doses frequently re- peated, than when the whole is taken at once. In the latter case, not only is absorption impeded by the fulness of the irritated ves- sels, but the agent is apt to be removed Vy vomiting or purgation. 1. Irritant Influence. In relation to the irritant effect of the preparations of lead, there is nothing peculiar. They are apt to operate in this way when applied largely, and to delicate surfaces; and the important point for the physician is to be able to regulate the dose of each, according to the susceptibility of the several parts with which it is brought into contact. The skin will bear more than the gastric mucous membrane, and the latter more than the delicate conjunctiva. Some of the preparations act as irritant poisons when swallowed in over doses. Too highly concentrated, they may indeed occasion the death of a part, either by excess of irritation beyond its vital capacity, or by chemical combination with one or more of its organic constituents. 2. Peculiar Influence. This, so far as it can be generalized, is the influence conjointly of an astringent and sedative. The sedative influ- ence, though felt in some degree in the circulation, is more espe- cially directed to the nervous system, and appears to affect the nerve tissue directly, rather than through the nervous centres, though these may also be involved. When the preparations of lead are given in such doses as gradually to bring the system under their influence, no observable effects may be experienced for some time, in a state of health; but, after a shorter or longer period, which varies much in different cases, the secretions are generally somewhat diminished, and the pulse often lessened in frequency and fulness. These may be considered as their legitimate effects, when they are used therapeutically; and they will sometimes prove use- ful in restraining morbid discharges, even before any change is noticed in the healthy functions. If longer continued, whether accidentally, or for medical purposes, they are capable of inducing a poisonous condition, which presents very peculiar phenomena, and not unfrequently ends in death if neglected. Practically, this poisonous condition results much more frequently from expo- sure to the influence of the metal accidentally, or in the pursuit of business, than from its use as a remedy; no doubt because, in the latter case, its operation is carefully watched, and its employ- ment suspended upon the occurrence of unpleasant symptoms. The toxicological influence of lead was investigated, with peculiar care, by M. Tanquerel des Planches; and, though much was known 1 144 GENERAL STIMULANTS. [PART II. before the publication of his treatise, and many observations have since been made, yet his account of the symptoms has served as the basis of most subsequent descriptions. Poisonous Effects. Among the earlier symptoms of lead-poisoning, are dryness of the mouth and nostrils, diminished urine, and a tendency to costiveness, with small, dry, and sometimes light- coloured stools, evincing diminished biliary and intestinal secre- tion. There are often also uneasy epigastric sensations, impaired appetite, colicky pains, and sometimes nausea and vomiting. If the gums are now examined, they will generally present a bluish or slate-coloured line along their margin, of greater or less extent; and the same discoloration will be found to affect the teeth them- selves, where joined by the gums. This appearance is ascribed to the formation of sulphuret of lead, probably through the agency of the saliva, acting upon the metallic combination in the tissue. It has also been noticed in the mucous membrane of the lips and cheeks. A sweetish, astringent taste, and a peculiar offensive odour of the breath, are said to accompany the poisonous action of lead, which is also characterized by emaciation, especially of the face, and by a dirty yellowish hue of the conjunctiva and the skin. The circulation is usually somewhat depressed, as evinced by the slow and contracted pulse; and the mind is often dejected. This cachectic condition may exist, for a long time, without any other very striking phenomena; but much more frequently it is attended either with violent abdominal symptoms, constituting a variety of colic, with external nervous disorder in the form of neuralgia or paralysis, or with serious cerebral affections. These different com- plications may exist in the same or in different persons, and, in the former case, may occur successively, or in a greater or less degree conjointly. The most frequent of them, and usually the first in the order of time, is the affection called variously, colica pictonum, painter's colic, or lead colic, which is ordinarily described as a dis- tinct disease. Lead colic is characterized by severe pains about the umbilicus, occurring more or less paroxysmally, in general not increased but rather relieved by pressure, with sensations of twisting, and a feel- ing of wretchedness, often strongly expressed upon the counte- nance. The walls of the abdomen are usually hard and somewhat retracted, and the muscles not unfrequently gathered into knots. The bowels are obstinately constipated, though there may be fre- quent desire to go to stool, with straining and tenesmus. Bilious CHAP. I.] ASTRINGENTS.—LEAD. 145 vomiting is not uncommon. The patient loses sleep, and is ex- tremely restless, often changing his position, and sometimes rising and walking about the chamber, with his body stooping, and both hands pressed upon the abdomen. If the cause be withdrawn, these symptoms will generally subside in a few days, especially under appropriate treatment; but they sometimes assume a pro- tracted form, and, more or less moderated in violence, may run on for weeks or months. Lead palsy may occur among the earlier phenomena, but is gene- rally a sequela of the colic. It may affect sensation and the power of motion severally or conjointly, and, when it affects both, may do so in different degrees. It is frequently accompanied with neuralgic pains in the muscles, joints, &c, counterfeiting rheumatism, which are usually continual, though liable to exacerbations, and are increased by motion, but relieved by pressure. Sometimes there is spasmodic rigidity of certain muscles. The part first attacked with palsy is generally the hand and forearm; and the extensor muscles are chiefly affected, so as to cause the hand, when the arm is held up, to fall as if strongly flexed. The falling hand is among the most striking diagnostic symptoms of lead-poisoning. The lower extremities are also attacked in some cases; and there is, particularly in the advanced stages, a general defect of muscular power, evinced by tremulous movements, and especially by trem- bling of the tongue when protruded. The external paralytic and neuralgic complications are generally more difficult to cure than the colic. By far the most serious effects of lead are those upon the brain. They usually occur at the close of protracted cases; but some- times earlyj either by themselves, or associated with colic or palsy. Among the most prominent are convulsive attacks similar to those of epilepsy, which are generally fatal. Sometimes the muscles become cataleptic; and sudden comatose seizures imitating apo- plexy now and then occur. Impaired sight and hearing, complete amaurosis, diminished general sensibility, delirium, stupor, and coma, are usually the last effects of the poison. Lead-poisoning may end fatally in an acute attack, or may last for years, with alternations of exacerbation and remission, of seem- ing recovery and relapse, or with a more or less continuous course of deterioration of health, under an intermittent or steady exposure to the cause. . Local Effects. Applied locally, and in a quantity insufficient to vol. I.—10 146 general stimulants. [part II. irritate, the preparations of lead produce contraction with some diminution of sensibility in the surface, and, if continued, generally occasion a bluish colour, probably by penetrating into the tissue, and forming there some new chemical combination. Anatomical Changes. The blood is deficient in red corpuscles. In one case examined by Andral, they had been reduced to 83.8 parts in 1000, the mean normal proportion being about 125. The serum has a yellowish hue, as also have the viscera. In some cases no alteration is observable in the bowels; in others, one portion has been found contracted, and another dilated in the same subject. No characteristic lesion has been noticed in the brain or spinal marrow; but the muscles long affected with paralysis are usually pale and atrophied, and the heart and blood-vessels are said some- times to be contracted. Lead has been discovered in the tissue of all the organs which have evinced signs of its poisonous influence during life. 2. Mode of Operation. There can be little doubt that the preparations of lead operate by direct contact with the parts affected, being in the first place absorbed into the blood, and then distributed over the system. By Tiedemann and Gmelin, Orfila, and other chemists, the metal has been detected in the blood, the urine and milk, the brain and spinal marrow, the muscles, the bones, the liver, spleen, and kidneys, and in the coats of the stomach, bowels, and gall-bladder. As it exists in the tissues, it is sometimes not discoverable by the ordinary tests; incineration being necessary to break up the combination in which it is probably held with organic matter. The precise character of this combination, whether in the blood or the solid tissues, is un- known. The system has in general the power of throwing off the poison sooner or later, unless in quantities sufficient to destroy life. It is eliminated by the kidneys, skin, mammae, and probably by the various secretory organs which empty into the alimentary canal. How long it may remain in the system is not certainly known; but it was found by Orfila in the liver, intestinal coats, and bones of an animal eight months after it was administered. (Med. Times and Gaz., iv. 279.) It may operate through the susceptibilities of the parts with which it is brought into contact; but there is reason to think that it sometimes at least enters into elementary combination with the tissues, and thus necessarily modifies their action. (See Arch. Gen., 4e ser. xxvii. 75.) It is probably through its presence CHAP. I.] ASTRINGENTS.—LEAD. 147 in the substance of the nerves themselves that it occasions neural- gic pains, and at length loss of power, both sensory and motive. Colica pictonum is a combination of neuralgia and partial palsy of the bowels; and thus the internal correspond exactly with the external effects of the poison. The chief avenues through which lead enters the system are the alimentary canal and the lungs. The skin, and the mucous mem- branes of the eyes, mouth, and nostrils, may possibly admit its passage in small proportion; but, with the epidermis sound, it is doubtful whether it ever enters through the skin in quantities sufficient to produce poisonous effects. It is very often applied to the surface of the body largely,-and for a long time consecutively, even in its most soluble forms, without any observable general effect. When applied to excoriated surfaces and ulcers, it is said sometimes to have occasioned serious lead-poisoning; though I have never witnessed a case of the kind. The particular part upon which it may first display its effects, and the rapidity of its operation, depend in some measure upon the surface of application. Thus, when taken into the alimentary canal, it may be inferred to be more likely to occasion colica pictonum than through any other avenue; but it must be allowed that positive proof to this effect is wanting. It probably acts most readily and rapidly through the respiratory organs. The late J. Price Wetherill, who was long and largely engaged in the manufacture of white lead, informed me that the workmen in his employ, most liable to be poisoned, were those engaged in preparing the thin sheets of lead used in the process. The operation exposed them constantly to the fumes of the melted metal. It is, moreover, well known that painters are more apt to be attacked when they use oil of turpentine in mixing the white lead, than when they employ fixed oil alone; the terebin- thinate vapours in the former case carrying a portion of the lead with them into the lungs. The persons most exposed to the poisonous influence of lead, are those engaged in the different manufactures and arts in which the metal is concerned. Miners and smelters of lead, manufacturers of white lead and other preparations of the metal, painters, plumbers, &c, are apt to be affected. The poison is frequently taken in with food or drink; and in many instances its ill effects are allowed to continue long, and are perhaps misinterpreted, because the source of impregnation is hidden. The practitioner should be careful to guard against mistakes of this kind, and, whenever symp- 148 GENERAL STIMULANTS. [PART II. toms analogous to those of lead-poisoning come under his obser- vation, should diligently search for the cause in the occupations, habits, diet, and various exposures of the patient. It is not only those engaged in the processes in which lead is used who are liable to be affected; but also all who may be exposed, from residence or accidental vicinity, to the same influence. In relation to food, independently of the occasional presence of the preparations of lead from pure accident, carelessness, or malicious intention, the poisonous impregnation may proceed from the use of lead-glazing for earthen-ware, or of soldering in metallic vessels, especially when acid substances are introduced into them, as in the instance of pickles or preserves. But drinks are much more liable to this impurity. Water, through the agency of the absorbed oxygen and carbonic acid, always contained in it when exposed to the air, is capable of acting on metallic lead, forming an oxide or carbonate, which may be held in solution in minute proportion. Of course the same result must happen from contact with the carbonate already formed. Hence, lead-poisoning has often proceeded from the use of water as drink, which had stood long in leaden reservoirs, or passed through leaden pipes; and the similar use of rain-water falling from a painted roof has produced the same effect. Certain natural waters, in consequence of the protective agency of the salts which they contain, are less liable to be thus noxious than pure water. This is particularly true of those containing carbonates and sulphates. It has been supposed that these act by forming carbonate and sulphate of lead, which, being insoluble, are pre- cipitated as rapidly as they are formed, and, giving a coating to the surface, prevent the contact of the water with the metal. This may be partially true; but such a coating must be an uncertain protection, and in fact has often proved insufficient. A better explanation of the effect of these salts is, I think, the following. The carbonates and sulphates referred to are usually those of lime. In the instance of carbonate of lime, which is in fact a bicarbon- ate, the proper carbonate being insoluble, one equivalent of the carbonic acid seizes the oxide of lead, as fast as formed, and the reproduced carbonate then appropriates the free carbonic acid in the water, which is thus rendered incapable of acting as a solvent to the carbonate of lead produced; for this carbonate is quite insoluble in pure water. A little carbonate of lime in the water may thus serve as a carrier of the carbonic acid from the water to the oxide of lead, and keep the liquid free from both. In the CHAP. I.] ASTRINGENTS.—LEAD. 149 instance of the sulphate of lime, the sulphuric acid combines with the oxide of lead as rapidly as it is generated, or decomposes any carbonate of lead that may have been produced, in either case form- ing a totally insoluble sulphate of lead, while the liberated lime would neutralize any free carbonic acid in the water. It is thus seen that these salts preserve the purity of the water, not simply by forming a mechanical impediment to its contact with the lead, but by separating the impurity at the moment of its generation. It is in this way probably that the Schuylkill water, with which the city of Philadelphia is supplied, is kept free from lead, though con- stantly flowing through leaden pipes. Water containing chlorides is not similarly protected. I have known colica pictonum to prevail in a neighbourhood where the pump-water is brackish, simply from the introduction, as a substitute for the common pump, of an apparatus containing a small portion of leaden pipe. Carbonic acid water is capable of dissolving a small proportion of lead. I have known of two cases of colica pictonum produced by drinking, every morning, the first draught from a soda-water fountain; in the leaden pipe proceeding from which, the liquid had been allowed to stand over night. The use of fermented and spirituous liquors containing lead has been a fruitful source of poisoning. Cider has sometimes been kept in leaden vats, or vessels having lead in or about them, and thus become impregnated with malate or acetate of lead with the most fatal effects. I have beet informed of cases of lead colic, produced by drinking cider which had been allowed to run from the press through a spout of that metal. Wines have become poisonous in a similar manner; and sometimes also by the purposed addition of metallic lead, or acetate of lead, to improve their flavour. I have seen an account of large numbers of a regiment in the East Indies having been poisoned by drinking arrack containing lead. Even the metal itself, in the ordinary state in which it exists of partial oxidation upon the surface, is not without effect. Lead- poisoning has been produced by the habitual chewing of sheet-lead, such as lines the tea-chests from China. I have given the above particulars by no means as illustrating all the sources of lead-poisoning, but as examples, which may serve to direct the inquiries of the inexperienced practitioner, in any suspected case of the kind. 150 GENERAL STIMULANTS. [PART II. 3. Treatment of the Effects of Lead. When a quantity of any one of the preparations has been swal- lowed, sufficient to produce severe irritation or inflammation of the stomach, an emetic of ipecacuanha should be immediately adminis- tered, along with sulphate of magnesia, or other harmless sulphate, as an antidote, and with free dilution. The salt acts by forming with the preparation of lead the insoluble and comparatively inno- cent sulphate of that metal. After the stomach has been thoroughly evacuated, a cathartic dose of the sulphate of magnesia or of soda should be given, to decompose and carry out of the bowels any of the poison which may have entered them. The remaining treat- ment must consist of measures calculated to remove any irritation or inflammation that may have been produced; as the use of opiates, demulcent drinks, counter-irritation to the epigastrium, and, if ne- cessary, leeching. The peculiar poisonous effects of lead require a different treat- ment. In such cases the metal has entered the blood, and is pro- bably lodged in the various tissues. The indications are to obviate the pathological conditions produced, and to eliminate the poison from the system. Sulphuric acid and the different sulphates have been recommended as antidotes; but it is obvious that they are not calculated to correct the action of the absorbed poison in this way; for, if absorbed themselves, they could act only by converting the combination of lead, existing in the blood or the tissues, into a sul- phate, which, from its comparative insolubility, would resist elimi- nation, and might continue to exercise a noxious influence, if fixed in the solids. It is only by operating on any portion of the poison existing in the alimentary canal, that they could do good in this way; and, when there is reason to suppose that such a condition of things exists, they should be employed. The sulphurets have a similar antidotal power; but, from their more irritant properties, they are seldom given internally. Used externally, in the form of bath, they prove advantageous by converting into the inert sul- phuret any preparation of lead that may adhere to the surface; and probably still more so, by disposing, through their chemical agency, to an elimination, upon the surface of the body, of the lead which may be circulating in the blood. It is asserted that, in cases of saturnine impregnation of the system, the use of these baths is fol- lowed by the production, upon the skin, of a dark matter, which is the sulphuret of lead. The result may, it is true, be ascribed to the excretion of the lead by the skin, through the unaided powers CHAP. I.] ASTRINGENTS.—LEAD. 151 of the system; and the antidote may act simply by forming a sul- phuret with the excreted metal. Even in this case, it might prove useful by putting the poison into a condition unfitting it for reab- sorption; but the probability, I think, is, that it has a positive power of elimination through its affinity for the lead in the blood- vessels, acting through the epidermis and the capillary walls; and that thus the poison is withdrawn much more rapidly than it would b-e by the excretory power of the skin alone. The bath may be made by dissolving four ounces of sulphuret of potassium in thirty gallons of warm water, in a wooden tub. After immersion, the dark coating formed should be removed from the surface by scrub- bing with a stiff flesh-brush, with soap and water; after which the patient should be again immersed, and the process repeated so long as any obvious discoloration of the skin is produced. In a short time, a renewal of the bath will be found aga'in to discolour the skin. The measure, therefore, should be repeated twice a week, and not abandoned until this effect ceases to be produced, which may not happen for many weeks. Another method by which lead may be eliminated from the sys- tem, is through the agency of some body, which, received into the blood, and circulating with it, maybe brought into contact with the insoluble compound of lead in the tissues, and, rendering it soluble in the blood, may enable that fluid to take it up, and discharge it through the different emunctories. Iodide of potassium, which, in an alkaline solution, has the property of dissolving lead, was recom- mended for this purpose by M. Melsens, and was found by him to be one of the most efficacious remedies in lead-poisoning. Accord- ing to this theory of its action, evidences should be presented of the absence of lead in the urine or other excretions before the use of the iodide, and its presence afterwards. This evidence M. Melsens did not produce; but, subsequently to the publication of his me- moir, Dr. E. A. Parkes, of London, found the requisite proof in a case which came under his notice (Brit, and For. Medico-Chirurg. Rev., Am. ed., xi. 411); and Dr. H. S. Swift, of New York, has given an account of no less than twenty-three cases, in which the iodide was used very advantageously in obstinate lead-poisoning, and in many of which lead was detected in the urine after the use of the remedy, though in no instance could it be discovered previously. (N. Y. Med. Times, iii. 145.) M. Melsens found, in his experiments on animals, that the poisonous effects of the lead were increased when the iodide was early employed, probably in consequence of 152 GENERAL STIMULANTS. [PART II. its rendering the poison in the alimentary canal more soluble, and consequently more readily absorbed; and it is not impossible that the liberation of the lead from certain tissues, and its reintroduc- tion into the blood, may occasionally, for a time, aggravate the symptoms. Dr. Swift noticed this in two out of twenty-three cases; but the aggravation was slight, and improvement was soon evinced. From five to twenty grains of the iodide may be given three times a day, and continued until the symptoms of poisoning cease. One evidence of improvement is the disappearance of the blue discoloration of the gums produced by the lead. The above remarks are applicable to lead-poisoning in general. Particular forms of it require special modifications of treatment. In the form of colic, it is necessary to relieve the pain and over- come the obstinate constipation. For this purpose, the preparations of opium are to be employed in connexion with purgatives, of ^ which calomel, croton oil, castor oil, and sulphate of magnesia are perhaps the best. The last mentioned remedy has the additional advantage, of converting the poisonous preparation of lead in the bowels into the sulphate. The purgatives may be aided by cathartic enemata. Tobacco cataplasms, and chloroform over the abdomen, have been recommended for the purpose of relieving pain and re- laxing spasm; and the latter remedy has been used internally with the same view. The mercurial impression has been considered as antidotal to the saturnine, and calomel with a view to salivation has been considerably used; but it is seldom necessary. Alum often acts most happily in the disease, sometimes speedily relieving all the symptoms, when the opiate and purgative plans have failed. It may be employed conjointly with them from the beginning of the treatment. It has been supposed to operate chemically, either upon the poison remaining in the bowels, or on that contained in the tissue of their coats, by converting the compound of lead into a sulphate; but, were this its mode of action, the same effects should be obtained from diluted sulphuric acid or Epsom salt, which have not been found to answer as well in practice. As the insensibility of the bowels to purgative influence is probably owing to a partial condition of paralysis, the use of strychnia is indicated in obstinate cases. In the paralytic cases, besides the use of the antidotal measures above referred to, and especially iodide of potassium and sulphu- retted baths, recourse may be had to strychnia, electricity, and the application of blisters; and the mercurial impression may be tried, CHAP. I.] ASTRINGENTS.—LEAD. 153 should other measures fail. When neuralgic pains complicate the palsy, opiates or other anodynes may be conjoined with the antidote. In the cerebral cases, whether convulsive, comatose, or delirious, general and local bleeding, cold to the head, sinapisms or blisters to the extremities, and purgation have been generally deemed ad- visable; and, should the state of the circulation call for these reme- dies, they should undoubtedly be employed. But there is reason to believe that these phenomena, sometimes at least, depend upon a direct impression made by the lead upon the cerebral centres, analogous to that upon the bowels and the external muscles; and, as this is rather of a depressing than excitant character, it may be a question, whether opiates and other cerebral stimulants may not prove more effectual than depletory measures. In a fatal case, with violent delirium, spasmodic rigidity of the muscles, and convulsions, ending in coma, in which the depletory and revulsive measures were employed with no effect, no sign could be discovered after death of inflammation or active congestion of the brain or its mem- branes. (Arch. Gen., 4e ser. xxvii. 71.) In such a case, if attended with an unexcited state of the pulse, and paleness of the face, I should be disposed to try the plan referred to, of course in conj unc- tion with the proper antidotal measures. Prevention. In relation to preventive measures, the best rule is to guard, by extreme care, against the introduction of the poi- son into the system. For this purpose, the cautions should be observed to keep the hands and surface of the body clean, and, as far as possible, to avoid swallowing any of the poison whether in food, drink, or mixed with the saliva. It cannot be kept from the lungs when the air inspired is impregnated with it; but much may be done for self-protection by preventing this im- pregnation, and by avoiding the inhalation of the poisoned atmo- sphere. Thus, in the manufacture of white lead, it has been found that the disease is less prevalent since the introduction of grinding the salt under water, than when it was powdered dry, and thus caused to fill the air with its fine particles. The habitual use of sulphuric acid, diluted so as to form an agreeable drink, has been recommended as a preventive to those who are necessarily exposed. But it is evident that the acid can act only on the portion of the poi- son swallowed; and, as the sulphate has been shown not to be alto- gether innocuous, it cannot be a complete safeguard even against this; while the steady use of a substance so active as sulphuric acid cannot itself be without its inconveniences. 154 GENERAL STIMULANTS. [PART II. 4. Therapeutic Application. The therapeutic indications to be fulfilled by the preparations of lead, based upon their astringent and sedative properties, are mainly to arrest hemorrhage and morbidly increased secretions, and to reduce inflammation. But it will be most convenient to consider the remedial uses of the metal, under the head of its several preparations, and especially under that of the acetate, which is the only one much employed internally. 5. Preparations of Lead. I. ACETATE OF LEAD.—Plumbi Acetas. U.S., Lond., Ed., Dub. — Sugar of Lead. — Saccharum Saturni. Acetate of lead is prepared by the action of vinegar, or other form of dilute acetic acid, either upon plates of metallic lead oxi- dized by exposure to the air, or directly upon the protoxide of lead with the aid of heat. It is the neutral acetate of the protoxide of lead, consisting of one equivalent of acetic acid, one of protoxide of lead, and three equivalents of water. Sensible and Chemical Properties. This salt is in the form of shin- ing, white, acicular crystals, isolated or in masses, efflorescent, of a sweet and astringent taste, and often, when long kept, of an acetous odour, owing probably to the action of the carbonic acid of the air, and the slow escape of acetic acid. It is readily dissolved by water; and the solution has a white turbid appearance, which, when the water is free from saline impurities, is removed by the addition of vinegar or acetic acid. The whiteness is owing to the carbonate of lead, formed by the combination of the carbonic acid which is contained in all natural waters, with a portion of the protoxide of lead, liberating the acetic acid, and thereby giving the solution an acetous smell. In hard waters, the white precipitate is usually a sulphate or chloride of lead, and not redissolved. Dis- tilled water, recently boiled, forms a perfectly clear solution with the acetate, if quite pure; but, as found in the shops, the salt often contains a portion of carbonate, in which case the solution will be more or less opaque. Incompatibles. Acetate of lead yields precipitates with sulphuric, phosphoric, citric, tartaric, meconic, and carbonic acids,* and all * I have verified by experiment the decomposition of perfectly neutral and pure acetate of lead by carbonic acid. The whole of the salt, however, is not decom- posed ; as, when the acetic acid has attained a certain degree of excess, it appears to prevent the further action of the carbonic acid. CHAP. I.] ASTRINGENTS.—ACETATE OF LEAD. 155 the soluble salts of these acids; with hydrochloric and hydriodic acid, and all the soluble chlorides and iodides; with hydrosulphuric acid, and the soluble sulphurets; with tannic acid, and consequently all the vegetable astringents; with certain mucilages, and espe- cially that of slippery elm bark, but not with pure gum; with chondrin and albumen; and with lime-water, and solutions of am- monia, potassa, and soda, the last two redissolving the precipitate if added in excess. The precipitate formed with the sulphurets is black, with the iodides yellow, and with the other reagents mentioned white or whitish. But, though the above substances are chemically incompatible, it does not follow that they are medi- cinally so. On the contrary, many of the precipitates are probably not less efficient than the acetate; and, in fact, this salt is often ex- hibited in connexion with substances which decompose it. What it is necessary for the practitioner to guard against is the addition of the incompatible substances in solution. In the form of pill or powder, they may frequently be added with advantage, when reme- dially indicated. The only substances which should always be avoided are sulphuric or hydrosulphuric acid, and the soluble sul- phates or sulphurets; as the precipitates formed with these are feeble, if not inert. It is probable that acetate of lead is always decomposed in the alimentary canal, either by the hydrochloric acid or the chlorides in the stomach, or hydrosulphuric acid in the bowels. Effects upon the System. Acetate of lead has all the effects upon the system which have already been described as characterizing the preparations of lead in general. In large doses, or unsuitably ap- plied, it is irritant; but, when so employed as to obtain its peculiar influence, it is astringent and sedative. 1. Its irritant effects are shown when it is applied in strong so- lution to delicate surfaces, as to the conjunctiva, the urethra, or the skin denuded of the cuticle, or when taken too largely into the stomach. Orfila found it, when introduced in large quantity into the stomach of dogs, to occasion fatal inflammation; and the gastric and intestinal mucous membrane was observed to be whitened by its chemical action. In man, when taken in excessive doses, it generally produces vomiting, burning pain in the oesophagus and stomach, and tenderness in the epigastrium, usually followed by severe griping in the bowels, and sometimes by convulsions, coma, and local palsy, especially if the bowels are not acted on. Its dan- gers, however, as an irritant poison, were formerly much overrated; 156 GENERAL STIMULANTS. [PART II. for, though often taken accidentally in quantities varying from a drachm to an ounce, no fatal case is, I believe, on record from its immediate effects. Being frequently prescribed for external use, at the same time that Epsom salt is directed as a cathartic, it has not unfrequently been swallowed instead of the latter, which, in its turn, has been applied locally; and this accident should be care- fully guarded against by the practitioner. I was once called to a case of the kind, in which two drachms of the acetate had been swallowed, with the effect of producing severe gastric pain; but before I reached the patient, a dose of sulphate of zinc had been taken, which caused vomiting; and no injury ensued. What quan- tity, therefore, may be considered as poisonous, in reference to the irritant action, it is impossible to say; but this much may be in- ferred, that there is less danger to life from its temporary influence in an excessive dose, than from the same amount given in minute doses frequently repeated, and spread over a considerable length of time. The mode of treating its poisonous effects, as an irritant, has been given under the general head of the preparations of lead. The best antidote is sulphate of magnesia, or sulphate of soda. 2. It has been doubted whether acetate of lead is capable of pro- ducing the poisonous constitutional effects of the metal, especially if protected against conversion into the carbonate by an excess of acetic acid. Certainly, considerable doses have been given daily, and continued long, without any observable influence on the gene- ral system; and the extreme fear formerly entertained by many, as to the danger of its internal use as a medicine, have been shown to have had little foundation in fact. Nevertheless, that it is capable of producing, when incautiously or recklessly employed, all the dangerous constitutional effects of lead, has been abundantly proved by experience. Dr. Mulford, of Camden, N. J., many years ago, assured me that he had witnessed two cases of colica pictonum re- sulting from its medicinal use; and many instances to the same effect have since been placed on record. Death has occurred in one instance from colic and paralysis, in a boy of fifteen, to whom from one to eight grains, in divided portions, were given daily until the whole amounted to somewhat more than two drachms. In the Provincial Medical and Surgical Journal (June 27, 1849), Dr. Wm. Norris, of Stourbridge, relates an occurrence in which nearly a thousand persons were more or less poisoned, in consequence of a mistake made by a baker, who mixed thirty pounds of acetate of lead, instead of the same quantity of alum, with sixty or eighty CHAP. I.] ASTRINGENTS.—ACETATE OF LEAD. 157 sacks of flour. It may be said that, in this case, the acetate was decomposed before being taken. It probably was so; but not more certainly than it is decomposed in the stomach, after having been swallowed. Dr. L. S. Joynes, of Accomack, Va., has related a case of obstinate colica pictonum, which resulted from thirty grains of the acetate, given in four days, though care was taken to accom- pany the use of the medicine with vinegar. (Stethoscope, i. 664.) It is proper, therefore, to observe some caution in the use of this medicine. With such caution, I believe it may always be given safely. I have been in the habit of using acetate of lead for more than thirty-five years, have given it in a vast number of cases, and though, after a certain continuance of the medicine, griping pains in the bowels have generally occurred, frequently with nausea and general malaise, I have never witnessed more than one instance in my practice, in which anything that could properly be denominated colica pictonum has resulted. I have not unfre- quently prescribed two grains every two hours through the day, and continued it for several days, sometimes even for weeks, before any sign of its constitutional effects were evinced. I have, how- ever, always been careful to suspend the medicine as soon as the effects on the stomach and bowels just referred to, or a blue dis- coloration of the gums, have been noticed. Therapeutic Application. This medicine is much used for the general purposes of the astringents. In consequence of its combi- nation of sedative with astringent properties, it will frequently act very efficiently in the relief of inflammation, when brought directly into contact with the surface affected; and it is to this agency that much of its therapeutic value is to be ascribed. I shall first treat of its internal, and subsequently of its external or local use. 1. Internal Use. The hemorrhages are among the complaints in which it is most useful. Its sedative property gives it a great advantage in these affections, especially when of the active kind, over other astringents, which, being somewhat, however slightly, stimulant, cannot always be employed with propriety in the early stage. Acetate of lead may always be given when the indication exists to suppress the discharge. From the facility, however, with which lead is absorbed, the medicine is more especially adapted to those cases in which the affected part can be reached only by the medium of absorption and circulation. When the seat of the hemor- rhage is such that the astringent can be directly applied to it, alum is probably more efficient as a mere hemostatic. Such are the cases 158 GENERAL STIMULANTS. [PART II. of hemorrhage from different parts of the alimentary canal. But in hemorrhage from the lungs, acetate of lead is preferable to all other astringents, and is very much used. In hemorrhage from the kidneys, and from the uterus, it is also one of the best remedies. In the former, I have seen it promptly effectual, and would strongly recommend it. In all these cases, but especially in haemoptysis, it should generally be combined with a little opium to prevent irri- tation of stomach, and with ipecacuanha if there is febrile excite- ment, without nausea or a tendency to it. The opiate is especially indicated in the pulmonary affection, from its effect in quieting the cough. About one-sixth of a grain of opium, and an equal or double quantity of ipecacuanha, may be combined with each dose of the acetate. Though, as above stated, alum is probably more effectual in hsematemesis and intestinal hemorrhage, yet the salt of lead is frequently employed in these affections, and not without advantage. It should in these also be combined with opium. In certain conditions of diarrhoea, this medicine is very useful. I do not think it adapted to the acute form of the disease, attended with inflammatory excitement; but rather to chronic cases with copious and exhausting discharges, with or without ulceration of the small intestines; and I have also found it extremely useful in certain cases, whether recent or of long standing, in which, without evidences of inflammation, the evacuations are very copious, and of a whitish gruel-like appearance from the absence of bile. In these latter cases, it should be given in combination with small doses of calomel and opium, and frequently repeated* In epidemic cholera, with exhausting rice-water discharges, the above mentioned combination is, I think, the most efficacious which can be employed; but the urgency of the danger in this case de- mands larger doses than simple diarrhoea; as it is of the utmost importance to produce a prompt impression. The advanced stages of cholera infantum may sometimes be treated advantageously with this astringent. It may be tried in all obstinate cases of the disease, in connexion with opiates, and with a little calomel or blue mass when bile is wanting in the pas- sages. Occasionally it has been found efficient, not only in arrest- ing the diarrhoea, but also in correcting the irritable stomach of * The following formula may be used. R. Plumbi acetat., gr. vj; Hydrarg. chlorid. mit., Opii pulv., aa gr. j; Acaciae pulv., Syrup., aa q. s. Mix, so as to form a mass, to be divided into six pills, of which one may be taken every half hour, hour, or two hours, according to the urgency of the case. CHAP. I.] ASTRINGENTS.—ACETATE OF LEAD. 159 this disorder, probably by an antiphlogistic influence on the gastric mucous membrane. It is the same antiphlogistic action which has recommended it in dysentery, in the treatment of which it is highly esteemed by some. Its use in acute dysentery originated with the late Dr. Richard Harlan, of Philadelphia; and has found many advocates. I con- fess, however, that my experience with it, in the ordinary forms of this affection, does not accord with theirs. It no doubt appears to act favourably in some cases; but I have often met with others, in which, after an employment of several days, it has in- creased the griping and uneasiness of the patient, without any bene- ficial influence over the disease, and in which the symptoms have speedily subsided, under proper treatment, after its omission. But in chronic cases, with rather copious discharges, it is often useful. I shall have occasion directly to refer to a condition of dysentery, in which it may be employed as an injection with the greatest ad- vantage. As in other bowel affections, it should in this also be associated with opium. Excessive sweating, exhausting diuresis, copious mucous or purulent discharges from the respiratory and urinary passages, and abundant suppuration, from whatever source, have been considered as offer- ing indications for the astringent influence of acetate of lead. In phthisis it has been recommended for the night-sweats, the muco- purulent expectoration, which is sometimes exhaustingly copious and the diarrhoea, either severally or conjointly. As to the night- sweats, I think they are, in general, more effectually and more safely controlled by other means, less calculated than the acetate of lead to disturb the digestive process, which it is all-important to sustain. The same remark is applicable to the expectoration. In these affections, therefore, separately, I would not advise the remedy; but, when they exist in combination with obstinate diarrhoea, and a chronic sub-inflammatory condition of the gastric mucous mem- brane, the indication for its use, in reference to the latter condi- tions, is perhaps strengthened by the possible benefit which may be hoped for from it, in reference to the former. Obstinate mercurial salivation is said to have yielded to the in- ternal use of this remedy; but its local application is preferable. In yellow fever, acetate of lead was strongly recommended by the late Dr. Irvine, of Charleston, S. C. It is only in the second stage, after the subsidence of the first long febrile paroxysm, that the remedy should be employed. At this period, with greatly reduced 160 GENERAL STIMULANTS. [PART II. powers of system, and probable depravation of the blood, there is usually phlogosis of the gastric mucous membrane, with a tendency to prostrating hemorrhage, in the form either of unaltered blood or black vomit. Should the blood be fatally depraved, no medicine could save the patient; but in doubtful cases, where a slight im- pression might turn the scale in the favourable direction, it seems reasonable to expect benefit from a medicine, calculated, by con- tracting the vessels, and exercising a sedative influence on the nerves, at once to correct the inflammation and obviate the hemorrhage. I have, myself, used the acetate of lead under these circumstances, in a few instances, and in all with favourable results. In one case, there was an appearance, in the evacuations from the stomach, of commencing black vomit. Two grains should be given, with a little opium, every two hours, and continued until thirty-six or forty-eight grains have been taken, or until the dangerous period is past, unless some unpleasant effect of the medicine should be first experienced. I would repeat, that the acetate is not to be used until the first febrile symptoms have begun to subside, which is usually on the second or third day. In enteric or typhoid fever, acetate of lead would seem to be indi- cated as an alterative and antiphlogistic remedy for the diseased state of the mucous membrane of the ileum. Hence, it has been recommended in this affection by the German practitioners. In this country, it has been employed very successfully by Dr. John L. Atlee, of Lancaster, Pa., who gives it in doses of from one to three grains every two, three, or four hours, commencing, after having first evacuated the bowels by a mild cathartic, and perse- vering so long as the enteric symptoms continue. I cannot speak of the remedy from experience, having never used it in this com- plaint. In the irritable stomach of bilious fever, and in other cases of obsti- nate vomiting, the medicine has been employed with supposed ad- vantage ; though it might be difficult to say, in many instances of this kind, how much was due to the acetate, and how much to the opium usually given along with it. Aneurisms of the aorta and other large internal vessels have been treated with some advantage by acetate of lead. Introduced into use originally in Germany, the practice was imitated by Dupuytren and others in France; and I have myself tested its efficacy in some degree in this country. The astringent and sedative influence of the preparations of lead would seem to be indicated in this affec- CHAP. I.] ASTRINGENTS.—ACETATE OF LEAD. 161 tion; and several instances are on "record in which the tumour has very much diminished in size under the use of the acetate. (Arch. Gen., 3e se'r. 5, 443.) In one of several cases in which I employed it in the Pennsylvania Hospital, an aneurismal tumour, which showed itself projecting from the thorax near the left sterno- clavicular junction, underwent a marked diminution, and became at length scarcely perceptible; but the patient left the house be- fore any definitive result was obtained. I am not aware that any satisfactory case of a complete cure by this remedy has been reported. Indeed, considering the condition of the coats of the vessels in internal aneurisms, altered as they generally are by atheromatous deposit, cartilaginous or bony degeneration, or other organic affection, a cure by this measure would be in most cases im- possible ; and, even when no insurmountable difficulty of this kind might be in the way, few constitutions would probably be found to tolerate, and few patients to submit to the long-continued and per- severing use of th% medicine which would be necessary to success. The plan is to give six or eight grains of the medicine daily, in doses of one or two grains, at equal intervals, and to continue until nausea or griping pains in the bowels, or other symptoms of lead- poisoning are exhibited; then to suspend the remedy until these symptoms have subsided; after which it is to be resumed; and thus alternately, until the end aimed at is effected, or found to be unattainable. Simple enlargement of the heart, independent of disease of the valves, would seem to offer quite as good a chance of success, under this treatment, as internal aneurism. I have employed it in cases of this kind; and, in one of great cardiac dilatation in a boy, found the dimensions of the heart, as indicated by percussion, to diminish considerably. What finally became of the case I do not know; as the patient passed from under my care in the midst of the treatment. Acetate of lead has been used in various nervous diseases, as epilepsy, hysteria, hooping-cough, and even tetanus; but few would at present expect from it any very material benefit in these affections. I remember to have seen somewhere an account of a case of hydro- phobia which had ended favourably under its use; but there can be little doubt that the disease was mistaken. . 2. Local, or External Use. Under this head, it is intended to em- brace all those modes of using the remedy, in which it is brought into direct contact with the seat of its intended operation through vol. i.—11 162 GENERAL STIMULANTS. [PART II. extraneous agency, including injection into the various passages opening externally, as well as application to the surface of the body. In these it acts upon the same principles as when used in- ternally. But it is more especially for its antiphlogistic effects that it is employed. As a mere styptic, either for arresting hemorrhage, or controlling increased secretion unconnected with inflammation, as excessive sweating for example, it is less efficient than alum, or probably the vegetable astringents. In reference to the mucous surfaces, it is, as a general rule, better adapted to the earliest stage of inflammation, or the very advanced stage when suppuration has taken place, or to the chronic forms of the affection, than to the condition of acute inflammation in full vigour. But this remark does not apply to affections of the skin, protected by the cuticle. As an eye-wash in ophthalmia, from one to two grains of the acetate may be dissolved in a fluidounce of rose water, or simple distilled water. In chronic inflammation of the nasal passages, Sjoith purulent dis- charge, a solution containing from ten to twenty grains to the fluid- ounce of water, may be injected or otherwise introduced into the nostrils, once or twice daily, with hope of benefit. Care, however, should be taken, in such cases, that none of the solution is swal- lowed. Chronic suppuration of the auditory meatus may be treated in a similar manner; though it would be prudent to commence with a weaker solution, say from two to five grains to the fluidounce, and to increase if found necessary. As a mouth-wash or gargle, acetate of lead is chiefly employed in cases of mercurial salivation, in which it is one of the best appli- cations. For this purpose, the solution may have the strength of two or three grains to the fluidounce, to begin with. It often blackens the teeth and tongue, in consequence of the formation of sulphuret of lead, through reaction with the sulphur contained in the salivary liquids. But this discoloration is of no serious importance, and gradually disappears. In ordinary ulceration, or pseudomembranous affections of the mouth and fauces, sulphate of zinc, or nitrate of silver, in solution, is more effectual than the salts of lead. In certain cases of dysentery affecting the rectum especially, and attended with little general disturbance of the system, a solution of acetate of lead injected into the rectum often serves an excellent purpose. It will sometimes put an almost immediate end to cases, CHAP. I.] ASTRINGENTS.—ACETATE OF LEAD. 163_ which have proved tedious under other treatment. From four to six fluidounces of a solution, containing two or three grains of the acetate in each fluidounce, with thirty or forty drops of laudanum in the whole quantity, should be injected three times a day. The laudanum is useful by facilitating the retention of the liquid, as well as by directly calming irritation. It is true that the meconate of morphia is converted into the acetate, while a little insoluble meconate of lead is formed; but this result is of no practical im- portance. It may be obviated, however, by substituting for the laudanum one-quarter or one-third of a grain of acetate of morphia. Enemata composed of ten grains of this salt dissolved in six fluidounces of warm water, and administered every two hours, are said to have been used, with remarkable success, in strangulated hernia. In gonorrhoea and leucorrhcea, injections of acetate of lead are often very useful. For the effectual treatment, however, of these affec- tions, the solution should be very frequently repeated, so that the impression may be steadily maintained. In gonorrhoea, the injec- tion should be administered not less than six times a day, at equal intervals. It should be at first of the strength of two or three grains to the fluidounce, which may be increased if necessary. Perhaps for no purpose is this salt more employed than for the relief of inflammatory affections of the skin and the subcutaneous tissue. In erysipelas, when the inflammation is very high; in the more in- flammatory forms of erythema, as E. nodosum; in certain cases of herpes, eczema, and other cutaneous eruptions attended with much heat, pain, and redness; in inflammation of the subcutaneous areolar tissue, either arising spontaneously, as in phlegmon, or resulting from sprains, bruises, &c.; and in acute swelling of the external lymphatic glands, a solution of acetate of lead is often highly useful in the alleviation or cure of the inflammation. For these purposes, two drachms of the acetate may be dissolved in a pint of soft water; the turbidness being corrected by a fluidrachm of vinegar or diluted acetic acid. In some cases, laudanum or acetate of morphia may be usefully added. The solution may be applied by means of folded linen wet with it, or by the cold poultice, formed by mixing the solution with crumb of bread, and enclosing the soft mass in linen or gauze. It is customary, in cases of superficial inflammation, particularly the erysipelatous, to apply mucilaginous solutions with a view to their antiphlogistic effect. This may be increased by the addition 164 GENERAL STIMULANTS. [PART II. of acetate of lead to the solution; but it should be remembered that this salt is incompatible with certain mucilages, particularly with those of slippery elm and quince-seeds, with which it forms precipi- tates, and thus deprives the liquid of its mucilaginous property. But with the mucilages of flaxseed and the pith of sassafras it reacts but slightly, not sufficiently to impair materially their demulcent properties, or to interfere with its own efficiency. These latter mucilages, therefore, should always be selected, preferably to those first mentioned, for external use in connexion with acetate of lead. Thus, we may add this salt with propriety to an eye-wash of mu- cilage of sassafras pith, often used in ophthalmia, while it would be incompatible with mucilage of quince-seeds, also used for the same purpose. In irritable or inflamed ulcers, and those attended with very pro- fuse discharges, and in inflamed blistered surfaces, a solution of ace- tate of lead may also be used, but of not more than half the strength of that employed where the cuticle is entire. In these cases, the acetate often reacts with the albumen and salts of the secreted liquid, producing a white insoluble compound. This is ordinarily of no inconvenience; but, in ulcers of the cornea, there is danger that this compound may become permanently incorporated with the tissue, forming an opaque spot, which cannot be removed. In this affection, therefore, the salt should not be used. Administration. Acetate of lead may be given in pill or solution. The pill is best made with mucilage of gum Arabic and syrup, as these are not incompatible with the salt. It should be prepared as wanted for use. Opium is often combined with the salt; and, though mutual decomposition may take place between the meco- nate of morphia and the acetate of lead, no practical disadvantage results. Nor is the addition of the vegetable astringents impro- per, as the resulting tannate of lead is efficient. When the salt is given in solution, the preparation is rendered more elegant by the addition of a few drops of acetic acid, or a little distilled vinegar; but Dr. Thomson was mistaken in thinking that the poisonous effects of the lead could in this way be prevented. Colica pictonum has followed the use of the acetate thus protected. Indeed, it may be considered nearly certain that the salt is always decomposed in the stomach, whether given with or without a little acetic acid. Laudanum renders the solution turbid by the formation of meco- nate of lead; but its efficiency is not impaired. The other incom- patibles before referred to (see pages 154-5) should be avoided in CHAP. I.] ASTRINGENTS.—SUB ACETATE OF LEAD. 165 connexion with the salt in solution, though many of them may be given with it in the pilular form. The dose of acetate of lead is from one to three grains, which, in acute cases, may be repeated every hour, two, or three hours, and in chronic cases, three or four times daily. The British Pharmacopoeias direct an ointment or cerate of ace- tate of lead, which may be employed as a dressing for irritable or inflamed ulcers, excoriated surfaces, and blisters, and may be made extemporaneously by thoroughly rubbing together half a drachm of the salt very finely powdered, and an ounce of simple ointment; but the cerate of the subacetate is preferable, for the purposes mentioned. II. SOLUTION OF SUBACETATE OF LEAD.—LlQUOR Plum- BI SUBACETATIS. U.S., Dub. — LlQUOR PLUMBI DlACETATIS. Lond. — Plumbi Diacetatis Solutio. Ed. — Goulard's Ex- tract. This is made by boiling together litharge or protoxide of lead, and solution of acetate of lead, and filtering. It is a solution of diacetate of lead, consisting of one equiva- lent of acetic acid and two of protoxide of lead. Sensible and Chemical Properties. The solution is a colourless liquid, of a sweetish and astringent taste, of the sp. gr. 1.267 as prepared by the U. S. process, and of an alkaline reaction. Ex- posed to the air, it absorbs carbonic acid, forming the carbonate of lead, which is deposited at the bottom and on the sides of the ves- sel. Its constituents are known by the same tests as those of the neutral acetate, from which it is distinguished by forming a heavy white precipitate with solution of pure gum Arabic, which is not affected by that salt, and by being more copiously precipitated by carbonic acid. Incompatibles. These are the same as those of the neutral ace- tate, with the addition of pure gum Arabic, and certain mucilages, as those of sassafras pith and flaxseed, which are strongly preci- pitated by the diacetate, while, though in some degree affected- by the neutral salt, they are scarcely sufficiently so to be incompatible with it. Gum mezquite, recently brought into notice by Dr. Shu- mard, as a product of New Mexico, though strongly resembling gum Arabic in many of its properties, does not, according to Pro- fessor Procter, yield a precipitate with the solution of subacetate of lead. 166 GENERAL STIMULANTS. [PART II. • 3Iedical Properties and Uses. This solution has all the effects on the system of the other preparations of lead, but in this country and Great Britain, is seldom if ever given internally. In France, it has been prescribed by M. Boudin, with some success, in the vo- miting of epidemic cholera. Its local effects are the same as those of the acetate, but proba- bly somewhat more intense. In France, it is much employed for all the purposes for which the acetate is used locally with us; for example, as a collyriurn in ophthalmia; as an injection in morbid discharges from the nostrils and ear; as a mouth wash and gargle in different forms of angina and stomatitis; as an enema in chronic mucoid or purulent discharges from the rectum, with or without ulceration; and as a topical remedy in leucorrhoea and gonorrhoea. I have long been in the habit of using acetate of lead, by injection, in cases of acute dysentery affecting especially the rectum. M. Barthez has successfully used the solution of the subacetate in the same way; and the practice has been extended to acute diarrhoea and epidemic cholera, with satisfactory results. Vast quantities were injected, largely diluted with warm water, without any un- pleasant constitutional effect; the liquid producing its local im- pression upon the mucous membrane, but not being retained long enough to be largely absorbed. M. Barthez administered at first somewhat more than a drachm in 100 times its weight of water; but afterwards increased the quantity to one, two, and even three ounces in one injection, without poisonous effects.* (Trousseau et Pidoux, Traits, &c., 4e ed. i. 129.) In this country, the use of the solution of subacetate of lead is confined chiefly to superficial inflammations, either of the skin, the subcutaneous cellular tissue, the lymphatic glands, the tendons and aponeuroses, or the more superficial vessels, whether absorbents or veins. In the inflammation of sprains, bruises, wounds, &c.; in the more inflammatory states of certain cutaneous eruptions, as erythema, erysipelas, eczema, herpes, and impetigo; in burns, blis- ters, and excoriations; and in various ulcerative affections attended with irritation, inflammation, excessive secretory discharge, or he- morrhage; it may be employed as an antiphlogistic, astringent, anodyne, or haemostatic. For the purposes above mentioned, the solution is usually employed very much diluted, and the officinal diluted solution is usually employed. * The sp. gr. of the French preparation is 1.261, while that of the U. S. Pharm. is 1.267; so that the strength of the two does not differ materially. CHAP. I.] ASTRINGENTS.—SUBACETATE OF LEAD. 167 The following are preparations of the solution now under con- sideration. 1. DILUTED SOLUTION OP SUBACETATE OP LEAD.—Ll- QUOR Plumbi Subacetatis Dilutus. U.S. — Liquor Plumbi Dia- cetatis Dilutus. Lond.—Plumbi Subacetatis Liquor Composi- tus. Dub. — Lead Water. This dilute solution, usually called lead water, is made by adding two drachms of the strong solution to a pint of water. The car- bonic acid in the water causes some turbidness in the diluted pre- paration, which does not, however, interfere with its virtues. The strength of the diluted solution may often be much increased with advantage; and from half a fluidounce to a fluidounce may be em- ployed to each pint, with perfect impunity, when the cuticle is un- broken. Local paralysis is stated in the books to have resulted from its use; and though this must be extremely rare, as I have never witnessed nor heard of a well-authenticated case of it, still some-caution should be exercised in applying the solution to abraded surfaces. It may be applied by means of linen cloths, or in the form of the cold poultice, as the solution of acetate of lead. In France it has recently been recommended in very strong so- lution in mercurial salivation, not less than a sixth, or an eighth part being used in the mouth-water or gargle employed; and a preparation of equal strength is recommended in leucorrhoeal dis- charges, especially connected with superficial ulceration of the neck of the uterus, being applied by means of a sponge or roll of linen saturated with the liquid. 2. CERATE OP SUBACETATE OP LEAD. — CERATUM PLUMBI Subacetatis. U.S.—Ceratum Plumbi Compositum. Lond.—Gou- lards Cerate. This consists of the solution of subacetate of lead, incorporated with wax, olive oil, and a very little camphor. It is an excellent preparation, admirably calculated to produce the local effects of lead, in cases in which the cuticle is wanting. Irritable, inflamed, and painful ulcers are often relieved by it, while by its astringency it favours desiccation in those which are copiously suppurating, and disposes the loose and flabby to take on the healing process. In blisters, burns or scalds, chilblains, intertrigo and other forms of superficial abrasion or excoriation, herpetic, eczematous, and impetiginous eruptions with serous or puruloid discharge, and a similar condition in lichen agrius and other cutaneous affections, it is one of the best applications that can be made. I know nothing 168 GENERAL STIMULANTS. [PART II. equal to it as a dressing for blisters indisposed to heal. In many instances, and particularly in the one last mentioned, it may be combined at first with an equal weight of simple cerate. The cau- tion should always be observed not to employ it in a rancid state, in which it becomes irritant. Hence it should be made with per- fectly sweet oil, and used as fresh as possible. It is sometimes combined with opium, or calomel, or both, as an application in skin diseases of a local character. 3. SOAP CERATE. — Ceratum Saponis. U.S.—Ceratum Sapo- nis Compositum. Lond. This is made by boiling the solution of subacetate of lead with soap, and, after due evaporation, adding wax and olive oil. The U. S. process yields a fine white cerate, capable of being spread by a knife upon linen or muslin. It is a mild sedative and desic- cant preparation, applicable to similar purposes with the preceding, and employed in scrofulous swellings, and other external inflam- mations. III. CARBONATE OF LEAD.—PLUMBI CARBONAS. U.S., Ed., Dub. — Cerusse. — Cerussa. — White Lead. . White lead is made either, 1. by the reaction of the vapour of vinegar, and exhalations from decomposing stable manure, upon coiled plates of lead, or 2. by passing carbonic acid through a so- lution of the subacetate of lead. Its composition is somewhat dif- ferent according to the mode of preparation. The neutral car- bonate, made by double decomposition between a soluble salt of lead and an alkaline carbonate, consists of one eq. of acetic acid, and one of protoxide of lead; the white lead of commerce is ge- nerally believed to be a compound of this neutral carbonate with variable proportions of hydrate of lead. Sensible and Chemical Properties. Carbonate of lead is in the form of a white powder or pulverulent lumps, heavy, inodorous and nearly tasteless, insoluble in pure water, very slightly soluble in water con- taining carbonic acid,* dissolved with effervescence by nitric acid, * To test the solubility of carbonate of lead, the following experiment was per- formed at my request by Professor Procter. A solution of neutral acetate of lead was precipitated by carbonate of potassa, and the carbonate of lead thus obtained was thoroughly washed. This was introduced into a bottle containing carbonic acid water, which was instantly corked. After standing for twelve hours, with occasional agitation, the liquid was filtered, exposed to the air, so as to allow that portion of the carbonic acid to escape which had been retained by pressure, and subsequently boiled so as to drive off the remainder. No appreciable deposition CHAP. I.] ASTRINGENTS.—NITRATE OF LEAD. 169 blackened by sulphuretted hydrogen, reduced by heat to the yel- low protoxide, and by heat with charcoal to the metallic state. Impurities. The commercial carbonate of lead is very often adulterated; the most common impurities being sulphates of lime, baryta, and lead, and carbonate of lime. Effects on the System. This salt, in consequence of its insolu- bility, is less apt than the acetates to irritate or inflame the aliment- ary mucous membrane; but it more readily affects the system at large, and is supposed by some to be the most noxious of all the preparations of lead. This proneness to act on the system may possibly, as suggested by Dr. Christison, be owing to the dispo- sition which, from its weight and insolubility, the carbonate of lead has to adhere to the membrane, so that it is not carried off with the contents of the bowels, and is more exposed to absorption. Medical Uses. Carbonate of lead is never given internally. Ex- ternally, it is employed as a desiccant and antiphlogistic application. Some recommend it to be sprinkled in the state of powder upon excoriated surfaces; but it should be used in this way with caution. I have known it, sprinkled thickly upon an abraded surface on the leg, to produce severe inflammation, with much pain and swelling, and a superficial slough. There is some danger, too, from its absorption; for a case is on record in which death in a child resulted from the external use of the medicine. The best method of application is in the form of an ointment, which may be made by rubbing up a drachm of very finely powdered carbonate very thoroughly with six or eight drachms of simple ointment. In this way it may be used in ulcers, burns and scalds, excoriations of different kinds, and in irritating cutaneous eruptions. A liniment, formed by mixing it with flaxseed oil to the consistence of cream, has been particularly recommended in burns. IV. NITRATE OF LEAD. — Plumbi NiTRAS. U.S., Ed., Dub. 9 This is made by direct combination of litharge and nitric acid. It consists of one equivalent of protoxide of lead and one of nitric acid, without water. took place, nor was the liquid affected by iodide of potassium ; but when a cur- rent of sulphuretted hydrogen was passed through it, the liquid was perceptibly darkened, and upon standing deposited a minute quantity of sulphuret of lead. This experiment proves that carbonate of lead is appreciably dissolved by water impregnated with carbonic acid, and is retained by the water after the carbonic acid has been driven off by heat. 170 GENERAL STIMULANTS. [PART II. Sensible and Chemical Properties. Nitrate of lead is in white, nearly opaque, four or eight-sided crystals, inodorous, sweet and astringent to the taste, permanent in the air, soluble in water and alcohol, and characterized by evolving nitrous vapour when heated, and by yielding a white precipitate with ferrocyanuret of potassium, a yellow one with iodide of potassium, and a black one with hydro- sulphate of ammonia. Effects on the System. So far as known, these are the same as those of the other soluble salts of lead. Therapeutic Application. Nitrate of lead was long since employed as an internal remedy in asthma, epilepsy, and the hemorrhages; but it is now almost entirely out of use, having been superseded by the acetate. As it possesses the property of decomposing hydrosulphuric acid and the hydrosulphates, it corrects fetid odours proceeding from these substances, and may be employed with this object. Hence it is occasionally sprinkled in the rooms of the sick, and added to offensive discharges to obviate their smell. For this purpose, a solution may be employed containing a fluidrachm in each fluid- ounce of water. Ledoyeris disinfecting liquid is of this nature. But, though it will correct offensive odours, there is no proof that it will prevent putrefaction, or decompose and render innoxious con- tagious effluvia, or the malaria of marshes. It should, therefore, never be depended on as an antidote to these noxious agents. Having, with the corrective property above referred to, the desic- cant and sedative powers of the saturnine preparations generally, it may be employed, with reference to both, as an external application, in offensive ulcers, and fetid discharges from the nostrils, ear, vagina, and uterus. To these purposes it has been applied by Dr. Ogier Ward, who also uses it in gleety discharges from the urethra, and in chronic impetiginous affections. He employs, however, an extemporaneous preparation, made by dissolving one scruple of carbonate of lead in as much diluted nitric acid as may be necessary for the purpose, and adding this to a pint of distilled water. It may be applied two or three times daily. In the more obstinate cases, a much stronger solution may be used with impunity. On the continent of Europe, a solution containing ten grains of the nitrate in a fluidounce of water, has been advantageously employed in sore nipples, chapped hands, cracked lips, and various excoria- tions. CHAP. I.] ASTRINGENTS.—IODIDE OF LEAD. 171 The dose of the nitrate, for internal use, would be from one quarter of a grain to a grain, to be repeated, in acute cases, every two or three hours; in the chronic, two or three times a day. V. IODIDE OF LEAD.—Plumbi Iodidum. U.S.,Lond.,Ed., Dub. This is made by mutual decomposition between iodide of potas- sium, and nitrate or acetate of lead in solution; the resulting pre- cipitate being washed with distilled water. It consists of one equivalent of lead and one of iodine. Sensible and Chemical Properties. It is a yellow, heavy, inodorous, and nearly tasteless powder, soluble in somewhat more than 1000 parts of cold water, and about 200 of boiling water, soluble also in alcohol, fusible and volatilizable by heat, yielding vapours at first yellow, but ultimately violet from the disengagement of iodine. It should be kept excluded from the light. Medical Effects and Uses. Its effects are probably identical with those produced by the other preparations of lead. The preparation has been supposed to produce also the effects of iodine, and, under this impression, has been given in tuberculous affections, but with little advantage. In scrofulous and syphilitic swellings of the ab- sorbent glands, both external and internal, and in obstinate ulcers, it is said to have proved useful, given internally, and applied locally, at the same time. The dose is from one to four grains three times daily. Dr. O'Shaughnessy gave ten grains without inconvenience, and even thirty grains have been prescribed. Externally it is used in the form of an ointment, made by rubbing one drachm with an ounce of lard. VI. SEMIVITRIFIED OXIDE OF LEAD. — OxiDUM Plum- bi Semivitreum. U.S.—Plumbi Oxidum. Lond.—Lithar- GYRUM. Ed., Dub.—Litharge. Litharge is prepared by exposing melted lead, at a high tempera- ture, to a current of air from a pafr of blast-bellows, which blows off the oxide formed on the surface of the metal into a recipient, where it solidifies in minute scales. It is a protoxide of lead, containing one equivalent of lead and one of oxygen. Sensible and Chemical Properties. This oxide is in small, shining scales, of a yellowish colour usually tinged with red, inodorous and tasteless, fusible and at a high temperature volatilizable, and re- ducible by heat with charcoal to the metallic state. For practical purposes it may be considered insoluble, though it is said that one 172 GENERAL STIMULANTS. [PART II. part is dissolved by 7000 parts of water. It is wholly dissolved by dilute nitric acid, and is blackened by hydrosulphuric acid. On ex- posure to the air, it slowly absorbs carbonic acid, and therefore usually contains a little carbonate of lead. Effects on the System. Litharge is capable of producing the pecu- liar effects of lead upon the system, whether taken into the stomach, or inhaled, in the state of vapour or of powder, into the lungs. But it is never used internally. Locally it has the ordinary seda- tive properties of the metal. 3Iedical Uses. It has sometimes been used, sprinkled, in fine powder, on the surface of ulcers; but its almost exclusive employ- ment at present is as an ingredient in various officinal prepara- tions, for which it is very important. I shall notice here those which are considered under no other head. 1. LEAD PLASTER. — EMPLASTRUM PLUMBI. U.S., Lond. — Em- PLASTRUM LlTHARGYRI. Ed., Dub.—Litharge Plaster.—Diachylon. This is made by boiling litharge, olive oil, and water together, over a slow fire, until they concrete into a plaster. According to the views now generally received, olive oil consists of two fatty acids, the oleic and margaric, combined with the oxide of a hypo- thetical radical denominated glyceryle. During the process, the oxide of lead unites with these acids, and the oxide of glyceryle takes an equivalent of water to form glycerin, which is in great mea- sure separated by kneading under water. The plaster is, therefore, oleate and margarate of lead, probably with a little unseparated glycerin, which is useful by giving it more plasticity. As kept in the shops, it is in cylindrical rolls, of a grayish or yellowish-white colour deepening on exposure, brittle when cold, but softening and becoming adhesive by a very moderate heat. This preparation is much employed as the basis of other plasters, but is also itself highly useful as a direct application to the skin. In excoriations and slight superficial wounds and sores, it promotes healing by its sedative property, and by protecting them from the air. To protect surfaces against friction and pressure, and thus to prevent bed-sores, it is one of the best applications that can be made. Surgeons sometimes employ it to keep the edges of wounds in contact, and for strapping the leg in ulcers of that part, when bandaging is employed in their treatment. For these purposes its freedom from all irritant properties peculiarly adapts it; but it is not sufficiently adhesive without some resinous addition, and CHAP. I.] ASTRINGENTS.—SEMIVITRIFIED OXIDE OF LEAD. 173 should, therefore, be used only when the skin is peculiarly delicate. It may be spread on leather, linen, or muslin. 2. RESIN PLASTER.—EMPLASTRUM RESINS. U.S., Lond., Dub. Emplastrum Resinosum. Ed.—Adhesive Plaster. This is made by melting lead plaster and resin together. The Dublin Pharmacopoeia adds a little soap, which renders the plaster more pliable, and less apt to crack in cold weather. It is the common adhesive plaster of the shops, much used for keeping the surfaces of wounds together, and as a dressing for ulcers by gently compressing them, and gradually approximating their edges. It is usually kept in the shops, already spread, by means of a machine, upon muslin cloths. As it becomes less adhesive by exposure, the fresher it is when used, the better. 3. SOAP PLASTER. — EMPLASTRUM SAPONIS. U.S., Lond., Ed., Dub. This is made by incorporating soap with the lead plaster. It is a very mild preparation, sedative, and supposed to be discutient, and hence employed in chronic swellings and indurations, spread usually upon leather. A few other preparations of lead are noticed by authors; but they are little employed, and probably capable of producing no effect, which could not be as well or better obtained from some one of those already referred to. Among them may be mentioned the chloride, saccharate, and tannate of lead, of which an account may be seen in Pereira's Materia Medica. Besides Alum and the Preparations of Lead, there are several other mineral substances which are decidedly astringent; but all of them have other properties, more important, and for which they are more employed; and it is deemed best, in order to give due promi- nence to these properties, and at the same time to avoid repetition, to classify them with those medicines with which they agree in their greatest efficiency, and to treat of their astringent qualities incident- ally. Such are especially the sulphates of iron, zinc, and copper, and, in a less degree, other preparations of the same metals, nitrate of silver, corrosive chloride of mercury, sulphuric acid, and lime. (See Tonics, Alteratives, and Antacids) 174 GENERAL STIMULANTS. [PART II. CLASS XI. TONICS. Tonics are medicines which moderately and somewhat durably exalt the vital actions. They promote the appetite, invigorate di- gestion, render the pulse fuller, stronger, and sometimes more fre- quent, raise the temperature of the body, augment in some degree the various secretions, give increased firmness to the muscles, and probably operate also on the nervous centres, especially those of organic life, somewhat elevating, though not always observably, the various functions over which they preside. It is not pretended that all these effects are produced by every tonic medicine, or by any one of them at all times, and under all circumstances. It will, how- ever, I think, be generally admitted that, as a class, they operate as above stated upon the system in a state of health. They differ from astringents in the universality of their action. The latter affect the single vital property of organic contractility; and whatever other effects they may produce result from their influ- ence upon this. Tonics operate not only on the vital contractility, but upon all the other vital properties, and may be said to be uni- versal excitants to the functions. But this very diffusiveness of action prevents a concentration of their influence on any one func- tion; and consequently their power of producing contraction of the tissues is much less obvious than that of astringents. A notion formerly prevailed that strength depended on a certain rigidity, tension, or tone, as it was called, of the living fibres, and especially of the muscular; and medicines calculated to increase the strength were supposed to do so by increasing this tension or tone of the fibres, and hence were denominated tonics. But views so mechanical as this are now no longer tenable. There may be a certain physical tension of the muscles, tendons, and ligaments, re- sulting from mere position; but this has nothing to do with vital force, and an increase of it will not increase the general strength. The arteries have an elasticity which, under the pressure of the heart's action, permits a tensive expansion of their coats; and a diminution of this property might lead to a defective condition of the circulation. We may even conceive that, in case of diminished CHAP. I.] TONICS. 175 elasticity, tonics might have some effect in restoring it by improv- ing the nutrition of the tissue; but the remedy would not in this case act immediately upon the physical property, but only second- arily through the vital functions. It is true that there is a certain vital cohesion of the living mole- cules, in every highly organized tissue, which is essential to the due performance of its office; and a moderate augmentation of this vital cohesion may give increased energy to the function; but this is very different from the physical property of tension. The muscles pos- sess this kind of cohesion in common with the living tissues gene- rally; but the strength of the system is not more dependent upon its due state in these than in other structures, and probably much less than in some others, as the nervous centres, and the mucous coat of the stomach. If, therefore, we admit the existence of tension or tone in this modified sense, and that tonics may act by increasing it, still, it does not follow that this class of medicines operates exclu- sively, or efen mainly, on the muscles. In the present state of our knowledge, it is best to throw out of view entirely the origin of the terms tone and tonic, and to consider that, by the former, is expressed simply the vital power by which the several constituents of the body are enabled, under the influ- ence of the proper excitants, to perform their function duly; and by the latter, the means calculated moderately to elevate the several functions, by causing an increased exertion of this power. In order to estimate properly the operation of this class of medi- cines, it is necessary to discriminate between strength and action. The former is obviously the capacity to act, the latter the exercise of that capacity. By increasing the latter, we do not necessarily increase the former. Tonics do not, therefore, essentially augment strength, and the name of roborantia or corroborants, by which it has been proposed to designate them, is not appropriate. In a state of perfect health, they cannot be said, in any degree, to increase the vital force or strength. I conceive that the greatest strength of system is that which enables it to perform all its functions in the best manner, and to offer the firmest resistance to all disturbing agencies, of whatever kind, whether excitant, depressing, or per- verting. It is in perfect health that this condition is presented. If any function, or any number of functions are exalted, either from a peculiar state of the power, or a peculiar application of excitant agency, beyond the healthy medium, the system generally, instead of being stronger, that is, better able to perform all its offices justly, and to resist noxious influences, is, in fact, upon the verge of dis- 176 GENERAL STIMULANTS. [PART II. ease, and may be brought into that state by causes, which, in its healthy condition, would not affect it injuriously. In health, there- fore, tonics are not strengthening. They may be, indeed, and not unfrequently are indirectly debili- tating. They are ranked among the permanent stimulants; but this epithet is only relative. No stimulant is or can be permanent. The excitability of living parts, in other words, their susceptibility to excitant impressions, is limited. If called into excessive action, it is proportionably exhausted; and, in this state of exhaustion, the ordinary healthful excitants have less than their normal effect.' De- pression, therefore, necessarily follows stimulation. This is obvious in the use of powerful stimulants; but it is no less true of tonics; though, in the use of these, as the excitation is more moderate and more slowly induced, the subsequent depression is less in degree and longer delayed. By a constant repetition of the stimulant, we may sustain the excess of action longer; but the result is obtained at the expense of the excitability, which is sooner or later still more exhausted, and may at length be so much reduced that the stimulus ceases to be felt, and depression occurs even under its continued use. This depression can be counteracted only by increasing the amount of the stimulus; but the same penalty is inevitably exacted; and in the end excitability is worn out altogether, and function ceases. It may be said, however, that excitability is not strength, and, consequently, that the latter does not necessarily diminish with the former. This is to a certain extent true. But the strength of an organ, or its power to act, depends on its due nutrition, on the steady repair of its losses by the assimilation of new material, on the maintenance in fine of its normal state of organization. Now, if its excitability is permanently impaired, it cannot feel duly the in- fluence of the materials essential to its repair, and they cannot, there- fore, be suitably appropriated. Its nourishment fails, its structure is impaired, and consequently its ability to perform its function is diminished. This is debility. It follows that a constant use of tonics not only exhausts excitability, and secondarily depresses function, but positively debilitates the system. Other evils arise from the abuse of these medicines. Allowing that they act equally on the whole system, and equally elevate all the functions, they of course promote digestion, increase the quan- tity and stimulant quality of the blood, augment the nutrition of all the organs, and thus put the system into a state in which, from its universal exaltation, a slight irregularity may cause the excess of excitement to fall, with an overwhelming force, on some important CHAP. I.] TONICS. 177 organ, and thus seriously endanger health if not life, before the compensating provision of impaired excitability has had time to come into play. But supposing, as generally happens, that the tonic operates with especial force on some one organ, or series of organs, the constant excitement sustained in it attracts an excess of blood and of nervous influence, which may in the end occasion inflammation. When the stimulation is powerful, the resulting inflammation may be acute; but, as resulting from tonics, it is generally chronic. Thus, the abuse of the medicine may lead in the end to general debility, and at the same time chronic inflammation of particular organs; a complication which it is difficult to treat, and which can, in fact, be treated successfully only by withdrawing the cause, either abruptly or gradually, and trusting to the recuperative powers of the system. The principles above stated are strongly illustrated by the results of the abuse of the Portland powder, formerly much employed in the treatment of gout. This powder consisted of a combination of vegetable bitters and aromatics, and was to be taken continuously for two years, at the end of which time a permanent cure might be expected. Dr. Cullen states that the cases of nine or ten persons had come under his knowledge, who took the remedy the required length of time, having previously been subject to regular attacks of inflammatory gout yearly, or twice a year. After a longer or shorter continuance of the remedy, they had missed the paroxysms, and, at the end of the two years, were entirely free from them, and had no attack afterwards for the remainder of their lives. But in every instance their health was impaired; they were much troubled with dyspeptic and nervous disorder, and lowness of spirits; and, in less fhan a year from the completion of the course, without excep- tion, they began to exhibit dropsical symptoms, which gradually increased, in the form of hydrothorax or ascites with anasarca, and in two or at most three years proved fatal. (CullerJs 3Iat. Med.) It is not difficult to explain the result in these cases. The constant use of the stimulant impaired and finally exhausted the excitability of the system; debility with anaemia ensued; and with these were probably combined chronic visceral inflammation, especially of the stomach, liver, and heart, resulting from the sustained irritation of the medicine, and the superadded irritation of the gout, invited from an external to an internal seat. It is inferrible from the above course of reasoning, the correctness vol. i.—12 178 GENERAL STIMULANTS. [PART II. of which has been abundantly confirmed by experience, that tonics should never be given in a state of sound health with the hope of increasing strength, nor for too great a length of time even in dis- eased conditions, in which they may have been originally indicated, for fear of inducing secondary debility and perhaps chronic inflam- mation. But, nevertheless, these remedies are of great value in various conditions of depressed and torpid function and debility. It may be said that here also, as well as in health, the principles above deve- loped are applicable; and that the ultimate effect ought to be, by an impairment of the excitability, still further to depress and weaken the system. It can, however, I think, be shown that this is not a legitimate deduction. 1. It has been stated that the characteristic office of tonics is moderately and somewhat durably to increase the vital actions. Their first direct effect, therefore, in depressed function, is to ob- viate this condition. As strength consists in the normal state of the ultimate organic constituents of the tissues, which can be sus- tained only by a due degree of all the vital processes which con- tribute to the nutrition or maintenance of parts, and tonics have the property of stimulating these processes, it follows that, when they are deficient, and debility has ensued as a result, tonics may prove not only stimulant but positively strengthening, provided the depressing causes do not outlast the excitability of the part or parts affected. Let us apply this principle. In numerous diseases, there is a depressed condition of function, with or without positive debility, which depends upon a cause either essentially temporary or removable. Such a condition exists, for example, in low states of fever of a typhoid character, in which a depressing poison is probably acting upon the system, and in the suppurative stage of inflammation, and in gangrene, in which the strength is exhausted by copious discharge, or prostrated by the sedative influence of the mortification. In either of these cases, life may be in imminent danger; but, as the operation of the cause is temporary, if the vital functions can be sustained until this ceases or is removed, the patient may be saved. Tonics may afford the support requisite for this purpose. They excite the depressed func- tions, and strengthen by due nutrition the debilitated structures; and long before the excitability, through which they operate, has had time to suffer materially from the stimulus, the cause ceases, and the system is left in a condition in which it can repair itself. CHAP. I.] TONICS. 179 2. We not unfrequently meet with cases of depression and de- bility, continuing after the cause has ceased. The system, or a part of it is, as it were, left paralyzed. It seems as though a habit of insufficient action had been established, which the inherent force of the system could not throw off. Living, like dead matter, has a sort of vis inertise, which disposes it to continue in any condition, in which it may have compulsorily continued for a considerable time. Under these circumstances, a little gentle stimulus serves to rouse it out of its torpor; and once again fairly in action, it will go on without further aid. As a watch stopped in the winding, and con- tinuing quiescent, will resume its accustomed motions with a little shaking; so the system, reduced by disease, and remaining torpid after the disease has ceased, will react with a slight excitation, and enter again into its ordinary round of action. Tonics are often sufficient to give the requisite impulse. Hence, in part at least, their use in the torpor of system, or that of a particular organ, so common in convalescence from acute disease. 3. General depression or debility may result from the torpidity of a particular function or organ, upon which, in turn, the general deficiency may react, so as to sustain and even increase its inertness. Thus, the stomach, or the function of digestion, may have been de- pressed by some cause acting upon it alone. The food, of course, is not properly digested, the quality of the blood is impaired, the general function of nutrition suffers, and consequently the stomach with other organs. The disease thus runs on in a vicious circle, at each round increasing the local condition in which the whole ori^i- nated, and deepening the general debility. By moderately stimu- lating the digestion, we restore the due qualities to the blood and the due energy to nutrition, the stomach recovers its powers when properly nourished, and the whole evil is corrected. A lite train of consequences, and a similar mode of repair, may occur in refer- ence to any one of the great organs or functions. Tonics often operate in this method in the cure of disease. It is seen, therefore, that numerous cases of depression and de- bility occur in which tonics may be useful. But they are not appli- cable to all affections of this kind indiscriminately. 1. That tonics may be serviceable in debility, there must be a certain amount of excitability remaining. Otherwise they may be useless, or even worse than useless. Depression and debility, result- ing from exhausted excitability, cannot be repaired by tonics. In the debility of drunkards, for example, which is the result of over- 180 GENERAL STIMULANTS. [PART II. stimulation, tonics, if felt at all, could produce only a slight excite- ment, to be followed by still greater depression; and their habitual use would only hasten the fatal issue. The only hope in these cases is in the cessation of the cause. The habit of stimulation must be abandoned, or there can be no remedy. With future abstinence, if the excitability of the organs has not been fatally im- paired, and no destructive disorganization has taken place, a gradual amendment and ultimate restoration may be hoped for, under the recuperative powers of the system. The only principle upon which tonics, under such circumstances, could be used with propriety, rests on the occasional necessity of not too hastily withdrawing all support from the system, lest fatal prostration should ensue. They may sometimes be resorted to, as a feebler stimulus than the accus- tomed one, in order that the transition may not be too abrupt. 2. Tonics cannot be relied on when the debility results from a constantly operating and irremovable cause. They would, in such cases, generally prove injurious by their secondarily debilitating influence, and would probably lead to a more rapid exhaustion of the patient. The debility, for example, resulting from cancer can- not be repaired by tonics. They may occasionally be useful in counteracting accidental debility of some one organ, which may be interfering with the proper exercise of the others; but the general rule holds true. 3. Depression, amounting even to apparent prostration of the system, sometimes depends upon an active and overwhelming con- gestion, or extensive inflammation of some important organ or tis- sue, as the brain, heart, lungs, stomach, peritoneum, &c, which either concentrates so much of the blood and nervous force in one part, that there is insufficient elsewhere to support the systemic actions generally, or immediately cramps the organ affected so as to arrest its function, and thus prostrate all dependent functions. In either of these cases, tonic medicines could be of no service; the indica- tion being by depletory measures to unload the congested organ. 4. In cases of great or sudden and transient depression, tonics are of little or no service; their action being too slow and mode- rate to meet the indication presented. When stimulation is re- quired, under such circumstances, it is necessary to have recourse to the diffusible stimulants for internal use, and the rubefacients externally. The general rule, then, in relation to the use of tonics, is that they are indicated in all cases of depression and debility, in which CHAP. I.] TONICS. 181 the excitability has not been exhausted by previous stimulation, which do not proceed from a permanent and irremovable cause, and in which the depression is neither the result of active conges- tion or irritation, nor so sudden and transient as to call for stimu- lation more prompt and fugitive than that which characterizes this class of medicines. Of the particular diseases in which tonics may be used, all that can be advantageously said will come better under the heading of the several individual medicines; as the peculiar character of each medicine very much influences its application. It remains here only to treat of their precise mode of action, so far as that is known. Mode of Operation. Most of the tonics probably act directly on the mucous coat of the stomach and bowels, thus stimulating im- mediately the digestive function; and there is reason to believe that some act chiefly, if not exclusively, in this way. It was for- merly thought, and some still think, that the impression made on this surface is propagated, to a greater or less extent, over the sys- tem by means of sympathy, or the intervention of the nervous centres; and it is not possible to prove that the tonic impression is never diffused in this way. But, when it is considered how slowly the tonics act, and that many of them, particularly those of mine- ral origin, have been detected by chemical reagents in the blood or secretions, it seems most reasonable to suppose that those, the direct influence of which extends beyond the digestive organs, operate through the route of the circulation. The different modes of action of the different tonics may be included under the follow- ing heads. l|l have stated that some appear to act chiefly, if not exclu- sively, so far as their immediate tonic influence is concerned, on the digestive organs. By promoting the appetite and invigorating digestion, they cause more food to be taken, and that which is taken to be more thoroughly prepared for absorption and assimilation. They thus enrich the blood, rendering it at once more stimulating to the functions, and nutritive to the tissues, and produce indirectly the general tonic effects upon the system at large. \ Such are the mineral acids, and to a certain extent the simple or pure bitters, whioh, though they may possibly operate directly on the system through absorption, display their effects much more obviously upon the stomach and bowels. 2. Other medicines of the class operate directly and mainly on the blood itself; not through the agency of the digestive process, 182 GENERAL STIMULANTS. [PART II. but by intimate admixture with that fluid, into which they find admission, either by venous absorption, or through the lacteals or intestinal lymphatics. They may act either 1. by entering imme- diately into the composition of some one of the proximate principles of the blood, 2. by modifying the vital condition of its organized constituents, or 3. by favouring, through a stimulant influence on its vital properties, the physiological actions which are constantly going on within it, and thus contributing to its full development and maintenance. The blood thus elevated in its constitution, performs its offices in the economy with more vigour, and operates with a tonic influence on all the functions. Upon this principle it probably is that the preparations of iron chiefly act; and I am disposed to ascribe the peculiar influences of cod-liver oil in disease, in some measure, to analogous modifications produced by it in the blood. 3. Most of the class probably operate directly upon the ultimate organic constituents of the tissues, entering the circulation either unchanged or more or less modified, and distributed everywhere by the blood as a mere vehicle; though it is not impossible that they may operate also upon the vital properties of that fluid, through the same power by which they affect the similar properties of the solids. How it is precisely that they affect the ultimate organic constitu- ents of the body is conjectural. They may act merely by their presence, or they may enter into a sort of chemical union with the living matter, though I am inclined preferably to the former of these views. At all events, some of them have been found, on chemical investigation, in the midst of the tissues. It is probable that each distinct function is performed through the instrumentality of a special power in the ultimate organic cells, nuclei, or mole- cules of the organ, and tonics may operate simply by stimulating this power into a somewhat increased activity. But we may ad- vance one step further, and adopt the very plausible opinion, that in all the tissues there is a certain vital cohesion which is essen- tial to the due performance of the function, and that tonics are moderate stimulants to this cohesion. To this mode of action we may ascribe in part the greater firmness of the tissues, especially the muscles and blood-vessels; and to this perhaps also that condi- tion of the nervous centres, resulting from the use of certain tonics, by which they are enabled to exercise their proper functions more energetically, and have greater power of resistance to all kinds of disturbing influences. Such an influence is exhibited in the con- trol evinced by some of the metallic tonics over various nervous diseases, as chorea, epilepsy, and neuralgia. CHAP. I.] TONICS.—TONIC DIET. 183 Before considering the several tonic medicines, with their subdi- visions, I propose to give a succinct account of various influences of a tonic character, which, though not strictly medicinal, are often very useful in disease, and must therefore rank among remedies. 1. TONIC DIET. A proper regulation of the diet is indispensable to the obtaining of satisfactory results from the use of tonic medicines./ Expe- rience has established the fact, beyond controversy, that a mixture of vegetable and animal food is best suited for man. There can be as little doubt, on the score of experience, that animal food is more supporting to the system, and more stimulating than vege- table.J Indeed, the effects of a relative increase of the former in the diet, are not dissimilar to those produced by tonic medicines; proceeding at first from a direct excitant impression on the sto- mach, and subsequently from an augmented richness of the blood. A long continued excess of animal food leads also, like an abuse of tonics, either to plethora with its dangers, or to a complication of diminished excitability with local inflammation. We may, therefore, rank the use of animal food, beyond the ordinary pro- portion, among tonic influences; and when an indication exists for this class of medicines, there is generally a coincident indication for the modification of diet referred to. As the main object of tonics is usually not merely to stimulate the functions, but to obviate debility by sustaining, through the process of nutrition, a due state of the organization, it is obvious that, in order to produce this effect, there must be nutrient material for them to operate with. It does not, however, necessarily follow, that the quantity or richness of the food taken should be increased; for the patient may have been in the habit of taking more than his digestive powers could manage; and the end desired is attained by a more thorough assimilation, and less waste of the nutriment, through the greater energy given to digestion by the medicine. In judging, therefore, as to the propriety of increasing the amount of food, the practitioner must take previous habits into consider- ation; and, if the diet should be found to have been in excess, in reference to the digestive and assimilative powers, there would be no propriety in augmenting it, at least until the balance should be restored. The kind of food previously used must also be allowed to modify the prescription. If the diet had been exclusively vegetable, it is 184 GENERAL STIMULANTS. [PART II. obvious that a relatively smaller quantity of animal food should be directed; if exclusively animal, it would be necessary, in order to obtain the same end, to employ it more freely. Reference must also be had to the habits of the patient in rela- tion to exercise. Food is consumed by bodily exertion, and the greater the latter is, the more will be required of the former. To produce a tonic effect, therefore, a greater elevation of the diet would be necessary in a person of active, than in one of sedentary habits. The quality of the animal food employed is scarcely less im- portant than its quantity. Some kinds are more stimulant, some more nutritious, and some more digestible than others. The most stimulating may produce an excitant effect greater than desired; but food can scarcely be too nutritious, or too easily digested for tonic purposes. A few words, therefore, on the more common articles of animal food, in reference to these points, may not be out of place here. One of the lowest varieties of animal food in stimulant and nutri- tive properties, taking bulk into consideration, is milk; but it is easy of digestion, and may be preferred in a tonic course when the digestion is feeble, and the previous habits of the patient have been those of abstinence. The same may be said, in less degree, of its derivative butter. Another derivative, cheese, while probably not more nutritious, is more difficult of digestion, and, in consequence of chemical changes, often much more stimulating. The latter, therefore, should not be given when the stomach is feeble. Next in the ascending scale of nutritive and excitant power, are oysters, eggs, and the lighter kinds of fish; and these are all generally easy of digestion, when properly prepared. Raw oysters, particularly salt oysters,.are themselves stomachic, often exciting the appetite, generally easy of digestion, and an excellent ingredient in a tonic regimen. The eggs should be soft boiled; or, if hard, should be grated very finely so as to overcome their cohesion, and render them more easily soluble in the gastric juice. Next come the different kinds of poultry with white flesh, and after these the ordinary meats, as mutton and beef The dark-fleshed poultry, as ducJcs and geese, and all the varieties of pork, are most stimulant and most difficult of digestion, and, though highly nutritious also, should be used only when the digestive powers are strong, and exercise is taken abundantly. Wild animal food is preferable to the same varieties tame, as being more easily digested. On the same score, adult CHAP. I.] TONICS.—EXERCISE. 185 animal food is preferable to the very young, which is too stringy, and less nutritive, or to the very old, which is often very tough. Beef, mutton, and fowls, are preferable to veal, lamb, and chickens. Very fat meats, though stimulant and nutritious, are not so easily digested, and often unsuitable. Salt meats are less nutritious than the fresh, and also less digestible, and, though often admissible, par- ticularly in small quantities as condiments, should be excluded, as main articles of diet, when the digestion is feeble. The mode of cook- ing, too, has much influence over the quality of the food. Boiling renders meats less nutritious, and therefore less suitable for a tonic diet. Frying, and other modes of preparation, in which butter and fats are heated with the meat to the point of decomposition, are unsuit- able, in consequence of the indigestible, as well as irritant character, often imparted to the food. Roasting, broiling, baking, and stewing are more appropriate modes of treatment. Soups, which contain the extractive, gelatin, and other soluble parts of meat, are more stimulant and less nutritious than solid flesh, and, though they may be employed, should never be relied on. The essences are too stimulating for a mere tonic course. Whatever food is taken should be thoroughly masticated. Vegetable food of easy diges- tion should not be excluded; for, though destitute of tonic proper- ties, it imparts qualities to the blood which are indispensable, and without which there would be constant danger of producing a scorbutic character of that fluid. Potatoes, from their highly nutrient and antiscorbutic properties, are very useful in a tonic regimen. 2. EXERCISE AS A TONIC. This is an invaluable tonic measure in debility. There are two kinds of exercise, which, though they produce the same ultimate effect, operate in a somewhat different manner, and are calculated to meet somewhat different indications; active, namely, and passive. Active exercise is that performed under the influence of the will; passive, that in which the will is quiescent, and extraneous influ- ences operate. Walking, running, leaping, wrestling, rowing, and the various gymnastic movements are examples of the former; riding on horseback, driving, steaming, sailing, &c, of the latter. The two are frequently more or less combined. Thus, in the active exercise of rowing, while the muscles of the extremities are operating under the will, the whole frame is jarred by the move- ments of the boat; and in the passive exercise on horseback, while 186 GENERAL STIMULANTS. [PART II. the body is shaken by the motions of the horse, the muscles are employed in regulating the animal, and maintaining the position of the rider. Active exercise is always primarily partial; passive is usually general, affecting every part of the body, though this is not necessarily the case in all instances; for a part only of the body may be agitated; as in that kind of exercise of the stomach recom- mended by Halsted in the treatment of dyspepsia, in which the body being bent, and the hands pressed backward beneath the epigastrium, gentle and quickly repeated succussions are given to the organ by the upward movement of the fingers. It is not difficult to explain the tonic effects of exercise. In the active variety, the cerebral centres are first stimulated; then the muscles; then the heart through the organic nervous centres; and finally all the functions indirectly, in consequence of the greater rapidity of the blood flowing everywhere through the capillaries, to which these functions are indebted for the supply at once of stimulus and material. A certain amount of exercise, varying according to the state of the individual, is requisite to support the functions in a condition corresponding with the degree of general strength. A moderate excess beyond this amount will produce only a moderate stimulation, or in other words a tonic effect; a great excess gives rise to proportional excitement, and may prove powerfully stimulant. The general laws above given, in reference to tonic medicines, are applicable to this remedial measure. In a state of debility, if the exercise be moderately increased, it will increase strength, by supporting all the organic functions, and among the rest digestion, sanguification, and nutrition. In perfect health, if urged beyond the point requisite for the sustenance of this condition, it leads to the evils before described as the result of the abuse of tonics. In either case, if used in great excess, so as to stimulate actively, it exhausts the excitability, and may thus lead to secondary prostration and debility. It is perceived, there- fore, that the employment of active exercise as a tonic requires the same judgment and discrimination as that of the medicines belong- ing to the class. The general rule is to proportion the amount of it to the strength, and never to push it so far as to occasion secondary exhaustion. A slight feeling of fatigue may be considered as an evidence that it has been carried sufficiently far for the time. In passive exercise, as a general rule, all parts of the body are excited by the agitation equably and moderately. The blood and nervous power are, therefore, invited in a nearly equal degree to CHAP. I.] TONICS.—EXERCISE. 187 the seat of every function, and a moderate diffusive tonic effect is experienced throughout the system. It may be said that, as there is only a certain quantity of blood, and certain amount of nervous power in the body, you cannot increase these, in the system at large, through any immediate influence, and, therefore, that such a diffusive tonic effect as I have referred to is impossible. But the whole nervous power is never called into full exercise in health, and, though it cannot be indefinitely drawn upon, yet it may be so in a moderate degree, beyond the ordinary wants of the system; and its influence, therefore, may be everywhere in the same degree augmented. In reference to the blood, if the whole quantity can- not be increased, yet the rapidity of its motion may; so that a greater amount is present within a given time in all the organs. Besides, so far as concerns the smaller vessels or capillaries, where alone the blood is operative in sustaining the functions, the quan- tity may certainly be increased at the expense of that in the heart and great vessels, which serve mainly for its conveyance, or in the spleen, which probably often acts as a mere receptacle. It is, therefore, quite possible that all the organic functions may be moderately excited at the same time; and this, I think, is the effect of passive exercise. In consequence of the equable and diffusive character of its influence, it has an advantage over active exercise in cases of great debility. In the latter, a slight excess of mus- cular action may call the heart into inordinate and even dangerous excitement. Patients greatly debilitated have sometimes fallen dead, upon slight exertion, in consequence of the excessive action and consequent speedy exhaustion of the heart; and, where there is no danger of such a result, there may be liability to serious con- gestions, to hemorrhage, and even to cardiac hypertrophy. So also, the encephalon may be inordinately stimulated through the influence sent up to it by the excited muscles, demanding through the nerve centres a supply of blood. Again, the over-excitement of particular organs leads to deficiency of action or depression in others; as shown in the result of violent exercise taken imme- diately after a full meal; the powers of the system being concen- trated in the muscular, and its immediately subsidiary functions, and withdrawn from the digestive, so that the food remains un- acted on. In short, the influence of active exercise is necessarily more or less partial, and therefore liable to occasion local excess or deficiency of function; that of passive exercise is general, and more equable, and therefore safer when the object is to correct great 188 GENERAL STIMULANTS. [PART II. general debility, especially when associated with morbid tendencies of any organ, as of the heart, which active exertion may serve to aggravate, or call into operation. Yet passive exercise is alone insufficient; for there are certain functions, such as that of muscular motion, which can be performed only through the agency of the will, and which will suffer if per- mitted to remain quiescent. Though the instruments of these functions may be invigorated, so far as their nutrition is concerned, by passive exercise; yet they will not operate efficiently for their peculiar purposes unless sustained in a due habit of action. On the whole, therefore, in order to strengthen a weakened system in all points, it is advisable to combine more or less together both kinds of exercise. Partial or local weakness may always be treated with partial exercise, whether active or passive. Thus, a limb which has become enfeebled, and incompletely paralyzed by long rest, as, for example, an arm or a leg in which the muscles have been restrained by bandaging, may be restored to its original powers by constantly repeated efforts on the part of the patient to use it; and attention has already been called to a useful method of producing passive exercise of the stomach in pure dyspepsia. The above remarks are applicable to the mental, or purely cere- bral functions as well as to the others. These may also be divided into the active and passive, the former being voluntary, as the intellectual functions, the latter involuntary, as the emotional. In debility of the active functions, it is necessary, in order to restore due vigour, to exercise them actively through the will of the patient; in that of the passive, to exercise them passively, by so regulating extraneous influences as to excite them into operation. It may be proper, before leaving the subject, to say a few words on the several varieties of exercise most resorted to in the treat- ment of disease. 3Iodes of Active Exercise. Upon the whole, walking is probably the safest and most efficient mode of active exercise, in cases of simple general debility. It should be continued at one time no longer than may be sufficient to cause a slight sense of fatigue, and should be frequently repeated. The amount must, of course, be regulated by the strength of the patient. It should never, in de- bility, be so rapid as to induce much palpitation of the heart. When the weather is such as to forbid the invalid to walk in the open air, he should take the exercise within doors, throwing up the CHAP. I.] TONICS.—EXERCISE. 189 windows, so as to admit the fresh air, and maintaining a tempera- ture in the apartment, somewhat below that which is comfortable to him when seated. Other and more energetic modes of active exercise are running, leaping, wrestling, the various kinds of bodily labour, athletic games, as those of quoits, ball-playing, bullet-rolling, bar-pitching, &c, and, within doors, dancing, billiards, nine-pins, the use of dumb-bells, battledore and shuttlecock, gymnastics, calisthenics, &c. It is often necessary, in order that the invalid may be duly amused or inte- rested, to vary the modes of exercise to suit his taste or caprices; and hence the propriety of having a considerable list out of which to choose. To those already mentioned, as suitable for patients confined to their houses, may be added, sawing and splitting wood, rubbing furniture, and various other household operations, which, by amusing the patient with the idea of usefulness, may lessen the irksomeness of the measure, considered merely in a therapeutic point of view. Indeed, this idea should be carried out in all plans of exercise. There should be some other ostensible object than that merely of improving health. The patient should, if possible, become interested in the act, occupation, or pursuit for itself alone. Other advantages of this diversity of plans are that, by a proper choice among them, we may duly proportion the activity of the exercise to the strength of the patient, and that, in consequence of the vari- ous muscles brought into play in the different methods, we may by successive changes operate on the whole system of voluntary muscles, or bring some particular method to bear upon special muscles or organs, which may stand peculiarly in need of invigor- ation. But in all the methods referred to, care must be taken to avoid excess; and this is particularly necessary of those which have in themselves something fascinating or seductive. Serious evils, for example, have sometimes arisen from the abuse of dancing, and gymnastic exercises. The modes of exercise above referred to are often useful, not only by their tonic influence on the muscular system directly, and other systems indirectly, but also by a derivative influence, tending to draw away an excess of blood and nervous action from internal organs, congested or chronically inflamed. Every one of sedentary and studious habits must have been sensible of the great relief, in instances of visceral uneasiness, or oppressed and clouded thought, afforded by rising and walking briskly for some time, or otherwise actively employing the voluntary muscles; and chronic inflamma- 190 GENERAL STIMULANTS. [PART II. tion of the liver, stomach, brain, &c, may often be greatly benefited by a systematic external derivation of the same kind. 3Iodes of Passive Exercise. Horseback exercise is probably the most effective, and generally applicable, of all the different passive methods. It is, however, too fatiguing for great debility. Moderate at first, it should be gradually increased with the increasing strength and tolerance; and a patient who has commenced with less than a mile, may often extend his rides to fifteen or twenty miles daily with propriety. It is more especially applicable to cases in which the abdominal or thoracic viscera are enfeebled. No remedy, probably, is more effectual in pure dyspepsia; and, since the times of Sydenham, it has been considered a most valuable pro- phylactic in phthisis. Indeed, there is reason to think that it often proves useful, and sometimes even curative, after the disease has actually commenced. Hepatic torpor without inflammation, habit- ual constipation from enfeebled function, and hemorrhoidal affec- tions arising from one or both of the preceding conditions, are often benefited by this mode of exercise. The same may be said of headaches and other cerebral affections, purely functional, and connected with debility. In relation to riding on horseback, the remark before made as to the importance of combining other objects with the pursuit of health, is peculiarly applicable. I have been told that the late Professor Wistar, of Philadelphia, used to recommend his dyspeptic patients to ride out every day to a certain chalybeate spring, several miles from the city; his object being much more the benefit of the ride than that of the waters. A long journey on horseback is an almost certain cure for pure dyspepsia. Carriage exercise is more purely passive than that on horseback, for which, in its rougher modes, it is the best substitute. The jolt- ing of a rough vehicle over smooth roads, or of a smooth vehicle over rough and stony roads, is often highly useful in cases to which attention was called in the last paragraph. The jarring movement of the railroad car, and that of the steamboat, is next perhaps in efficiency to that just referred to. That of a row-boat is of the same character; and the exercise of the rower himself, combining the active and passive kinds, is an admirable measure for imparting vigour to the system, if not overdone. Riding in a smooth carriage and sailing are the mildest methods, applicable to the feeblest con- dition of system requiring exercise. Substitutes for these methods may be found within doors. Chairs have been invented which enable the invalid to imitate horseback CHAP. I.] TONICS.—PURE AIR. 191 riding; and the same effect is in some degree obtainable by the jogging motion of an ordinary chair. The rocking-chair and the swing are partial substitutes for the smooth carriage and the sailing vessel; but, in these methods, it must be recollected that the pecu- liar character of the motion gives a special direction to the blood; in that of rocking centrifugally to the head, in that of swinging centripetally from the head. From the former, therefore, inju- diciously indulged in, there may be some risk of cerebral con- gestion, in the latter of defective circulation in the brain. Friction and shampooing may be considered as local varieties of passive exercise. Friction may be performed by the patient himself, in which case the active is combined with the passive, and more universal effects are obtained. It may be performed with the naked hand, or by means of flannel, a coarse linen towel, the flesh-brush, or any other roughish material; and should be carried so far as to excite some redness in the surface, but not to abrade or inflame it. The more extensively it is performed over the body the better; as its influence is thus proportionably generalized. It should be repeated once or twice daily in chronic cases. Shampooing is a practice introduced from the East, and consists essentially in a kind of kneading process, performed on the surface, but reaching in its effects deeper than mere friction, in fact throughout the soft parts of the body not protected by a bony case. Slapping over the sur- face with the sole of a slipper, or any slight flat body of a similar character, operates in the same way as the above processes. The effect of all of them is moderately to excite the surface and the soft parts near it, thereby attracting the blood and nervous action, and producing a tonic impression; while they operate deriva- tively in relation to the internal organs. They are, therefore, especially indicated in cases of torpor of the skin and muscles, attended with congestion or chronic inflammation of the viscera. 3. PURE AIR AS A TONIC. This, though a very efficient tonic under certain circumstances, must be considered as acting negatively. In large towns, the atmo- sphere is impregnated with effluvia, the general effect of which on the system is at first depressing, and ultimately debilitating. By removing from town into country, we escape this influence; and, the cause of weakness being removed, our systems acquire renewed strength through the healthful agency of an uncontaminated atmo- sphere. This is especially the case with invalids, whose strength 192 GENERAL STIMULANTS. [PART II. has been impaired by disease, and whose systems are often unable duly to react, while exposed to the air of cities. I presume there are few inhabitants of large towns who have not felt, even in their ordinary health, the refreshing and invigorating effect of the coun- try atmosphere, or, to speak more accurately, of an escape from the enfeebling effluvia to which they are habitually exposed. The sick chamber is liable, in a still greater degree than the general atmosphere of towns, to the charge of unwholesomeness; and, even in the country, therefore, invalids are often greatly bene- fited by escaping from the confined and sedative air of their lodg- ings to that of the open fields. These remarks, while applicable to debility in general, are pecu- liarly so to that of convalescence. 4. MENTAL INFLUENCE AS A TONIC. Certain states of the mind are known, from experience, to have a sedative effect upon the system at large. Grief, anxiety, and all the various modifications of fear are distinguished, in common nomenclature, as the depressing emotions. Whatever, therefore, in any manner counteracts or removes these feelings, must be indi- rectly stimulant; and, even though purely negative in its operation, would rank among tonic influences. But there are also mental conditions which have a directly elevating or supporting effect. The more refined pleasures of sense and perception; the apprecia- tion of the beautiful, the picturesque, or the sublime in nature and art; the enjoyment attending the legitimate exercise of all our in- tellectual powers; the pleasurable emotions of love, hope, confi- dence, joy, of triumphs over difficulties, of temptations resisted, of a legitimate ambition gratified; all these produce in our physical systems an excitation, which, though, like stimulation from any other source, it may be excessive and injurious, is more generally within the limits of a healthful influence, and, in states of debility, is positively tonic and restorative. No practitioner can fully per- form his duty towards his patients, who does not avail himself of this instrumentality in cases of debility. It is probably more avail- able, in the treatment of defect of function in the digestive organs, the liver, and the brain, than in pure general debility; as it is upon these functions especially, that the opposite condition of mind ex- hibits most obviously its depressing tendencies. CHAP. I.] TONICS.—TRAVELLING. 193 5. TRAVELLING AS A TONIC. This agency is merely a combination of those already treated of; but it affords so ready and efficient a method of obtaining their con- joint influence, that it merits a distinct notice. Exercise steadily maintained, pure air, and a favourable mental condition, are the real tonic agents which give to travelling the powerful curative influence exerted by it in affections complicated with, or essentially consisting in debility, whether of the whole system, or some one or more of its parts. But, to be useful, it must be properly conducted. To jump into a rail-road carriage, or a steam-boat; to be whirled in crowds from point to point, with headlong rapidity; to lodge in densely thronged hotels, and swelter all the night in close apart- ments; to be ever on the anxious watch for a good position, or any position at all, in the intense competition of the masses; to eat hurriedly anything which is set before you, and at times adapted not to your own convenience, but to that of the transporting party; often, in the onward hurry, to pass nights without sleep, or with insufficient sleep, upon the road or the stream, and in an atmosphere contaminated with human exhalations; this is not relaxation and amusement; it is labour, often very fatiguing, vexatious, and ex- hausting labour; and it is no wonder that invalids, who travel thus, return weaker than when they started, and with very discouraging impressions as to the remedial virtues of travelling. All this should be reversed. There should be no hurry, no bustle, no anxiety or struggle. Arrangements should be made for quiet movement, on foot, in a carriage, on horse-back, or in two or more of these methods successively. The lodgings should be comfortable and airy, and a due amount of sleep procured. The meals should be taken as regu- larly as possible, eaten slowly, and of wholesome food. With a little care and forethought in regulating these points, the happiest effects may be hoped for. The charms of rural scenery and rural sounds, the frequent novelties, the succession of interesting inci- dents, the changing personal intercourse, the sweetness of repose after moderate fatigue, light and agreeable reading in the intervals of rest, the varied gratifications of the passing day, the as varied hopes and plans for the morrow; perhaps a short sojourn in some way-side inn, with charming scenery and cool shade without, and cleanliness, neatness, and a cordial welcome within; perhaps a longer abode in some place of more general resort, by the sea-shore, or near some mineral spring, for example, where salt-bathing or vol. i.—13 194 GENERAL STIMULANTS. [PART II. chalybeate waters may superadd their tonic effect to that of cheer- ful social intercourse; all these genial influences combine, with the sustained exercise and uncontaminated air, to elevate and support the physical functions, and often serve to restore energy to a debili- tated frame, upon which medicines have been tried in vain. In the debility of convalescence; in that resulting from an overstraining of the mental and corporeal functions, in the eager pursuits of busi- ness or ambition; in various chronic inflammations of the internal organs, in which the local mischief is sustained by a want of due energy in the system to institute a restorative course; in the nerv- ous affections, particularly the neuralgic, in which the nerve-centres are enfeebled in the general weakness, and unable to resist irritating or otherwise disturbing causes; in the torpor of stomach, liver, and bowels, which are so often met with conjointly in dyspeptic disease; in such cases as these, it is, that we may expect good from travelling. To obtain its full advantages, it is sometimes necessary to persevere long; and a journey of six months, or of one or two years, will often completely accomplish a cure, which, with a shorter continu- ance of the same means, would be only partial or temporary. 6. COLD AS A TONIC. Cold is directly sedative; but, as it does not for a time lessen power, while the excitability of the depressed part is increased by its comparative rest, the necessary consequence is that, upon the withdrawal of the cold, and, in some degree, without its withdrawal, the ordinary normal excitants produce more than their ordinary effect, and the part is excited beyond its original condition. Be- sides, the sensation of cold has, through a wise provision of nature, an excitant influence upon the nervous centres, causing them to send a stimulant impression to the circulatory system, by which injury is obviated. Through the operation of these principles, reaction follows the first depression produced by the cold; and this reaction is not confined to the part first impressed, but extends throughout the system. Thus, cold secondarily elevates the vital functions; and, as this effect is usually moderate, it must take rank among the tonics. The invigorating power of this agent has long been known, as a matter of observation; and it has been much employed in cases of local and general debility. Caution, however, in its use is very important. If too long continued, it at length exhausts excitability, and then produces a steady depression, with- out reaction. Too intensely applied, it rapidly exhausts the ex- CHAP. I.] TONICS.—COLD AS A TONIC. 195 citability; and the reaction, if produced at all, may be feeble, and soon cease. In proportion to the debility, is this indisposition to reaction; and a degree of cold, which would secondarily stimulate a healthy person, might prostrate still further one already much debilitated. Therefore, in its employment as a tonic, the degree and continuance of the cold should be proportioned to the remain- ing strength, and the remedy should be abandoned if found to be followed by a feeble reaction, or by none. When the skin is cool, and at the same time relaxed by perspiration, the ability to react is much diminished; and the remedy should never be employed in this state of the surface. When the reaction is insufficient, it should be aided by friction upon the skin, or by muscular exertion. As a general rule, cold should not be used as a tonic when there is tendency to dangerous internal congestions, as of the brain or lungs, and should, therefore, be avoided in organic diseases of the heart, which predispose to such congestions. The reason is ob- vious ; namely, that the blood, driven by the cold from the surface, accumulates internally, and thus greatly adds to the pre-existing danger. Methods of Application, The cold-air bath may sometimes be usefully employed. This is applied by simply stripping the body in a cold room, at a temperature from below the freezing point to 60° F., remaining thus exposed for a short time, then dressing, and aiding reaction by moderate exercise. The cold-water bath is more efficient. For the purposes of a tonic, this should seldom have a lower temperature than 60°, and may be as high as 70° or 75° F. When too cold, there is the twofold danger, first that it may not be followed by reaction, and secondly that, if reaction do take place, it may rise too high, even so as-to amount to a febrile paroxysm. There can, however, be no fixed point of heat applicable under all circumstances; so different are the susceptibilities of individuals even in health, and so much are these susceptibilities affected by habit, by the degree of debility, and by the varying influence of peculiarity in disease. The gene- ral rule is, that the temperature should be sufficiently low to pro- duce a decided feeling of coldness, with shivering, paleness and contraction of the surface, and some reduction of the pulse. The duration of immersion should be no longer than sufficient to pro- duce a decided impression, and should cease at once upon the oc- currence of headache, pain in the stomach, cramps in the muscles of the extremities, general uneasiness, a purple colour of the lips, 196 GENERAL STIMULANTS. [PART II. ears, fingers, &c, or other symptom indicating any material dis- turbance of the vital functions. There is usually a shivering on the first immersion; and a repetition of this should be the signal for leaving the bath. The time may be momentary, it may be for a minute or two, or it may extend, when the temperature is but moderately reduced, to fifteen minutes or more. From 70° to 75°, the bath is scarcely applicable as a tonic, except to cases of ready susceptibility, or considerable weakness, with less than the usual tendency to reaction. In health, the reactive influence, at this tem- perature, would generally be balanced by the sedative power of the water itself; and little tonic effect would be experienced. A de- cided, but not excessive reaction is the essential test of the pro- priety of the remedy; and trial must decide how great a coldness, and how long an immersion are necessary for this result. With a repetition of the remedy, an increase, in one or both of these re- spects, is generally necessary in order to sustain the original effect. Should but a feeble reaction or none occur, the remedy must be abandoned. Upon leaving the bath, the patient should be wiped quite dry, and then aid reaction by gentle exercise. The signs of a sufficient reaction are a general glow, the return of colour to the surface, a fuller and somewhat more frequent pulse, and a feeling of lightness, exhilaration, and increased muscular strength. The head should also be immersed or wetted, in order to prevent deter- mination to that part. The cold bath should not be employed by women in advanced pregnancy, nor during menstruation. It is applicable, as a tonic, only to cases of chronic debility; and espe- cially those of a nervous character, without serious structural lesion. It may be repeated daily, and should be taken rather on an empty than a full stomach. Probably the most suitable period in the twenty-four hours is early in the morning; for then the ex- citability of the system, having been recruited by rest, is greatest, and reaction will be most apt to take place. The patient, how- ever, should not pass immediately from the warmth of bed into the bath, especially if perspiring. A little exercise previously is desirable, so as to induce a moderate action of the surface, but without perspiration. An hour or two before dinner is also a suitable period, if the excitability of the patient has not been im- paired by physical exertion previously; but exposure to the hot sun is an objection to bathing, at this time of day, in the open air. The cold shower bath is often employed with reference to its secondary tonic effects. It is administered by causing water to fall CHAP. I.] TONICS.—COLD AS A TONIC. 197 over the body from a greater or less height, in minute streams, formed by passing the liquid through a vessel perforated at bottom by numerous small holes. A common colander may be employed for the purpose extemporaneously. The shower bath acts on the same principles as the cold bath; but the shock is somewhat greater, and the reaction, therefore, more speedy. It may be em- ployed in similar cases, and with the same cautions. The time of continuance, for a given temperature, should be somewhat shorter. The cold douche is often useful as a local corroborant. It con- sists in the continuous impinging upon a part of the body of a column of cold water, either falling upon the part, or forcibly im- pelled against it by mechanical means. It operates upon the same principles locally, as the cold bath does generally; that is, it first depresses, and then secondarily stimulates the part by the reaction. The affections to which it is applicable are old and persistent gouty or rheumatic swellings of the joints, obstinate and indolent tumours, local paralysis, debility of the joints following sprains, nervous deafness, certain conditions of amaurosis, and obstinate weakness of the eyes, sometimes following their aeute diseases. Sea-bathing, or the cold salt-water bath, is still more efficacious than the simple cold bath, in consequence of the stimulant influence of the salt on the surface of the body; while, from the same cause, there is less risk of dangerous prostration. The reaction, under its use, is more speedy and certain, and from a less amount of an- tecedent depression; and patients can remain in it longer without exhaustion. Hence it may be employed in cases of debility, in which reaction under the use of the simple cold bath is imperfect, or wanting. While adapted to chronic debility in general, it is peculiarly useful in scrofulous affections, as of the bones, joints, and lymphatic glands, both external and internal. Sea-bathing has long been considered as among the most efficacious remedies in these affections. In threatened and incipient phthisis, it may be resorted to with hope of benefit, when the air of the sea-shore is not found injuriously to irritate the lungs. Should it do so, the artificial salt bath should be substituted. But particular caution should be observed, in this disease, to abandon the measure if not attended with full reaction. The probability is that sea-water acts, in scrofula, not only as a tonic, but, through its iodine compounds, as an alterative also; and might be expected, therefore, to be more efficacious than mere salt water. The salt-water bath may be made 198 GENERAL STIMULANTS. [PART II. by dissolving common salt in water, in the proportion of four avoirdupois ounces to the gallon. AVhen a strong stimulant im- pression upon the skin is desired, in reference to a revulsive influ- ence from within, the solution may be much stronger; but simply as a tonic, the strength mentioned, which is about that of sea-water, is probably preferable, at least as a general rule. 7. TRANSFUSION OF BLOOD AS A TONIC. By this process is meant the transfer of the blood of one indi- vidual into the blood-vessels of another. It is eminently a tonic measure, as it aims to do directly what some of the most effective tonic medicines, the chalybeates, for example, do indirectly; that is, to increase the quantity, and improve the quality of the blood. The idea of this remedial measure seems to have occurred to the ancients, and, according to Lamartiniere, was absolutely carried into effect by them; but, in modern times, no notice of it exists antecedent to the year 1615, when an account was published by Labavius of a case of direct transfusion from a young and vigor- ous man into another feeble and scarcely breathing, with the effect ,of restoring the strength of the latter. (Cyc. of Pract. 3Ied., Amer. ed., iv. 468.) About the middle of the same century, the measure was tried by Dr. Christopher Wren, of England, upon inferior animals, and soon afterwards (A. D. 1666) by MM. Denys and Emmerez, in France, upon the human subject. Much attention was attracted to it by the experiments of the last-mentioned prac- titioners, and some favourable results were obtained; but two in- stances of death, following its employment, brought it into disre- pute ; and it was forbidden by law to be practised in France until it should receive the approval of the Faculty of Medicine of Paris, which it has never yet received. (Diet, de 3Ied., xxix. 738.) For considerably more than a century, it remained in total neglect; nor was it till the publication of the experiments of Dr. James Blun- dell, of London (Physiolog. and Patholog. Researches, A. D. 1825), that general attention was again called to it, as a practical measure. By this practitioner, and by others in considerable number who have followed him, it has been satisfactorily established that trans- fusion, properly performed, is a perfectly safe operation, and may be employed with the happiest results in certain very dangerous cases. It has been ascertained, as might have been anticipated, that the CHAP. I.] TONICS.—TRANSFUSION OF BLOOD. 199 blood of one animal cannot be safely transfused into the vessels of another, of a different species, in which the normal character of the blood corpuscles is quite different; death, sometimes speedy, sometimes more or less protracted, having resulted from such attempts. But it is not absolutely essential to a favourable result that the animals must be of the same species, provided the blood be of a similar character; for the blood of calves has been trans- ferred to lambs with perfect impunity; and cases have been recorded by Denys and others, in which blood abstracted from men has been replaced by that of lambs and calves, not only without harm, but with beneficial effects. (Archives Generales, 4e sdr., xxx. 333.) Still, as it is quite certain that the blood of different individuals of the same species may be interchanged with safety, it is certainly the best rule to confine the measure practically within these limits. The chief dangers of the operation have been supposed to be, first, the entrance of air into the blood-vessels, and, secondly, the coagulation of the fibrin during the transfer. In reference to the former, the case of an insane man operated on by Denys is recorded, in whom, upon the third trial of the process, death suddenly oc- curred, in consequence, as was supposed, of the entrance of air into the veins; but no other case of a similar kind has occurred; and Dr. Blundell has shown that no danger need be apprehended from this source, with ordinary care. Indeed, from the experiments of Dr. Giovanni Polli, and others, it may be inferred that some bub- bles of air thrown in with the blood have no sensible effects what- ever. As to the dangers of coagulation, it has been said that small portions of fibrin, solidified in the transferring tube, might be thrown in with the liquid portion, and produce serious conse- quences by obstruction. But this danger may be avoided by a due degree of activity in the transfer; and, should future expe- rience show that there is really some ground for apprehension from this cause, it may be obviated by defibrinating the blood, previously to injection, in the ordinary method of agitation with sticks. The experiments of Dumas, Prevost, Dieffenbach, Polli, and others appear to show, that blood thus treated has all the revi- vifying properties of that fluid unchanged, and that the absence of the fibrin is of no account. (Arch. Qen., 4e seV., xxx. 208.) Applications. The main therapeutical application of transfusion has been for the recovery of individuals, greatly exhausted and dangerously prostrated by the loss of blood; and it is particularly 200 GENERAL STIMULANTS. [PART II. in puerperal women, suffering under the effects of uterine hemor- rhage, that the remedy has been tried. In these cases it has proved highly serviceable, having in many instances rescued the patient from impending death, when no other hope apparently remained, and in no one recorded instance been productive of known evil. Of thirty-six cases in which transfusion was performed, in conse- quence of exhaustion or hemorrhage connected with the puerperal state, collected by Mr. Soden, and published in the London 3Iedico- Chirurgical Transactions (xxxv. 415), "twenty-nine were recovered from imminent death by the operation;" and of the seven unsuc- cessful cases, " it does not appear that the fatal termination, in any case, was due to or hastened by the operation." Though used chiefly, as just stated, in puerperal cases, the remedy has proved not less beneficial in exhaustion from spontaneous hemorrhage, and that following wounds and operations, of which Dr. Routh gives examples in a paper published in the 3Iedical Times (Aug. 11, 1849); and in one case at least of constitutional hemorrhage, in which the morbid tendency had existed from birth, and the patient had been reduced, by continual bleedings, for five days, to a state of extreme peril, not only were the urgent symptoms relieved, but the predisposition appears to have been eradicated by a consequent change in the character of the blood. (Arch. Gen., 4e ser., xxx. 338.) The remedy has also been found effectual in inanition, dependent on constant vomiting. (Medico- Chirurg. Trans., xxxv. 434.) Indeed, this appears to me among its most promising applications. Cases now and then occur in which, without incurable disease of the stomach, this organ becomes so irritable that no food can be retained, and death sometimes results. By allowing the stomach to rest in these cases, and introducing nothing into it except a little cold water, the diseased condition may be corrected by the efforts of nature, if the life of the patient can in the mean time be sustained. This has been done, in some instances, with the effect of saving life, under apparently desperate circumstances, by means of injections of ani- mal broths into the rectum; but, should this measure fail, nothing seems to be more clearly indicated than the occasional transfusion of blood, in such quantities as may be necessary to support the vital functions without undue excitement. Method of Operating. Under the impression that the blood would be injured by exposure to the air, the transfusion was originally effected through a tube, passing from an artery of the supplying indi- CHAP. I.] TONICS.—COD-LIVER OIL. 201 vidual into an artery of the patient. But this was a very unsatisfac- tory procedure, and founded, as has been fully established by expe- riment, upon a false basis. The short period for which the blood is exposed to the air has been found to be attended with no disad- vantage. The much more convenient and efficient plan, therefore, has been adopted, of drawing the blood from a vein of the healthy person into a deep vessel, and then immediately injecting it into a vein of the patient, by means of a syringe. The receiving vessel should be placed in warm water, so as to maintain the normal tem- perature of the blood, and the syringe should be warmed with the same view. The syringe should be plated or tinned within, should work accurately, and should have the capacity of three or four ounces. It is better to operate upon a vein in the arm than in the neck; as there is less risk of the admission of air. The blood should be injected slowly and steadily. Occasionally some force is requisite to overcome the resistance of the vein when collapsed. The quantity of blood thrown in must be regulated by the effects, and the apparent wants of the system. From less than an ounce to more than twenty-four ounces has been employed; about four ounces, in a greater number of cases than any other precise quan- tity. (Ibid., 427.) In a case operated on by Mr. Soden, the happiest effects followed the introduction of a single ounce. (Ibid., 423.) ——•+•— The tonics may be most conveniently arranged for special con- sideration in three subdivisions; namely, 1. those of animal, 2. those of vegetable, and 3. those of mineral origin. I. Tonics of Animal Origin. Though an animal diet may be considered as tonic, and this in- cludes many distinct substances, cod-liver oil is the only one, strictly entitled to the name of a medicine, which belongs to this subdi- vision. 202 GENERAL STIMULANTS. [PART II. COD-LIVER OIL. OLEUM MORRHU^E. U. S, Lond., Dub. Origin. Cod-liver oil is obtained from the livers of Gadus Mor- rhua, or the common cod, and several other species of the same genus, inhabiting the waters of the Atlantic, near the shores of Northern Europe and America. It is prepared either by exposing the livers in mass to the heat of the sun, and skimming off the oil as it rises; or by boiling them into a pultaceous mass with water, and straining; or by expression. Sensible Properties. Its consistence is that of ordinary fish-oil. In its purest form, it is of a colour varying from the slightest tint of transparent yellow to a fine golden yellow; when less pure, of a light-brown colour, but still transparent; when most impure, dark- brown and opaque in mass, though transparent in thin layers. Its odour and taste are quite peculiar, scarcely disagreeable in the finer kinds, but offensive in the most impure, which are also somewhat acrid. The oil is injured by long exposure to the air. Composition. It contains a peculiar principle called gaduin, not known to have any medicinal virtue, various biliary principles, a little iodine, olein and margarin, and many other constituents of no special interest. Characteristics. Its most obvious characteristic properties are its odour and taste, quite different from those of ordinary fish-oils, and strongly resembling those of shoe-leather, which owes these pro- perties to the cod-liver oil,, used in its preparation. Another dis- tinctive property, derived from its biliary constituents, is that of assuming fine changes of colour under the action of the mineral acids. A third peculiarity is that, when heated with potassa, lime, and muriate of ammonia, it yields a smell like that of her- ring-pickle, owing to the formation of a peculiar volatile alkali called propylamin. It is frequently adulterated with other oils. Effects on the System. When taken in the ordinary doses, cod- liver oil, in the great majority of cases, produces, for some time, no observable effect upon the system. In two or three weeks, how- ever, a fattening process usually commences; and there is a gradual increase of weight, with a moderate exaltation of the functions generally, and an augmentation of the red corpuscles of the blood. In some persons, the medicine produces nausea and disagreeable eructations, and, when the gastric sensibilities are extremely acute, CHAP. I.] TONICS.—COD-LIVER OIL. 203 even vomiting; but these results are most frequently dependent rather on its offensive taste, than its direct influence on the stomach; and, when the oil is taken without exciting disgust, are very rare in a healthy state of the organ. Occasionally the functions are over-excited; the medicine proving laxative, diaphoretic, or diu- retic, and even augmenting the menstrual flux; and I have very frequently noticed, after its continued use for two or three months, a decided odour of the oil exhaling from the body, distinctly ob- servable upon a near approach. At length the system seems to be accustomed to its use, and no further change is produced. In cases of debility and emaciation, with an anemic state of the blood, the alteration is frequently very striking. Beginning two or three weeks from the first use, of the medicine, the patient often rapidly fattens, the healthy colour returns, the • pulse, instead of being excitable and weak, becomes full, strong, and equable, the appetite and digestion improve, and a healthy vigorous tone of mind takes the place of the previous languor, listlessness, or depres- sion. These effects are all characteristic of a tonic operation, and, as in the case of other tonics, may be carried into excess, so as to produce a plethoric state of system, which is a result to be guarded against in the use of this remedy. 3Iode of Operation. It is supposed by some that cod-liver oil acts merely as a nutrient, and differs from other articles of diet only in consequence of its more ready assimilation. But from no other nutritious substance, and no combination of such substances, can equal effects be obtained, under the same circumstances. Surely there are many articles of food, much more analogous in constitu- tion to our own tissues, and even more readily digested, which, in the ordinary condition of the system, nourish it even better than this oil could do, but utterly fail in the morbid states in which it proves so efficacious. It has been said that it fattens by simply supplying oil, in a state in which it can readily enter the blood, and that other oils of easy assimilation will answer the same pur- pose. But it does not simply fatten. It improves the digestive process, increases the proportion of red corpuscles in the blood, and invigorates the whole nutritive function. The mere increase in the proportion of fat in the system is one of-ihe least important of its results. Besides, other fats do not produce the same effects. But- ter, fat pork, the fat of beef, mutton, and veal, olive oil, and various other oleaginous substances, are often largely consumed by the very individuals, who afterwards find relief, by the employment 204 GENERAL STIMULANTS. [PART II. of cod-liver oil, from morbid conditions which had arisen under the use of these articles of diet. Nothing has been more common, in the Hospital of which I have charge in the winter season, than to see consumptive seamen rapidly improve in their condition, under the influence of the oil, though they may have been previously consuming, on shipboard, much larger quantities of oily matter in the shape of fat pork. It is true that different practitioners have suggested different oleaginous substitutes for cod-liver oil; each maintaining that he has obtained satisfactory results from the one specially recommended. Thus, whale oil and other kinds of fish- oil, olive oil, almond oil, poppy oil, &c, have been recommended; but, though most of them are much more readily obtainable than pure cod-liver oil, not one of them has held its ground, and secured the confidence of the profession generally, simply because it has failed upon a more enlarged trial. It is proper to state that Dr. Theophilus Thompson, physician of the Brompton Hospital for consumptive persons, states, in his recently published clinical lectures on pulmonary consumption (Am, ed., p. 128), that he has found cocoa-nut oil to possess properties similar to those of cod- liver oil, and to bear comparison with that in its effects; but, if this estimate should prove correct, it would simply prove a close analogy in properties between the two oils, and not that they acted merely as nutrients. From these considerations, I think it must be admitted that cod-liver oil has positive medicinal properties; and the best explanation, I think, of its operation is, that it pos- sesses the power of directly stimulating the blood-making and nutritive functions, in a manner analogous to that of other tonics, and, in certain cases, more effectively than they. Whether its virtues depend upon a peculiar principle, the co-operation of two or more principles, or its general constitution, has not been deter- mined. Some have ascribed its powers to the iodine and bromine it contains; but these are in too small a proportion to exert much influence on the system; are incapable, when given alone, of produc- ing the same effect; and have quite failed when they have been given in combination with other oils, as has sometimes been done, in the hope that the artificially ioduretted oil might prove a suffi- cient substitute for that of the cod. Therapeutic Applications. Cod-liver oil has recently taken a place among the most valuable articles of the Materia Medica. Used from time immemorial, in the maritime districts of Holland, Germany, and the northern parts of Great Britain, as a popular remedy in rheu- CHAP. I.] TONICS.—COD-LIVER OIL. 205 matism and rickets, it was first brought to the notice of the medi- cal profession, in the year 1782, by Dr. T. Percival, of England, and was afterwards referred to by Dr. Bardsley, in his Hospital Reports, in 1807; but gained little attention until the publication of a paper by Schenck, in 1822, in Hufeland's Journal, containing a series of observations upon its efficacy in chronic rheumatism, particularly sciatica and lumbago. After this time, its employment was much extended in Germany, and other parts of the continent of Europe; and numerous communications in the medical journals set forth its claims to high consideration, not only in the complaints above mentioned, but in others, and especially in the different forms of scrofula and tuberculosis. In 1841, it was brought to the notice of the medical profession in Great Britain,, as a remedy in phthisis, by Dr. J. Hughes Bennett, of Edinburgh; his reports in its favour were confirmed by the ample experience of Dr. C. B. Williams, of London, and subsequently by that of Dr. Walshe; and, both in that country and in our own, the use of it extended rapidly, until it became almost universal, in the complaint referred to, and in other forms of scrofulous disease. Cod-liver oil is indicated generally in cases of chronic debility, with impoverished blood, and defective nutrition or assimilation, not connected with inflammation of the stomach. The class of affections in which it has obtained most reputation are those in- cluded under the term scrofulous ; and, in many of these, it has ex- hibited powers beyond those of all other remedies. To understand its effects, it is necessary to discriminate between these affections. The name scrofulosis may be applied to a condition of system, essentially connected with a low state of the vital forces, and defect- ive or depraved nutrition, which exhibits itself under two aspects. In one of these, there is a tendency to the production, in various parts of the body, sometimes in one part, sometimes in another, and some- times in several parts at once, of a feeble, protracted, obstinate kind of inflammation, strongly tending to the suppurative and ulcerative state, and indisposed to a spontaneous cure, which is usually desig- nated by writers as scrofulous inflammation. In the other, there is a disposition to deposit, in the various tissues, a peculiar matter called tubercle, which, at first solid, either remains in this condition, irri- tating the neighbouring parts like foreign matter, or gradually soft- ens, and is ultimately discharged through the inflammation, suppu- ration, and ulceration of the contiguous structure. These two differ- ent local expressions of the constitutional affection may exist quite 206 GENERAL STIMULANTS. [PART II. separately, or may be conjoined in the same case. Now cod-liver oil has an extraordinary influence over the state of system referred to, generally controlling it in a considerable degree, often suspend- ing it for a time when not completely eradicable, and sometimes curing it wholly and permanently. In the set of cases belonging to the first category above men- tioned, those, namely, in which the local affection is simply scrofu- lous inflammation, the oil will often effect complete cures; because, the morbid condition of system being corrected, and the strength im- proved, the local lesions are no longer produced, and those already existing are allowed to heal; and life may in general be saved, if the disorganization has not proceeded too far before the application of the remedy. In the second set, or that characterized by the tuberculous de- posit, the diathesis may be in like manner modified or corrected; but the remedy has no influence whatever over the tubercle when already formed, which will exercise its influence upon neighbouring parts, or pursue its own regular course of degeneration, quite inde- pendently of any corrective that can be applied. In such cases, it is obvious that the oil can prove curative only when employed, either before the tuberculous deposit has taken place, or when it has occurred in situations, or in quantities, not necessarily destruct- ive of life, through the disorganization of the tissue affected. Thus, when the tubercles are situated in the brain, or the arachnoid mem- brane, there is scarcely a chance of safety; because, being irremov- able, they will ultimately incapacitate, by their irritant influence, this vital organ for the performance of its functions. When, on the contrary, they are deposited in the external lymphatic glands, in the subcutaneous cellular tissue, and even in the bones, there is reasonable hope of a cure; as the parts are less essential to life, and the irritation can generally be supported until the offending matter has been discharged. Again, when such an organ as the lungs is the seat of the deposition, as there is a possibility that the tuberculous matter may be thrown off, it follows that, if the quantity is not so large as fatally to overwhelm the lung by irritation, as in diffused miliary tubercle, or to destroy the organ by ulcerative inflammation in the course of its discharge, or to exhaust the system by the pro- fuse suppuration, and the irritative influence of the local disease, one of which events generally happens in ordinary phthisis, there may be good hope of ultimate recovery. Upon these principles may, I think, be explained the frequent success, complete or partial, and the CHAP. I.] TONICS.—COD-LIVER OIL. 207 frequent failure also, of the remedy in scrofulous diseases. It will be proper, now, to treat specially of the several affections of this kind in which the oil is used. External Scrofula. In all the forms of external scrofula, un- attended with tuberculous deposition, much good may be expected from cod-liver oil; and, united with other measures calculated to improve the blood, and give vigour to the system at large, a cure may generally be expected. Its effects are peculiarly obvious in the suppurative and ulcerative stage of the affection, whether the lymphatic glands, the subcutaneous tissue, or the skin itself be the special seat of the disease. Scrofulous ulcers and abscesses of the neck, axilla, and groin, or of the skin, and the areolar tissue, in any part of the body, often rapidly improve, and ultimately get well under its use. I have seen large and exhausting abscesses of the lower extremities, which have reduced the patient, during months of suppuration, to the lowest condition of emaciation and debility compatible with life, recover slowly but steadily, from the period at which the system was put under the use of the remedy. Should tubercle, however, have been deposited in the glands, or other part affected, as this must be eliminated before a cure can take place, the result is more tedious and uncertain. In such cases, contrary to what often happens in the non-tuberculous cases, the swellings, whether glandular or otherwise, can very seldom be re- solved; and a long process of suppurative ulceration is necessary, before the patient can recover: but, even in these cases, much good is often done by preventing the further deposition, by sustaining the strength during the discharging process, and by determining healthy granulation and cicatrization afterwards. Scrofulous Ophthalmia. Cod-liver oil is among the most efficient remedies in this obstinate affection, conjoined with the local appli- cation of nitrate of silver to any existing ulcers of the cornea, or other part of the conjunctival surface. The oil has been recom- mended also as a local application in these cases; but I have no experience of its use in this way. Cutaneous Eruptions. When these are associated with scrofulous cachexia, they often yield to cod-liver oil very happily. It is more especially in the impetiginous and ecthymalous affections, and in rupia, that good may be expected; but eczema and pemphigus are sometimes similarly associated, and similarly benefited; and, in that most obstinate disease denominated lupus, this is among the most efficient remedies. In all the cutaneous eruptions; however, it is 208 GENERAL STIMULANTS. [PART II. more the condition of the system that must be considered, in rela- tion to the use of this remedy, than the particular character of the eruption itself. In these, as in ophthalmia, the oil has been recom- mended locally, as well as by the stomach. Scrofulous Disease of the Bones and Joints. No other single remedy is probably so efficient as cod-liver oil in this form of scrofula. In swellings of the hip, knee, and other joints, and in disease of the bones of the spine, extremities, cranium, &c, with or without abscess or caries; though the cure is often protracted; though more or less of deformity may follow from the organic mischief done; and though death will sometimes take place from exhaustion, when the remedy is applied too late, or even, from the great amount of disease, not- withstanding its employment, yet there are few practitioners, I pre- sume, by whom the oil has been tried, who do not consider it more effective than any other remedy previously used, and who have not found these affections much more manageable by its means than they had been before. As in scrofulous swellings of the glands, there may here also be tuberculous deposition, which adds greatly to the difficulties and dangers of the case; though, happily, it is comparatively rare. Tabes Mesenterica, or Swelling of the Mesenteric Glands. In cachec- tic children, there is often much abdominal distension, with more or less hardness, sometimes peritoneal effusion and enlarged liver, great emaciation, pallor, and debility, which have generally been ascribed to scrofulous disease of the mesenteric glands. Some of these cases yield quickly and most happily to cod-liver oil, and co-operating treatment; while others are more or less obstinate, and not a few end fatally. This difference of result may be. readily accounted for. Some of the cases depend essentially on tubercles, either scattered in the peritoneum or beneath it, or deposited in the mesenteric glands, which they enlarge and harden, or diffused throughout the whole abdomen, causing peritoneal inflammation, which some- times agglutinates all the viscera together. These are, in gene- ral, essentially incurable, except, perhaps, in a few instances, in which the tubercle, originally small in amount, may make its way, through ulceration,into the bowels, or possibly undergo ab- sorption or degeneration. But not unfrequently, also, there are no tubercles; the scrofulous affection of the liver and mesenteric glands being simply of the characteristic inflammatory character; and cases of this kind very often end favourably. The latter cases are most common in infancy, the former in children from two to CHAP. I.] TONICS.—COD-LIVER OIL. 209 ten; and, when adults are affected, it is most commonly in the tuberculous form. Disease of the Bronchial Glands. The same remarks are applicable to these as to the mesenteric glands. In scrofulous cases without tubercle, a cure may be expected; in the tuberculous, the result is more doubtful, though there is reason to believe that the tubercle is sometimes eliminated through the bronchia, and that recoveries take place; but in these cases the danger arises, not so much from the tubercle in the glands, as from that deposited also in the lungs. Disease in the Stomach and Bowels. Diarrhoea, with ulceration of the bowels, is a not unfrequent attendant on tuberculous affections. Sometimes this depends on tubercles in the substance of the bowels, leaving ulcers as they are discharged; in other instances it has been found to be unconnected with tubercles. There is reason to believe that scrofulous inflammation sometimes attacks especially the mucous membranes, showing, when it does so, a tendency to affect the follicles, and to result in ulceration of these structures. The gastric mucous membrane may be thus attacked, as well as the intestinal, though it is much more rarely tuberculous than the latter. In these cases, whether tuberculous or not, cod-liver oil is indicated whenever it can be supported by the stomach. Even when tuberculous, there may be hope of a favourable result, if the affection is confined to this part. Chronic Bronchitis, Laryngitis, Angina, Ozsena, &c. The remarks made in the last paragraph in relation to the mucous membrane of the alimentary canal, are applicable also to that of the respira- tory passages, as well as of the pharynx, though tuberculization is uncommon. Hence, in chronic inflammation of the nostrils or ozaena, chronic angina, and chronic laryngitis and bronchitis, when connected with the scrofulous, diathesis, cod-liver oil should be tried. Scrofulous Inflammation of the Serous Tissues. This often exists in connexion with tubercles, as already stated in reference to the peritoneum. The pleura, pericardium, and synovial membranes are similarly affected. Whether scrofulous inflammation occupies these tissues without tubercles may perhaps be considered un- certain; but analogy is in favour of the opinion that it does so; and, in relation to the arachnoid, or at least the subarachnoid tissue, and the synovial, analogy is strongly supported by facts. Exten- sive tuberculization of the proper serous tissues is almost always sooner or later fatal; but the event may probably be postponed vol. i.—14 210 GENERAL STIMULANTS. [PART II. by the use of the oil; and, in cases where the inflammation may be supposed to exist without tubercle, the remedy would probably prove occasionally curative. Hence, in chronic cases of these affections, the oil should be employed, not only to correct the dia- thesis as far as possible in the positively tuberculous cases, but as a curative measure, in the hope that the symptoms may depend simply on scrofulous inflammation. I have seen cerebral symp- toms in infancy, which seemed strongly to threaten chronic hydro- cephalus, and associated with other evidences of scrofulous cachexia, yield happily to this remedy. Phthisis. The principles upon which cod-liver oil is given in this complaint have been already stated. All that can be hoped for from it is, by improving the constitution, to correct the tend- ency to the deposition of tubercle, and to support the system during the exhausting process of its discharge. Unfortunately, the diathesis is often so strong, so intimately incorporated as it were with the inherited constitution of the patient, that no known in- fluence is sufficiently powerful to eradicate it; and, though it may be postponed, the fatal result is in most cases inevitable. This much, however, may be said in favour of cod-liver oil, that no one medicine, and no combination of medicines are known, which nearly equal it in efficacy. I believe that, if used before tubercle has been produced, it will not unfrequently prevent it; that, even after a moderate amount has been deposited, it will sometimes arrest its progress, and ultimately save the patient; and that it may, in some few cases, even in the advanced stage of the disease, and after cavities have been formed, rescue from death, if the quantity of tubercle already existing be not sufficient fatally to disorganize the lungs. Of this I have no doubt, that, if begun with early, and used perseveringly, with the aid of other measures calculated to invigorate the general health, it is capable of very considerably diminishing the amount of mortality from this fearful disease. All agree that it will often prolong life, when unable to preserve it, and that it very much contributes to the comfort of the patient, especially in the advanced period of the complaint. There is no stage, from the beginning to the close, in which it may not be given with reasonable hope of benefit. The misfortune is, that it is often given insufficiently, being abandoned too early, or taken irregularly, or in too small a quantity; and that patients, in consequence of its unpleasant effects on the palate or the stomach, will not, or, from the irritability of that organ, cannot take it in the CHAP. I.] TONICS.—COD-LIVER OIL. 211 requisite amount, or for the requisite length of time. No material effect need be looked for under two or three weeks; and it should not be abandoned, unless after a totally fruitless trial of six weeks or two months. When found useful, it should be persevered with for months or years; and, even after the apparent restoration of health, the least sign of relapse should be the signal for its resump- tion. In the inherited cases, there is a natural proclivity to the disease, which, though it may be corrected for a time, will again and again evince itself when the restraining cause is removed; and the only chance of safety is in the unremitting use of the proper measures, even when symptoms of disease have disappeared, until, in the spontaneous changes which the system undergoes in tfie advance of life, the original tendencies may have been subverted. But it is not in the scrofulous affections only that cod-liver oil is useful. There are other diseases, connected with a cachectic con- dition of the system, in which it has enjoyed much reputation. Chronic Rheumatism. This is one of the complaints in which the oil was first used. It has been particularly recommended in chronic lumbago and sciatica, and in obstinate swellings and deformities of the joints. It is no doubt beneficial in some of these cases; but I think it highly probable that not a few of the latter, which were taken for rheumatic, were really scrofulous, and that the remark- able efficacy of the oil may be in part ascribed to that cause. In the Pennsylvania Hospital, I have repeatedly witnessed cases of obstinate and painful swellings of the knee, ankle, or hip, which may possibly have been at first rheumatic, and had been treated as such for months without success, which were attended with great emaciation, a frequent pulse, night-sweats, and other evidences of debility, and were going on in a steady course of deterioration, that threatened death in the end. These cases, under the impres- sion that they were really scrofulous, having either been such in the beginning, or assumed this condition in their progress, I have treated with cod-liver oil, aided by rest, nourishing food, and auxiliary medicines, as iron, quinia, and iodide of potassium, and with the happiest results. At the usual period after the commence- ment of the remedy, they have begun to exhibit signs of amend- ment, and have gone on, steadily though gradually, to a perfect cure. How much of the result was ascribable to the oil, and how much to the auxiliary measures, it would be difficult to decide; but my impression on the whole is that, without the oil, I should have been much less successful. The remedy has been recommended in chronic gout; but is less efficacious. 212 GENERAL STIMULANTS. [PART II. Rickets. Perhaps in no disease does the oil display greater powers than in this, occurring in early childhood. Infants, affected with the disease, often begin to improve in a few days under its use, and rapidly advance to complete recovery. Besides the affections above mentioned, the oil may be used in chronic anaemia and chlorosis, in paralysis with debility, and in various nervous affections associated with impoverished blood. Amenorrhoea has sometimes yielded to it; probably through its influence over the blood-making functidta. Centra-indications. It is contra-indicated in an inflamed and irri- table stomach, a plethoric state of the circulation, and active local congestion; and when, in the course of its administration, these conditions may occur, either accidentally, or as a result of its operation, its use should be suspended for a time. This caution it is particularly necessary to observe in phthisis, in which, though it is highly important that the blood should be of good quality, yet in quantity it must bear a due relation to the reduced capa- city of the lungs; as otherwise it might endanger inflammation or hemorrhage. Administration. For an adult, a tablespoonful three or four times a day is about the proper dose; and for an infant, a tea- spoonful as often; and this quantity should always be aimed at. Some can take the oil out of the spoon without inconvenience; but generally it is desirable to obviate the disagreeable taste by some addition. This may often be done sufficiently by taking an aromatic substance into the mouth, immediately before and im- mediately after the medicine. Orange-peel has been particularly recommended for this purpose; so also has strong coffee, without cream or sugar, in the quantity of a teaspoonful. The oil may also be taken floating in an aromatic water, as that of cinnamon, or one of the mints. But probably the best vehicle, on the whole, is a little frothy porter or ale, which covers the taste very well, and is usually not contra-indicated. In hectic cases, the dose of oil may sometimes be advantageously administered in a wine- glassful of wild-cherry bark tea. When the stomach is very deli- cate, it may be given in the form of emulsion, made with an aromatic water. It has been recommended to employ the oil externally, by fric- tion, with a view to its constitutional impression ; but in this way it would be too offensive for ordinary use, and should be resorted to only when the stomach entirely rejects it. With a view to its CHAP. I.] TONICS OF VEGETABLE ORIGIN. 213 local effect, it has been applied to the eye in scrofulous ophthalmia, and to the skin in eruptive complaints. II. Tonics of Vegetable Origin. The vegetable tonics may be subdivided into three sets; namely, 1. the pure bitters, 2. the bitters with peculiar properties, and 3. the aromatics. 1. Pure Bitters, or Simple Bitters. These are characterized by bitterness with little or no intermix- ture of other taste, and by a purely tonic power, which is identical or nearly so in all. There appears to be a close relation between the bitter and tonic properties; so much so, that the possession ot the former may be considered as prima facie evidence of the pos- session of the latter also. Cullen, indeed, believed this connexion to be essential, and taught that it was the tonic power of bodies that gave them bitterness. Bitter substances might have other powers in addition, such as the narcotic and purgative, which might prevent their use in reference to their tonic property, but they still possessed it. He even seems to have thought that the bitterness might reside in a single principle of peculiar composi- tion. This, however, has been shown not to be true. A great number of proximate bitter principles have been discovered, very different in composition and chemical relations. Yet I am inclined to think that there is some ground for the opinion of the identity of the two properties. It is easy to conceive that the same ar- rangement or shape of particles which causes the impression of bitterness on the organs of taste, may give rise to the tonic impres- sion upon the stomach; and that, though all bitters may not seem to be tonic, this may be owing, not to the want of the property, but to the possession of other powers of affecting the system, so influ- ential as completely to overwhelm and conceal it. Nux vomica is tonic in small doses; but, largely given, produces a peculiar effect on the nervous system which quite obscures the tonic. Even quinia, in very large doses, loses apparently all its tonic powers, in its over- whelming influence upon the nervous centres. The same may be the case with other bitters of great medicinal energy, such as colo- cynthin, elaterin, digitalin, morphia, &c. If reduced in their dose so as to be unable to produce their more powerful and characteristic 214 GENERAL STIMULANTS. [PART II. effect, it is very possible that they might prove tonic to the digestive organs. Effects on the System. The effects of the simple bitters are to increase the appetite, invigorate digestion, and moderately to exalt the nutritive function. They have little direct influence on the circulation, and perhaps none upon the nervous system. The pro- per cerebral functions do not appear to be affected by them in any degree, unless in so far as these may be influenced by the condi- tion of the others mentioned. Their main operation is directly upon the mucous surface of the alimentary canal; and their gene- ral tonic effects may be ascribed chiefly to the increased quantity, and improved quality of the blood, resulting from the stimulated digestion. It is probable that a stimulant effect is extended sym- pathetically from the gastro-intestinal surface to the liver and pan- creas, upon the same principle as that by which the presence of chyme in the duodenum excites these organs. It is possible that the bitter principles may be absorbed, and, through the circulation, act on the nutritive function everywhere; but this has not been proved in relation to the set of substances now under consideration. One evidence that their direct operation is mainly upon the digest- ive organs is offered by the fact, that, when they are taken largely, so as to prove irritant, their increased effects are exhibited in those organs, and not directly elsewhere. The simple bitters are apt, in over doses, to prove laxative, and sometimes nauseate and even vomit; but they do not disturb the heart, nor the cerebro-spinal system, nor any other part of the body, unless in so far as these may feel the condition of the digestive organs. Therapeutic Application. The simple bitters are especially appli- cable to cases in which the indication is to promote the digestive function. In pure dyspepsia, they are, upon the whole, the best tonic remedies in our possession. By moderately stimulating the stomach, they probably favour the secretion of a healthy gastric juice, capable of dissolving the food, and thus obviate the stomachic uneasiness, flatulence, and sour or acrid eructations, resulting from the irritation of undigested matters, of substances generated by the chemical reaction of these matters, and probably also of the unhealthy secretions of the weakened stomach itself. They extend a similar stimulant influence to the torpid bowels, and probably also to the torpid liver, thus still further favouring the digestive function. Even in deficient action of the bowels and of the liver, unattended with symptoms of proper dyspepsia, they are often useful, espe- CHAP. I.] TONICS.—SIMPLE BITTERS. 215 cially in combination with remedies more especially addressed to those functions. Hence their use as adjuvants to laxatives in con- stipation, and to cholagogues in jaundice depending on hepatic torpor. From their usefulness in debility of digestion, it follows that good may be expected from them in all those disorders of sensation and function having their root in this affection. Hence, they are among the most efficacious remedies in headache, vertigo, and other deranged cephalic sensations, connected with excess of acid in the stomach; in which cases they should be given combined with an antacid, as magnesia, when there is costiveness, chalk when there is diarrhoea, the alkaline carbonates or bicarbonates when there is neither, and aromatic spirit of ammonia when there is great gastric insensibility. The simple bitters are also well adapted to the debility of con- valescence from acute diseases, whether general, as fevers, or local, as cholera, dysentery, and other affections of the alimentary canal. Whenever, under these circumstances, the original disease has been removed, and the appetite remains feeble, and the digestive powers insufficient for the management even of the food that may be taken, the gentle stimulation of the simple bitters is indicated, and will often contribute to the restoration of health. In all cases of general debility, and of impaired blood, originating in or connected with simple weakness of the digestive function, these medicines may be used with the hope of benefit; and they are often usefully combined with other tonics, which exercise a more powerful direct influence over the system at large. They were formerly employed in intermittent and remittent fevers; being administered, in the absence or decline of the fever, as antiperiodics, and were supposed to be peculiarly applicable to cases in which the apyrexia was not sufficiently complete for the use of Peruvian bark. But, since the discovery of quinia, this use of the simple bitters has been in great measure abandoned. They have been supposed to possess anthelmintic properties; and are no doubt occasionally useful in verminose cases. Some have supposed them to operate by poisoning the worms; and experiment has shown that some of them are noxious to inferior animals; but the probability is, that they do good much more by giving proper tone to the bowels, and thus removing the condition favourable to the development of the worms, than by a direct action on the para- sites themselves. Tliey are more freojuently given as adjuvants of other medicines 216 GENERAL STIMULANTS. [PART II. than by themselves. They are indicated, in this way, whenever weakness of the digestive function is complicated with the special disease prescribed for. Reference has already been made to their combination with laxatives in constipation, with the mercurial preparations in jaundice, or other cases of torpid liver, and with other tonics in general debility, as with the chalybeates in anaemia. In the various nervous affections, they are often useful in con- junction with the metallic tonics and the nervous stimulants, in dropsy with diuretics, and in amenorrhoea with emmenagogues. The different forms in which they are prepared, as those of powder, extract, infusion, and tincture, afford facilities for these combina- tions, which should not be overlooked in prescription. When given in chief, they are themselves .often aided by the addition of aro- matics, as of ginger, orange-peel, &c, which render them more stimulant to the stomach when very languid, and more easily re- tained by it when irritable. The different simple bitters are so similar in their effects, that they may be given indiscriminately; one being preferred to another according to convenience, the choice of the patient, or the existence of some idiosyncrasy which may render any one or more of them inadmissible. I. QUASSIA. U. S., Lond., Ed., Dub. Origin. Quassia is the wood of Quassia excelsa (Simaruba ex- celsa, De Cand.; Picraena excelsa, Lindley), a lofty tree growing in Jamaica, and other West India Islands; and of Quassia amara, a small tree or shrub inhabiting Surinam. At present, little or none from the latter source is imported. Properties. It is brought to us in billets, with the bark generally attached; but, as kept in the shops, is in the form of raspings or shavings, or split into small pieces. The wood is light, porous, yellowish, inodorous, and of an intense, unmixed, and adhesive bitterness. Active Principle. This is a peculiar, bitter, crystallizable prin- ciple, named quassin. Chemical Relations. Quassia yields its virtues to water and alcohol. Its chemical relations are such as not to interfere with the use of any other medicine, with which it may be desirable to associate it in prescription. It is asserted to have the property of opposing in CHAP. I.] TONICS.—QUASSIA. 217 some degree, though it will not altogether prevent the putrefaction of animal substances. Therapeutic Application. The use of quassia as a medicine origi- nated in Surinam, in South America. It was introduced into Europe in the year 1756, but was not made generally known until the publication of a dissertation by Linnaeus in 1763, after which it came quickly into general use. It was at first supposed to have virtues closely analogous to those of Peruvian bark, and was em- ployed in intermittent and remittent fevers, and sometimes also continued fevers, in the low forms of which its antiseptic properties were thought to render it useful. It was considered as especially applicable to cases in which, in consequence of irritability of sto- mach, the more powerful febrifuge could not be retained. But this use of quassia has been abandoned. It is now generally admitted to be nothing more than a simple bitter, and to be applicable only to affections, in which the tonics belonging to this last subdivision are indicated. Quassia is asserted to be noxious to insect life. Employed in cabinet ware, it is said to afford protection against insects, and the infusion has been used as a fly-poison. A grain of the alco- holic extract, inserted into a wound in the leg of a rabbit, is said to have caused the death of the animal on the third day, without any signs of inflammation; and from this, and other observations made of its effects on other animals, and on man, it has been sup- posed to have narcotic properties; but I have never witnessed any effect of this kind, or anything approaching it; and do not believe that it has the least special influence on the brain. In over-doses, its only known effects are to irritate the stomach and bowels. The uses of quassia are those of the simple bitters generally, of which it is probably the purest and most powerful. For an account of these, the reader is referred to the general remarks on this set of substances. (See page 214.) It is sufficient here to state, that the medicine is applicable to all cases of simple weakness of the digest- ive organs; being much used in dyspepsia, and the debility of convalescence, especially that of febrile diseases and disorders of the alimentary canal, after the entire subsidence of inflammatory action. In consequence of its noxious influence on worms, it has been employed, in the form of enema, in the treatment of ascarides, and with asserted success. A decoction, made by boiling half an ounce oLit in a pint of water, has been used for this purpose. 218 GENERAL STIMULANTS. [PART II. Administration. Quassia has been little used in the form of powder. Some dyspeptic patients, who have no objection to its bitterness, carry the wood along with them in small pieces, and chew it habitually with advantage. But care must be taken not to carry this habit into an abuse. The Infusion (Infusum Quassle, U.S.) is the preparation in which it is most frequently administered. This is made in the proportion of two drachms to a pint of water. Either cold or hot water may be used, the former making a clearer infusion, the latter acting more rapidly. The Officinal Extract (Extractum Quassia, U.S.) is a very effi- cient preparation, and is preferable when it is desirable to admi- nister the medicine in the form of pill. It is a watery extract, and probably stronger, in a given weight, than any other preparation of the simple bitters. It is very convenient for combination with other medicines in the pilular form; such as the chalybeates, aloes and rhubarb, myrrh, mercurial pill or calomel, &c. The Tincture (Tinctura Quassle, U.S.) is also officinal, and is resorted to, in cases of considerable insensibility of stomach, as an addition to the infusion, to other tonic infusions or decoctions, and to liquid purgative preparations. The dose of the powder is twenty or thirty grains, of the infusion two fluidounces, of the extract from two to five grains, of the tinc- ture one or two fluidrachms; each, three or four times a day. II. SIMARUBA. U. S., Lond., Ed, Origin. This is the bark of the root of Quassia Simaruba (Sima- ruba officinalis, De Cand.), a tree of considerable size, growing in the West Indies, and in Guiana. Properties. It is in long flat pieces, folded longitudinally, fibrous, flexible and tenacious, yellowish internally, inodorous, and very bitter, without admixture of other taste. It yields its taste and medical virtues to water and alcohol. Active Principle. It owes its virtues to the same bitter principle found in quassia. Therapeutic Application. Simaruba was first introduced into Eu- rope from South America in the year 1713, as a remedy in dysen- tery, diarrhoea, and the hemorrhages; and acquired great reputation in these complaints. With our present experience, it can be^d- mitted to have been useful in these affections only when complicmed CHAP. I.] TONICS.—GENTIAN. 219 with a debilitated state of the alimentary canal, or of the system, calling for the use of tonics; and, as there are other remedies more efficient under these circumstances, it has fallen into almost entire neglect. It is in fact a simple bitter, having nothing peculiar in its action, and so closely analogous in properties to quassia, that it may be looked on as identical with that medicine in its effects and appli- cations. It is usually administered in the form of infusion, which may be made in the proportion of two drachms of the bark to a pint of water, hot or cold, and given in the doseof two fluidounces three or four times a day. III. GENTIAN. GENTIAN A. U.S., Lond., Ed, Dub. Origin and Sensible Properties. Gentian is the root of Gentiana lutea, and of some other species of Gentiana, herbaceous peren- nials, growing in the mountainous regions of Europe. It is usually several inches in length, tapering, occasionally branching, some- times longitudinally sometimes transversely sliced, spongy, wrinkled spirally, grayish-brown externally, yellowish or brownish-yellow internally, of a feeble peculiar odour, and an intensely bitter, slightly sweetish taste. Chief Constituents. The root contains a peculiar bitter principle called gentianin, on which its tonic properties depend; a peculiar organic acid, called gentisic acid or gentisin, which is without effects on the system; a minute proportion of volatile oil, uncrystallizabte sugar, gum, pectin, &c. Chemical Relations. Gentian yields its bitterness and medical virtues to water and alcohol. Containing no tannic or gallic acid, it may be associated in prescription with the salts of iron; but, in consequence of its mucilaginous matter or pectin, it gives precipi- tates with the acetate and subacetate of lead; and sulphate of zinc occasions a slight flocculent deposit with the hot infusion. Tannic acid causes a bulky precipitate. Sulphuric, citric, and probably other acids sensibly diminish its bitterness. The addition of alka- lies does not affect the bitterness; but causes the infusion to gela- tinize on standing. (Procter.) In consequence of its saccharine matter, the infusion undergoes the vinous fermentation on the addition of yeast, and by distillation yields a spirituous liquor, said to be used as drink in Switzerland. 220 GENERAL STIMULANTS. [PART II. Effects on the System. Gentian has all the characteristic physio- logical effects of the simple bitters,'being perhaps somewhat more excitant to the circulation than most of them. It is said to render the perspiration and urine bitter; and hence its active principle is inferred to undergo absorption. In over-doses it is liable to pro- duce nausea and vomiting, and to act also on the bowels. Accord- ing to Planche, the distilled water of gentian occasions violent nausea and a kind of intoxication. Therapeutic Application. Gentian was known by the ancients, and has ranked among standard remedies from a period anterior to the Christian era. It is applicable to all the purposes for which the simple bitters are used, and is among those most employed. (Seepage 214.) As it is thought to be somewhat more excitant than the others, it should be used more cautiously when there is any suspicion of febrile action or gastric inflammation. Its chief employment is as a stomachic in feeble digestion and defective ap- petite, either original, or connected with, or consequent upon other diseases. As an ingredient in the Portland powder, it was at one time much used in gout; but it is indicated in this complaint only when complicated with dyspeptic symptoms, and even then should be used cautiously, lest it may prove too heating and otherwise excitant. At one time it was thought to be febrifuge; and Dr. Cullen, in his Treatise on Materia Medica, states that, mixed with equal parts of tormentil or galls, and given in sufficient quantity, it had not failed in any intermittents of his own country in which he had tried it; but it would command little confidence at present in the treatment of miasmatic intermittents. Locally, the powder has been used as a gentle stimulant in malignant and sloughing ulcers, and to maintain the discharge from issues. Administration. Gentian is given in poAvder, infusion, extract, wine, or tincture. The Officinal Infusion (Infusum Gentianm Compositum, U. S) is made with half an ounce of the root, a drachm of orange-peel, and a drachm of coriander, to a pint of menstruum, consisting of one part of diluted alcohol and four parts of water. It is, therefore, a feeble tincture, and should be used only when, in addition to the effects of a pure bitter, a somewhat more stimu- lant impression is indicated. The use of the alcohol is to extract the bitterness more thoroughly, and to enable the infusion to keep better. When this is made with water alone, especially with hot water, it spoils readily, in consequence probably of the CHAP. I.] TONICS.—GENTIAN. 221 pectin and mucilage it contains. This disadvantage may be in some degree obviated by the use of cold water, which dissolves less of the principles referred to. The most elegant method of preparing the infusion is undoubtedly by percolation with cold water, and the bitterness may be thus sufficiently extracted; but this demands time for its preparation. When the infusion is wanted hastily, and is not required to be kept long, it may be most conveniently made with hot water. A combination of senna, gentian, and one of the aromatics, in infusion, is well adapted to cases of dyspepsia with constipation. The Watery Extract (Extractum Gentians, U. S) is a good preparation, and is very much used in the form of pill, either alone, or combined with chalybeates, laxatives, &c. Though much weaker than the' extract of quassia, it is more convenient for making pills in consequence of its tenacity. The Compound Tincture (Tinctura Gentians Composita, U S) is prepared with the addition of orange-peel and cardamom. It is an excellent tonic and stomachic tincture, and was formerly much used, not only in debilitated conditions of the stomach, but also in health, as an addition to wine before dinner, under the impression that it promoted digestion, and increased the strength. It was called wine bitters. In the present state of medical knowledge, it will be generally admitted that this practice could do only harm. Indeed, the bitter tinctures generally require to be used with much caution, even in dyspeptic cases, lest incurable habits of intem- perance should be formed. Many a drunkard, in former times, could trace his bad habit back to the use of one of these tinctures, originally perhaps prescribed by his physician. The Wine of Gentian (Vinum Gentians, Ed), which is still retained by the Edinburgh College, is an unnecessary preparation. The dose of the powder is from a scruple to a drachm; of the infusion one or two fluidounces; of the extract from ten to thirty grains; of the tincture one or two fluidrachms; of the wine half a fluidounce to a fluidounce. Subordinate to gentian, and closely analogous to it in proper- ties, are several medicines derived from plants belonging to the same natural family of Gentianacea?, which merit a brief notice. 1. CHIRETTA. Ed., Dub. — Chiretta or chirayta consists of the herb and root of Agathotes Chirayta (Don.), an annual plant, grow- ing in Nepaul and other parts of Northern India. It is imported 222 GENERAL STIMULANTS. [PART II. in bundles consisting mainly of the stems, with portions of the root attached. It is inodorous and extremely bitter, and yields its bitter- ness and medical virtues to water and alcohol. MM. Lassaigne and Boissel have extracted from it a yellow bitter matter, upon which its virtues no doubt depend, but which cannot be considered as a pure proximate principle. The medicine has been long used in Bengal, but has only recently been introduced into Europe and this coun- try. It possesses the properties of the simple bitters, and proba- bly no other; though supposed by some to be more disposed to act on the liver and bowels; being nauseating and laxative in large doses, and asserted to produce bilious stools. In India it has been employed as a febrifuge in intermittent and remittent fevers, as a cholagogue in torpor of the liver, and as a laxative in habitual constipation; but it probably acts, in all these cases, as gentian and the other simple bitters. Like them, too, it may be used in the anorexia of convalescence, feeble indigestion, and in general debility connected with inertness of the primas vias. The dose of the powder is twenty grains; of an infusion made in the proportion of half an ounce of the herb to a pint of boiling water, one or two fluidounces; of the tincture (Tinctura Chiretlse, Dub.), one or two fluidrachms. 2. AMERICAN CENTAURY.—SABBATIA. U.S.—This is the herb and root of Sabbatia angularis, an indigenous, annual or biennial plant, growing in the Middle and Southern States, and collected for use when in flower. The leaves are so small, and shrink so much in drying, that the dried herb seems to consist mainly of the stems with a few shrivelled flowers at the end. American centaury is in- odorous and strongly bitter, and yields all its virtues to water and alcohol. It has long been popularly used, in this country, as a remedy and prophylactic in intermittent and remittent fevers, and has enjoyed, to a considerable degree, the confidence of some prac- titioners. But it has no special virtues in these affections, in which it acts as a simple bitter, like gentian and quassia, for which it may be substituted in dyspepsia, the debility of convalescence, &c, when on any account more convenient. The dose of the powder is from thirty grains to a drachm. The infusion, which is the most convenient form, and may be made in the proportion of an ounce to the pint of boiling water, is given in the dose of two fluidounces, which, in the remission or intermission of miasmatic fever, should be repeated every two hours, in other cases three or four times a day. CHAP. I.] TONICS.—COLUMBO. 223 3. EUROPEAN CENTAURY.—Centaurium. Ed.—This is often called lesser centaury (centaurium minus), and consists of the flow- ering tops of Erythraea Centaurium (Persoon), Chironia Centaurium (Linn.), a small annual plant, growing wild in some parts of Europe. Its medicinal virtues are said to have been known to the ancients. They are the same as those of gentian, for which it is sometimes employed as a substitute in its native country. In the U. States it is scarcely known; its place being supplied by our indigenous centaury, which resembles it^so closely as to have received the same name from the earlier settlers. The dose and mode of pre- paration are the same as those of the preceding article. 4. AMERICAN COLUMBO. —Frasera. U. S.—This is the root of Frasera Walteri (Michaux), Frasera Carolinensis (Walter), an ele- gant indigenous plant, growing profusely in our Western and South-Western States. Its long, spindle-shaped, fleshy root, being cut into transverse slices and dried, bears a slight resemblance in appearance to columbo, whence, and from a supposed resem- blance in medical properties, it derived its common name. Some- times the root is sliced longitudinally, and thus somewhat resem- bles gentian, to which it is botanically allied, belonging to the same natural family. It has a yellowish colour, and a bitter, sweetish taste, and yields its virtues to water and alcohol. The bitterness is much less intense than that of gentian; and, though similar in properties, the medicine is not so powerful. The fresh root is said to operate as an emetic and cathartic; but this probably happens only when it is largely administered; and the same is to some extent the case with most of the simple bitters. It may be used as a mild tonic, either in substance or infusion. The dose of the powder is from half a drachm to a drachm; of the infusion, made with an ounce of the bruised root to a pint of boiling water, two fluidounces. IV. COLUMBO. COLOMBA. U.S. — Calumba. Lond., Ed., Dub. Origin and Properties. Columbo is the root of Cocculus palmatus, a climbing plant, growing in the forests of Mozambique, on the south-eastern coast of Africa. As brought into the market, it is in transverse slices, circular or oval, from one to two inches in dia- meter, usually three or four lines thick, consisting of a thick 224 GENERAL STIMULANTS. [PART II. exterior cortical portion, with a brownish wrinkled epidermis, and of an interior medullary portion, light, spongy, and more or less shrunk. The cut surface is yellowish, with a greenish tinge near the circumference, of a feeble somewhat aromatic odour, and a very bitter taste, which is strongest in the cortical part. The powder is greenish when fresh. Active Principles. The root contains two bitter principles on which its virtues depend; one peculiar to it called cohmbin, the other supposed to be identical with ^erberin, an alkaloid found in Berberis vulgaris. Besides these, there are a peculiar volatile oil, in small proportion, albumen and starch in large quantity, and other principles of less importance. Chemical Relations. The bitterness and medical virtues of co- lumbo are extracted by water and alcohol. The infusion, prepared either with hot or cold water, is precipitated by tincture of galls, and the acetate and subacetate of lead; but the bitterness is not affected. No precipitates are produced by the salts of iron, zinc, or copper, nor by tartar emetic or corrosive sublimate. Tincture of iodine does not affect the infusion prepared with cold water, but gives to the decoction or hot infusion, after cooling, a blue colour. Effects on the System. Columbo has the properties of the simple bitters, with the advantage over several of them, that it is less heating and stimulant, and less apt to irritate the stomach. Buchner states that a grain of the ethereal extract, introduced into a wound in the leg of a rabbit, caused the death of the animal in ten hours; and hence it has been inferred that the root might possess narcotic pro- perties ; but this is much too narrow a basis for the support of such an opinion. I have never seen the slightest appearance of narcotism from the use of columbo, though I have prescribed it very fre- quently and freely. It is probably nothing more than a simple bitter, somewhat qualified by the minute proportion of volatile oil contained in it, which, however, can scarcely have any other effect than possibly to render the medicine more acceptable to the stomach. Therapeutic Application. This root is said to have been long employed, in bowel affections, by the natives of the country where it is produced. The first published notice of it was by Francis Redi in 1685; but it was not until after the publication of Dr. Thomas Perceval's Medical Essays, in 1773, that it came into general use. It may be employed for all the purposes to which the simple bitters generally are applied (see £>or<7e214), with this advantage, that, in consequence of its mildness and acceptability to CHAP. I.] TONICS.—COLUMBO. 225 the stomach, it may sometimes be advantageously employed when others prove offensive. The affection to which it is best adapted is probably dyspepsia. I have found few medicines more efficient in this complaint, when complicated with constipation and flatulence, than a compound infusion prepared with half an ounce of bruised columbo, half an ounce of ginger, a drachm or two of senna, and a pint of boiling water. A wineglassful should be taken before breakfast; if this do not open the bowels, another before dinner; and if this fail, a third in the evening. I have found the combi- nation also promptly successful in severe gastralgic pains attendant on an enfeebled stomach. Even when there is reason to suspect the coexistence of some degree of chronic inflammation with dys- pepsia, columbo is not always contra-indicated; though its use requires more caution. In gastric irritability, unconnected with active congestion or inflammation, it is thought by some to have the effect of composing the stomach; and hence it has been recom- mended in the vomiting of pregnancy or hysteria, bilious vomiting, &c; but I have no experience with it in these affections. It has also been especially recommended in the declining stages, or the imperfect convalescence of remittent fevers, and of various affections of the primas vias, as cholera morbus, cholera infantum, diarrhoea, dysen- tery, &c, under circumstances requiring the use of tonics. Administration. Columbo is sometimes given in the form of pow- der, which may be combined with ginger, subcarbonate of iron, or rhubarb, when one or more of these medicines is indicated. The infusion, however, is generally preferable. The Officinal Infusion (Infusum Colombo, U S) is made with half an ounce of the bruised or coarsely powdered root and a pint of water. It is a question for consideration whether the water should be cold or hot. The infusion is apt to spoil quickly; depositing a considerable quantity of insoluble matter, becoming more or less ropy, and acquiring a disagreeable taste. This tendency has been ascribed to the use of boiling water, by which the starch is dis- solved. But it has been found that the infusion made with cold water is also liable to change, even more so, according to one observ- er, than the hot, though this does not exactly accord with my own observation. If cold water does not dissolve the starch, it does dis- solve the albumen, which boiling water coagulates and renders in- soluble; and, as albumen undergoes decomposition very readily itself, and promotes the decomposition also of other associated substances, it may be readily understood why the infusion prepared VOL. I.—15 226 GENERAL STIMULANTS. [PART II. with cold water will not keep well. To obviate both these diffi- culties, the infusion may first be prepared with cold water, by which the starch is left behind, and then quickly raised to the boiling point, so as to coagulate the albumen dissolved, which may then be separated by filtration. This nicety, however, is necessary only when the infusion is required to be kept for several days. The most convenient method is to prepare it with hot water, and in small quantities at a time, as wanted for use. When cold water is employed, a much greater length of maceration is required, not less than twelve hours, unless the process of percolation be resorted to. The infusion of columbo may be appropriately combined with the soluble salts of iron, zinc, or copper, or with corrosive sublimate when indicated; but not with the salts of lead. Free iodine should not be given with the hot infusion. There is an officinal Tincture of Columbo (Tinctura Colombo, U S), which may be used like the other bitter tinctures, and is liable to the same objections. (See Compound Tincture of Gentian, page 221.) The dose of powdered columbo is from ten to thirty grains; of the infusion, two fluidounces; of the tincture, from one to four fluidrachms; in each case, to be taken three or four times a day. From the simple bitters above described, all the effects which this subdivision of tonics is capable of producing may be obtained; but there are two others, of indigenous growth, which, though less frequently used, deserve a brief notice, as they are scarcely less efficacious, and may sometimes be found convenient. 1. GOLDTHREAD.— CoPTIS. U.S. This is the product of Coptis trifolia, a very small plant, with a perennial creeping root, inhabiting low and shaded places in the northern parts of this continent, and of Asia. It is abundant in our own Northern States. All parts of it have some bitterness, which, however, is strongest in the root; and this is the portion directed by the U. S. Pharmacopoeia, though, as the medicine is kept in the shops, the roots, leaves, and stems are generally intermingled. The root is long, slender, thread-like, of a deep orange-yellow colour, inodorous, and intensely and purely bitter. It yields its bitterness to water and alcohol. The medicine is closely allied to quassia in its properties, and might probably be substituted for it in all cases without disadvantage; but the smallness of the product of each plant will always be an obstacle to its general use, unless some supe- CHAP. I.] TONICS.—PERUVIAN BARK. 227 riority of virtues can be shown. It is sometimes used in New Eng- land, in aphthous affections of the mouth, as a local application. The dose of the powder is from ten to thirty grains; of an infusion made with two drachms to a pint of water, one or two fluidounces; of a tincture, containing the virtues of an ounce in a pint of diluted alcohol, one or two fluidrachms. 2. YELLOW-ROOT.—XANTHORRHIZA. U.S. By this name is designated, in the secondary list of the U. S. Pharmacopoeia, the root of Xanthorrhiza apiifolia, an indigenous shrub, growing in the interior of the Southern, and in the Western States. Though the bark of the stem is also bitter, the root alone is officinal. This is cylindrical, from three inches to a foot long, about half an inch thick, yellow, inodorous, and extremely bitter, without astringency. It imparts its colour, bitterness, and medical virtues to water; and the infusion is not affected by the salts of iron. It may be employed in the same affections, in the same man- ner, and in the same dose as quassia. 2. Peculiar Bitters. These are medicines which, with the simple tonic powers charac- teristic of the pure bitters, possess others also, which modify the tonic action, and give them an influence on the system more or less peculiar. This peculiarity may be owing either to the distinctive character of the bitter principle itself, or to some other principle or principles which may be associated with it. Thus, Peruvian bark owes its characteristic remedial virtues to the peculiarity of its bitter principles; while serpentaria and wild-cherry bark have other active constituents besides the bitter; the additional consti- tuent being, in the one, hydrocyanic acid which is sedative, and in the other, a stimulating volatile oil. I. PERUVIAN BARK. CINCHONA, U.S. Origin. This is the bark of different species of Cinchona, trees growing in South America, along the course of the Andes, extend- ing from the northern coast near Caracas to La Paz in Bolivia, tlirough nine degrees of latitude, at various elevations on the moun- 228 GENERAL STIMULANTS. [PART II. tain sides, seldom less than four thousand feet above the level of the sea. The species known to yield bark to commerce are C. Cali- saya and C. Boliviana, growing in Bolivia; C. micrantha and C. nitida, inhabiting the provinces of Huamilies, Huanuco, &c, in the interior of Peru; C. Condaminea and C. scrobiculata, of northern Peru and Equador; and C. lancifolia, C. cordifolia, and C. Pitayensis, of New Granada; besides several others less known, or of less importance. Classification. The varieties of Peruvian bark may be arranged in two divisions; 1. the officinal or those recognized in the U.S. Pharmacopoeia, and brought exclusively from the Pacific coast of S. America; and 2. the non-officinal, commonly designated as Car- thagena barks, and exported from the northern coast of the conti- nent. The officinal barks are divided by the Pharmacopoeia into the pale, yellow, and red; the non-officinal include the three varieties of hard Carthagena, fibrous Carthagena, and hard Pitaya bark. Properties. Peruvian bark is in quills or flat pieces, of various dimensions, with or without epidermis, of a yellowish-brown, red- dish-brown, reddish, or orange-brown colour in the interior, of a feeble somewhat aromatic odour in powder or decoction, and of a bitter taste varying in degree, sometimes nearly pure, but more commonly also nauseous or astringent. It yields its virtues partially to pure water, but completely to alcohol, or to w,ater acidulated with sulphuric or muriatic acid. The several varieties require special notice. 1. Officinal Barks. 1. PALE BARK (CINCHONA PALLIDA, U.S.,Lond.; CINCHONA Corona, Cinchona Cinerea, Ed.; Cinchona Condaminea, Cin- chona Micrantha, Dub) is in cylindrical pieces, called quills from being rolled, from a few inches to eighteen in length, from two lines to an inch in diameter, and from half a line to two or three lines thick. The colour of the epidermis, which is always adherent, is light-gray, brownish-gray, or grayish-fawn; of the true bark, brownish, more or less deep, and inclining to red, yellow, or orange; of the powder, pale-fawn, and sometimes dusky. The taste is moderately bitter, somewhat astringent, and not nauseous. The commercial varieties belonging to this division are 1. Loxa barks, usually in smallish quills, derived from C Condaminea and other species, and named from the town of Loxa which was for- merly the entrepot of the trade in them; 2. Lima or Huanuco barks, usually larger than the preceding, derived from C. micran- CHAP. I.] TONICS.—PERUVIAN BARK. 229 tha, and C. nitida, and named from the town of Huanuco in the neighbourhood of which they are gathered, or from Lima, where the trade in them centres; 3. Jaen or ash-bark, differing little in size from the Loxa barks, named from the town of Jaen, supposed to be derived from C. ovata, and scarcely known as a distinct variety in the commerce of the United States; and 4. Huamilies bark, of larger size, in flat pieces and quills, named from the province where it is gathered, conjecturally referred to C. pubescens, and little if at all known in our markets. 2. YELLOW BARK (CINCHONA FLAVA, U.S., Lond., Ed., Dub), called in commerce Calisaya Bark, is in quills and flat pieces; the former from three inches to two feet in length, from a quarter of an inch to two inches in diameter; the latter, quite flat or slightly curved, usually thicker than the quilled, and derived from the larger stems or branches. The epidermis is in general easily separable, and is often separated from the proper bark, especially in the flat pieces, which are almost always quite free from it, and, on their outer surface, show that it was removed without violence, from the mere looseness of adhesion. When present, it is of a brownish colour diversified with whitish lichens, is marked with longitudinal wrinkles and transverse fissures, and is tasteless and inert. With- out it, the bark is from one to two lines thick, firm and compact, of a short fibrous fracture with shining points, and, when viewed along its length, exhibiting similar shining points, which are the ends of small transparent spiculae. These spiculae, when the bark is rubbed, separate from it, and prove highly irritant to the fingers, like cowhage. The colour of the bark is a fine brownish-yellow, usually with a tinge of red; the taste, intensely bitter without astringency or nauseousness; the powder, of a bright yellowish- cinnamon hue, often inclining to orange. The officinal yellow or Calisaya bark is the product mainly of Cinchona Calisaya, and is obtained exclusively from Bolivia. 3. RED BARK (CINCHONA RUBRA, U.S., Lond., Ed., Dub) is, like the preceding, in quills or flat pieces; the former, completely or partially rolled, of various lengths, sometimes exceeding eighteen inches, and from less than half an inch to more than two inches in diameter; the latter, often very large and thick. The epidermis is strongly adherent, of a reddish-brown, gray, or whitish colour, wrinkled longitudinally, and sometimes warty. Beneath the epi- dermis is a layer dark-red, compact, brittle, and of feeble taste. (The proper bark is woody and fibrous, of a brownish-red colour, 230 GENERAL STIMULANTS. [PART II. passing from deep red to reddish-yellow, and of a taste very bitter and somewhat astringent. The colour of the powder is a fine brownish-red. The bark is of unknown origin, but is supposed to be derived from the trunks and larger branches of the trees, the smaller branches of which yield the pale barks. 2. Non-officinal or Carthagena Barks. 1. HARD CARTHAGENA BARK comes usually in pieces some- what regular in shape, either completely or partially quilled, or flat, and frequently warped; the quills being from five inches to a foot long, from three to eight lines in diameter, and from half a line to a line and a half thick; the flat, somewhat thicker, about the same in length, and from one to two inches broad. But sometimes also it comes in small irregularly square or oblong, flatfish pieces, va- riously warped, and mixed with small quills or fragments of quills. The epidermis is often absent, especially from the larger and flatter pieces, having been obviously scraped or pared off with a knife, and not separated, as in the Calisaya bark, by the natural juncture. When present, it is usually soft, whitish or yellowish, and of the character which has been called micaceous. The proper bark is of a pale, dull, brownish-yellow colour, often appearing as if rubbed over with the powder. Its texture is firm and compact; its frac- ture abrupt, though not smooth; its taste bitter and nauseous. It is derived from Cinchona cordifolia. 2. FIBROUS CARTHAGENA BARK is in quills, half quills, slightly rolled, or flat pieces, of dimensions and shape not mate- rially different from the preceding, and like that coming generally in somewhat regular forms, but sometimes in small irregular frag- ments. Some of the largest pieces expeed in thickness and other dimensions any that I have seen of the hard variety. The epider- mis when remaining is soft, whitish or yellowish, and micaceous; but in the larger and flatter pieces it is generally absent, being arti- ficially removed, as in the preceding. The proper bark differs much in character from the hard variety, being very fibrous, light, loose, soft, and spongy under the teeth. Its colour varies from a light brownish-yellow to an orange or red, the latter existing espe- cially in the largest pieces. The colour of the powder is yellowish, often with an orange tint. The taste is usually bitter, but varies much in degree, being in some specimens strong, in others very feeble. The fibrous Carthagena bark bears considerable resem- CHAP. I.] TONICS.—PERUVIAN BARK. 231 blance in colour to the Calisaya, but differs greatly in its soft and spongy consistence, and in the circumstance that its epidermis has been artificially removed by the knife, instead of spontaneously separating at the natural junction. It is the product of Cinchona lancifolia. 3. HARD PITAYA BARK, or Brown Carthagena bark, as it has sometimes been called to distinguish it from the two preceding, which are sometimes designated as yellow Carthagena bark, is usually, as I have seen it, in small irregular pieces, either quilled or flat, from one to four inches long, and from one to four lines thick. The epidermis is sometimes whitish and soft as in the other Car- thagena barks, but sometimes also dark-brown, with innumerable cracks in different directions, giving the surface a grater-like appearance. Sometimes it is absent. Beneath the epidermis there is often a resinous layer, of a dark reddish-brown colour, and a shining surface when cut; but, though highly characteristic when present, it is wanting in some of the pieces. The proper bark is rather hard, compact, and heavy, closely and finely fibrous, and of a dull yellowish-brown colour with a reddish tint. It somewhat resembles the hard Carthagena, but differs in the resinous layer, the grater-like epidermis of many of the pieces, and the deeper and redder colour. It has a very bitter taste. It is probably the pro- duct of the Cinchona Pitayensis of Weddell. 3. Constituents and Chemical Relations. Constituents. The most important of these are the alkaloids, quinia, cinchonia, quinidia, and quinoidia, the last of which, however, is probably only a modification of quinia, produced mainly by the influence of heat, in the process for preparing the sulphate of that base. These alkaloids are believed to exist in the bark chiefly in combination with kinic acid, in the form of soluble kinates, but partly also combined with colouring matter or tannic acid, forming compounds insoluble in water, which, therefore, is of itself incom- petent to exhaust all the virtues of bark. Other constituents are a bitter substance called kinovic bitter or kinovic acid, tannic acid, a red colouring matter called cinchonic red, a yellow colouring matter resin, gum, starch, fatty matter, kinate of lime, &c. Properties of the Alkaloids. The alkaloids are the active princi- ples, and exist probably in all the varieties of bark, though in very different proportion. In the pale barks, cinchonia predominates; in the officinal yellow or Calisaya barks, quinia is most abundant; 232 GENERAL STIMULANTS. [PART II. in the red, both these alkaloids are found in considerable propor- tion ; while in the more active of the Carthagena barks, quinidia exists largely. Quinia, which may be obtained by decomposing the sulphate by means of an alkali, is whitish, flocculent, crystallizable with diffi- culty, inodorous, and very bitter. It is fusible by heat without chemical change, is very slightly soluble in cold water, somewhat more so in boiling water, and very soluble in alcohol, ether, and the volatile and fixed oils. With the acids it forms crystallizable salts, of which there are two sets, one containing twice as much acid as the other. Different views are entertained of the equivalent con- stitution of these salts; some believing those containing the smaller proportion of acid to be subsalts (with one eq. of acid and two eqs. of base), and those containing the larger proportion to be neu- tral (with one eq. of acid and one of base); while others consider the first set to be neutral (with one eq. of acid and one eq. of base), and the second to be super or bi-salts (with two eqs. of acid and one eq. of base). Thus, the two sulphates would be denominated by one party disulphate and sulphate of quinia, by the other sul- phate and bisulphate. Of course, the equivalent of the alkaloid is stated differently, according to these different views; being 162 in accordance with the former, and double this number with the latter. Quinia is distinguished from all other substances by the emerald- green colour which its solution, or that of its salts assumes, when treated, first with chlorine, and then with ammonia, and which changes to violet upon saturation with a dilute acid. Quinoidia, quinoidine, or amorphous quinia is now generally sup- posed to be a mere modification of quinia, identical with it in com- position, but differing in being quite uncrystallizable, and yield- ing uncrystallizable salts with the acids. It is obtained from the mother liquors of sulphate of quinia, by the addition of an alka- line carbonate, which throws down all the alkaline matter con- tained in them. It is amorphous, has a yellowish-white or brownish colour, is very bitter, and, when moderately heated, agglutinates into a mass having a resinous appearance. There is little doubt that it is much increased in quantity, if not entirely produced, during the process for preparing sulphate of quinia from bark. Cinchonia may be prepared from the sulphate in the same manner as quinia from its sulphate. It is white, crystallizable, almost in- soluble in cold water, very slightly soluble in boiling water, freely soluble in boiling alcohol, which deposits it on cooling, scarcely CHAP. I.] TONICS.—PERUVIAN BARK. 233 soluble in ether, and but slightly so in volatile or fixed oils. In consequence of its comparative insolubility, it is much less bitter than quinia; scarcely having any taste when first applied to the tongue, but becoming bitter in a short time as it dissolves; and its solutions are very bitter. By a moderate heat it melts, but is at the same time decomposed. It forms with the acids crystallizable salts, of which, as in the case of quinia, there are two sets, to which the same remarks are applicable as those made in reference to the salts of the latter alkaloid. Its equivalent is consequently given differently, either 154, or double that number. It is distinguished by affording a white precipitate, when its solution, or that of its salts, in chlorine water is treated with ammonia. Quinidia is obtained by precipitating the solution of one of its salts by means of an alkali. It is in hard, shining, colourless crys- tals, yielding a snow-white powder upon pulverization. Its taste is bitter, but less intense than that of quinia. Like that alkaloid, it may be melted by heat without suffering decomposition, and on cooling concretes into a grayish-white crystalline mass. Scarcely soluble in cold water, and very slightly so in boiling water, it is readily dissolved by alcohol even cold, and less readily by ether. With acids it forms crystalline salts much more soluble than those of quinia. It forms two sets of salts, like quinia and cinchonia; and, according to the view taken of the constitution of these salts, its equivalent is either 141, or double that number. It differs from quinia and cinchonia in undergoing no apparent change, when treated successively by chlorine and ammonia. From quinia it differs also in being much less soluble in ether, and from cinchonia in being more so. Chemical Relations and Incompatibilities. The alkalies and their carbonates, and the alkaline earths, precipitate the alkaloids from the infusion and decoction of bark; tannic acid, and all the astrin- gent substances containing it, precipitate insoluble tannates of the alkaloids. By the reagents mentioned, therefore, the liquid aqueous preparations of bark are deprived of the active principles of that medicine; but, as the precipitated matter is active, the preparations, if the sediment be diffused through them, will still be efficient, though inelegant from their turbidness. The same may be said of the slight precipitates produced by the soluble salts of oxalic, tar- taric, gallic, and acetic acids, in consequence of the difficult solu- bility of the compounds of these acids with the cinchona alkaloids. These precipitates, moreover, are redissolved by a slight excess of 234 GENERAL STIMULANTS. [PART II. acid. Besides the precipitants mentioned, all of which disturb the relations of the active principles, there are many others, which, through reaction with the tannic acid often found in bark, or with other relatively inert constituents, form insoluble compounds, and occasion turbidness or deposition in the infusion. Among these are the soluble salts of lead, iron, zinc, silver, and mercury, tartar emetic, arsenious acid, and solutions of gelatin. Some of these act on certain varieties of bark, and not on others; as, for example, tartar emetic, which sometimes produces copious precipitates, and sometimes does not disturb the infusion. In consequence of the large proportion of kinate of lime in the Calisaya or officinal yellow bark, a strong infusion of this variety is precipitated by sulphate of soda, which does not affect most of the other barks. But the virtues of the infusion are not impaired by these reagents, as the active principles remain undisturbed; so that the incompatibility has reference, not to the Peruvian bark, but to the substance added. Signs of Value. The taste affords some evidence of the strength of bark, which, as a general rule, may be considered proportionate to the bitterness; but this test cannot be relied on with certainty; as in some inferior barks there is considerable bitterness, in conse- quence of the presence of kinovic acid, which has not the charac- teristic virtues of the medicine. The best method of testing any specimen of bark is to determine the percentage of the alkaloids contained in it, which is a pretty accurate measure of its medicinal activity. For the method of doing this, the reader is referred to the U. S. Dispensatory (10th ed. p. 257). 4. Effects of Peruvian Bark on the System. As the virtues of the bark reside mainly in its alkaloids, and these are closely analogous in their effects, it will be most conve- nient to treat first of quinia, as the one best known and most used; and afterwards to point out any difference that may exist between its operation and that of the bark itself, or the other alkaloids. The effects of quinia are usually obtained from the sulphate; and this may be considered, in the following observations, as representing the alkaloid. When sulphate of quinia is administered to a healthy person, in quantities not exceeding six grains daily, in doses of half a grain or a grain, it produces effects very analogous, if not identical with those of the simple bitters. At first no sensible effects whatever may be experienced; but, after a short time, the appetite is in- CHAP. I.] TONICS.—PERUVIAN BARK. 235 creased, the food appears to be more rapidly digested, the pulse becomes somewhat fuller and stronger, if not accelerated, the tem- perature of the surface is correspondingly elevated, the processes of sanguification and nutrition are promoted, and other vital functions are moderately stimulated either directly or indirectly. In other words, the medicine operates as a pure tonic, according to the defi- nition of the term given in this work. In irritable states of the digestive organs, or of the system at large, these effects are some- times exalted, by the free use of the medicine, into a moderately febrile state, with anorexia, gastric oppression, thirst, a furred tongue, accelerated pulse, heat and dryness of the surface, and head- ache or other cephalic uneasiness. This condition, however, is pro- bably not the direct result of the action of the medicine upon the system at large, but indirect, and symptomatic of some local irri- tation produced by it, especially in the stomach or other parts of the digestive apparatus. This state of excessive excitement is rarely experienced in health; because, with an increase in the quantity of quinia administered, other effects are developed, of a contrary tendency, which overcome its general excitant influence. Given to the amount of from six to twelve grains daily, in divided doses, or to a less amount in a single dose, sulphate of quinia evinces a tendency to act specially upon the brain, and often produces very decided effects upon that organ. The quantity, however, neces- sary to the production of obvious cerebral symptoms, varies greatly in different individuals; some evincing an extraordinary suscepti- bility to the influence of even small doses, while others scarcely feel the largest quantity above mentioned. The first cerebral phenomenon usually presented is abnormal sound, such as buzzing, roaring like that of a strong wind or of a cataract, singing, hissing, ringing, &c. Along with this there is generally more or less hard- ness of hearing, which, indeed, is one of the most characteristic effects of quinia. Uneasy sensations in the head are also frequent, as of weight, fulness, tension, and sometimes positive pain, though very seldom severe. The circulation is not much affected; the pulse being sometimes increased sometimes diminished in fre- quency, but for the most part little altered. When, instead of the quantities above mentioned, from twelve to sixty grains or more are given daily, in divided doses, the effect upon the cerebral functions is increased, and a decided sedative influence upon the circulation produced, as evinced by a diminu- tion of the frequency and force of the pulse, proportionate to the 236 GENERAL STIMULANTS. [PART II. amount of the salt used. Along with the abnormal sounds before referred to, there is now giddiness or dizziness; the individual, if erect, often staggers; occasionally there is irregular muscular move- ment; the hardness of hearing is not unfrequently increased to positive deafness, and in a few instances vision is disturbed and blindness induced. At first, if the individual dose is large, there may be flushing of the face, headache, ar.d sometimes epistaxis, indi- cating decided sanguineous determination to the head; and occasion- ally, though very rarely, active delirium occurs. In experiments upon dogs, even meningitis has in some relatively few instances been brought on by very large doses. (Briquet, Traite Therap. du Quin- quina, p. 161.) But these evidences of over-excitement of the brain give way to others indicating a reduction of nervous power, such as diminished hearing and sight, uncontrollable tremblings, depressed spirits, sighing or yawning, and very rarely a kind of mental disor- der, compared by Dr. James McCaw of Virginia to delirium tremens. (Stethoscope, ii. 666.) In some instances a tendency to drowsiness or stupor is evinced; in others, morbid wakefulness; but in the greater number, neither the one nor the other. Though the pulse is at first sometimes temporarily excited by these large doses, probably in sympathy with the excited brain, it in general soon becomes slower, and always feebler. The pulsations of the heart are often reduced ten or twelve in the minute, sometimes as much as twenty or twenty-five; and the whole number in the minute to forty, but seldom if ever lower. In strength, the pulse is diminished very nearly in proportion to the dose, as shown by the experiments of Briquet upon dogs, by means of Poiseuille's haemadynameter; and, in extreme cases, it may be so much reduced as no longer to be felt at the wrist. The skin at the same time becomes cool, pale, and moist, and the face pale or livid, and shrunk. This prostration under the use of quinia may be carried so far as to constitute real poisoning. Death has often been produced iu dogs by excessive doses; and in one case, cited by M. Guersent, the same result is said to have taken place in the human subject.* * In this case, M. Bazire, a practitioner of medicine, in an excited state of imagination bordering on insanity, believing himself to be attacked with pernicious fever, took within a short time 60 grammes (very nearly two ounces Troy) of sul- phate of quinia by the mouth and rectum. Symptoms of great prostration, with loss of sight and hearing, came on, which he unfortunately ascribed to the per- nicious fever, and hoped to counteract by a continuance of these enormous doses. CHAP. I.] TONICS.—PERUVIAN BARK. 237 Giacommini, who first called attention to the powerful sedative influence of quinia, records the case of an individual, who took by accident about three drachms of the sulphate. Extreme prostra- tion came on, with an almost absent pulse, cold skin, slow respira- tion, feeble voice, and apparently imminent danger of death, which was, however, averted. In these protrate cases, the pupil is often dilated, and there is sometimes coma. Hitherto our attention has been directed to the influence of qui- nia, in large doses, upon the circulation, or the cerebral functions. But it also produces other effects. It has been supposed by some to render the blood more fluid, and to lessen its coagulability by diminishing the proportion of fibrin, or altering its quality; and in some cases, in which death has occurred during its administration, the blood has been found fluid. But this result was ascribable to the existing disease, and not to quinia; and more numerous experi- ments and observations have proved, that, in any quantity in which it can be introduced into the system, it does not impair the coagu- lability of the blood. Indeed, Briquet found, in his experiments, that it had the opposite effect of increasing the proportion of fibrin. It has been said that quinia has the property of immediately reducing the bulk of the spleen. This view of it was taken by Piorry; but he has not been fully sustained by other observers; and the existence of the property must be considered as doubtful. Enlargement of the spleen is undoubtedly often gradually dimi- nished under the use of quinia, especially in miasmatic fevers; but it is quite as probable that the effect proceeds indirectly from the removal of the cause, as directly from the operation of the remedy on the organ. In the urinary passages quinia occasionally induces irritation, probably by its direct contact with the mucous membrane of these passages, as it escapes with the urine. It is not known to exercise any special influence on the genital function; though it may no doubt operate beneficially in certain abnormal states of that function through its tonic powers. Occasional effects are experienced from quinia differing from In the course of nine or ten days, he took additionally five ounces of the salt. Another physician being then called in, found him covered with cold sweat, completely deaf and blind, with difficult and rattling respiration, profound stupor, and an expression of countenance like that of drunkenness. Though partially roused with much difficulty, so as to give rational answers, he quickly became delirious, and died. (Diet, de He'd., 2e ed., xxvi. 570.) 238 GENERAL STIMULANTS. [PART II. those which are most common and characteristic. Sometimes it irritates the stomach considerably, causing a sense of weight or oppression, gastric pains, and nausea or vomiting. This is espe- cially the case in febrile diseases, in which the stomach is already not unfrequently in a state of irritation, or strongly disposed to it. Sometimes also it acts similarly on the bowels, causing griping pain, and diarrhoea. It has been accused of producing constipa- tion ; but this is doubtful. Its operation, in large doses, is some- times attended with great oppression of chest and precordial unea- siness, probably dependent upon its irritant influence over the nervous centres. The constitutional effects of quinia are essentially the same, by whatever avenue it enters the system, whether taken by the stomach, injected into the rectum, or introduced into the areolar tissue, the serous cavities, or directly into the circulation. When applied to the skin denuded of the cuticle, it produces so much irritation as materially to interfere with its absorption. The period, after its administration, at which quinia begins to evince signs of its characteristic action on the nervous system, and the length of time during which these signs persist, vary with the dose and the intervals of exhibition. Less than three or four grains, in one dose, rarely produces any sensible effect; six or eight grains usually occasion some cerebral disturbance in half an hour, an hour, or at the latest two hours; while twelve to sixteen grains, or more, may operate sensibly in so short a time as fifteen minutes. But, when the medicine is given in the dose of a grain or two, repeated at intervals of one or two hours, little or no effect on the nervous system is experienced until nine or ten grains have been taken; and often considerably more is required. The operation of a single dose, just large enough to make itself felt, say five or six grains, continues generally two or three hours; of double the quantity, given through the day, in divided doses, about eight or ten hours; of larger amounts, given in the same way, up to a drachm daily, from twelve to thirty-six hours. (Briquet) In animals which have perished under the influence of quinia, no lesion has been discovered, as a general result, sufficient to account for the fatal effect. Almost invariably the pi a mater has been found more or less injected; but not to such a degree as to account for the fatal issue, though the appearance may aid in the explanation of its mode of operation. It has already been stated that, in a few instances, traces of meningitis have been noticed. CHAP. I.J TONICS.—PERUVIAN BARK. 239 The probability is that, if any characteristic lesion be found, it will be in the nervous centres near the base of the brain, upon which the medicine appears mainly to expend its influence, so far as that organ is concerned. Perhaps a careful examination of these parts, by means of the microscope, might reveal some characteristic ab- normal condition. In relation to Peruvian bark itself, the effects are essentially the same as those of quinia; but, in consequence of its bulk, or of certain non alkaline principles contained in it, as the cinchonic red and the yellow colouring matter, it is much more disposed to irritate the stomach and bowels. It often, therefore, nauseates, and occasion- ally causes vomiting or purging, especially if the alimentary mu- cous membrane is in an irritable state; and in some instances it cannot be borne on the stomach, in quantities sufficient to produce its characteristic effects on the system. When very largely given, it generally becomes intolerably offensive to the stomach; so that it is difficult to obtain from it the sedative and prostrating effects produced by excessive doses of sulphate of quinia; and, when such effects are observed, it is not always easy to discriminate be- tween them, and the sympathetic effects of the attendant nausea. Hence, the highly important property of diminishing the force and frequency of the pulse long escaped attention, and became known only after the discovery of quinia. The bark differs also from its alkaloids in another particular; in its occasional tendency, namely, to produce constipation, resulting probably from the tannic acid it contains. This effect is of course evinced only in states of the bowels, in which they are not disposed to be irritated by it. Cinchonia has been found to be identical in its effects with quinia, except that it is about one-third weaker; in other words, requiring to be given in a quantity about one-third greater to produce the same result. Briquet, in his experiments, never obtained from it the effect upon the vision sometimes produced by quinia; but this was probably owing either to the insufficient number of trials, or to the insufficient amount employed. Quinidia appears not to differ from quinia, in its operation on the system, whether physiologically or therapeutically. Quinoidia or amorphous quinia, when quite pure, is believed to have the same effects, and in the same degree, as quinia in its regu- lar form. 240 GENERAL STIMULANTS. [PART II. 5. Mode and Nature of Operation, It is probable that the tonic operation of quinia upon the diges- tive organs is chiefly direct; as it certainly possesses the property of local stimulation. This is evinced by the pain and inflamma- tion, often followed by superficial sloughing, which result from its application, undiluted, to the surface of the skin deprived of the epidermis. The gastric and intestinal irritation, occasionally caused by it, is probably nothing more than an exaggeration of its legiti- mate tonic influence upon the alimentary mucous membrane. There is reason to suppose that the febriculous condition, some- times attendant upon its action, is the result of the sympathetic extension of this irritation to the system at large. But the consti- tutional impression thus produced is not the normal and charac- teristic effect of quinia upon the system. The latter arises from the absorption of the medicine, and its direct contact with all parts of the body affected; and is in fact interfered with by any gastric irritation which may proceed from the quinia, because absorption is thus impeded. Nevertheless, it is not impossible that the tonic effect of the medicine on the digestive organs may depend, in part, upon its entrance, through the circulation, into the interior of their tissues, and the exercise there of an excitant influence upon their nutrition. That the active principles of Peruvian bark enter the circulation can no longer be doubted. Several experimenters have detected quinia in the blood; and it may easily be recognized in the urine, a short time after its administration, by a simple chemical test. A solution of iodide of potassium, in which free iodine has been dis- solved, throws down an orange-brown precipitate from the solution of a salt of quinia. In ordinary urine no such effect is produced; but, during the use of sulphate of quinia, the application of the reagent is followed by a precipitate as soon as the system becomes affected, and as long as it continues to be so.* The quantity which * The solution employed by Briquet for this purpose contained 2 parts of iodine, 8 of iodide of potassium, and 250 of water. He found the action of the test to correspond closely with the observable effects of the medicine upon the nervous system. Thus, after the exhibition of 8 grains of sulphate of quinia in one dose, a precipitate sometimes appeared in half an hour, though more frequently at the end of two hours; after 4 grains, in two or three hours ; after 2.5 grains, if any ap- peared, it was not till the expiration of five or six hours. Thus, the length of time before the appearance of quinia is inversely proportionate to the quantity taken; CHAP. I.] TONICS.—PERUVIAN BARK. 241 passes by urine is proportionate to that administered; and, as little or none has been satisfactorily detected in other secretions, it fol- lows that most, if not all of the salt, is eliminated by the kidneys. It is an interesting fact, moreover, that the quinia ceases to appear in the urine soon after its observable effects upon the system have ceased. The inferences deducible from these facts are, in the first place, that Peruvian bark acts on the system through the medium of the circulation, and, secondly, that its action is dynamic, that is, upon the vital properties of the parts affected, and not through any chemical combination with the tissues, which would otherwise retain it. But are the effects of the medicine on the system at large the same as those upon the digestive organs? Is it a general as well as local tonic? Does it stimulate the functions of the brain, heart, and other organs which it reaches by the route of the circulation, as it is admitted to stimulate the stomach ? These are questions of great importance, as they are not theoretical merely, but have a strong practical bearing. There are many who agree with the Italian contra-stimulant school, in believing that sulphate of quinia is a powerful direct sedative, especially in large doses, and conse- quently that it is applicable to cases of high excitement, and even of active inflammation. If, as others suppose, it be essentially stimulant, this application of it is certainly not indicated, and must often be highly injurious. I believe that it is the general impression, and it certainly is my own, that, in small doses, quinia is essentially and universally tonic. Not only upon the digestive organs, but in all the parts to which it is carried by the circulation, its effects thus administered are to excite moderately the nutritive function, and probably in some degree also that of secretion. Through its influence upon the pro- cesses by which the blood is formed, it probably tends to augment the quantity of that fluid, and to render it richer. Thus, by its and the same rule holds in relation to the period at which its effects are felt. (Trait. TMrap. du Qulnquin, p. 220.) Another fact, noticed by the same experimenter, is that the quantity of the salt of quinia eliminated is directly proportionate to that introduced. A third, also highly interesting, is that the elimination always ceases after a short time, generally little exceeding that during which the effects of the quinia persist. Thus, after a single dose of about 3 grains, the quinia disappeared from the urine in from 20 to 24 hours ; after 30 grains taken during 12 hours, in about 40 hours ; and after large doses taken for several days, in from 60 to 80 hours. (Ibid., p. 230.) VOL. I.—16 242 GENERAL STIMULANTS. [PART II. own operatiou upon the nutrition of the heart, and through the agency of the enriched blood, it gives greater energy to the con- tractions of the organ; and hence the fuller and stronger pulse, not unfrequently resulting from its moderate and continued use. It does not, however, appear, like the arterial stimulants, to excite the heart immediately into increased frequency of pulsation; and, when this effect is occasionally experienced, it is probably through sympathy with the irritated stomach or brain. In all the points just referred to, quinia agrees with the simple bitters. But there is another in which it materially differs from that set of tonics; I refer to its action on the brain. The simple bitters may affect that organ through the enriched blood, or possibly by directly stimu- lating its nutrition; but its special functions are not immediately excited, and in no degree observably interfered with. Quinia, on the contrary, acts with a special predilection on the cerebral func- tions, stimulating them moderately, and within the limits of tonic action, when given moderately; but, in excess, producing the effects of over-excitement or irritation proportionate to the quan- tity used. In small doses, this influence is not evinced by any striking phenomena; but it is no doubt felt, and contributes to give to Peruvian bark that pre-eminence over other tonics which it has so long enjoyed. But discrimination is necessary in order to an accurate understanding of its operation on the brain. Ee- sembling in some respects the stimulant narcotics, it yet differs from them in the special seat of its action. Both obey the general laws of stimulation; that is, they at first increase the normal func- tion of the excited part, then derange it, and finally, by a conti- nuance of their influence, diminish or suppress it. But, while the cerebral stimulants or stimulating narcotics operate more or less upon the whole encephalon, and especially upon the seat of the intellectual and emotional functions in the cerebral lobes; quinia leaves these almost unaffected, and confines its influence more especially to the centres near the base of the brain; those, namely, of sensation, and those which control the organic functions of the system. Hence we seldom see mental exhilaration, delirium, or stupor produced by quinia; while excitement, disturbance, and de- pression of hearing or sight, and of the reflex muscular move- ments of circulation and respiration, are its constant results when taken in full doses. Admitting quinia to be moderately stimulant, in small doses, to those cerebral functions which it specially affects, we have next CHAP. I.] TONICS.—PERUVIAN BARK. 243 to consider the question, whether the sedative effects undoubtedly produced by it, when largely given, are direct or indirect; that is, whether they proceed from an immediately depressing influence exerted by the quinia upon the encephalic centres, or are the con- sequences of a preceding state of excitation. To solve this ques- tion, it must first be determined, what are the immediate effects of a large dose of the medicine, sufficient to induce the ultimate pros- tration. Close observation upon the human subject and the lower animals has shown, I think, that so far as the brain is concerned, these effects are such as characterize excitation. The flushed face, the feeling of tension or fulness in the head, the sensitiveness to light, the buzzing and roaring in the ears, the vertiginous sensa- tions, the involuntary muscular movements, the increased frequency of pulse and heat of skin, and the active delirium and convulsions which occasionally though rarely occur, are all proofs of stimulation and active congestion of the brain; and these proofs are still further strengthened by the fulness of the vessels of the pia mater, uni- formly observed on post-mortem examination, and the evidences of positive meningitis which have been observed in a few instances. It is true that these phenomena of excitation are much less observ able, when the same quantity is administered in small portions, at intervals of an hour or two; but, in this case, the stimulation from the several portions, not exceeding the degree of tonic action, is scarcely observable in the pulse, and subsides before being fully reinforced by the succeeding doses; while the secondary depression of the whole accumulates, and in the end becomes very obvious. The excitant effects of the large single dose may continue for two or three hours, when they gradually subside into a contrary con- dition, proportionate to the quantity taken, and, when this is in great excess, the prostration is in the end extreme. Now this is the ordinary and necessary result of over-stimulation; and it is altogether supererogatory to imagine the existence of a directly depressing power in the medicine. The stimulation of an organ first excites its function; if it be continued and increased, the function is disturbed and becomes irregular; if still further in- creased, the organ is overwhelmed by the congestion induced, and its function is impaired or suppressed. The first excitement is thus followed by depression; and this is deepened through another physiological law, which determines that the excitability of a part is exhausted by over-exercise. Thus, after the first excitant effects of quinia above referred to have continued a short time, the cerebral 244 GENERAL STIMULANTS. [PART II. centres become incapacitated for their duties through their conges- tion, and secondary exhaustion; and cease to send forth the influ- ence necessary for the support of the functions over which they preside, or which they in any degree control. Hence the diminu- tion or loss of hearing, the occasional loss of sight, the general feebleness of the muscular power, the trembling, the gradually diminishing frequency and force of the pulse, the coldness and pallor of the surface, and the universal prostration. Now this is a very different condition, in relation to therapeutical indications, from an apparently similar condition produced by a direct sedative to the nervous centres, or to the heart itself; and, though it might prove useful in certain cases if safely induced, yet, in determining upon the propriety of having recourse to it, reference must always be had to the possible danger of the great over-excitement and congestion of the nervous centres involved. This point will again be brought under discussion, when we come to treat of certain therapeutical applications of quinia, proposed on the ground of its sedative properties* * Some experiments of Briquet upon dogs would seem to prove a direct sedative influence of quinia upon the motor power of the heart. By injecting quantities of sulphate of quinia in solution, varying from 7.5 to 30 grains, into the external jugular vein of dogs, he found the force of the heart's contractions, as measured by the hemadynameter of Poiseuille, to be diminished in proportion to the quan- tity used, very slighly by the first quantity, and very greatly by the last, which caused the speedy death of the animal by syncope. In other experiments, in which similar solutions were made to enter directly the cerebral vessels, the brain was excited, and the force of the heart's pulsation considerably increased. (Traiti Therap. du, Quinquina.) The inference from these results is that quinia is directly stimulant to the brain, and, through it, is capable of exciting the heart; while, in- troduced into the heart itself, it has a tendency to paralyze that organ. A great objection to these experiments, so far as the heart is concerned, is that, in order to produce the least depressing effect on that organ, the quantity of sulphate of quinia, introduced into the jugular vein, must produce a much stronger impregnation of the blood reaching the heart, than can be produced by any amount of the medicine swallowed, which is eliminated by the kidneys almost as fast as it is absorbed. The inference is, that no direct observable depression of the heart would follow the internal administration of quinia. But, even though we should admit the entire accuracy and relevancy of these experiments, they do not invalidate the force of the argument in the text, in relation to the use of quinia as a sedative. Whether the depression in the actions of the heart, produced by large doses, depends wholly upon the secondary depression of the brain, as supposed in the text, or partly upon that, and partly upon the direct action of the quinia on the heart, in either case, the danger of an over-excitement of the brain, which the same experiments show to result from the medicine, must be encountered, whenever the sedative effect on the circulation is resorted to as a therapeutic agency. CHAP. I.] TONICS.—PERUVIAN BARK. 215 6. Injurious Effects and their Treatment. In ordinary doses, quinia is not apt to produce deleterious effects, unless through want of appropriateness to the pathological condi- tion in which it may be prescribed; but, when very largely adminis- tered, it sometimes causes unpleasant symptoms from congestion or over-excitement of the brain, among which a greater or less degree of deafness is the most common. Generally this deafness subsides, with the other phenomena, in a period of time varying from a few hours to two or three days; but sometimes it persists much longer, at length gradually yielding; and, in very rare instances, has proved permanent and incurable. Cases are on record in which death has occurred from inflammation of the brain, under the excessive use of quinia; though there is reason to believe that there may have been, in these cases, either a strong predisposition requiring only a special cause to call it into action, or a certain amount of pre- existing inflammation, which was easily aggravated into fatal vio- lence. Still, experiments upon animals have shown that, even in healthy conditions of the brain, encephalitis may possibly result from the abuse of this medicine. In all cases of over-excitement of the brain, the obvious remedies are leaching or cupping behind the ears, cold water to the head, a saline purgative not only to deplete and act revulsively, but to carry off' any unabsorbed por- tion of the alkaloid, and, lastly, bleeding from the arm, if the symp- toms should be urgent, and the pulse permit. Another danger from quinia is the great secondary prostration from enormous doses, which, in persons already feeble, may possibly in some instances prove fatal* Experience has shown that, under such circumstances, stimulants are not only safe, but useful. Car- bonate of ammonia I should prefer to the alcoholic stimulants, as it excites the heart, with less effect on the brain; but, if this fail, recourse may be had to wine or other fermented liquor, and even to brandy, should the prostration be alarming. If much nervous disturbance, as tremulousness, convulsions, or delirium, attend the * It is strange, however, considering the powerful effects often produced by com- paratively moderate doses, how far the quantity may be increased without fatal results. The case of Giacommini has already been referred to (see page 237). Another is mentioned by Briquet, in which 41 grammes (about ten drachms and a half) were taken in the course of a few days. The patient lost for a time sight, hearing, and speech, and became as cold as a corpse, but nevertheless recovered. (Trait. The'rap. du Quinquin., p. 490.) 246 GENERAL STIMULANTS. [PART II. prostration, one of the salts of morphia may be employed. Gia- commini found coffee useful in cases of cinchonic syncope which came under his notice. In all cases in which the salts of the cin- chona alkaloids have been given too largely, tannic acid or an astringent infusion should be administered internally; for, though the tannate is not without effect on the system, it is certainly less rapidly absorbed than the soluble salts. 7. Therapeutic Application. It is an undecided question, whether Peruvian bark was known as a medicine to the aborigines of S. America, before the discovery of the country by Europeans. Both sides of the question have the support of high authority; the affirmative being maintained by Ruiz and Joseph de Jussieu, and the negative by Humboldt. Leav- ing aside some absurd stories in reference to the manner in which the remedy was discovered by the natives, and the mysterious secrecy said to have been observed by them in relation to it, the weight of probability appears to me to be in favour of its indige- nous employment, long before the invasion of the Spaniards. The traditions in the country were to this effect; and it scarcely seems probable that a people, so civilized as the ancient Peruvians, should have overlooked a remedy so abundant, so easy of access, and so vitally important in the treatment of the fevers which must have prevailed among them. That among the ignorant and degenerate natives, at the time of the visit of Humboldt, violent prejudices should have existed against the bark, and an idea been entertained that it was poisonous instead of remedial, can hardly be admitted as an argument against this view of the subject; as a similar preju- dice may be found among the vulgar, even in the most enlightened countries, where the remedy is much employed, and highly valued by the intelligent. Peruvian bark, either of itself, or in some one of its preparations, is calculated to meet several distinct therapeutical indications; 1. as a simple tonic, 2. as an antiperiodic or anti-intermittent, 3. as a su- perseded, and 4. in reference to its secondary sedative properties. Of these I shall treat severally, premising that not unfrequently two or more of these indications are presented conjointly in the same disease. 1. As a Simple Tonic. For this purpose, the medicine is em- ployed in small doses, repeated several times a day. Difference of opinion exists as to the preferable form of administration. Some CHAP. I.] TONICS.—PERUVIAN BARK. 247 suppose that the tonic property resides mainly, if not exclusively, in the alkaloids; others, that it belongs essentially to other principles in the bark, the alkaloids having little or none of it; while a third opinion, admitting its existence in quinia, cinchonia, &c, maintains that the colouring matters, tannic acid, &c, associated with them in the bark, so modify their influence as to render the conjoint opera- tion of all considerably more effective than that of the alkaloids alone. My own conviction, derived from no little experience with the different forms of preparation of Peruvian bark, is, that its medicinal powers reside almost exclusively in the alkaloids, and, though the form of combination in which these naturally exist may somewhat modify their effects, by influencing their acceptability to the stomach, or the facility of their absorption or elimination, yet that the bark itself, wholly deprived of them, would be nearly if not quite medicinally inert and useless. The general experience too corresponds, I suspect, with my own; as quinia and its asso- ciated alkaloids have to a considerable extent superseded, even in reference to tonic effects, the use of bark, and of the various pre- parations most completely representing it. The medicine may be used in simple debility of the digestive organs, or dyspepsia. Bark, in substance, is too apt to nauseate and oppress the stomach to be employed advantageously for this purpose; but recourse may be had to the extract, or one of the liquid prepara- tions, especially the compound infusion of the U.S. Pharmacopoeia, which, in great debility of the stomach or system, may sometimes be usefully combined with the simple or compound tincture. Sul- phate of quinia, however, is, upon the whole, the most convenient preparation. Still, it is in no respect superior, in this affection, to the simple bitters; while it is more apt to oppress the stomach, and is, therefore, comparatively little used. In general debility, however, it stands at the very head of the tonics. It probably owes its superiority, in this condition, over the simple bitters, to the greater universality of its action. The latter medicines, though stimulant to the digestive, blood-making, and nutritive functions, have little influence over the nervous centres. Quinia acts energetically upon these centres, and extends, through them, independently of its direct influence upon the tissues, a pow- erful support to the weakened organic functions. In the debility of convalescence it acts very favourably. In pure anaemia, when the morbid condition exists speciallv in the blood, without obvious deficiency in the digestive or nutritive powers, or 248 GENERAL STIMULANTS. [PART II. in nervous excitability, as often happens in chlorosis, quinia does little good; the appropriate tonic in such cases being iron. But, in that debility of all the functions which is apt to follow the agitations of acute febrile and inflammatory diseases, and from which it often happens that the unaided system rises slowly and with difficulty, no medicine is probably more efficient; and, if along with this con- dition there is a relative deficiency of the red corpuscles, it adds greatly to the effectiveness of the chalybeates. When debility is associated with any organic mischief, as in the ulcerative condition left by inflammation and gangrene, the system is sometimes so prostrated as to be unable to carry on the reparative processes, and ultimately sinks unless sustained. The tendencies are towards health, but the power to act duly is wanting. Under these circumstances, the preparations of Peruvian bark, in connexion with a nutritious diet, are highly important. When debility is produced or maintained by temporary exhaust- ing influences, as from profuse suppuration, excessive secretion, or pas- sive hemorrhage, it is often of the utmost importance to support the strength until the discharge has ceased; and a strong indication is offered, in such cases, for quinia or bark in some other shape, which may often be advantageously combined with opiates and alcoholic stimulants, especially the fermented liquors. Examples of this kind, dependent on profuse suppuration, we have in the advanced stages of extensive inflammation of the ordinary character, whether of the internal organs or external parts; in scrofulous abscesses; in erysipe- las affecting the subcutaneous tissue; in metastatic abscess, purulent infection, pyogenic fever, or suppurative phlebitis; and in the last stage of confluent smallpox, in which large portions of the surface are bathed in pus, and subcutaneous purulent deposits sometimes form in enormous quantity. Of exhaustion from excessive secretion we have examples in the effects of colliquative sweats, diuresis, and diarrhoea, and in copious mucous discharges from the bronchial lubes and urinary passages. In these cases, quinia sometimes acts happily, not only by sustaining the system under the exhaustion, but by correcting the excessive discharge, which itself not unfrequently depends on a pre-existing debility and relaxation. But astringents are generally still more useful here than quinia, which may often be advantageously asso- ciated with them; and it is probable that the infusion, decoction, tincture, or extract of bark may be more useful than the alkaloids, in consequence of the tannic acid they may contain. CHAP. I.] TONICS.—PERUVIAN BARK. 249 The same remark is applicable to passive hemorrhages, which at once depend upon and increase debility, and in which the conjunc- tion of astringents with the preparations of bark is often indicated. Another condition of debility, in which this medicine is highly serviceable, is that produced and kept up by some directly depress- ing agency, independently of any exhausting discharge. Such are all those conditions of the system in which extensive gangrene has taken place, or even a small degree of it, if in one of the internal and vital organs. How it is that the connexion of a mortified part with living tissue should produce general prostration is not always very evident; but such is certainly the case, even where there has been no preceding debility. When the debility gradually ensues, and is attended with typhoid symptoms, there has probably been ab- sorption of the deleterious matters resulting from putrefaction, and a consequent contamination of the blood. But frequently the result is too sudden to admit of this explanation. A part dies; and almost instantaneously the pulse becomes feeble, the skin cold, the countenance pale, shrunken, and ghastly; and, though reaction to a certain extent may take place, yet the energies of the system are still depressed, and continue so more or less until the offending cause is removed. Possibly a depressing effect from the dead matter upon the adjoining nerves may be reflected to the system, through the nervous centres, in the same manner as local irritation. But, however produced, the debility exists, and often requires the inter- ference of tonics and other stimulants to support life, and give the parts power to throw off" the offending cause. Certainly, among the tonics there is none so efficient for this purpose as cinchona. So beneficial is it, that an idea formerly prevailed that it possessed a positive and peculiar property of checking or obviating mortifi- cation and putrescency. At present, however, this idea is not ad- mitted. All that the bark can do is to sustain the failing energies; and this it is perhaps better able to do than others, because of its stimulating influence on those very nervous centres through which the depressing impression is propagated. In the gangrenous cases in which a pre-existing condition of system, or depraved state of the blood, has caused the mortifica- tion, there is a double indication for the tonic. Hence, the prepa- rations of bark have always been among the most approved remedies in anthrax, gangrsena oris, malignant sore throat with or without scarlet fever, and erysipelas ivith sloughing of the subcutaneous tissue. 250 GENERAL STIMULANTS. [PART II. Another large list of diseases, in which debility, depending on a direct sedative influence, indicates the use of bark until the depress- ing cause shall cease to act, are the typhoid affections. In these, either the morbific cause itself, or the depraved state of the blood resulting from it, acts with a special influence on the brain, pro- ducing dulness, stupor, low delirium, and other evidences of cerebral debility. Cinchona, therefore, is specially called for, both for its excitant action on the nervous centres, and the rapidity with which it acts. Typhus fever, the advanced stages of typhoid or enteric fever, scarlatina particularly of the anginose and malignant varieties, malignant smallpox and erysipelas, and even the phlegmasiae when they assume the typhoid condition, as typhoid pneumonia and dysen- tery, are often usefully treated with this pervading and powerful tonic. Though of itself insufficient to support strength in many of these cases, and therefore requiring the aid of more potent stimu- lants, as carbonate of ammonia, opium, and the alcoholic liquids, it gives a durability of impression, and power of resistance, not equally obtainable from these .agents, and, therefore, cannot be fully replaced by any one or all of them. In protracted diseases, particularly those of a febrile character, though perhaps sthenic in the beginning, the vital forces are gradu- ally impaired by their over-exercise, and a state of debility ensues requiring tonic treatment. Here too the preparations of bark are the most efficient. It is highly important to know when exactly the period for this treatment has arrived; for, if prematurely em- ployed, it may injuriously aggravate the excitement. I have noticed that the occurrence of night-sweats, under these circum- stances, offers one of the best criteria of the new condition. When a patient with a febrile disease, not having been especially affected with diaphoresis, begins to sweat profusely whenever he sleeps, and only then, I consider the symptom as an almost sure sign of debility; and quinia, though previously contraindicated, may now be used with safety and advantage. This condition is quite different from the typhoid. In both there is debility; but in the latter, it is con- nected essentially with depravation of the blood; in the former, it is merely the result of an over-exercise and consequent exhaustion of the vital forces, and the blood is no otherwise diseased than as it may be deficient in quantity, either considered generally, or in relation to the red corpuscles. My attention has been particularly directed to the condition as it occurs in acute rheumatism, in which it is not very uncommon, though the disease may still be associated CHAP. I.] TONICS—PERUVIAN BARK. 251 with considerable pain and swelling in the joints. Whenever night-sweats take place in that disease, I invariably employ quinia, and almost uniformly with favourable effects, not only checking the excessive sweating, but very much ameliorating if not promptly curing the rheumatism itself. I have been long in the habit of employing and recommending this practice; for many years, in- deed, before the recent revival of an old method of treating acute rheumatism by Peruvian bark. Various derangements of health which have been classed to- gether under the designation of cachectic, the only common charac- ters of which are chronic debility, and a not well understood depravity of system, in which the blood is probably always involved, such as syphilis in its advanced stages, scrofula, and vari- ous obstinate cutaneous eruptions, including ecthyma, rupia, and impetigo, are not unfrequently benefited by quinia, in conjunction with certain alterative remedies, as iodine, mercury, and arsenic. Under this head may perhaps also be ranked the use of quinia in enlarged spleen, especially when following miasmatic fevers, or occur- ring in malarious regions. Some ascribe the efficacy of the medicine, in these cases, to a property which they suppose it to possess of directly contracting the spleen. But quite as probably it is ascrib- able to an alteration, under the tonic influence of the remedy, of that condition of system, and especially perhaps of the blood, which originated and sustains the affection. In many instances of en- larged spleen of a different origin, even when there is no reason to suspect cancer, tubercle, or other incurable heterologous formation, quinia proves, as I have often witnessed, wholly inoperative. 2. As an Antiperiodic, or Anti-intermittent. No remedy ap- proaches Peruvian bark in antiperiodic powers. There is scarcely a doubt that, for its peculiar properties in this respect, it is indebted exclusively to its alkaloid constituents, and that everything which bark can do, can be effected by quinia. Indeed, in consequence of being less offensive to the stomach, the latter is the more effective of the two, where a strong impression is necessary, or when the affection is complicated with gastric irritability. In all regularly intermit- tent or periodic diseases, quinia may be considered as an almost certain remedy; at least I do not remember to have met with a case which has not yielded to it, since the management of this medicine has been well understood. But it is not all diseases occurring paroxysmally that belong to the category here referred 252 GENERAL STIMULANTS. [PART II. to. To come under the head of regular intermittent diseases, the affection must occur about the same hour, at the interval of a cer- tain number of days, one, two, or more, without any positive or recognizable disease, in the period between the paroxysms, by which they can be reproduced. In other words, the complaint must be at once idiopathic, and regularly periodic. Hectic fever, therefore, though it has paroxysms closely resembling those of intermittent fever, does not belong to the class referred to; because it depends upon an ever-present organic source of irritation, and its paroxysms are irregular in their recurrence. Epilepsy and hysteria are equally excluded, though both paroxysmal, because often dependent on a constant though perhaps concealed lesion, and almost always more or less irregular. But even these affections, or imitations of them, when purely functional, and occurring at regular periods of one or a few days, will yield for a time to the antiperiodic treatment. Indeed this treatment is, in its nature, essentially temporary; its only effect being to guard the system against the recurring paroxysms, not to secure future immunity, when its direct influence has ceased. If, therefore, there should be some cause in operation capable of inducing a paroxysm of the disease, the patient is still liable to an attack after apparent cure, supposing the direct influence of the remedy to have been withdrawn. Hence, even in ordinary intermittent fevers, it very frequently happens that the paroxysms recur, at a somewhat varying period, after the suspension of the antiperiodic treatment. All that we can accomplish, then, by this treatment, is to prevent the recurring paroxysms so long as the remqdy acts. If, in the meantime, the cause cease to operate, or the susceptibility to its influence no longer exist, when the chain of morbid association, or the force of habit is broken, a per- manent cure is effected; if not, the disease is liable to return, and may continue to do so until the cause is at length removed, or the system becomes insensible to its influence, as it does in time to noxious agencies in , general, when not fatal in their effects, or applied in increased quantity or force. Intermittent fever is a disease in which quinia exhibits, probably, its most extraordinary powers. Before the discovery of Peruvian bark, some of the forms of this affection were extremely embarrass- ing to physicians, and an obstinate quartan was scarcely less dreaded than pulmonary consumption. Afterwards it was found in general to be very manageable under the new remedy; but cases were now and then met with which resisted its influence, in consequence CHAP. I.] TONICS.—PERUVIAN BARK. 253 sometimes of insurmountable obstacles to its administration in the ordinary quantity, or to its retention when administered, and some- times of the impossibility of introducing into the system a quantity large enough to meet the requisitions of the case. But, since the introduction of quinia into use, the disease may be considered as completely under command, so far at least as regards any single attack. The only requisitions are, that the remedy be administered in sufficient quantity, and at the proper time. If upon trial a cer- tain amount is not found to answer, it must be increased; and no limitation should be put to this increase, except the production of the desired effect, or a reasonable apprehension of serious mischief to the patient. The general rule is to give enough to affect the cerebral centres decidedly, as indicated by the buzzing or roaring in the ears, or by a greater or less degree of deafness. The question at once presents itself, whether any previous pre- paration is necessary, and, if any, what? Formerly it was cus- tomary to anticipate the antiperiodic by an emetic. Experience has shown this to be unnecessary in the vast majority of instances. Should, however, the attack surprise the system with the stomach loaded, and evidences of gastric irritation at the same time exist, it might be advisable to aid nature in getting rid of the offending mat- ter, by means of warm water, or warm chamomile tea drank freely, or if necessary by a dose of ipecacuanha. Ordinarily the only pre- liminary measure desirable is the evacuation of the bowels. In urgent cases, where it is important to produce the antiperiodic im- pression as soon as possible, even this may be dispensed with, and the administration of the quinia commenced at once. I think, however, that it is generally best to begin with a cathartic, in order to remove any possibly offending, matter from the bowels, to unload the portal circulation, and thus promote the absorption of the medi- cine. If the liver* is torpid, a portion of calomel or blue mass should be given with the cathartic. Another question to be decided is, how far the treatment is to be influenced by any existing complication of the intermittent fever. Some have supposed that a coexisting inflammation contraindicates the use of quinia, and that the inflammation should be subdued before commencing with the administration of that medicine. I have long been of a contrary opinion. If the inflammation is in- sufficient to sustain a febrile excitement between the paroxysms, that is, to convert the intermittent into a remittent, it is either periodical itself, and obeys the laws of periodical diseases in general, 254 GENERAL STIMULANTS. [PART II. or is insufficient to be materially aggravated by the stimulant properties of sulphate of quinia. Indeed, the general stimulation of the paroxysm is vastly greater than that of the medicine, and consequently much more likely to aggravate the inflammation. It would seem clear, therefore, that by interrupting the paroxysms, we must, instead of aggravating, really relieve the inflammation, by removing the most powerful source of excitement. If theory jus- tifies the use of the antiperiodic under these circumstances, expe- rience is no less decidedly in its favour. I have never known the inflammation, attendant on a perfect intermittent, to be increased by the use of quinia; I have not known it to prevent the antiperiodic medicine from having its due effect; while I have observed that the inflammation is mitigated, and indeed often ceases, almost im- mediately upon the interruption of the paroxysms; and I believe that my experience, upon these points, coincides with that of the great majority of practitioners in the miasmatic districts of the United States. I am, indeed, prepared to go further, and to state that the same thing is true, in a great degree, even where the in- flammation is sufficient to maintain some degree of fever between the paroxysms; but, in such cases, I should premise bloodletting, general or topical, or both, when apparently called for by the severity of the local disease, and permitted by the state of the pulse. The same reasoning applies here as in the former case; the stimu- lation of the paroxysm is vastly greater than that of the medicine; and experience equally confirms its justness by the result. There are only two instances, in which I would admit of an exception to the general rule; namely, when the cerebral centres, which are especially susceptible to the stimulant influence of quinia, and the mucous membrane of the stomach, which is liable to be irritated by it, are the seat of the inflammation; and, in the latter case, though I might not administer the medicine by the stomach, I should not hesitate to give it freely by the rectum. If inflammatory compli- cation offer no contra-indication to the use of quinia in intermittent fever, I know of no other impediment, unless it may be active cere- bral congestion, which should if possible be removed, prior to its employment. Much has been said of the proper period for the administration of quinia. Some give it indiscriminately at all periods of the dis- ease, without reference to pyrexia or apyrexia; but the great majority confine its employment to the intermission, and, as I think, correctly, unless in certain cases of pernicious fever, where it CHAP. I.] TONICS.—PERUVIAN BARK. 255 is of the utmost importance that the approaching paroxysm should be prevented, and there is reason to apprehend that the intermis- sion may be too short for the purpose. In the first place, there is no necessity for giving the quinia during the paroxysm; and, secondly, though it may often be given with impunity, yet there is always some risk of aggravating into positive inflammation any pre-existing tendency to it in the brain or the stomach, or of causing effusion of blood in cases of active cerebral congestion. In the true pernicious variety, in which the great danger arises from de- fective or perverted innervation of the vital organs, and there is little tendency to active congestion or inflammation, the risk from quinia in the paroxysm can scarcely be said to exist, while the loss of time in withholding it may be fatal. There is one caution, however, which should be observed in the use of quinia during the pernicious paroxysm; namely, never to give it so largely, in the cold stage, as to induce its secondary sedative effect, and thus add to the prostration, which is often itself very alarming, and not un- frequently fatal. Admitting then that, as a general rule, the medicine should be given only in the intermission, we have still to determine at what time, during this period, we are to begin with it, and when to suspend it. Without referring particularly to the various shades of opinion among authors on this point, I will merely state my own, based upon what is known of the action of quinia, and upon personal observation, that the best plan is to com- mence immediately after the cessation of the paroxysm, and to continue, with repeated doses, until within about an hour of its expected recurrence, so that, at the time referred to, the system may be under the full influence of the medicine. I prefer the exhibition of the sulphate of quinia in small doses, repeated at intervals of an hour or two, to the use of the full quan- tity, required for a single intermission, in one or a very few doses. We thus incur less risk of irritating the stomach, or over-exciting the brain, while we have it in our power to modify the dose, if the effects should be unexpectedly and unnecessarily severe. The ab- sorption is probably also more complete, and the whole amount necessary for the required effect diminished. But there are cir- cumstances which justify, and even demand a departure from the general rule; as when the intermission is very short, or when it occurs at night, so that a frequent administration might interrupt sleep, and in this way injure the patient. In such cases, the whole quantity may be given in one, two, or three doses; care being 256 GENERAL STIMULANTS. [PART II. taken to throw the medicine mainly into the earlier period of the apyrexia; as, if withheld until immediately before the paroxysm, time is not allowed for its absorption and full operation, while, even if confined entirely to the earlier period, as its action continues for many hours, this may be in full force at the time required. Used in the method above pointed out, sulphate of quinia is capable of interrupting almost any case of intermittent fever, from the mildest to the most violent. But different quantities are re- quired in different varieties of the disease. The purely irritative intermittent, occurring independently of miasmatic influence, and sometimes ceasing spontaneously after a few paroxysms, may usually be checked by from six to twelve grains, given in each in- termission. The ordinary miasmatic intermittent, though it will sometimes yield to the same quantity, is much more effectively treated with from twelve to twenty-four grains in the same time. The pernicious form of the same affection cannot be trusted to less than from twenty to sixty grains. The great rule, in the admi- nistration of the medicine, is to give enough to produce an obvious impression on the brain, and to maintain that impression until every vestige of a paroxysm shall have ceased. In many instances, the disease is at once arrested, and there is no return of the parox- ysm, especially if the required impression has been produced some hours before the period for its recurrence. More frequently, per- haps, one paroxysm occurs, though with mitigated severity, and the succession is arrested at the second. Rarely does the disease pass on to a third. Sometimes, instead of having been quite set aside, the paroxysm returns in a very mild or partial form, without a distinct chill, and with very little fever, and altogether so slight that, in itself, it would scarcely attract attention. It is important, however, as indicating that the disease is not yet arrested, and that, unless the impression of the medicine is maintained, the paroxysms may again assume their original severity. It is not impossible that a quotidian, which has been once interrupted, may return on the following day as a tertian; and, in like manner, a broken tertian may assume the quartan type. These results may be guarded against by continuing the quinia beyond the period for the tertian or quartan paroxysm; though they are so rare that this caution may generally be dispensed with, and the plan only put in force in cases presenting this peculiarity. As a general rule, therefore, the medicine may be omitted immediately after the complete interrup- tion of the paroxysms. It is of no advantage to continue with it CHAP. I.] TONICS.—PERUVIAN BARK. 257 regularly afterwards, with a view to prevent the septenary, or bi- septenary recurrence of the paroxysms, to which the disease is lia- ble ; for a smaller daily amount than that originally necessary for arresting the disease, cannot be depended on for preventing these returns; and to persist in the use of so large a quantity may ren- der the system at length insusceptible to its operation. The best plan for checking the weekly or bi-weekly returns, the latter of which are by far the most common, is, I think, to ascertain at what period, in any particular case, the paroxysm is disposed to recur, and to anticipate this by giving the patient, during the two days preceding that period, as much as was at first neces- sary to interrupt the disease; and to pursue this course every week afterwards for one or two months, or longer if necessary. The interrupted use of the medicine prevents the system from becoming accustomed to it; and, after a time, the disposition of the disease to recur ceases. Writers speak of latent intermittent fever, in which the disease is masked under other forms. Thus, there may be a chill and per- spiration without fever, or a headache with loss of appetite, mal- aise, &c, recurring at the regular day and hour; or the effects of the cause may be shown in an attack of violent periodical neuralgia, or some special local affection, as diarrhoea or dysentery; and all such cases will yield to the antiperiodic treatment quite as readily as the regular disease. There seems, however, to. be no necessity for considering these affections as masked intermittent fever. They are «simply different morbid results of the same cause, and, like intermittent fever itself, are not exclusively of miasmatic origin, but may result also from other causes. But, whatever may be their source, they are equally amenable to the antiperiodic treatment. Intermittent neuralgia is probably, next to intermittent fever, the most frequent form of regular periodical disease. It may attack almost any part of the body, internal or external. I have seen it, I think, most frequently in or about the eye. Sometimes there is reason to believe that it is the effect of marsh miasm; but I have seen it much more frequently quite independent of this cause. It is often probably of a rheumatic or gouty character, sometimes apparently the result of debility, occurring in the convalescence from other diseases; but quite as often, its source cannot be satis- factorily traced. I have never witnessed a case of this kind, if unconnected with organic disease, which has not yielded to sul- phate of quinia. The ordinary doses of this medicine used in inter- vol. I.—17 1 258 GENERAL STIMULANTS. [PART II. mittent fever will often cure it; but they will often also fail. Not unfrequently double the quantity, and sometimes even triple is necessary to produce the desired effect. Intermittent headache, especially hemicrania, may be considered as closely analogous with neuralgia, and is treated in the same way. But organic lesions of the brain are not unfrequently attended with severe pain in the head, assuming a somewhat regular periodical character, and liable, without caution, to be mistaken for pure func- tional neuralgia. In these cases, quinia may sometimes afford par- tial relief; but it is frequently quite powerless, at least in any quantity in which I have ventured to prescribe it; and, I believe, may do harm by over-exciting the already irritated nervous cen- tres. Rheumatism and Gout are not unfrequently intermittent, in their nervous forms, whether as neuralgia, or painless disorder of func- tion ; and sometimes, klso, in their inflammatory state. In either case, they yield in general readily to quinia. The various neuroses occasionally assume the same regularity of recurrence. Epileptic convulsions, in general so intractable, may be treated with quinia with good hope of success, when they occur regularly, for any length of time, at the same hour daily, or every other day. The same may be said of hysteria. Cramps, internal spasmodic affections, asthma, nervous cough, and amaurosis, are other complaints occasionally periodical in their character, and, in that state, curable by the great antiperiodic remedy. Hemorrhages are said also to be sometimes regularly intermittent, and remediable in the same way. The fact is undoubtedly true of certain complaints of an appa- rently inflammatory character. Among these, ophthalmia is men- tioned; but, considering the frequency of neuralgia of the eye, I am disposed to think that these cases of apparent inflammation are little more than active congestion, sustained by the extreme nervous irritation, and subsiding when that ceases. I have repeatedly seen diarrhoea periodical, and in that condition yielding to quinia; but it is not always easy to determine whether the affection is inflammatory, or merely irritative. One of the most apparently violent attacks of dysentery which I ever saw proved to be regularly periodical. The case occurred in the Pennsylvania Hospital. At my first visit, the man was seemingly very ill, complained excessively of pain, was constantly going to stool with the characteristic dysenteric discharges, and seemed to me to be in great danger of his life. CHAP. I.] TONICS.—PERUVIAN BARK. 259 Next day he was almost well; and I supposed that the disease had yielded to the measures employed. On the following day, however, it returned with all its former violence, and subsided again as before. There were several similar paroxysms. Convinced that it was periodical, I gave sulphate of quinia very largely in the inter- mission, and almost immediately checked the disease. The proba- bility, however, I think, is that, in all these regularly intermittent inflammations, the nervous element of the disease is predominant, and that the vascular disturbance is directly dependent upon it. In many cases, however, of apparent intermittent inflammation, espe- cially of the lungs, the local affection is a mere appendage of a miasmatic fever, being lighted up by the general vascular excite- ment of the paroxysm, acting probably upon a predisposition to inflammation in the organ affected. But, whether its origin be as here supposed or not, it yields with great facility to quinia, when there is proof that the inflammation is quite absent during the period of the apparent intermission. In regular remittent diseases, quinia is scarcely less efficient than in intermittents. In this category, however, are not included all affections having the remittent character. In consequence of the varying excitability of the system, almost all complaints, perhaps it may be said all complaints of any considerable duration, are more or less remittent, even though the cause may be constantly ope- rating. But to constitute a regular remittent, in the sense here intended, there must be a paroxysm recurring daily, or every other day, at regular intervals; and, though the morbid action may con- tinue, in a moderated degree, throughout the intervening period, yet it is rather a prolongation of the paroxysm, than a continuous and sustained effect of the action of the cause. It is as if the cause operated only paroxysmally, and the disturbance of system pro- duced by it did not subside completely before the period arrived for the recurrence of its action. These diseases, then, are not con- tinuous affections, undergoing occasional exacerbation and remis- sion ; but consist of successive paroxysms, more or less intercurrent. They are closely analogous to intermittent disease, and are sub- missive to the same antiperiodic treatment. The most important of these diseases is the miasmatic remittent, or common bilious fever. In this complaint, sulphate of quinia is a most efficient remedy. Whenever a decided remission is observed, after due evacuation of the bowels, and of the stomach if necessary, 260 GENERAL STIMULANTS. [PART II. it may be given in quantities similar to those administered in inter- mittent fever, and will not often fail. In the pernicious variety of remittent fever, or when pernicious symptoms supervene in a case before simple, it is all-important, and, indeed, is the only remedy on which reliance can be placed. As in the pernicious intermittent, the quantity should be double, or even triple that given in the milder form of the disease. In this affection, it is of vast import- ance that no time should be lost. The next paroxysm may very possibly prove fatal, unless prevented. Nothing, therefore, should be allowed to interfere with the use of sulphate of quinia, upon the first occurrence of signs of remission; and sometimes it might be advisable not to wait for this period, but, when the nature of the disease is well ascertained, to have recourse to the antiperiodic, by anticipation, even in the paroxysm; for the tendency here is not to active congestion or inflammation, but rather to nervous prostra- tion and passive congestion, and there is little probability of serious injury to the brain, or other vital organ. In some instances it is difficult to retain the remedy, on account of great irritability of sto- mach. It should not be omitted on this account, but given not- withstanding, in the hope that a portion at least may be retained; and its retention may be aided by the simultaneous administration of opiates, and by the application of a sinapism to the epigastrium. The remedy should also, under such circumstances, \>e additionally employed as an enema with opium, and as .an application to the surface of the body by the endermic method. In regular remittent neuralgia, also, the best effects may be ex- pected from sulphate of quinia, given in the same manner as in the intermittent form of the disease. Preventive Influence. Upon the same principles as those on which periodical diseases may be cured, they may also be prevented by sulphate of quinia. There is no prophylactic measure against the miasmatic fevers at all comparable in efficacy to the use of this medicine. It seems reasonable to suppose that the same impression on the system which prevents the return of the paroxysms, will prevent the occurrence of the first. Experience has established the correctness of this inference. All that is necessary is to give, twice every week, in divided doses, a quantity equal to that re- quired for the interruption of the disease when formed. From ten to fifteen grains, in doses of two grains every two hours, will pro- bably answer the purpose. I am not sure that the same amount CHAP. I.] TONICS.—PERUVIAN BARK. 261 taken weekly will not be sufficient, considering the tendency to septenary periods which characterizes the relapses of the disease. In the irregular intermittent diseases, such as hectic fever, for ex- ample, sulphate of quinia, given in the same manner as in regular intermittents, will often check the paroxysms; but cannot be relied on even for this purpose, and is generally quite inadequate to the cure. The cause of these affections is generally continuous in its action, and is always, therefore, lying in wait to renew its assaults, though sometimes temporarily restrained. In hectic fever, the nervous centres, through which the sources of irritation operate in producing the paroxysm, may be rendered insensible for a time to their influence; but, as soon as the protective force is withdrawn, the cause again operates; and, if the quinia be given constantly, the system at length becomes insensible to its effects, and its reme- dial power ceases. Nature of the Antiperiodic Action. Various theories have been broached to explain the antiperiodic effect of Peruvian bark. Most of them are scarcely deserving of notice. One of the most plausible, in reference to the miasmatic intermittents and remittents, is that the alkaloids have th» property of neutralizing the poison in the system. But this is not tenable; as quinia cures the irrita- tive intermittents even more readily than the miasmatic; and, if there be any disposed to deny the existence of the former affection, the argument will still hold; for intermittent neuralgia, which often occurs where there can be no possible suspicion of the influence of marsh miasms, even in the midst of cities the air of which serves as a protection against these miasms, will jet almost invariably yield to the same remedy. I know no better explanation of the antiperiodic property, than that which supposes it to depend upon the powerful influence exer- cised by the remedy upon the nervous centres, through which probably the paroxysms are produced. Every consideration, in connexion with the peculiarities of regular intermittent diseases, leads to the conclusion, that the paroxysms are produced by an influence acting through the cerebral centres, without which the result would not take place. Now, if these cerebral centres can be preoccupied by a strong impression from some other source, they may be rendered insensible to the morbid influence, and the paroxysm, therefore, is set aside. Quinia is characterized by its disposition to act energetically upon certain nervous centres, which are probably the same as those through which the cause of the 262 GENERAL STIMULANTS. [PART II. disease operates. Quinia, therefore, interrupts the succession of the paroxysms; and, as they are sustained probably, in part at least, either by habit, or by some chain of morbid action passing insen- sibly from one paroxysm to the succeeding, the interruption is either permanent, or continues until the original cause may re- assume, in some mysterious way, its original activity, and produce a relapse in the now unguarded system. It is obvious that this explanation of the antiperiodic power of remedies implies an identity with that next to be considered; namely, the property of supersession; but, as the explanation is only conjectural, it is deemed best to treat of these two therapeutic agencies distinctly. 3. As A Supersedent. What has been stated above explains the meaning attached to this term. It simply implies that the medi- cine so named has the power, by instituting an action of its own in any part or organ, to displace disease previously existing in that part or organ, or to exclude it if not already established. It is known that quinia acts powerfully on the cerebral centres, especially those of the organic functions, and produces in those centres an impres- sion of considerable permanence. The probable influence of such an impression in preventing the return of regular periodical paroxysms has been referred to. It is evinced also, though much less certainly and strikingly, in the prevention of irregular parox- ysms of various kinds, and even in the relief of existing disease occupying especially the nervous centres, or acting through them, though not necessarily paroxysmal. Upon this principle, we may explain the occasional efficiency of sulphate of quinia in irregular neuralgia, when given very freely. In chorea, functional epilepsy, hysteria, spasmodic asthma, and the advanced stage of pertussis, it has sometimes been used advantageously, and it is said to have proved efficacious, in large doses, even in tetanus. 4. As a Sedative. It will be recollected that I consider the sedative effect, produced by large doses of quinia, as essentially secondary; being always preceded by a longer or shorter period of excitement in certain cerebral centres, and probably dependent, at least in some degree, on this previous excitement, overwhelming, and as it were paralyzing these centres, and disabling them from extending their normal influence to the organic functions generally. In reference to this sedative property of quinia, it would seem to be applicable generally to diseases of over-excitement, not con- nected with active congestion, inflammation, or peculiar excitability CHAP. I.] TONICS.—PERUVIAN BARK. 263 of the brain. Some, who believe in the direct sedative power of the medicine, do not admit even this exception. By these it is recommended in all inflammatory affections, even those of the en- cephalon; but experience has shown that it may prove very inju- rious, and even fatal, in such cases. The quantity requisite for the production of the secondary depression varies from fifteen to sixty grains daily. From a less amount, there might be danger of obtain- ing the direct stimulating effects of the medicine. The following are the complaints in which quinia has been specially recommended as a sedative. Fevers. There can be no doubt that large doses of quinia will often control febrile phenomena, reducing the frequency and force of the pulse, diminishing the heat and dryness of the surface, and sometimes even relieving headache and delirium. Carried far enough, it will suppress all signs of over-excitement, and may even bring on great prostration. In remittent miasmatic fever it is thus employed, especially in our Southern and South-western States, very soon after the commence- ment of the disease, before a remission has become decidedly established, and even in the height of the paroxysm. There can be no doubt, from the abundant testimony on the subject, that, thus given, it will often speedily put an end to the febrile phenomena by its sedative operation; while, through its antiperiodic powers, it prevents a return of the paroxysms, and thus puts an end to the attack.. The effects are, in very numerous cases, so prompt and happy, and the injurious results comparatively so few, that the practice has become very popular, and, in some districts, almost exclusive. But, if my views of the action of quinia in these cases are correct, it is not without its dangers. Should active congestion, or positive inflammation of the brain, complicate the disease, it might be fatally aggravated, especially if it should happen to be seated, not in the lobes, which are comparatively little affected by quinia, but near the base of the brain, in the centres of vision and hearing, and of the great organic functions, which it powerfully excites. Even without the positive existence of high vascular irritation or inflammation, a simple morbid tendency to these con- ditions might be goaded into dangerous action. This is not pure theory. One case at least is on record, in which fatal encephalitis, in an attack of miasmatic fever, was ascribed to the excessive use of quinia (Baldwin, Am. Journ. of 3Ied. Sci, N. S., xiii. 293); and, were unfavourable results as often noted as the favourable, it is not 261 GENERAL STIMULANTS. [PART II. improbable that others might be adduced. It seems to me, there- fore, a safer practice, in these fevers, to wait for a decided remis- sion before prescribing quinia. The only exceptions I would make to this rule are cases, either originally pernicious, or becom- ing so in the course of the disease. In these, the danger of a fatal issue is imminent, and there is little risk of inducing active cere- bral congestion or inflammation; as the tendencies are asthenic rather than otherwise, and the disposition much greater to nervous prostration, and passive congestion, than to inflammatory action. In the pernicious remittent, therefore, or congestive fever of the South, quinia may be given freely after reaction has taken place, and before the occurrence of a distinct remission; and the main error to be guarded against is the exhibition of the remedy, in over- whelming doses, during the cold stage, or that of prostration, for fear of fatally aggravating the existing debility by the secondary depression of the quinia. In yellow fever, also, quinia has been largely employed in this country, upon the same principle; that, namely, of suppressing the fever by its sedative influence. Given in doses of fifteen, twenty, or thirty grains, at an early stage of this complaint, it will un- doubtedly often relieve and even remove the febrile phenomena; and, if the disease be moderate, and spontaneously curable, the patient will experience little subsequent inconvenience. But expe- rience has shown that, though it may suppress the febrile symp- toms, it is incapable of controlling those deeper derangements, and especially that depravation of the blood, in which the chief danger consists; and, in serious cases, the patient dies with prostration, hemorrhage, black vomit, &c, quite as certainly as though no quinia had been given. There is even reason for believing that the great secondary depression, resulting from the overwhelming doses sometimes used, may, when superadded to the debility of the second stage of the disease, produce a fatal result in cases, which, if otherwise treated, might end in recovery. There is, moreover, the risk of seriously aggravating any inflammatory condition or tend- ency which may exist in the brain, in the early stage, and of still fur- ther irritating the mucous membrane of the stomach, already perhaps the seat of high vascular irritation, if not of inflammation. The reader will perceive, therefore, that the sedative treatment by quinia is not that which I am disposed to recommend in yellow fever; though it is proper to state, that my conclusions have been deduced CHAP. I.] TONICS.—PERUVIAN BARK. 265 from d priori reasoning, and the recorded experience of others, and not from any experience of my own with this mode of treatment. Ti/phoid or enteric fever is also among the diseases in which this method of treatment has been employed. Some have supposed that, like miasmatic fever, this affection could be promptly arrested, strangled as it were, by large doses of quinia. A knowledge of its pathology, one would imagine, should be sufficient to guard against this error; for that it is an error has, I think, been abundantly shown by experience. Sometimes, it is true, the disease seems to be mixed with remittent fever, having regular paroxysms, recurring at a particular hour every day, probably owing to the simultaneous action of the causes of the two complaints. In such cases, as I know from observation, quinia will check the paroxysms, and re- move the regular remittent character; but the febrile affection will still march on, with its characteristic phenomena, to its regular termination. In France, sulphate of quinia in large doses has been used, not with a view to the prompt suppression of the disease, but in order to diminish the fever, lessen the danger, and lead to a speedier issue. M. Briquet, who employed it largely, states, as the result of his observation, that the pulse is moderated under its influence, the heat of skin diminished, and the cerebral symptoms very much alleviated; and, on the whole, believes that this treat- ment will compare very favourably with any other which has been adopted. An apparently curious point, in his experience, is the effect of the medicine in diminishing stupor, quieting delirium, and otherwise favourably influencing the head affection. But the cere- bral symptoms in this complaint are not those of active congestion or inflammation. They have probably a double origin, depending, in part, upon the depressing influence of the cause upon the brain, either immediately, or through the instrumentality of the diseased blood, and partly upon the irritating influence of the diseased bow- els upon the cerebral centres. Now, quinia is calculated to obviate both these effects. By its excitant influence, it may counteract the operation of the depressing cause, and thus correct in some degree the characteristic stupor; while, in large doses, through an excess of the same influence on the organic centres, it renders them less impressible by the diseased glands of Peyer. We might, therefore, expect some favourable effects from large doses of quinia; but, though I have given quinia often and freely in this complaint, I have never found from it any other favourable influ- ence than a moderate supporting effect in the low states of the 266 GENERAL STIMULANTS. [PART II. disease; and have often been compelled to omit it by an aggrava- tion of the symptoms. I have certainly never seen it cure a case of the disease. Nor can the results obtained by M. Briquet be considered remarkably favourable, when judged of by his sta- tistical report. Of forty-three cases of a serious character, includ- ing all that came under their notice, treated by himself and M. Blache, either in part or exclusively with sulphate of quinia, eight terminated fatally; and, of these eight, four, on post-mortem ex- amination, exhibited undoubted signs of meningitis. (Trait. ThS- rap. du Quinq., pp. 383 and 385.) Now, the proportion of deaths is here much greater than we habitually meet with in the Pennsyl- vania Hospital (see my work on the Practice of Medicine, 4th ed,, i. 342), even if the serious cases only be taken into account; and the number of cases, four out of eight, in which signs of meningitis were discovered, is far beyond the usual proportion, under any ordi- nary treatment. The inference is fair, that the general result of the heroic treatment with sulphate of quinia is unfavourable, and that it causes death, either by directly inducing meningitis, or by aggra- vating a tendency to that affection already existing; which is exactly what might have been anticipated, from the views here inculcated of the action of quinia on the brain. In typhus fever, the abortive treatment by sulphate of quinia has been recommended strongly by Dr. Robert Dundas, of Liverpool; and has been tried with success by other British practitioners. Among those who report most strongly in its favour is Mr. J. 0. Fletcher, who found it very effectual in cases of pure typhus, but not in those complicated with ulcerated bowels, in other words, not in typhoid fever. (Lond. Med. Times and Gaz., vi. 422.) As a tonic, Peruvian bark has long been an established remedy in typhus fever; but the idea of employing it in large doses, with the view of speedily arresting the disease, is, so far as I know, of recent origin. Though I have used it much in the former capacity, I have no ex- perience with it in large doses, given at the commencement of the fever, with a view to a direct febrifuge effect, and have no right, therefore, to speak decidedly on this point; but, if the humoral views of the pathology, of this disease now prevailing are correct, that it depends, namely, on a poison which enters the circulation, and alters the state of the blood, depraving that fluid, and causing the generation within the system, and elimination from it, of a poi- sonous matter like itself, we know of no properties in quinia which should enable it to correct this condition of things; and, though by CHAP. I.] TONICS.—PERUVIAN BARK. 267 its secondary sedative influence it may suppress the febrile phe- nomena, it would be considered, with these views, as not likely to eradicate the disease. If it has the power of arresting that quasi zymotic action in the blood, which is supposed to characterize con- tagious diseases, it ought to be competent to the interruption of the course of smallpox, measles, and scarlatina; an influence which would scarcely be claimed for it by the most sanguine. Acute Rheumatism. Peruvian bark was long since employed as a remedy in acute rheumatism in Great Britain; but the practice had been abandoned, and only came again into general notice after the publication of the results obtained by M. Briquet, and other French physicians, about the year 1842, with large doses of sul- phate of quinia in that disease. There can be no doubt that, under the use of this salt, in the quantity of half a drachm, more or less, given daily in divided doses, cases of acute rheumatism have often yielded, and entered into convalescence, without any serious incon- venience, at a much earlier period than they ordinarily do if left alone. Very soon after the system has come under the full influ- ence of the remedy, the pains and swelling abate, sleeplessness is relieved, and the pulse reduced in frequency and force; an*d the patient, in most instances, when the disease is uncomplicated with inflammation of the internal organs, as of the heart, will become convalescent, in about ten or twelve days from the commencement of treatment. Sometimes, however, as under every other treat- ment, the disease is much more prolonged, and, when complicated with pericardial or endocardial inflammation, extends to an average period of sixteen days or more; though it is asserted that these inflammations, especially if encountered by general or local bleed- ing, afford no contra-indication to the use of quinia. According to Briquet, the cases least benefited by the sulphate of quinia are those of a plethoric character, in which the inflammatory fever is intense, and the pulse full, hard, and frequent; while those in which it proves most advantageous are in lymphatic subjects, or those weakened by previous disease, or excessive depletion, with pale skin, and a very frequent but not well developed pulse. This is exactly what might have been expected, from the views of the action of sulphate of quinia here advocated, and quite contradic- tory to the notion of its direct sedative power. The medicine suppresses the morbid phenomena by an over-excitement, and con- sequent diminution of the excitability of the nervous centres through which the phenomena are induced, and not by a direct sedative in- 268 GENERAL STIMULANTS. [PART II. fluence on those centres, or on the circulation. But in this very circumstance exists the danger of the practice. Should there hap- pen to exist already in these centres, as now and then happens in acute rheumatism, a vascular irritation or positive inflammation, or a strong tendency to it, then the fear is that quinia may aggravate this condition, and lead to fatal inflammation within the encephalon. This is asserted to have happened in several cases, in consequence of which, the practice has not been generally adopted by the pro- fession ; and I am not inclined to recommend it. The only circum- stances under which I should think it advisable to administer quinia, in acute rheumatism, not complicated with miasmatic fever, are those of general debility, and especially as indicated by profuse sweats, occurring during sleep, and not at other times. As before stated, I have for a long time been in the habit of employing, and of recommending, in my lectures, the use of quinia freely in this condition, and have almost always found it promptly effectual in relieving the symptoms, and generally curative. In chronic rheumatism, the remedy is less efficient than in the acute; but, when carried to the amount of thirty or forty grains daily, it has sometimes proved effectual, especially in cases in which the inflammation has been disposed to change its seat, and thus approach the acute in character. Gout is affected by quinia in a manner very similar to its mode of action in rheumatism. In the acute form, large doses of it will sometimes suppress the local inflammation; but the disease is not subdued, and there is always danger of its appearance in some other of its numerous shapes. The practice, therefore, is almost never resorted to. But, in debilitated states of the disease, it may be used advantageously as a tonic, and, in the nervous forms, is not unfrequently useful as an antiperiodic or superseding remedy. In the phlegmasias or local inflammations attended with symp- tomatic fever, quinia has been thought by some to have a curative effect, in large doses, through its sedative influence. But, for the cure of inflammation, something more is necessary than to reduce the force and frequency of the pulse. Otherwise digitalis would be among the most efficient remedies in that affection, over which, indeed, it has been found to have little influence. An important indication, in the phlegmasias, is to reduce or alter the quality of the blood, as well as to lessen the quantity, or the force with which it enters the inflamed part. Now quinia has no effect of this kind. As already stated, it has a tendency rather to increase than to diminish CHAP. I.] TONICS.—PERUVIAN BARK. 269 the proportion of fibrin in the blood, the augmentation of which is one of the characteristics of severe inflammation. It is true that, except in the phlegmasiae of the brain, and the alimentary mucous membrane, and probably the urinary passages, it has little if any direct effect in increasing inflammation; and the existence, therefore, of this condition does not positively forbid the use of quinia when decidedly indicated on other grounds; but, in simple inflammation in its active stage, there is no sufficient ground for its use; and, in the large quantities which would be required to sup- press the febrile phenomena, it might in various ways do harm. But there are states of inflammation in which it is highly useful. As before mentioned, it may be employed, often with the greatest benefit, in miasmatic intermittent and remittent fever complicated with this condition; acting as an antiperiodic in reference to the general disease, and relieving, if not curing, the local by removing the injurious influence of the paroxysmal excitement upon it. Thus too, when inflammation is attended with a low, asthenic, or typhoid state of system, this medicine is highly useful as a tonic, aiding in the support of the system until the inflammation has run its course. Upon the same principle, it is useful in the suppurative or gan- grenous state of inflammation; and, in these cases, has the addi- tional advantage that, by its tonic powers, it assists in the repair of the local injuries inflicted by the disease, which might not be car- ried on to completion without this or equivalent aid. 5. Local Use. Peruvian bark is slightly irritant to the parts with which it is brought into contact, and sulphate of • quinia more so. Hence, the powdered bark was formerly sprinkled over indolent, flabby, and sloughing ulcers; and the decoction was employed as a gargle in gangrenous ulceration of the fauces. The remedy was supposed to be peculiarly useful in mortifying parts, from the fact that bark has some influence in retarding the putrefaction of ani- mal matters; but it is now well understood that the antiseptic pro- perty, though it may tend to prevent the decomposition of parts already dead, and, therefore, to correct fetor in sloughing ulcers, has no influence whatever, as such, on the process of mortification; and consequently, if Peruvian bark is useful in such cases, it is by sup- porting the vital actions through its tonic, and not through its anti- septic powers. The effect of the medicine in giving tone to the stomach may be considered as, in some degree, the direct result of its local ap- 270 GENERAL STIMULANTS. [PART II. plication to the gastric mucous membrane; and, in the same way, it may do good in ulcerative conditions of the bowels, in which a local stimulant impression is desirable; as in some cases of chronic diarrhoea and dysentery, and in the advanced stages of enteric or typhoid fever. As quinia passes unchanged through the kidneys, and is thus brought into immediate contact with the urinary passages, it must exert upon these its ordinary local stimulation, and may thus prove useful in certain cases of chronic inflammation and ulceration of the pelvis of the kidneys, the ureter, and the bladder. Sulphate of quinia may be used locally for the same purposes as the bark, but, in this case, should be much diluted with some un- irritating material. 8. Preparations, and Modes of Administration. Powdered Bark. The powder would probably be the most effica- cious form for administration, could it always be taken in sufficient quantities, and without irritation of the stomach. But its taste is so revolting to most patients, and it is so apt to occasion nausea, if not vomiting, that it is often almost impossible to employ it in quantities sufficiently large to produce the effects required. The taste may, it is true, to a considerable extent, be concealed or cor- rected by appropriate management; but still the medicine will often offend the stomach by its directly nauseating properties, and, if in no other way, by its great bulk alone. So much do these disad- vantages impair its efficiency, that formerly, when the bark in sub- stance was mainly relied on in the treatment of periodical fevers, it was not unfrequently difficult to break them, and sometimes almost impossible; and, at all events, the treatment was much more prolonged than at present. Trousseau, indeed, considers the pow- der preferable to the sulphate of quinia, being, as he thinks, less apt to irritate the stomach, and, if properly administered, less offen- sive to the taste; but, it seems to me that this eminent therapeutist must either never have taken the medicine himself, or be misled by personal idiosyncrasy; for certainly the general experience is very much opposed to him. Nevertheless, there may be instances in which, from constitutional peculiarity, sulphate of quinia may fail of its usual effect; or may be accidentally unattainable in due time; and, in either case, recourse may be had to the bark in sub- stance. The variety selected for internal use should be one of those CHAP. I.] TONICS.—PERUVIAN BARK. 271 richest in alkaloids; as it is important that as much strength should be concentrated in as small a bulk as possible. Hence, either the Calisaya bark, or the best red bark, or one of the finest varieties of the Carthagena barks recently introduced, as the soft or hard Pitaya, should be preferred. (See U. S. Dispensatory, 10th ed.) Any bark containing two per cent, of alkaloids may be ranked among the efficient varieties. The dose of powdered bark, as an antiperiodic, is about a drachm, repeated every hour or two, or at such intervals that from one to two ounces may be taken between the paroxysms. In reference merely to the tonic effect, from ten to thirty grains are sufficient to commence with. The powder should be given diffused in water, or other liquid vehicle. It is not the best plan to mix each dose extemporaneously when administered; for the dry powder is not readily diffused in water, and the attempt often results in producing a very offensive dose, sufficient, by its very appearance, to produce nausea in one who may have previously taken the medicine. A better method is to introduce a certain quantity of the bark and of the vehicle, say two ounces of the former and two pints of the latter, into a bottle, allow them to stand until the powder has become wet throughout, and then, when the dose is to be taken, to shake them well, and pour out a wineglassful of the turbid liquid. The addition of *a fluidrachm of aromatic sulphuric acid, for each ounce of the bark, will correct in some degree the nauseous taste, and increase its efficiency by rendering soluble the compounds of the alkaloids with the colouring matter. Wine was formerly much employed as the vehicle; but it would be too stimulating for ordinary use. Trous- seau strongly recommends hot sweetened coffee, which he says completely corrects the taste. When the bark purges, it should be conjoined with opium, when it constipates, with a little rhubarb. Infusion. The U. S. Pharmacopoeia recognizes three simple in- fusions, one prepared from the yellow bark (Infusum Cinchona Flav^:), another from the pale (Infusum Cinchona Pallida), and the third from the red (Infusum Cinchona Rubr^i). They are made, in the proportion of an ounce to a pint of water, either by macerating the bruised bark in boiling water, or by treating the coarsely powdered bark by percolation with cold water, which forms a more elegant, and probably stronger preparation. The hot infusion is somewhat turbid; that made with cold water, perfectly clear. In neither is the bark nearly exhausted; for water will not 272 GENERAL STIMULANTS. [PART II. dissolve that portion of the alkaloids which is combined with the cinchonic red. Pale bark has sometimes been preferred, in conse- quence of its less disagreeable taste; but just in the same propor- tion is it less efficient. The preparation is at best feeble, and is used only as a tonic. The dose is two fluidounces, three or four times a day in chronic cases, more frequently in the acute. Compound Infusion (Infusum Cinchona Compositum, U.S.). This, though peculiar to the U. S. Pharmacopoeia, is among the most elegant and efficient preparations of Peruvian bark. It is made by macerating for twelve hours, with frequent agitation, an ounce of powdered bark in a pint of cold water, acidulated by a fluidrachm of aromatic sulphuric acid; or, more conveniently and efficiently, by the method of percolation, the liquid being passed through the powder as often as may be necessary completely to exhaust it. All the virtues of the bark are thus extracted, and probably in a condition of greater activity than in the powder itself; as the whole of the active matter is now dissolved, and therefore readily absorbable. The compound infusion may be used for all the purposes of the medicine. The dose is two fluidounces, to be repeated three or four times a day, as a tonic, in chronic debility; every two hours, in low fevers; and in such a manner as to amount to one or two pints between the paroxysms, in periodical diseases. For use in the typhous state of fever, it may be prepared with wine as the menstruum instead of water. Decoction. The U. S. Pharmacopoeia directs separately the decoc- tion of the yellow bark (Decoctum Cinchona Flav^;), and of the reel (Decoctum Cinchona Rubr^:). These are made by boiling an ounce of the bruised bark in a pint of water, for ten minutes, in a covered vessel, and straining while hot. At the end of the boiling, and before the liquid begins to cool, two drachms of orange- peel may be advantageously added. This preparation was formerly much resorted to, when it was deemed desirable to obtain the vir- tues of the bark speedily in a liquid form. Its disadvantages are that it does not completely exhaust the bark, and that on cooling it becomes turbid, and deposits a precipitate. The turbidness is owing, partly, to the formation of tannate of starch, which, though dissolved by the water when hot, is insoluble in cold water, and therefore subsides on cooling; and, partly, to a similar deposition of a compound of the alkaloids with the colouring matter, pre- viously existing in the bark, and partially taken up by the water at the boiling temperature. Hence the necessity of straining while CHAP. I.] TONICS.—PERUVIAN BARK. 273 hot, so that a portion of the active matter extracted in the decoc- tion may not be lost. Of course, the precipitated matter should be again mixed with the water by stirring, when the decoction is ad- ministered. It would be a great improvement in this preparation to add a little sulphuric, muriatic, or citric acid to the menstruum before boiling. The bark would then be exhausted, and the active matter would be retained in solution upon the cooling of the de- coction. Wine might be advantageously substituted for water in the preparation, when there is an indication at once for alcoholic stimulation and the effect of the bark, as often happens in low fevers. Indeed, the decoction of bark in wine was formerly much used in the prostrate state of fevers of a typhoid character, and with great advantage. The dose of the decoction is two fluid- ounces, to be repeated in the same manner as the infusion. Tincture. Two tinctures are directed by our officinal code, one simple, and the other compound. The Simple Tincture (Tinctura Cinchona, U. S) is ordered to be made with the officinal yellow or Calisaya bark. This is in order to#insure efficiency; for this variety of bark is more uniformly strong with alkaloids than the others; but any variety ascertained to be of equal strength may be employed. The bark is probably completely exhausted when the process is properly conducted, especially if percolation be employed. The tincture would, there- fore, be very efficient, were it not that the proportion of alcohol to the active matter dissolved by it is so great as to give undue promi- nence to its effects, and thus often to render impossible the adminis- tration of a sufficient quantity to obtain the desired influence of the bark. Though the tincture is strong, yet a fluidounce of it con- tains the virtues of only two drachms of the bark. In patients of intemperate habits, or in very prostrate states of fever, this would be an advantage; and,in such cases, the tincture may be used with propriety. But it is more used as an addition to the infusion or decoction, or in connexion with sulphate of quinia, in cases re- quiring alcoholic stimulation, than by itself. It may be thus em- ployed with propriety in cases of pernicious fever, attended with great prostration, as well as in fevers of the typhous character. In consequence of the resin it contains, it becomes turbid on dilution with water. The dose is from one to four fluidrachms. The Compound Tincture (Tinctura Cinchona Composita, U. S) is the preparation commonly known as Huxham's tincture. It dif- fers from the preceding in containing serpentaria and orange-peel VOL. I.—18 274 GENERAL STIMULANTS. [PART II. with colouring matter, and in being prepared with red instead of yellow bark. It is made with a much smaller proportion of bark than the simple tincture, and is, therefore, less suitable as an anti- periodic, or in cases requiring a strong impression from that medi- cine. It is, however, an elegant stomachic cordial, useful in cases of feeble digestion and general debility, but requiring the same caution against perversion as the other tonic tinctures. The dose is a fluidrachm. The Extract is prepared, according to our officinal code, either from the yellow bark (Extractum Cinchona Flav^e, U.S.), or from the red (Extractum Cinchona RuBRiE, U. S); and, if the bark is well chosen, it is of little consequence which of these varie- ties is employed. In its preparation, the bark is exhausted first by alcohol, and afterwards by water; the tincture and infusion are separately evaporated to the consistence of honey; and the two are then mixed, and the evaporation completed. It thus appears that the bark is deprived of all its active matter; and the extract cannot but be very efficient, if due care is exercised in selecting the bark, and in conducting the evaporation. But, as a large proportion of the matter dissolved by the menstrua is inert, as the gum, resin, and cinchonic red, the preparation is much less efficient than the separated alkaloids, and is now little used. As found in the shops, it is not unfrequently very feeble, from the want of attention to the points above referred to. The dose is from ten to thirty grains. The Fluid Extract, or Inspissated Infusion of the London Pharma- copoeia (Infusum Cinchona Spissatum, Lond), is simply an infu- sion highly concentrated by evaporation, with the addition, after the concentration, of a portion of officinal alcohol, which serves at once to prevent spontaneous decomposition, and to redissolve the matter deposited during the latter part of the process. The propor- tion of alcohol is three fluidrachms in eleven of the fluid extract. The preparation is no doubt efficacious, but is liable to the same objection as all others in which water alone is the menstruum; namely, that the virtues of the bark are not wholly extracted. The dose, representing a drachm of bark, is about twenty minims. SULPHATE OP QUINIA.—Quinia Sulphas. U. S.—Quince Sulphas. Ed., Dub.—Quin^ Disulphas. Lond. Preparation. This is, beyond all comparison, the most important and most extensively used of the preparations of bark, and mav be considered as a sufficient representative of its virtues, on all ordi- nary occasions. For the details of its preparation, the reader is CHAP. I.J TONICS.—SULPHATE OF QUINIA. 275 referred to the U.S. Dispensatory. For our purposes here, it is sufficient to state, that officinal yellow or Calisaya bark, which is usually selected, is exhausted by boiling it with water acidulated with muriatic or sulphuric acid; that, from the decoction thus ob- tained, the quinia and other alkaloids are precipitated, together with impurities, by means of lime; that the precipitate is treated with alcohol, which dissolves the alkaloids; that the alcoholic solu- tion is then evaporated; and, finally, that from the residue, consist- ing mainly of quinia, the sulphate is obtained by treating it with boiling water and sulphuric acid, purifying with animal charcoal, and crystallizing. Sensible and Chemical Properties. Sulphate of quinia is in minute, white, silky, flexible, needle-shaped crystals, in tufts or interlaced, inodorous, intensely bitter, fusible at 240° F., soluble in 740 parts of cold water, 30 of boiling water, and 60 of alcohol, and very slightly soluble in ether. It is, however, very readily dissolved by water acidulated with almost any one of the sour acids. Its aqueous solution exhibits a beautiful bluish colour or opalescence on its surface. Two views are taken of its composition; one, that it is a neutral sulphate, containing one eq. of acid and one of base; the other, that it is a disulphate, containing one eq. of acid and two eqs. of base. The former opinion, which was first entertained, sub- sequently gave way to the latter; but some chemists are disposed to return to it, and the author has always considered it as most pro- bably correct; so that the ordinary designation of the salt should, in his view, be retained. If it be considered a neutral salt, its exact composition will be expressed by the formula; one eq. of sulphuric acid 40, one of quinia 324, and eight eqs. of water 72 = 436. It loses part of its water of crystallization by exposure, or by heat, but always retains about 4 per cent, or two eqs. of water, from which it cannot be separated without decomposition. Bisulphate of Quinia. By an additional equivalent of sulphuric acid, the sulphate is converted into the bisulphate, generally con- sidered as the neutral salt. This is much more soluble in water than the ordinary sulphate, requiring only 11 parts of cold water for solution, and is freely dissolved by alcohol. It is formed ex- temporaneously in solution, with the utmost facility, by gradually dropping a little diluted sulphuric acid into a mixture of the ordi- nary sulphate with water, until the latter is dissolved. Incompatibhs. The substances which yield precipitates with solu- tions of sulphate of quinia, and should, therefore, not be adminis- 276 GENERAL STIMULANTS. [PART II. tered, as a general rule, along with it, are the alkalies and their carbonates, the alkaline earths, all astringent solutions containing tannic acid, and the soluble salts of lead and baryta. The soluble salts of oxalic, tartaric, and gallic acids also occasion more or less precipitation with solution of sulphate of quinia, without excess of acid; and the same has been ascertained to be the case, by Mr. John M. Maisch, with the soluble acetates (Am. Journ. of Pharm., xxvii. 97); but the precipitates may be redissolved by the addition of an acid. Adulteration. Sulphate of quinia is liable to adulteration; but this can generally be easily detected by referring to its peculiar solubilities. The presence of mineral substances, not easily vola- tilized by heat, will be evinced by a residue left behind when a small portion of the salt is put upon red-hot iron. (See U. S. Dis- pensatory, 10th ed., p. 1173.) Effects. The properties of sulphate of quinia as a therapeutic agent have already been sufficiently considered. In reference to its antiperiodic and secondary sedative effects, it has all the power of bark, and more indeed than can always be exerted by the crude medicine. As a mere tonic, it is possible that the compound infu- sion, or some other preparation in which all the active principles of bark are contained, or the bark itself in substance, may be more efficacious; but I do not think that the fact has been rigidly demon- strated. The peculiar advantages of the salt are its convenience of administration, its general acceptability to the stomach, the rapidity with which it is absorbed, the facility of ascertaining its purity and genuineness, and the opportunity which it affords, by the smallness of its dose, of obtaining the peculiar effects of bark in a degree greater than can be obtained, as a general rule, from the bark itself. Administration. Sulphate of quinia may be administered in sub- stance or solution. In my own experience I have been able to, discover little difference, in therapeutical results, between these two modes of exhibition; though it is asserted by M. Briquet, as an inference from his experiments, that the solution formed by the addition of a little sulphuric acid, and containing, therefore, the bisulphate, will produce the antiperiodic effect more quickly, and in considerably smaller doses, than the ordinary sulphate given in substance. There can be no doubt that the salt in solution will be more readily absorbed into the circulation than the undissolved salt; but the ordinary sulphate is so readily dissolved by water slightly acidulated with almost any acid, that the instances must be CHAP. I.] TONICS.—SULPHATE OF QUINIA. 277 very few, in which there is not sufficient acid in the primae viae for this purpose. It is, I presume, very seldom that the sulphate of quinia passes undissolved through the stomach, unless secured against the action of the gastric acids by a vicious mode of exhi- bition. The salt in substance is usually given in pill, or suspended in water; very rarely in the form of powder. The officinal Pills of Sulphate of Quinia (Pilule Quinle Sul- phatis, U.S.) are made by the addition of gum and honey, and contain, each, a grain of the salt. They answer very well when made extemporaneously; but, if kept very long, there is danger that they may become so hard as to afford a mechanical impedi- ment to solution, and consequently to pass through the stomach unchanged. Nevertheless, I have used very old officinal pills, with prompt and powerful effect, as an antiperiodic. A method of pre- paring them suggested by Mr. Edward Parrish seems to offer some advantages. This plan is simply to triturate together 20 grains of the salt and 15 drops of aromatic sulphuric acid, until a pilular mass is formed. The pills are thus obtained of smaller bulk and more soluble; and a pill of five grains is not inconveniently large. (See U. S. Dispensatory, 10th ed., p. 1122.) The salt, if finely powdered, may be suspended in water by simple agitation; but the intervention of syrup or mucilage is preferable. M. Trousseau gives it stirred up in hot and sweetened coffee, which seems to correct its taste. The probable conversion of the salt into an insoluble tannate may be urged against this method of exhibi- tion ; and the same objection holds against the plan of mixing the salt with tannic acid, as recommended by Dr. Thomas, of Baltimore; but when it is very important, as in some infantile cases, to destroy the taste, either method may be employed; as, though the tannate may act less rapidly, and require a larger quantity for a given effect, than the sulphate, yet it is in fact dissolved in the stomach whenever acid is present, and experience has proved its efficiency. Dr. W. H. Edwards, of Virginia, has found that, by enveloping sulphate of quinia in a spoonful of thick mucilage of slippery elm, without allowing it to touch the sides of the spoon, it may be taken without the taste being in the least degree observed. (Stethoscope, iv. 338.) The solution of sulphate of quinia, which, when its bitter taste is not objectionable, is the best form for administration, may be made by adding 12 minims of aromatic sulphuric acid to 8 grains of the 278 general stimulants. [part ii. salt, in a fluidounce of water, in other words, a minim and a half for each grain. Twelve grains of the sulphate may be considered as equivalent to one ounce of good bark. The doses proper under different circumstances have been already given. It may be repeated that, as a tonic, the dose of sulphate of quinia is a grain, to be repeated in chronic cases three or four times a day, in acute cases every two or three hours; as an antiperiodic, from twelve to twenty-four grains between the paroxysms, in ordi- nary periodical diseases, which may be increased, in pernicious fever, and very obstinate neuralgia, to from thirty to sixty grains, these amounts being, as a general rule, divided into doses of from one to five grains at equal intervals; and, in reference to the secondary sedative effects, not less than fifteen or twenty grains daily, which must sometimes be considerably increased. If the stomach will not retain the salt, it may be given by the rectum; from six to twelve grains, in ordinary cases, either dis- solved by means of a little citric acid, or suspended in two fluid- ounces of mucilage or solution of starch, and mixed with from twenty to forty drorjfe of laudanum, being injected into the rectum every six hours. In urgent cases, this quantity may be very greatly increased. The endermic method is sometimes resorted to; but the application of sulphate of quinia, undiluted, upon a surface deprived of the cuticle, is apt to produce superficial sloughs; and its use in this way should be restricted to cases of emergency. It should also be mixed, before application, with some unirritating substance, as powdered gum or arrowroot. The epigastrium, and insides of the thighs and arms, are proper positions for its endermic use. Friction upon the surface with sulphate of quinia, in the form of liniment or ointment, has also been recommended. For this pur- pose, a drachm of the sulphate, finely powdered, may be incorpo- rated with two drachms of lard; but it would be better that the salt should be preliminarily dissolved, as it is more readily absorbed in this state. The following formula is essentially that of M. Boudin. Dissolve a drachm of sulphate of quinia in the least possible quantity of alcohol, with the aid of a little aromatic sulphuric acid, and incorporate the solution with four drachms of melted lard. The salt being soluble in oleic acid, or pure lard oil, M. Lhermite recommends to dissolve one part of it in ten parts of the oil, with the aid of a gentle heat, the oil being previously CHAP. I.] TONICS.—CRUDE QUINIA. 279 scented with an agreeable volatile oil, as that of bergamot, for ex- ample. Either of these preparations may be rubbed, ad libitum-, upon the inside of the upper or lower extremities, or in the axilla. The idea of bringing young infants under the influence of quinia through the milk of the mother, by administering the medicine to the latter, has suggested itself to practitioners; but the alkaloid is probably not thrown off with this secretion; at least numerous attempts to detect it in the milk of women under its influence have failed. This plan, therefore, should never be relied on, and is the less necessary, as it is very easy to give the remedy to the child directly, by resorting to pome expedient for covering the taste. Other Salts of Quinia, Numerous other salts of quinia have been recommended, on various grounds, as substitutes for the sul- phate. The acetate, antim-oniate, arsenite and arsenate, citrate, ferro- cyanate, lactate, muriate, tannate, and valerianate, have severally had their peculiar advocates; but the insolubility of most of them is one objection; and, though this may be overcome by the acid of the stomach, or the addition of an acid previously to administration, yet there exists another objection; that, namely, as they act through the quinia they contain, and all of them have a less pro- portion of this than the sulphate, in consequence of the higher combining number of their acid, they must be proportionably less efficient, even when dissolved. Besides, experience has failed to establish any superiority of any one of them over the sulphate, except as regards the taste; and, in relation to the salts with arsenious and arsenic acids, they cannot be given in quantities suf- ficient to obtain the influence of quinia over the system, without incurring the risk of danger from the arsenical ingredient. CRUDE QUINIA. In the process for preparing sulphate of quinia, after the evaporation of the alcoholic solution, and before the addition of sulphuric acid, a semiliquid substance is obtained, which, being dried, constitutes the substance here referred to, under the name of crude quinia. It has a resinous aspect, and a brownish- fawn colour more or less deep, is softened by heat so as easily to be formed into pills, is much less bitter than the sulphate, and consists, as procured from Calisa}ra bark, mainly of quinia, which is mixed with whatever other alkaloids may exist in the bark, and more or less colouring and perhaps resinous matter. It has all the effects of sulphate of quinia, and may be employed for the same purposes. Thoutrh but very slightly soluble in water, it is readily dissolved by the addition of an acid, and is consequently soluble 280 GENERAL STIMULANTS. [PART II. in the gastric liquor. From its comparative want of taste, it is applicable to infantile cases. The only objection to it is that, from its want of a precisely definite composition, it cannot be so readily guarded against adulteration. It may be given in the same doses as sulphate of quinia, either in the form of pill, or suspended in water. Dissolved by means of an acid, it of course acquires the bitter taste of the sulphate. QUINOIDIA or QUINOIDIN.—AMORPHOUS QuiNlA. After the crystallization of all the sulphate of quinia that can be obtained in that form, in the process for preparing the salt, there is left behind a mother liquor, by the evaporation of which a dark amor- phous substance is obtained, which was formerly recognized by our Pharmacopoeia under the name of impure sulphate of quinia. This had been used, before being thus officinally recognized, by the late Dr. Samuel Emlen, of Philadelphia, and by the author, with all the effects of the pure sulphate in the case of intermittents, though requiring to be given in about double the dose. It was supposed to consist of sulphate of quinia with a little sulphate of cinchonia, and colouring impurities. From the want of precise characters by which it could be recognized, it has been abandoned in the recent revisions of the Pharmacopoeia. Sertiirner supposed that, in this residuary matter, he had found a new alkaloid, which was named quinoidin from its resemblance to quinia. According to Liebig, however, this new alkaloid has the same composition as quinia, from which it differs only in being un- crystallizable, and imparting this same property to its salts. He therefore named it amorphous quinia; and his views as to its nature have been generally adopted. It is probably mainly the result of the process for extracting the alkaloids; the heat employed having the effect of modifying the state of the quinia, as the same agency converts crystallizable into uncrystallizable sugar. This substance is obtained, not by evaporating the mother liquors, as in the case of the impure sulphate of quinia above referred to, but precipi- tating these liquors by means of an alkaline carbonate, which de- composes the sulphates contained in them, and throws down the uncombined alkaloid. By repeated solution and precipitation, the alkaline matter may be obtained quite pure, and, in this state, con- sists of the quinoidin or amorphous quinia, together with whatever other organic alkali may have existed in the bark, as cinchonia, and possibly sometimes quinidia. When pure, it is an excellent pre- CHAP. I.] TONICS.—SULPHATE OF QUINIDIA. 281 paration, and may be employed, in all cases, as a substitute for sul- phate of quinia, in about the same dose. SULPHATE OP QUINIDIA. This has but recently been brought into notice, in a pure and isolated state, though long employed in connexion with sulphate of quinia, with which it is conjoined, when the latter salt is procured from barks containing both alkaloids. It is obtained for use from the barks which most abound in quinidia, by the same process as that employed in the preparation of sul- phate of quinia from Calisaya bark. Like the analogous salt of quinia, this is considered by some as a neutral, by others as a subsalt, and by the latter would be called disulphate of quinidia. It is in long, silky, acicular crystals, soluble in 130 parts of cold and 16 of boiling water, readily soluble in alcohol, but nearly insoluble in ether; and by these properties may be distinguished from the corresponding salt of quinia. It has the same effects as sulphate of quinia, and may be employed in the same doses. That it is little if at all inferior, in the treatment of intermittent fever, has been abundantly proved by the trials made with it by Dr. J. S. Dorsey Cullen, in the Almshouse Hospital of Philadelphia (Am. Journ. of 3Ied. Sci., N. S., xxix. 81); and those of Dr. Geo. L. Upshur, sur- geon to the U.S. Marine Hospital at Norfolk (Med. Examiner, N.S., x. 740). From fifteen to thirty grains were employed between the paroxysms. SULPHATE OP CINCHONIA. This may be made by directly combining its ingredients, or by crystallization from the mother waters of sulphate of quinia, after this salt has been wholly sepa- rated from them. It is in short, oblique, shining, prismatic crystals, with dihedral summits, which melt at 212° F., are soluble in 54 parts of cold, and a much smaller proportion of boiling water, are readily dissolved by alcohol, and have a very bitter taste. The salt is either a neutral sidphate or a disulphate, according to the opinion which may be adopted as to the equivalent of cinchonia; and, like the sulphate of quinia, may be converted into a more soluble salt by combination with an additional equivalent of acid. It has been abundantly proved to have the therapeutic virtues of sulphate of quinia, though somewhat feebler. To obtain the same effects from it, the dose should be about one-third, or at least, one-quarter, greater than that of the salt of quinia. 282 GENERAL STIMULANTS. [PART II. II. HOPS. HUMULUS. U. S.—Lupulus. Lond., Ed. Origin. Hops are the fruit or strobiles of Humulus Lupulus, a climbing perennial plant, growing wild in Europe and North Ame- rica, and largely cultivated in both continents. The fruit is picked when ripe, dried by artificial heat, packed in bales, and thus sent into market. Sensible Properties. Each strobile is of a conical shape, flattened by pressure, and consists of a number of thin, translucent, leaf-like scales, one overlapping another, of a pale yellowish-green colour, with two small black seeds near the base of each, and minute yel- lowish granules upon their surface, easily separable when the fruit is quite dry. Hops are of difficult pulverization, of a strong, pecu- liar, narcotic, yet fragrant odour, and of an extremely bitter, aro- matic, somewhat astringent taste. They impart their sensible and medicinal properties to alcohol and water. Active Constituents. The virtues of hops depend probably, in chief, upon a peculiar bitter principle called lupulite or lupuline, but to which the name of humulin would be more appropriate, as more distinct from lupulin, which had been introduced into use, with another meaning, before the discovery of the principle referred to. They contain also a volatile oil, which is the source of their aroma, and a small proportion of tannic acid. Their other con- stituents have no special interest for the physician. The active principles of hops are diffused, in some degree, through- out their whole substance, but are mainly concentrated in the yel- lowish granules upon the surface of the scales. These granules are separated for use, and constitute a distinct medicine, recognized in our Pharmacopoeia by the name of lupulin, proposed for it by the late Dr. A. W. Ives, of New York, who first brought it into notice. Lupulin (Lupulina, U.S.) is prepared by rubbing or threshing the hops, and then sifting the coarse powder obtained. It consists of yellowish granules, almost always interspersed with minute frag- ments of the scales themselves, from which it is impossible entirely to separate them, as ordinarily procured. Lupulin has the odour and taste of hops, and contains the volatile oil and bitter principle above mentioned, with mere traces of the tannic acid. As it pos- sesses all the virtues of hops, in a more concentrated and convenient form, it is generally preferred for internal use. CHAP. I.] TONICS.—HOPS. 283 Effects on the System, Notwithstanding the vast consumption of hops in malt liquors, their effects on the system, and mode of ope- ration, have not yet been thoroughly investigated, or satifactorily determined. That they are tonic to the digestive function is gene- rally admitted, and might be inferred from their intense bitterness. Almost universal experience would seem to have determined that they have the additional property of inducing heaviness, drowsiness, and even sleep; and by most they are believed to have that also, in some degree, of relieving pain. Nevertheless, Magendie was dis- posed to reject their claim to be considered narcotic, having given lupulin to the lower animals without any such effect; and others are not wanting who maintain the same opinion. Dr. Maton, however, found them to allay pain, produce sleep, and lower the pulse in twenty-four hours from 96 to 60 in the minute. (Pereira, Mat. 31ed., 3d ed., p. 1247.) Dr. William Byrd Page, of this city, in February, 1849, stated to the College of Physicians of Phila- delphia, that he had found lupulin to possess extraordinary powers in allaying irritation of the ge:.ical organs, and had been in the habit of using it for that purpose for two years.* The same fact has since been confirmed, on the continent of Europe, by Zambaco, who was induced to make experiments with it by an observation of Debout, in relation to its favourable influence in relieving painful erections. He gave from one to sixteen scruples, without producing disturbance of the nervous system, but with decided effects, of the nature referred to, on the genital organs. (See Lond. Med. Times and Gaz., Feb. 1855, p. 118.) With their tonic, soporific, and anodyne properties, hops may, therefore, be considered antaphrodisiac. That they possess the power of stimulating the cerebral functions is ex- tremely doubtful; and I am not, therefore, disposed to class them in the same category with opium and alcohol. From the large quan- tities taken with impunity, it is probable that their influence over the brain is feeble, and, from the symptoms evinced, that it is rather sedative than stimulant. In this uncertainty as to the precise posi- tion they ought to occupy, in reference to their influence over the nervous system, I have thought it best to rank them with the division of bitter tonics having peculiar properties, to which they undoubtedly belong, whatever claim they may have to a position elsewhere. Opinion is not more settled as to the special influence of the several active principles of hops. It is a very general impression that the odorous and volatile principle is that to which they owe 284 GENERAL STIMULANTS. [PART II. their narcotic properties. The effect of a pillow of hops in pro- ducing sleep may be said to be almost notorious; and it is asserted that stupor has sometimes occurred in persons who have remained long in warehouses containing hops; but, in the former case, much allowance must be made for the operation of the patient's imagina- tion; and, in the latter, it might be suggested that the experience of such an effect, if real, should be more than occasional, and that there might have been some other cause for the stupor when ob- served. Besides, Dr. Wagner states that he gave twenty drops of the volatile oil to a rabbit without observable effect. (Chem. Gaz., July 15, 1853.) In reference to the bitter principle, opinion is not more settled, except as to its tonic action on the digestive organs. Dr. Christison is disposed to think, that whatever soporific virtues may be possessed by hops reside in the volatile oil, and consequently that the bitter principle is destitute entirely of narcotic properties. (Dispensatory) No well grounded conclusion on these various points can be reached, except after more minute and accurate in- vestigation than has yet been given to the subject. Like all other bitters, hops are offensive to the stomach in over-doses. Therapeutic Application. Hops may be used as a tonic in dys- peptic or debilitated states of the digestive organs, and are specially indicated in cases attended with nervous restlessness and want of sleep. This condition not unfrequently exists in the convalescence from acute diseases, and in persons of a nervous temperament, who have been exposed to the influence of other debilitating causes. On any occasion of obstinate wakefulness, dependent on mere nerv- ous disturbance, hops may be tried among other means of relief, and especially when some objection may exist to the use of opiates. They are supposed sometimes to have operated usefully in the morbid vigilance of insanity. In all these cases, a dose of the in- fusion of hops, of lupulin, or, when stimulation is also indicated, of one of the tinctures, may be given three or four times a day. But the case to which hops are probably most appropriate is that of the inebriate, suffering under the want of his accustomed stimulus. The medicine appears sometimes to operate most hap- pily in such cases, in supporting the digestive function, con- trolling nervous tremors, obviating hallucinations, and disposing to sleep. Unassisted by stimulants, it is not adequate to sup- ply the want of alcoholic drinks altogether; but, in the form of malt liquors, or that of the tincture of hops or of lupulin, it will, I believe, often enable the patient to escape the horrors of delirium tremens, with a smaller amount of alcoholic stimulus than CHAP. I.] TONICS.—HOPS. 285 would otherwise be necessary. In delirium tremens itself, the tinc- ture is often an admirable adjuvant to opium; and I feel confident that I have seen sleep induced by it, in cases of this kind, which resisted the opiate treatment, without any reason for ascribing the result merely to the alcoholic ingredient. In convalescence, more- over, from that disease, it is one of our best remedies for sustaining a moderate tonic and soporific influence over the patient, until nature shall have recovered her powers. In these conditions, the tincture of lupulin may be given in the dose of half a fluidounce every two or three hours in the beginning, to be gradually dimi- nished, and with lengthened intervals, as it may cease to be requi- site, either for supporting strength, or producing sleep. Dr. Maton found the medicine useful in allaying the pains of acute rheumatism; but it is vastly inferior to opium for this purpose. It has occasionally been used in intermittent fever without very encouraging success; but has recently been recommended in that complaint by Dr. W. Y. Godberry, of Benton, Miss., as equal to any other article of the Materia Medica except quinia; and he has often succeeded in arresting the disease by means of it, after that medicine had failed. He prefers the infusion, which should be made with an ounce to a pint of boiling water; the whole to be taken during the intermission. (Am. Journ. of 3Ied. Sci, N. S., xxvi. 283, from West. Journ. of Med. and Surg., March, 1853.) From the statements of Dr. Page before referred to, lupulin would appear to be one of the best remedies in our possession for relieving irritations of the genital organs in men. In the painful erections occurring in gonorrhoea, he gives it in doses of from five to ten grains, and has never known an instance in which the second dose did not afford relief. He has also found it useful in sperma- torrhoea ; preventing the discharges while the patient is under its influence, though inadequate to the cure. Administration. Hops are seldom if ever given in substance. The Infusion (Infusum Humuli, U.S.), which is made in the pro- portion of half an ounce to a pint of boiling water, may be given in the dose of a wineglassful. Decoction is an unsuitable mode of preparation, as boiling dissipates the volatile principle, on which possibly the virtues of the hops partly depend. The Extract (Extractum Lupuli, Lond., Ed) is liable to the same objection as the decoction. It has the bitterness without the aroma of the hops. Nevertheless, it is said to have acted as an anodyne and soporific; but it has been almost entirely superseded by lupulin, 286 GENERAL STIMULANTS. [PART II. which has all its advantages without its defect. The dose of the extract is from ten to thirty grains. Lupulin is now probably most used when the influence of hops is wanted. The dose is from six to twelve grains; but may be much increased, if thought advisable. It is most conveniently given in pill, which may be made by rubbing the powder, in a warm mortar, till it acquires a plastic consistence. The Tincture of Hops (Tinctura Humuli, U S) is not an eligible preparation, being too feeble and uncertain to be relied on. The usual dose is from one to three fluidrachms. The Tincture of Lupulin (Tinctura Lupulin^;, U. S) is more efficient, and is an excellent preparation when the alcoholic ingre- dient is not objectionable. The dose for ordinary purposes is one or two fluidrachms. ■♦» The two tonics last treated of owe their special virtues to the peculiarity of their respective active principles. There are two substances of minor importance, supposed to possess peculiar vir- tues, which, if the claim be admitted, must rank in the same cate- gory. I allude to the dogwood and willow barks. It is true that these have a portion of tannic acid associated with the bitter prin- ciple; but it is not to this that the remedial effects ascribed to them, and to which they mainly owe what reputation they possess, can be attributed, any more than the characteristic remedial properties of Peruvian bark can be attributed to the tannic acid which it also contains. If they have special virtues, these reside, in all proba- bility, in their bitter principle; and the* medicines, therefore, may be appropriately considered here. 1. DOGWOOD. —Cornus Florida. U.S. This is the bark of Cornus Florida, or common dogwood, a small indigenous tree, remarkable for its conspicuous white flowers, which render it one of the finest ornaments of our forests in the spring, as its glossy-red fruit, and leaves beautifully tinted by the frost, do in the autumn. The bark is taken indiscriminately from the root, stem, and branches; but that of the root is preferred. It is in pieces of various size, partially or completely rolled, sometimes with and sometimes without epidermis, of a reddish-gray colour, a feeble odour, and a bitter, astringent, slightly aromatic taste. It is brittle, and yields a gray, slightly reddish powder. Either water or alcohol will extract its virtues. These probably reside in a pe- CHAP. I.] TONICS.—DOGWOOD.—WILLOW BARK. 287 culiar bitter principle, which, however, has not yet been isolated ; for neither the cornin of Mr. Carpenter, nor the substance used, un- der the same name, by the eclectic physicians, so called, can be admitted to this rank. The bark'contains also tannic acid, but not in sufficient proportion to give it any considerable medicinal activity. The effects of dogwood on the system, so far as they can be traced, are those of a mild tonic and feeble astringent. It is said to increase the strength and frequency of the pulse, and the heat of the body; but, so far as known, it produces none of those effects upon the brain which characterize the action of Peruvian bark. In the recent state, it is said to act unkindly on the-stomach and bowels; but, in this respect, it resembles most other tonics, when too freely administered. Dogwood has been used almost exclusively, as a substitute for Peruvian bark, in the treatment of intermittent and remittent fevers; and, from the amount of testimony in its favour, there can be no doubt that it has often proved efficacious in the former of these complaints. But it has often also failed; and, since the intro- duction of sulphate of quinia into use, has been little employed by regular practitioners. It may be used in powder or decoction. The dose of the powder in intermittents is stated at a drachm, so repeated as to amount to one or two ounces between the paroxysms. The U. S. Pharmaco- poeia directs a decoction (Decoctum Cornus Florida, U. S) to be made by boiling an ounce, in a pint of water, for ten minutes. The whole pint may be taken in one intermission, in doses of two fluid- ounces. An extract prepared with water or alcohol, might be sub- stituted for either of the above forms with advantage. The pro- fession is indebted chiefly to Dr. John M. Walker, who published a thesis on dogwood in Philadelphia in the year 1797, for what is known upon the subject. The bark of two other indigenous species of Cornus, C. circinata or round-leaved dogwood, and C. sericea or swamp dogwood, have similar sensible properties, and are supposed to have the same medical virtues as that of C. Florida. 2. WILLOW BARK —Salix. U.S. The barks of all the species of willow, possessing a very bitter taste, may be considered as designated by the title above given; for all probably have identical properties; but it is only that of the Salix alba which has been recognized by our national standard. 288 GENERAL STIMULANTS. [PART IT. This is the common European or white willow, and has been intro- duced into this country, where it grows extensively. When dried, willow bark taken from the branches rolls into close quills, which are fibrous, flexible, and difficult to powder. It has a feeble, somewhat aromatic odour, and a peculiar, bitter, astrin- gent taste. Water and alcohol extract its virtues. The active in- gredients are a peculiar principle called salicin and tannic acid, the latter of which, however, though in considerable proportion, is yet scarcely sufficient to entitle the medicine to rank among the effi- cient astringents. Salicin will be particularly noticed at the end of this article among the preparations of the bark. The effects of willow bark upon the system, so far as they are obvious, are those of a mild tonic and astringent; but it probably also has an antiperiodic action; as it has been used with some success as a substitute for Peruvian bark in intermittents. This, indeed, has been its chief employment; though it is not without efficacy in relaxed and debilitated states of the system, as in the weakness of convalescence, certain conditions of scrofula, passive hemorrhages, &c., in which a slight astringency is indicated along with a tonic influence. Like many other bitters, it has been used as an anthelmintic. The states of preparation in which it may be used are those of powder, infusion or decoction, or of salicin. The powder is better borne by the stomach than cinchona and many other tonics. The dose of it for other purposes than those of an antiperiodic is half a drachm, repeated three times a day. As a substitute for Peruvian bark, in intermittents, it must be given, during a single intermission, in the quantity of one or two ounces, which may be distributed into doses of a drachm, repeated as often as may be necessary. The infusion or decoction is made in the proportion of an ounce to the pint of water; and the dose is one or two fluidounces. From one to two pints must be given between the paroxysms of an intermittent. The decoction has been used as a topical application in indolent, flabby, or foul ulcers. Salicin is by far the most efficient preparation in reference to the antiperiodic effect. Several processes have been suggested for its preparation. Among the best is that of Merck. The boiling con- centrated decoction is treated with litharge, in order to precipitate various substances that tend to prevent the crystallization of the salicin. This principle remains in solution, probably holding a portion of the oxide of lead in combination. The lead is thrown CHAP. I.] TONICS.—WILLOW BARK. 289 down by the addition first of sulphuric acid, and then of sulphuret of barium; and the remaining liquid, being evaporated and allowed to cool, deposits the salicin, which is purified by repeated solution and crystallization. When pure, it is beautifully white, in minute, soft, shining, slender crystals, inodorous, and very bitter, with the peculiar flavour of the bark. It melts at 230°, and is inflammable at a higher temperature. It is soluble in water, much more so in hot than cold, is soluble also in alcohol, but not in ether, or the volatile oils. It is neuter in relation to acids and alkalies, and is not thrown down by any reagent. Sulphuric acid gives it a blood- red colour; but a more certain test is the odour of meadow-sweet (Spiraea ulmaria), which it yields when heated in solution with chromic acid; salicin being resolved by that acid into the oil of meadow-sweet or salicylous acid, among other products. Having been employed to adulterate sulphate of quinia, it is important that there should be some method of detecting it. When taken inter- nally, it gives to the urine the odour of salicylous acid, into which it is probably converted in its passage through the system. Since the discovery of salicin, this preparation has been almost exclusively used. At one time, so favourable were the reports of its efficacy in intermittents, that the hope was indulged that it might supersede quinia. But further experience has shown that, though it will often cure intermittents, it cannot be relied on with certainty; and the best that can be said of it is that, when quinia cannot be obtained, it is among the best substitutes of vegetable origin. The dose as an antiperiodic is from two to eight grains, repeated so as to amount to from twenty to forty grains during the intermission. It is less apt to oppress the stomach than quinia. The substances which follow, belonging to the subdivision of bitter tonics of peculiar properties, owe their peculiarity in general to the association of some other active constituent with their bitter principle. This associated constituent is, with one or two excep- tions, a stimulant volatile oil. The most decided exception to this general rule is afforded by the medicine immediately following, in which, though a somewhat stimulating volatile oil is always gene- rated, vet, in connexion with this oil, a powerful sedative is also produced, namely, hydrocyanic acid, to which the medicine is mainly indebted for its peculiar and characteristic effects. vol. i.—19 290 GENERAL STIMULANTS. [PART II. III. WILD-CHERRY BARK. PRUNUS VIRGINIANA. U.S. Origin. This is the inner bark of Cerasus serotina, or wild-cherry, a large indigenous tree, growing abundantly in the Middle and Western States. The officinal name originated in the mistaken supposition, that the Prunus Virginiana of Linnaeus was the tree in question; whereas, according to Torrey and Gray, that title really belongs to the choke-cherry (Cerasus Virginiana of the N. American Flora), a small tree or shrub, inhabiting the Northern States. The bark is obtained from the root, stem, and branches of the tree; but that from the root is preferred. It should be collected in the fall, when it is strongest.. The recently dried bark is more efficacious than that which has been long kept. Sensible Properties. Wild-cherry bark, as found in the shops, is usually destitute of epidermis, of a reddish-yellow colour, brittle, and easily pulverized, yielding a fawn-coloured powder. When fresh or treated with water, it has the odour of peach-leaves. The taste is agreeably bitter, astringent, and somewhat aromatic. It yields its bitterness to water, to which it imparts a reddish-brown colour like that of Madeira wine. Active Constituents. Among the active principles existing in the bark are amygdalin and tannic acid. There is probably also some emulsin, a kind of nitrogenous or albuminous matter, found in the bitter almond, where it plays an essential part in changes, analogous if not identical with those which are now to be noticed as occurring in wild-cherry bark. When this bark comes in con- tact with water, a reaction takes place, probably under the influence of the emulsin operating as a ferment, between the water and the amygdalin of the bark, whereby the latter is converted into a pecu- liar volatile oil and hydrocyanic acid, which may be obtained together by distillation, constituting a product which is probably identical with the volatile oil of bitter almonds. When, therefore, wild-cherry bark is used in the form of infusion, it is not merely the amygdalin and tannic acid which act, but the new product also, which is essen- tially, in relation to its effects on the system, the hydrocyanic acid; for the volatile oil which attends it has little effect. When the medicine is taken in the form of powder, it is highly probable that the same change takes place in the stomach, under the reagency of CHAP. I.] TONICS.—WILD-CHERRY BARK. 291 the water there. It is a question whether the bark does or does not contain a bitter principle distinct from amygdalin. I believe that it does so, not only from its tonic effects, which cannot be ascribed either to the volatile oil or hydrocyanic acid, but from an experiment made at my request by Professor Procter, which ap- pears to determine the question.* Though boiling water will ex- tract the active matters existing in the bark; yet cold water is medicinally the best solvent; for the emulsin is coagulated and rendered inert at a high temperature, and the formation of hydro- cyanic acid consequently prevented. Effects on the System. Wild-cherry bark is, through its bitter principle, a gentle stimulant to the digestive and probably to the nutritive function; while the hydrocyanic acid, evolved by the reaction of water upon the amygdalin, renders it sedative to the nervous system, and, when freely taken, to the general circula- tion. Dr. Eberle states that, in his own person, he has "several times reduced his pulse from seventy-five to fifty strokes in the minute by copious draughts of the cold infusion, taken several times a day, and continued for twelve or fourteen days." (Mat.3Ied. and Therap., 4th ed., i. 301.) Therapeutic Application. The joint tonic and sedative properties of this bark admirably adapt it to the treatment of cases of general debility, with enfeebled digestion, an irritable state of the nervous system, and excessive frequency of pulse. Long before its chemi- cal peculiarities were discovered, experience had established this application of the remedy. In the treatment of pulmonary con- sumption, it has for many years been a favourite in this country, and, before cod-liver oil came into notice, was probably more relied on than any other single medicine. It was employed not only in * A portion of the bark was exhausted by alcohol, and the tincture evaporated to an extract. This contained the amygdalin, and whatever bitter matter and tan- nic acid existed in the bark. The extract was triturated with water, and with gelatin to remove the tannic acid. The liquor being then filtered, was mixed with an excess of the emulsion of sweet almonds, containing of course the emulsin necessary for causing reaction between the amygdalin and water. A strong odour of hydrocyanic acid was produced, which had not previously existed in the solution of the alcoholic extract. As the emulsin was in excess, the whole of the amygda- lin must have been destroyed. The liquid was evaporated to a soft extract, and mixed with water. Sweet almond emulsion now added generated no more hydro- cyanic acid, and there was none of the peculiar odour of that product; yet the taste was decidedly bitter, proving the existence in the bark of a bitter principle distinct from amygdalin. 292 GENERAL STIMULANTS. [PART II. the advanced stages when hectic fever had set in, but from the beginning, and often as a preventive, in cases in which a strong tendency to the disease seemed to be displayed. It was given with the view of imparting tone to the digestive organs and system generally, and thereby modifying the tuberculous diathesis, and was preferred to other tonics, because it was thought to produce these effects with less danger of undue excitement. Now that it is known to be positively sedative to the heart, and to the nervous system, we can better understand its usefulness in that complaint. In other forms of scrofulous disease, presenting a similar complica- tion of debility of the digestive and "nutritive functions with fre- quency of the pulse, it is equally indicated. Few remedies are better adapted to hectic fever, from whatever source it may pro- ceed. In the debility of convalescence from fevers', and other severe acute diseases, when attended, as it often is, with night- sweats, a frequent pulse, and sleeplessness, restlessness, or other functional nervous disorder, the wild-cherry bark is also an excel- lent remedy. Perhaps the tannic acid it contains may contribute to its usefulness in correcting the excessive sweating in these cases; but I am not inclined to attribute much to it in estimating the virtues of the bark. It has been recommended also in-simple dyspepsia, and as an antiperiodic in intermittents; but in the former it is much inferior to the pure bitters, and in the latter, though sometimes successful, it very often also fails, and is not comparable in efficacy with Peru- vian bark. It may be employed, however, in cases of conva- lescence from miasmatic fevers, in which there is a strong tendency to relapse, and in which a long continuance of the preventive in- fluence may be necessary for the eradication of the predisposition. In such cases, though less effectual than sulphate of quinia, it may perhaps be safer. I have employed the remedy much in functional and organic disease of the heart, attended with a frequent, perhaps irregular, but rather feeble pulse, with an anemic, or otherwise debilitated state of system; and consider it one of our best remedies in s"uch cases, combined, if anaemia exist, with the use of the chalybeates. As the infusion, however, contains tannic acid, it is better not to. add the preparation of iron to it, but to administer the two sepa- rately. . ' Administration. The bark may be given in the form of pow- der, infusion, or syrup. The powder is seldom used, because CHAP. I.] TONICS.—CHAMOMILE. 293 less convenient, more apt to oppress the stomach, and less likely to undergo those chemical changes which are essential to the cha- racteristic effects of the remedy. The dose is from thirty grains to a drachm, which may be repeated three or four times daily. The Infusion made with cold water (Infusum Pruni Virginians, U.S.) is the most appropriate form. It is made in the proportion of half an ounce to the pint of water, and is best prepared by the process of percolation.. Any one can perform this process. Intro- duce an ounce of the bark, rather coarsely powdered, into a com- mon funnel, pack it somewhat closely, and pour upon it a quart of cold water; the point of the funnel being inserted into the mouth of a glass decanter. When the water has all passed, pour it back into the funnel, and repeat this measure until the liquid acquires the colour of Madeira wine. Two fluidounces of the infusion, thus prepared, may be given three or four times a day, or more fre- quently when a strong impression is desired. A Syrup (Syrupus Pruni Virginians, U. S.) is directed by our Pharmacopoeia. It is an elegant preparation, and, where there is no contraindication, from delicacy of stomach or other cause, to the use of so much saccharine matter, may be substituted without disad- vantage for the infusion. The dose is half a fluidounce, to be repeated as directed for the other forms. Wild-cherry bark should not be prepared in the form of tinc- ture, extract, or decoction. In reference to the two latter, inde- pendently of the chemical objection above stated, there is another in the volatile character of the hydrocyanic acid, which, if formed, would be driven off, to a greater or less extent, in the processes for their preparation. —♦—■ IV. CHAMOMILE. ANTHEMIS. U.S., Lond, Ed., Dub. Origin. Tjie chamomile of the shops consists of the flowers of Anthemis nobilis, a perennial, herbaceous plant, growing wild in Europe, where it is also cultivated for use. Though it has been Introduced into our gardens, none of the chamomile of the shops is produced in this country. All parts of the plant have medicinal properties; but it is only the flowers that are officinal. They are imported from Germany and England. 294 GENERAL STIMULANTS. [PART II. Varieties. The flowers of chamomile are compound, consisting, in their perfect state, of a central yellow disk, with a circle of white ray florets around it. There are two varieties, distinguished as the single and double; the former retaining their yellow central disk florets, the latter having had these converted by cultivation into white ray florets. But the distinction is not precise; for there is a large proportion of the flowers in which this conversion is incom- plete; and, as found in the shops, there is generally a mixture of the single and double flowers, and others in the intermediate state. In most parcels, as brought to this country, the double or white flowers greatly predominate. The single or yellow, however, are more odorous, and more stimulant to the stomach, because the volatile oil upon which these properties depend, is much more abundant in the central or yellow florets. Sensible Properties. The odour of chamomile is fragrant and peculiar, the taste bitter, warm, and somewhat aromatic. It yields these properties, and its medical virtues, to water and alcohol. Active Constituents. With a minute proportion of tannic acid, which is therapeutically of no account, the flowers contain a bitter principle and volatile oil, upon which their medical virtues depend. It is said that they yield also, on distillation, in very small pro- portion, a substance resembling valerianic acid. Effects on the System. In small doses frequently repeated, chamo- mile is a mild tonic, operating like the simple bitters, but with a somewhat more excitant influence on the stomach, owing to its volatile oil. In large doses, it is apt to prove emetic, more so proba- bly than the simple bitters, which it resembles in its tonic effects. Therapeutic Application. Chamomile has been employed as a medicine from the earliest times. On the continent of Europe, it is distinguished by the name of Roman chamomile. It is particu- larly adapted to cases of general debility, in which the stomach participates in a greater degree than other organs. The gentle stimulant influence of its volatile oil on the stomach renders it peculiarly applicable under such circumstances. Hence, it is much used in the convalescence from acute febrile diseases. In mild dyspepsia, with defective appetite, .flatulent eructations, or slight colicy pains from wind in the stomach or bowels, it may often be given with advantage. Its general mildness and harmlessness adapt it to those slight cases of debility, frequently occurring, especially in sedentary females, in which stronger medicines are scarcely required, and might prove hurtful. CHAP. I.] TONICS.—CHAMOMILE. 295 By the ancients it was used in the treatment of intermittent fevers, and continued to be esteemed among the most valuable remedies in that complaint, down to the period of the discovery of Peruvian bark. Even after that period, it long continued to retain some reputation as a febrifuge, being employed in cases which resisted the bark, and especially in the remission of remittent fevers, before the febrile phenomena of the paroxysms had suf- ficiently subsided to justify the use of the more powerful anti- periodic. But, since the introduction of sulphate of quinia into use, this application of chamomile has been generally abandoned; as it is now understood that, in miasmatic remittents, when there is a sufficient abatement of the fever to justify a resort to the bitter tonics, quinia may almost always be used, with equal safety, and vastly greater effect. In cases, however, of intermittent and remit- tent fever, distinctly paroxysmal, in which circumstances may prevent the employment of cinchona or its preparations, large draughts of warm chamomile tea, given immediately before the paroxysm, the patient being kept warm in bed, will sometimes pre- vent the recurrence of the fever, either by operating as an emetic, or by a joint tonic and diaphoretic action. It has already been stated that, in large doses, chamomile is apt to vomit. To produce this effect, however, it should be given in the form of warm infusion, and in large draughts, so as to aid the medicine by the nauseating effects of tepid water. It may fre- quently be employed with advantage, in this way, in cases of gastric spasm arising from undigested food or other irritating matters in the stomach, and attended with sensations of nausea, or.ineffectual efforts to vomit. Indeed, in any case of irritable stomach, when that organ seems unable wholly to free itself from its contents, it may very properly be aided by large draughts of warm chamomile tea. In febrile and bilious diseases, there is often a good deal of retching from the presence of acrid bile in the stomach, which may thus be promptly relieved. The tea is often also administered along with other emetics, or shortly afterwards when they are tardy, in order to promote their action, or to render it more easy to the patient, by giving the stomach a greater bulk to act upon. The flowers were formerly much used externally with hot water, in the way of fomentation, or as a sort of cataplasm inclosed in a flannel bag. They add nothing to the virtues of the hot water; but, in the latter case, may be useful by absorbing the liquid. 296 GENERAL STIMULANTS. [PART II. Administration. Chamomile is given in powder, infusion, or ex- tract ; and the volatile oil is sometimes separately administered. The powder was formerly given occasionally, with a view to the antiperiodic effect, in doses of from half a drachm to a drachm, repeated three or four times a day, or oftener if required. As a mere tonic, its dose may be stated at from ten to thirty grains; but it is almost never administered in this way. The flowers themselves are sometimes chewed by dyspeptic persons, and by those who wish to break themselves of the habit of chewing tobacco, by substituting a more innocent substance in its place. The Infusion (Infusum Anthemidis, U S) is made in the pro- portion of half an ounce to a pint of water. When time is allowed for a sufficient maceration, cold water is preferable to hot as the menstruum, as it yields an infusion more acceptable at once to the palate and the stomach; but in case of haste, boiling water may be used; and, with the view to its emetic operation, the latter is decidedly preferable, and the infusiop should be taken warm. The dose as a tonic is a wineglassful, three or four times a day. When given to aid emetics, a small bowlful, containing from six to twelve fluidounces, may be given at once, and repeated if required. The extract, as directed by the Edinburgh Pharmacopoeia, is not an eligible preparation; as the volatile oil is driven off in the eva- poration, and the remaining bitter substance is in no respect supe- rior to the simple bitters. It is, however, occasionally used as an addition to laxatives or metallic tonics, and as*a vehicle for other medicines, given in the pilular form. The effects of the chamomile may be obtained, if desired, by adding a few drops of the volatile oil; or an extract may be prepared containing most of the volatile oil, by macerating the flowers in cold water, and evaporating in vacuo. The dose is from five to thirty grains, the strength being about double that of the flowers. The decoction was formerly used as an external fomentation, as an enema, or as a local application to flabby or indolent ulcers; but has been abandoned, because in no respect preferable to the infusion, and inferior from the circumstance, that a portion of the volatile oil must be driven off in its preparation. The Volatile Oil (Oleum Anthemidis, Lond) is occasionally prescribed. It is obtained by distillation with water from the flowers. As first procured, it has a sky-blue colour, which is changed by time to yellow or brown. Its odour is that of chamo- mile, its taste pungent and aromatic. It is stimulant to the sto- CHAP. I.J TONICS.—EUPATORIUM. 297 mach, and may be given in gastric pains of a purely functional character, and in flatulence, in the dose of five or six drops. It is sometimes associated with purgatives to prevent griping. Other species of Anthemis have been used. A. Cotula, may-weed, or wild chamomile, which grows abundantly in this country, and is one of the most common weeds in our public roads, has virtues ana- logous to those of A. nobilis, but, in consequence of its very unplea- sant odour, is little if at all used with us. In Europe it is said to be occasionally employed as an antispasmodic and emmenagogue. Our national Pharmacopoeia recognizes it, in the secondary list, under the name of Cotula. V. THOROUGHWORT, or BOXESET. EUPATORIUM. U.S. Origin. This consists of the leaves and flowering tops of Eupa- torium perfoliatum, an indigenous, perennial, herbaceous plant, growing abundantly, usually in clusters, in low moist grounds, in most parts of the United States. All portions of the plant are medicinal. It is in flower from July to October, and should be* collected during that period. Sensible Properties. Boneset is sometimes kept in the shops in bunches, sometimes in small oblong packages, in which it is much broken up. In the former state, it may be known by its perfoliate and decussating leaves, and by its flattish, dense summit of white, almost feathery flowers. The leaves may be considered as consisting of two, joined at their base, where they are perforated . by the stem. Each leaf is broadest at the base, long, narrow, and gradually tapering to a point, serrate on the edges, wrinkled, whit- ish below and green above, and hairy. The pairs are so placed on the stem, that each one is at right angles with the one above and below it. The odour is feeble, yet distinct, and the taste strongly bitter and peculiar. It yields its sensible and medicinal properties to water and alcohol. Active Constituents. Little is known, positively, on this point. There is little doubt that the bitterness, resides in one or more proximate principles; but they have not yet been satisfactorily isolated. From the smell, it may be inferred to contain a small proportion of volatile oil, and the fact seems to have been esta- 298 GENERAL STIMULANTS. [PART II. blished by the examination of Mr. Bickley. (Am. Journ. of Pharm., xxvi. 495.) The medicine is placed next to chamomile, more from its analogy to that medicine in effects, than from any known re- semblance in composition. Effects on the System. Eupatorium, in moderate doses, produces on the system effects like those of the simple bitters; but superadds to these, especially when taken in warm infusion, and somewhat freely, a decided diaphoretic action. It is said, also, sometimes to be diuretic, and, in large doses, proves emetic and laxative. It is among the remedies derived' from the aborigines, from whom it passed into popular use, and thence into the hands of the profession. Therapeutic Application. Eupatorium may be given, like the simple bitters, in pure dyspepsia or general debility; but, being more liable than they to irritate the stomach, and probably les.s efficient as a mere tonic, should not be allowed to supersede them, unless under peculiar circumstances of idiosyncrasy or prejudice. Dr. Burgon, of Bucks County, Pennsylvania, preferred it to all other tonics, in the loss of appetite incident to the abuse of alcoholic drinks. (Am. Med. Record., iii. 331.) Dr. Eberle found it peculiarly useful in the indigestion of old people, in whom, while it restored tone to the stomach, it rendered the skin soft and comfortable. (3Iat. Med. and Therap., 4th ed., ii. 219.) But its highest reputation has been as a febrifuge. From the inaugural dissertation of Dr. Anderson (New York, 1813), it would appear to have been employed with very great success, in the treat- »ment of intermittents, in one of the New York hospitals. Subse- quent observation of its effects has proved less favourable; and, employed as a mere antiperiodic, in the ordinary mode of pre- scribing bark or quinia in the intermissions, it cannot be relied on. But I have known it to supersede the paroxysms of intermittent fever, when given in emetic doses, in the state of strong tepid infu- sion, shortly before the period for the return of the chills; and if, jointly with this method of exhibition, it be administered in mode- rate doses, at short intervals, during the apyrexia, there is little doubt that it will often prove successful. Still, it is greatly inferior to sulphate of quinia in certainty, while, in its effects as thus used, it is much more disagreeable. It may be very appropriately tried in obstinate and frequently recurring attacks of intermittent fever, in which quinia has become offensive to the patient, or inoperative from repetition. The same remarks are applicable to CHAP. I.] TONICS.—EUPATORIUM. 299 its comparative efficacy in remittents; in which, however, its tend- ency to produce perspiration is somewhat in its favour. It was recommended, by Drs. Bard and Hosack, in yellow fever (Eberle, loc.cit); and has been used as a tonic and diaphoretic in low fevers, and typhoid pneumonia; but its special merits in these affections are at best equivocal, and it is now seldom employed. Perhaps its best application is to the treatment of catarrhal affec- tions, more particularly the epidemic catarrh or influenza, which is frequently attended with an asthenic state of system, calling for supporting measures. The most effectual method of employing it, in these cases, is, very soon after the attack of the disease, to ad- minister it freely at bedtime, in the form of hot infusion, the patient being well covered,.so as to provoke copious and lasting perspira- tion; and, if vomiting should take place, the effect would be more certain. In the morning, the disease will often be found to have been arrested, or very much moderated; and afterwards the medicine may be given in small and repeated doses, so as not to nauseate. Dr. Chapman, in his Therapeutics (2d ed., i. 388), speaking of its employment in a species of influenza which had prevailed many years previously in the United States, and which, in consequence of the pain attending it, was commonly denominated break-bone fever, states that, from its prompt success in relieving this symptom, it acquired the popular name of boneset, by which it is still known. The probability is, that the epidemic alluded to by Dr. Chapman was that described by Dr. Rush as having occurred in Philadelphia, in the summer and autumn of 1780, called break-bone fever, from the violence of its pains, but which, there is every reason to sup- pose, was the disease since better known under the name of dengue. This fact would suggest a trial of eupatorium in that very painful epidemic disease. In acute rheumatism, the medicine is said to have proved useful; and, in the atonic variety, occurring in feeble constitutions, without plethora, it might be very properly tried, with a view to its con- joined tonic and diaphoretic effects. Though said to have been advantageously employed in obstinate cutaneous diseases, I have no faith whatever in its efficacy, except in so far as it may operate, like any other tonic, in promoting the general health. The same may be said of its re*medial powers in dropsy, in which it has been recommended. Administration. As an antiperiodic or tonic, the medicine may 300 GENERAL STIMULANTS. [PART II. be given in powder, in doses of twenty or thirty grains, or more; but it is very little used in this form. The Infusion (Infusum Eupatorii, U. S) is a more eligible pre- paration. It is made in the proportion of an ounce to the pint of water, and given in the dose of one or two fluidounces, repeated more or less frequently, according to circumstances; three or four times a day, as a tonic, in chronic cases; and every hour, two, or three hours, as an antiperiodic, or joint tonic and diaphoretic, in those more acute. When its emetic effect is wanted, six or eight ounces of the hot infusion may be given at a draught. A watery extract has been used in the dose of four or five grains. Several other species of Eupatorium have been employed. Among our indigenous species, E. purpureum, or gravel root, has tonic and astringent properties, and is said to be diuretic. E. teucrifolium, or wild horehound, corresponds with the officinal species in properties, though less powerful; and E. aromaticum is considered, among the so-called eclectic physicians, as a valuable remedy in a number of diseases. The root of E. Cannabinum was formerly used in Europe as a purgative; and E. Aya-pana, of Brazil, resembles the boneset, but is weaker. VI. VIRGINIA SNAKEROOT. SERPENTARIA. U. S., Lond., Ed., Dub. Origin. This consists of the roots of Aristolochia Serpentaria, Aristolochia reticulata, and probably several other analogous species of the same genus, all of them small, indigenous, herbaceous peren- nials, growing in the woods in the Middle, Southern, and Western States; A. Serpentaria abounding in western Pennsylvania, Virginia, Ohio, Kentucky, &c; A. reticulata in Louisiana, Arkansas, and the neighbouring regions. Sensible Properties. The root consists of a short, contorted, knotty head, with numerous long, slender fibres or rootlets pro- ceeding from it, which are often more or less interlaced, as the medicine is found in the shops. The roots of A. reticulata are straighter, thicker, and less flexible than the others, and conse- quently much less interlaced. The colour is at first yellowish, but becomes brownish by time; the odour is strong, aromatic, and agreeable; the taste very bitter, aromatic, and somewhat camphor- CHAP. I.] TONICS.—VIRGINIA SNAKEROOT. 301 ous. The root yields its sensible properties and medical virtues to water and alcohol. Active Constituents. These are a peculiar bitter principle, and a peculiar volatile oil, which may be separated by distillation. Adulterations. Occasionally, the roots of Spigelia 3Iarilandica, and the young roots of Polygala Senega, are mixed with ser- pentaria, but probably not by design. They are distinguishable by the total want of the odour and taste of the genuine root. Effects on the System. Serpentaria is a stimulating, diaphoretic tonic; owing its tonic properties, which are probably identical with those of the simple bitters, to its bitter principle, and its stimulant and diaphoretic influence mainly to its volatile oil. Taken inter- nally, it sharpens the appetite, hastens the digestive process, in- creases the frequency of pulse and warmth of skin, and occasions, not unfrequently, either diaphoresis or diuresis; being disposed to produce the former effect, if given in warm infusion while the pa- tient is well covered in bed, and the latter, if in powder, or cold infusion, while he is walking about and exposed to the air. When taken in over-doses, it may produce nausea, griping pain in the bowels, even vomiting or tenesmus, and will sometimes cause pain or a sense of weight in the head, with disturbed sleep. Therapeutic Application. Virginia snakeroot has been known as a medicine from an early period of the settlement of this country. Like others of our valuable indigenous remedies, it originally attracted notice as an antidote to the bite of serpents; and, as such, is alluded to in a work by Dr. J. Cornutus, published at Paris in 1635 (W. P. C. Barton, Veg. Mat. Med. of the U. S., ii. 48); but the first known mention of it was by Thomas Johnson, an apothecary of London, in an edition of Gerarde's Herbal, published in 1633 (Pereira, 3Iat. 31ed., ii. 1299). Its supposed efficacy in the poison of serpents, led naturally to its use in low and malignant febrile diseases, in which the blood was believed to be poisoned; and, by an easy transition, it came to be employed in other fevers, in which this malignant type was not presented. It is favourably spoken of by many of the medical writers of the last century. Among others, Sydenham recommended it as an addition to Peruvian bark, or as a cheap substitute for that medicine in the tertian ague. Its real value is now probably better known than formerly.„ It is simply tonic and stimulant to the circulation, with a tendency to produce perspiration, generally acceptable to the stomach in moderate doses, 302 GENERAL STIMULANTS. [PART II, and probably without special influence on the brain or nervous system. It may be employed in pure dyspepsia, attended with a degree of debility calling for something more stimulating than the simple bitters, and especially where there is a disposition to dryness of the surface; but its most appropriate application continues to be that for which it was early recommended, to the treatment, namely, of fevers of a low or typhoid character, or disposed to take on that character. Whenever any febrile disease begins to exhibit this tendency, and stimulation is demanded, serpentaria is one of the first medicines to which we may have recourse, provided the sto- mach be wholly free from inflammation, or vascular irritation. It may be used, therefore, with the condition of stomach mentioned, in typhus or typhoid fever when passing from the first stage of ex- citement into that of debility, in protracted remittent fever assum- ing a low character, in typhoid pneumonia, and in smallpox, scarlatina, malignant sore throat, and erysipelas, under similar circumstances. But it should be understood that, in none of these affections, does it possess any specific curative powers, that it can act merely as a tonic and gentle stimulant, and that it should be used only as an adjuvant in very serious cases, being alone wholly incom- petent to the support of the system under powerful depressing influences. In many of these cases, it may be very properly asso- ciated with Peruvian bark or quinia. From my own observation, I should infer that serpentaria pos- sesses no peculiar antiperiodic power, and that it cannot, therefore, be relied on for breaking the course of an intermittent or remittent fever; but in either, it may be conjoined with sulphate of quinia when the system is feeble, and the stomach somewhat insusceptible. The association of serpentaria with Peruvian bark has long been a habit among practitioners. It exists in the compound tincture of Peruvian bark of the British and American Pharmacopoeias, better known under the name of Huxham's tincture of bark. Dr. Chapman says of serpentaria "that it is admirably suited to check vomiting, and to tranquillize the stomach, especially in bilious cases." (Elem. of Therap., &c, 2d ed., ii. 434.) Administration. The medicine is sometimes, but rarely, given in powder. The Infusion (Infusum Serpentaris, U. S), made in the proportion of half an ounce to a pint of boiling water, is the prepa- ration ordinarily used. There is an officinal Tincture (Tinctura Serpentaris, U. S), which is rendered turbid by water. CHAP. I.J TONICS.—MYRRH. 303 The dose of the powder is from ten to thirty grains; that of the infusion, one or two fluidounces, to be repeated three or four times a day in chronic cases, every hour, two, or three hours, in acute. Of the tincture, which is chiefly employed as a stimulant and stomachic addition to other medicines, the dose is one or two fluidrachms. VII. MYRRH. MYRRHA. U.S., Lond., Ed, Dub. Origin. Myrrh is a concrete exudation from Balsamodendron Myrrha, a shrub or small tree, growing in the deserts of Arabia and North-eastern Africa. Two commercial varieties were formerly brought into market, one from the ports of Egypt in the Mediter- ranean, the other from the ports of India; both, however, being originally obtained from the same neighbourhood. They were dis- tinguished by the names of Turkey and India myrrh. The former was much purer and finer than the latter, because selected with greater care, in reference to its more expensive carriage. At pre- sent both kinds are imported from India, whither they are taken by Arab vessels from the Red Sea. Sensible Properties. Myrrh is in small fragments, irregular or rounded, like tears, or in larger masses, as if consisting of the smaller agglutinated together. The best specimens, formerly called Turkey myrrh, are of a pale reddish-yellow, or reddish-brown colour, often powdery on the surface, and translucent. The larger agglutinated pieces exhibit various shades of colour. The inferior kinds, for- merly known as India myrrh, are in very irregular lumps, of a dark colour, opaque, and full of impurities. Myrrh is brit- tle, with a shining fracture. The powder of the best kinds is whitish or yellowish-white, of the inferior darker, with a somewhat reddish hue. It is not fusible by heat, but is inflammable. The odour is strong, peculiar, and fragrant; the taste bitter, somewhat acrid or pungent, and aromatic. Composition, and Relation to Solvents. The active principles of myrrh are a, peculiar bitter resin, which has been called myrrhin, and a volatile oil. In composition it is a gum-resin, containing volatile oil, and other ingredients of little or no practical importance. AVater dissolves the gum and a very small proportion of the vola- tile oil; alcohol the resin and the whole of the oil; and, as these 304 GENERAL STIMULANTS. [PART II. two are the active principles, alcohol would seem to be the best menstruum. But when the gum-resin is rubbed with water, it rea- dily forms a white or yellowish-white opaque emulsion, in which the resin and oil are held in suspension by the gummy matter dissolved in the water; and, though a portion of the resin soon subsides, the mixture is sufficiently permanent, or so easily rendered uniform by shaking, that this form is usually preferred for the administration of the medicine. Alkalies unite with the resin, and render it much more soluble in water; so that, by the addition of a portion of alka- line carbonate in forming the emulsion, this is rendered of easier preparation, and more permanent. The volatile oil may be sepa- rated from the gum-resin by distillation. Effects on the System. Myrrh acts on the system probably as a simple bitter tonic through its resin, and as a stimulant to the cir- culation through its volatile oil. It has no special influence on the brain or nervous system generally; but is supposed to have a peculiar tendency to the lungs and uterus, stimulating their func- tions respectively, and consequently acting as an expectorant and emmenagogue. When swallowed in small doses, it increases the appetite, produces a feeling of warmth in the stomach, and invigor- ates digestion, as well probably as the vital functions generally. In larger quantities, it increases the pulse, produces a glow over the system, and operates generally as a mild arterial stimulant. In over-doses, it irritates, or may even inflame the stomach, and gives rise to general febrile phenomena. Therapeutic Application. Myrrh has been known as a medicine from the earliest records of our science. It is now probably less esteemed than formerly, but is still much employed, and is not without valuable powers. As a tonic simply, it is not often used; being too stimulating, and too apt to irritate the stomach, if this be at all disposed to be so affected, or to augment any existing irri- tation or inflammation. But in a perfectly sound, though weakened state of the stomach, with a languid condition of the functions generally, it may be given advantageously; and especially when, with this debilitated state of the system, there coexists either amenorrhoea, or a chronic bronchial inflammation with profuse expectoration, or both these conditions jointly. The particular affections, therefore, to which it is best adapted, are chlorosis in females with amenorrhoea, and chronic bronchitis in the old or debili- tated, with or without hectic fever, but with copious and especially r CHAP. I.J TONICS.—MYRRH. 305 puruloid expectoration; and, when these affections are associated, the indications for its use are still stronger. But particular care must be taken that the stomach is in no degree phlogosed when it is administered. It has been much used in phthisis; but I cannot say that I have known it to be of material service in that com- plaint; while it has often done harm by disturbing the stomach. It is seldom given alone. In anemic states of the system with amenorrhoea, it is often combined with one of the preparations of iron, and, if there be constipation at the same time, or a tendency to it, with aloes or rhubarb. Being a local stimulant, myrrh has been much used externally in foul, flabby, or indolent ulcers, as a mouth wash in spongy or ulcerated gums, and as a gargle in ulcerous affections of the fauces. For these purposes, the powder is, in external ulcers, simply sprin- kled on the diseased surface, or applied in the form of an oint- ment; in affections of the mouth and fauces, is employed rubbed up with water. Administration. Myrrh may be administered in powder, pill, or • emulsion, in the dose of from ten to thirty grains. In the simple form of powder, it is little used. Nor is it often given, uncombined, in the form of pill; but it enters into several officinal combinations in this form. Such are the Pilulae Aloes et Myrrhas formerly called Rufus's pills, Pil. Ferri Comp., Pil. Golbani Comp., and Pil. Rhei Cornp., of the U.S. Phar- macopoeia, to which the reader is referred, under the heads of their prominent ingredients respectively. Emulsion is the form of administration most frequently used. It should be made by selecting the finest pieces, powdering them, and rubbing the powder up thoroughly with such a proportion of water, that a tablespoonful of the mixture may contain the dose of the gum-resin which it may be desired to exhibit. If an alkaline carbonate be indicated at the same time, its addition will tend to facilitate the preparation. The noted anti-hectic mixture of Dr. Griffiths, formerly very popular, and still considerably used in chlorosis, amenorrhoea, hysteria, and the hectic fever of pulmonary complaints, is made of these ingredients, with the addition of sul- phate of iron, which is converted into the carbonate through the reagency of the carbonate of potassa used. The Mistura Ferri Com- posita of the Pharmacopoeias is an imitation of this preparation. Decoction is not an appropriate mode of preparing myrrh; though it is directed by the Dublin College, and the gum-resin is an vol. i—20 306 GENERAL STIMULANTS. [PART II. ingredient in the compound decoction of (does of the British Phar- macopoeias. But little of the active matter of the gum-resin can exist in the former preparation. In the latter, the resin may be dissolved by means of the alkaline carbonate used. Tincture of 3Iyrrh (Tinctura Myrrhs, U. S), though little used internally, is often employed locally as a stimulant to indolent and foul ulcers, to promote the exfoliation of bones, and, diluted with water, as a mouth-wash or gargle, in spongy gums, aphthous sore mouth, and ulceration of the mouth and fauces. When mixed with water, it becomes turbid "by the separation of the resin. The dose is from thirty minims to a fluidrachm. There are several other stimulant tonics, which owe their virtues to bitter principles and volatile oils, but, having little to recommend them beyond those in more general use, and not being at present much employed, will be more appropriately considered in a subor- dinate position. Such are angustura, cascarilla, contrayerva, worm- wood, tansy, and horehound. A brief notice will suffice for each of these. 1. ANGUSTURA BARK.— Angustura. U.S.—Cusp aria. Lond. This is the bark of the Galipea officinalis of Hancock, a small tree growing in the interior of South America, on the banks of the Orinoco. It is taken first to the town of Angustura upon the Orinoco, and thence to the West Indies, whence it enters into gene- ral commerce. Properties. It is in pieces of various length, usually short, slightly rolled or nearly flat, thin, with edges pared obliquely, ex- ternally covered with a soft, yellowish-gray or whitish epidermis, internally yellowish, and when pulverized yielding a pale-yellow powder. It has a peculiar odour becoming fainter with age, and a bitter, slightly aromatic, and adhesive taste, leaving a sense of pun- gency on the end of the tongue. Active Constituents. These appear to be a peculiar bitter principle soluble in water and alcohol, called angusturin or cusparin, a hard bitter resin, a soft acrid resin, and a volatile oil; but it may be ques- tioned whether the bitter resin referred to may not owe its taste to an unseparated portion of the proper bitter principle. The soft resin is probably the oxidized volatile oil. 3Iedical Properties and Use%. Angustura was employed by the aborigines, who appear to have made it known to the early settlers. r CHAP. I.] TONICS.-^ANGUSTURA BARK. 307 From the continent it passed to the West Indies; and was not in- troduced into Europe till between seventy and eighty years since. Its effects on the system are those of a stimulant tonic, in small doses acceptable to the stomach, but in larger apt to vomit and purge. Its tonic property depends probably on the bitter principle, the stimulant on the volatile oil. It has no special influence on the brain or nervous system. In South America and the West Indies, it has been used as a substitute for cinchona in intermittent and remittent fevers, and is said to have proved very efficacious in the bilious malignant fevers of those latitudes. Experience in Europe has not proved favourable to its claims as an antiperiodic, and it probably possesses no peculiar property of this kind. Though it has succeeded in arresting some slight cases of ague and fever, which almost anything capable of impressing the system at all will occasionally do, yet in the more obstinate kinds it has failed, and certainly can be relied upon in none. Another application made of it has been to the treatment of bilious diarrhoea and dysentery, as they occur in tropical countries, and it may have been useful as a tonic and stimulant in some of those cases; but, in the diseases as they occur with us, it would in general probably do more harm than good. It is little used in this country. Administration. It may be given in powder, in the dose of from ten to thirty grains. The Infusion (Infusum Angusturse, U. S.) is, however, preferred. It is made in the proportion of half an ounce to a pint of boiling water, and given in the dose of two fluidounces. The Tincture, which has been dropped from the U. S. Pharmacopoeia, has been retained by the Edinburgh College, under the name of Tinctura Cusparise. The dose is one or two fluidrachms. The doses may be repeated three or four times a day. False Angustura Bark. Under this name, a bark, now be lieved to be the product of Strychnos Nux Vomica, has sometimes been sold for genuine Angustura bark, with fatal effects. This could only happen before attention had been called to the subject. Such a mistake would be unpardonable now; for there is little real re- semblance between the two barks, and it is only necessary that the slightest caution should be observed. In this country, I do not think that the substitution has ever taken place. I have never seen false Angustura bark in the United States, except parcels which have been sent hither as specimens. It is not used in medi- cine, but, containing a large proportion of brucia, and probably also s*.r vchnia, it might be employed for the extraction of those principles. ,1 308 GENERAL STIMULANTS. [PART II. 2. CASCARILLA. U. S., Lond., Ed., Dub. Cascarilla is the bark of Croton Eleuteria, a small West India shrub, inhabiting especially the Bahamas, and abundant in the little island of Eleuteria, from which it derived its name. Properties. It is in small quills or pieces of quills, from three or four inches long and half an inch in diameter, down to the smallest fragment. Sometimes it is in pieces curved longitudinally, and ap- pearing as if shaved from the stem, having now and then portions of the wood attached to their inner surface. Externally the bark is invested with a whitish or grayish-white epidermis, which, however, is sometimes wanting, in which case the surface of the proper bark presents a dark-brown colour. The inner surface is of a chocolate colour, and the fracture, which is short and abrupt, is reddish-brown. The odour is agreeably aromatic and increased by friction; the taste, warm, spicy, and bitter. When burnt, the bark emits an odour resembling that of musk, though not so strong, and more agreeable. On this account, it is used for fumigation; and smokers sometimes add it to their tobacco. It yields its virtues to water or alcohol, but more completely, it is said, to a mixture of the two. Active Constituents. These are a peculiar bitter principle, called cascarillin, and a volatile oil, which is abundant, and may be ob- tained by distillation. Medical Properties and Uses. The first account of the use of cas- carilla dates as far back as about the year 1690. It was for a time a very popular remedy in Europe, having been seized upon, as a sub- stitute for bark, by many who were prejudiced against that remedy; and its febrifuge virtues were for some time in high esteem. It came, however, at length to be estimated at its true value; and at present is considered nothing more than a mild aromatic tonic, usually acceptable to the stomach, and, in consequence of the predominance of its aromatic properties, deserving perhaps better to rank in that division of the tonics, than among the bitters. When smoked in connexion with tobacco, it is said to have induced vertigo and in- toxication ; but, admitting this effect, which, however, is doubtful, it must be ascribed, not to the cascarilla itself, but to its empyreu- matic product. The strong resemblance of its odour, when burned, to that of musk, would justify an attempt to collect the volatile products resulting from its combustion, and to ascertain whether they might not also imitate that powerful antispasmodic in its effects on the system. CHAP. I.] TONICS.—CONTRAYERVA.—WORMWOOD. 309 The bark is used chiefly in debilitated states of the stomach and bowels, as in dyspepsia, flatulence, and diarrhoea and dysentery con- nected with weakness or relaxation of the bowels, or in the conva- lescence from these affections. It is a good addition to more power- ful tonics. The dose of the powder is from ten to thirty grains. The Infu- sion (Infusum Cascarillae, U. S.) is made in the proportion of an ounce to a pint of boiling water, and given in doses of two fluid- ounces, repeated as usual with tonic medicines. The Tincture is recognized by the British Pharmacopoeias, though not by ours. It may be added to stomachic or purgative infusions in the quantity of one or two fluidrachms. 3. CONTRAYERVA. U. S. Contrayerva is the root or rhizoma of Dorstenia Contrayerva, a small perennial plant, growing in the West Indies, Mexico, and Peru. As in the shops it is of a somewhat oblong shape, an inch or two in length, rough, very -hard, reddish-brown externally, pale internally, and furnished with numerous long, slender, yellowish radicles, attached to the lower part. The odour is aromatic; the taste warm, pungent, and bitter. Boiling water or alcohol ex- tracts its virtues, which probably depend on a volatile oil, and a bitter principle, though the latter has not been isolated. In its effects on the system, it is gently tonic, aromatic, stimulant, and diaphoretic, bearing some resemblance to serpentaria, but less powerful as a tonic. It was formerly used in low febrile diseases, disposed to assume a typhous or malignant character, in dysentery and diarrhoea with debility, and in other conditions supposed to call for stimulation; but it has given place to more convenient or efficient remedies, and is now scarcely used. The dose of the pow- der is from twenty to thirty grains. An infusion, made in the proportion of an ounce of the bruised root to a pint of boiling water, may be given in doses of one or two fluidounces. 4. WORMWOOD.—Absinthium. U.S., Lond., Ed. Wormwood, as a medicine, consists of the leaves and flowering tops of Artemisia Absinthium, the common wormwood of our gardens, though a native of Europe. It has a strong, peculiar odour, and an extremely bitter, disagreeable, nauseous taste. These properties, as well as its medical virtues, it imparts to water and alcohol. They reside chiefly, if not exclusively, in a bitter princi- ple called absiuthin, and a peculiar volatile oil, which, when separated by distillation with water, has a deep-green, brown, or yellowish 310 GENERAL STIMULANTS. [PART II. colour, an acrid bitter taste, and a strong odour of the plant. The herb may contain a little tannic acid, but not enough sensibly to modify its effects. Wormwood is a stimulating tonic, resembling chamomile in its effects, but stronger and more disagreeable. In small doses, it ope- rates like the simple bitters; in larger, excites the pulse, increases the heat of skin, produces headache, and is said sometimes to have exhibited narcotic effects. Its active principles are no doubt ab- sorbed, as it renders the flesh and milk of animals fed with it bitter. In very large doses it is apt to vomit. It is among the medicines used by the ancients, and, before the discovery of Peruvian bark, was much relied on in the treatment of intermittents. Though greatly inferior in antiperiodic power to cinchona, it has some efficacy in arresting intermittent fevers, and is particularly recom- mended as a preventive. It has been also used as an anthelmintic and emmenagogue, and probably has some efficiency in these respects. It is probably not without a stimulant influence over the nervous system, such as characterizes the antispasmodics or nervous stimulants of the classification adopted in this work; and hence may be used, with hope of benefit, in some hysterical cases, attended with feeble digestion, and defective menstruation. The dose of the powder is one or two scruples; that of the in- fusion, made in the proportion of an ounce to the pint, is two fluidounces. The herb has been used externally with hot water as a fomentation, but probably with little other benefit than such as may be ascribed to the heat and moisture. 5. TANSY. —Tanacetum. U.S. The tansy, or Tanacetum vulgare, is an herbaceous perennial, indi- genous in Europe, but introduced into the United States, where it grows wild, and is cultivated in gardens. The whole herbaceous part is used. It has a strong, peculiar odour, which is much dimi- nished by drying, and a warm, bitter, sub-acrid, aromatic taste. Its activity, which is imparted to water and alcohol, depends on a bitter ingredient, and a volatile oil. There is also a little tannic acid, but insufficient materially to influence the operation of the medicine. The oil is greenish yellow, and has the characteristic odour of the plant. Tansy has been known as a medicine for at least one thousand years. It is a stimulating tonic, and supposed also to possess an- thelmintic and emmenagogue properties. In large quantities, it is CHAP. I.] TONICS.—TANSY.—HOREHOUND. 311 probably somewhat narcotic; at least, so we may infer from the operation of the volatile oil. From its supposed possession of the power of causing abortion, this oil has been repeatedly taken in large doses; and three cases of death from it, in this country, have been recorded; one resulting from a single fluidrachm of the oil, a second from half a fluidounce, and the third from an ounce. The symptoms were violent convulsions, coma, and great prostration, which speedily ended in death. The fatal issue was too rapid to be owing to any irritant operation on the stomach, and in one case, which was examined after death, no inflammation was found. The medicine has been given in dyspeptic affections, intermittent fever, to prevent the paroxysms of gout, in hysteria, amenorrhoea, and worms in the bowels. At present, its use is confined mainly to the two latter affections, and in these it is employed much more in popular than regular practice. The seeds are thought to be more powerful, as a vermifuge, than the oil. The dose of the powder is from thirty grains to a drachm; that of an infusion, made with an ounce of the herb to a pint of water, two or three fluidounces, two or three times a day. A drop or two of the oil may be added to each dose of the infusion. 6. HOREHOUND.—Marrubium. U.S. Common horehound, or Marrubium vulgare, is a perennial herba- ceous plant, a native of Europe, but introduced into the United States, where it grows abundantly along the roadsides. The whole herbaceous part is used. This has, when fresh, a strong, rather agreeable odour, which is diminished by drying, and lost by long keeping. The taste is bitter and lasting. The herb yields its sen- sible properties and medical virtues to water and alcohol. These depend on a bitter constituent and a volatile oil. It contains also a little tannic acid. Horehound has been known as a medicine from the times of Charlemagne. In reference to its effects on the system, it is mildly tonic and gently stimulant, and is thought also to be some- what diaphoretic, diuretic, and laxative. If we may judge of the opinion entertained of its action by the use made of it, we must add to the properties just mentioned those also of an expectorant. The complaints in which it has been given are dyspepsia, chronic hepatitis, jaundice, amenorrhoea, various cachectic affections, chronic bronchitis, pulmonary consumption, and ordinary catarrh. What good'can be effected, in these and other complaints, from a mild 312 GENER'AL STIMULANTS. [PART II. tonic, which, when taken in warm infusion, may gently promote the cutaneous and bronchial secretions, and perhaps the uterine, may be expected from horehound, but nothing more. It is at present seldom used by regular practitioners, and, even as a domestic medi- cine, is chiefly employed in catarrhal affections of the air-passages. The dose of the powder is from thirty grains to a drachm. The infusion is made in the proportion of an ounce to a pint of hot water, and given in wineglassful doses. A syrup is often prepared from it, and a candy impregnated with its taste is sold in the shops; both being used for ordinary colds. 3. Aromatics. This subdivision of medicines is characterized by an agreeable odour and taste, dependent on the presence of volatile oil. They do not correspond exactly with the tonics, being more excitant, though less so than the class of circulatory stimulants. They do not equal the bitter tonics in the property of promoting the digestive and nutritive functions. Their action, moreover, is more speedy, and less durable. Yet they approach more closely to these medicines than to any other division in the classification I have adopted, and are often used, in conjunction with tonics, to increase their stimulant influence, or in other ways modify their action. I have, therefore, thought it best to follow the example of Dr. J. Murray, of Edinburgh, in his excellent system of Materia Medica, in arranging them in the position they here hold; guarding the student, however, against the mistake of supposing them identical, or even very analogous, in their operation, with the bitters. Effects on the System. When taken internally, the aromatics occa- sion generally an agreeable feeling of warmth in the stomach, mode- rately increase the frequency of pulse and heat of the surface, and often diffuse a pleasant glow over the system, without exhibiting any special tendency towards the brain or nervous system gene- rally, or any particular influence over the secretions. They re- semble, in their direction to the circulatory function, the medicines hereafter to be described under the name of arterial stimulants; but they differ, in being much more powerful, relatively, in their local than their general excitant effect. Thus, to whatever surface they are directly applied, whether the skin, the mouth and fauces, or the mucous membrane of the stomach, they stimulate actively the blood-vessels of the part, and, largely used, cause high vascular CHAP. I.] TONICS.—AROMATICS. 313 irritation, or even inflammation; while upon the heart and general circulation they produce little greater effect than might be ascribed to sympathy with the local excitement. This disproportion in their local stimulation may be ascribed to the difficult absorption of the volatile oils, to which they owe their powers. There is a great difference in the absorbability of the different volatile oils. Some, as those of turpentine, copaiba, garlic, &c, enter the circulation with great facility, and hence display considerable energy in their action upon the system generally, or on organs remote from the point of their application. The aromatic oils, as those of cinnamon, cloves, ginger, peppermint, &c, have, in general, much less of this facility; and, though they may act locally with equal power, are much less diffusible in their effects. In their operation specially upon the stomach and other portions of the alimentary canal, they do not so much invigorate the par- ticular function of digestion, as produce a general vascular excite- ment of the parts, attended with a comfortable or. pleasurable sensation, comparable to that of a genial glow on the surface of the body. In this plentiful, but not excessive supply of blood, which is the proper material for all the functions, that of the sto- mach is in a state to respond to its special stimulants; and tonics, therefore, will often operate with greater energy than when admi- nistered alone. The muscular tissue, too, without being stimulated, as by purgatives, to an increase of its regular peristaltic action, is yet put into a condition of greater power, and will contract with increased energy under the special stimulus of distension, or with a better regulated movement under that of cathartic medicine. Upon these principles may be explained all the peculiar therapeutic uses of the aromatics. Therapeutic Application. They are much used as cordial stimu- lants to the stomach and bowels, in debility of these organs; and have the great advantage over the more diffusible stimulants, such as alcohol in its different forms, that their operation is limited mainly to the part. Given in connexion with food, particularly with such as may be of difficult digestion, they favour its solution in the stomach, by enabling this organ both to secrete the solvent juice more vigorously, and the muscular coat of the stomach to perform its office more efficiently under the stimulus of the nutri- ment. Hence their use as condiments in all times, and in all parts of the world. They are given also to relieve nervous uneasiness and spasmodic 314 GENERAL STIMULANTS. [PART II. pain of the stomach, to aid in the expulsion of flatus, and to cor- rect nausea. All these offices they perform upon the principle above stated. The nervous tissue, duly supplied with blood, is relieved of those irregular sensations and actions to which it is so liable when debilitated, and can better resist the disturbing influ- ence of substances calculated to produce nausea or griping pain. The muscular coat, in the same state of its supply, feels duly the presence of the distending flatus, which it now expels by a vigor- ous contraction, instead of being thrown by it into those irregular and vain contractions called spasms. In reference to this operation of aromatics, they are called carminatives, a word handed down from the ancients, who were familiar with this effect, but could not so satisfactorily explain it, and therefore referred it to the mysterious influence of charms, and believed it to be much promoted by singing verses (carmina), during the administration of the medicine. To sum up, in a few words, the therapeutic applications of aro- matics, they are used to relieve the nervous pains, spasms, disor- dered sensations, and languor of stomach, attendant on dyspepsia or other debilitated states of the organ; to correct flatulence and pains arising from it, whether in the stomach or bowels; as anti-emetics to obviate nausea or gastric irritability when purely nervous; and, lastly, to aid or correct the operation of other medicines, or facilitate their administration by concealing or modifying their disagreeable taste. They are given with substances disposed to nauseate; whether by their taste, or their direct influence on the stomach, in order to obviate this effect. With cathartics they are very often exhibited, not only in refer- ence to the influence just referred to, but also to correct or obviate their griping tendency. With tonics they are habitually administered, to cover their taste, to render them more acceptable to the stomach, to give them in- creased efficiency in the promotion of digestion, and to increase their stimulant effect, when such an increase is indicated. They are contraindicated by existing vascular irritation or inflammation of the stomach, and by any considerable febrile ex- citement, in a sthenic state of the system. In very large quantities, some of them, and all in the concen- trated form of their volatile oil, are capable of inducing inflam- mation of the stomach, and thus proving dangerous if not fatal. When abused as condiments, they may cause the following evil CHAP. I.] TONICS.—AROMATICS. 315 effects. In the first place, they may give rise to chronic inflammation of the stomach, by sustaining a constant vascular irritation of that organ; secondly, they may debilitate the stomach by wearing out its excitability through over-excitement; and thirdly, by increasing the amount of food digested, they may lead to an excess in the supply of blood, a consequent plethoric state of system, and, in conjunc- tion with other influences, to the generation of a gouty diathesis. They are not unfrequently used externally, either alone, or in conjunction with other medicines, as irritants to the skin, or rube- facients. (See Rubefacients) As they depend mainly for their efficiency upon the volatile oils they contain, these are often separated by distillation with water, and very advantageously used as substitutes for the aromatics themselves. Their effects are the same; but they require to be administered with more caution, as they are more liable to produce serious effects, if taken in over-doses. As to the modes of prepar- ing the aromatic volatile oils, their chemical composition and reactions, the tests of their purity, and the general rules regulating their pharmaceutical management, the reader is referred to the U. S. Dispensatory. Administration. The aromatics may be given in substance, or in the forms of infusion, tincture, fluid extract, and volatile oil. The form of infusion is much used, and generally very suitable; but it should be remembered that water will dissolve but a small pro- portion of volatile oil, and, in the case of those particular aromatics which depend for their influence exclusively on the oil, the pro- portion of the medicine to the menstruum should be small, to avoid waste. Decoction and dry extract are inappropriate forms; as the volatile oil on which their virtues depend is more or less driven off during their preparation. In the fluid extract, if properly made, the oil may be retained; and this is often a very convenient form for use. Tincture is a very appropriate form, whenever the necessary amount of alcohol, used in the preparation, may not be objectionable. The aromatic oils are frequently preferred, in consequence of their less bulk, their greater power, and their greater convenience of ad- ministration. Some of them may be given undiluted, simply drop- ped on sugar; but most of them are too pungent and powerful to be exhibited in that way. They are, however, often and very con- veniently exhibited by dropping them on sugar, and then mixing this thoroughly with water. The sugar enables the water to hold the oil suspended sufficiently long for use. 316 GENERAL STIMULANTS. [PART II. A common method of exhibiting the oil is in alcoholic solution, in the shape of spirits or essences. The name spirit, in relation to the aromatic oils, was formerly used to designate preparations made by exposing a mixture of the aromatic and alcohol to distillation; the oil coming over dissolved in the alcohol. It is now also applied to similar preparations, made either by directly dissolving the oil in alcohol, or by distilling the oil and alcohol together. But to entitle such a preparation to the officinal title of spirit, it must be of a strength approaching that of the spirits made in the original method. The name of essences has been popularly appropriated to stronger solutions of the oil in alcohol; generally of such a strength as to permit the preparation to be taken on sugar without further dilution. These are designated in the U. S. Pharmacopoeia as tinc- tures of the respective oils. Thus, we have tinctures of the oil of pep- permint, and oil of spearmint; which terms, therefore, must be considered as synonymous with essences. Another very common and useful form of exhibition is that of the aromatic waters. These were originally made by distilling water from the aromatic in substance; but this method of prepa- ration has, in the United States, been almost entirely abandoned for the much more convenient method of simply dissolving the oil in water. When the oil. and water are merely shaken together, they unite but sparingly, and the resulting solution is very feeble. But, by the intervention of some body which, without being itself solu- ble, may, by trituration with the oil, so divide its particles as to bring them into intimate contact with the particles of water, when the two are shaken or rubbed together, a considerable proportion of the oil is taken up; enough to give a decided odour and taste, and some medicinal activity, to the solution. The substance pre- ferred for this purpose is usually carbonate of magnesia; and the aromatic waters of our national standard are prepared in this way; care being always taken to separate the insoluble matter by fil- tration. The aromatic waters may sometimes be advantageously given with a view simply to the medicinal effect of the oil; but much more frequently they are used as menstrua or vehicles for other substances, the taste of which they cover, while they often render them more acceptable to the stomach. r CHAP. I.] TONICS.—AROMATICS.—ORANGE PEEL. 317 I. ORAXGE-PEEL. AURANTII CORTEX. U.S., Lond., Ed., Dub. Origin. This is the rind of the orange, of which there are two kinds, derived from different species or varieties of Citrus ; the one Citrus vulgaris, the bitter, or Seville orange; the other, Citrus Aurantium, or common sweet orange. Both are natives of India and China, but cultivated generally in tropical latitudes. Sensible and Chemical Properties. The rind consists of two parts, the outer which is coloured, and the inner, white and spongy. In the former exclusively reside the virtues of the medicine; and sometimes it is only the outer coating that is kept in the shops. The bitter orange-peel, which is imported into the United States, is generally, as found in the shops, in vertical slices, though some- times in thin parings, as if cut off from the orange with a knife, like the paring of an apple. In the former, the white inner portion is retained, in the latter is wanting. The peel has an agreeable cha- racteristic odour, and a bitter taste. The sweet orange-peel is also in vertical slices, usually thinner than the other variety, with the same characteristic odour, and warm, aromatic taste, but without bitterness. In both, there is a peculiar volatile oil, which resides in distinct cells in the rind, and may be obtained by pressure when the rind is fresh. In addition to this, there is, in the bitter orange-peel, a principle to which it owes its bitterness, but which has not been fully investigated. Water and alcohol extract all the virtues of the peel. Kept in moist places, orange-peel is apt to spoil, in consequence of the attraction of the inner spongy portion for moisture. The parings keep better. 3Iedical Effects and Uses. Bitter orange-peel has the virtues of the aromatics combined with those of the simple bitters; the sweet variety is simply aromatic. Both are mild, and the tonic powers of the bitter are feeble. They are used almost exclusively in connexion with other medicines, to render them less disagree- able to the taste, and more acceptable to the stomach. It is usually with tonics that they are associated, as with Peruvian bark, gen- tian, &c; or with purgatives, as rhubarb. When with the former, 318 GENERAL STIMULANTS. [PART II. the bitter variety should be preferred; when with the latter, the sweet. Orange-peel is not altogether without danger if abused. I knew of a case in which death occurred, in an infant, from swallow- ing considerable quantities of the fresh rind. The child died with symptoms of obstruction of the bowels; and, on examination after death, the rind was found impacted in the intestines. But I am by no means certain that the oil contained in the rind may not have acted injuriously. • In Buchner's Neues Repertorium (ii. 440-5) are given the results of numerous observations, by Dr. A. Imbert-Gour- beyre, of the effects of the oil of bitter orange, among' which are mentioned headache, painful vision, buzzing in the ears, oppression of chest, loss of sleep, and phenomena similar to those of epileptic spasms. (Cent. Blatt, 15 Feb. 1854, S. 128.) These symptoms would indicate the'possession of narcotic properties by the oil. Administration. The peel is rarely given in substance. The dose of the powder might be from ten grains to a drachm. The infusion is generally preferred. When used as an adjuvant or corrective of other medicines, the peel is generally employed in this form; half an ounce of it, well bruised, being added to a pint of the liquid. When the other ingredients are prepared in decoction, the peel should not be added till the end of the boiling. The British Colleges direct a Compound Infusion (Infusum Auranth Compositum, Lond., Dub), prepared with half an ounce of orange- peel, two drachms of lemon-peel, one drachm of cloves, and an imperial pint, or twenty fluidounces of water. This may be used for the general purposes of the aromatics (see page 313), in wine- glassful doses. A Confection (Confectio Auranth, U. S) is prepared by separat- ing the rind by a grater, and incorporating the coarse powder thus made with sugar. It is used chiefly as a vehicle for tonic and purgative medicines in powder. An aromatic water (Auranth Floris Aqua, Lond), made by distilling water from the fresh flowers, is occasionally used as a perfume in the sick room. Other products of the genus Citrus are occasionally used in medicine for their aromatic properties. Among these are the fol- lowing. f CHAP. I.] TONICS.—AROMATICS.—CINNAMON. 319 1. LEMON-PEEL—Limonis Cortex. U. & —Limonum Cortex. Lond., EL This is the rind of the lemon, which is the fruit of a variety of Citrus medica, a native of Asia, but now cultivated throughout the civilized world, either in the open air, or in conservatories. It has the same aromatic properties as the orange peel, though less agreeable, and is employed for the same purposes. The Volatile Oil of Lemons (Oleum Limonis, U.S.) is often obtained from the fresh rind, either by distillation or pressure ; that procured in the latter method having more exactly the odour of the rind, though the former is more clear. It is used to impart an agreeable flavour to other medicines, for which purpose a drop or two may be added to a fluidounce of a liquid for internal use, and ten drops to an ounce of unctuous matter for outward application. It has been employed, undiluted, as a local application to the conjunctiva, in affections requiring stimulation; being pressed from the fresh peel directly into the eye. It produces, however, excessive pain, and should be used with caution. 2. OIL OF BERGAMOT.— Oleum Bergamii. U.S.—Bergamots Oleum. Ed. This oil is obtained by expression, or distillation, from the fresh rind of the fruit of Citrus Limetta. It is used chiefly, if not exclu- sively, for the sake of its very agreeable odour; being mixed with substances used as liniment or ointment, in the same manner as oil of lemons. II. CINNAMOX. CINNAMOMUM. U.S., Lond., Ed., Dub. Under the above name, the U.S. Pharmacopoeia recognizes two products, the proper cinnamon gathered in Ceylon, and another kind brought from China, and known in commerce by the name of cassia. These may be conveniently distinguished, in reference to their commercial origin, as Ceylon cinnamon and Chinese cinnamon. It is the latter which is most commonly found in our shops, being brought to this country directly frOm Canton. The former is used only in small proportion, and generally comes to us by special order from England. Cinnamon was known to the ancients. Origin. Ceylon cinnamon is the prepared inner bark of Cinna- 320 GENERAL STIMULANTS. [PART II. momum Zeylanicum, a tree growing wild in the East India island of Ceylon, where it is largely cultivated. The tree has been intro- duced into other tropical countries, and is cultivated to a consider- able extent in the French province of Cayenne in South America. When the tree has attained a proper age, the stems are cut and decorticated; and the bark, deprived of its epidermis, is allowed to roll into quills, which are inserted one within another, so as to form a solid cylinder. Chinese cinnamon or cassia (Cassis Cortex, Ed) is the inner bark of a species of Cinnamomum growing in China, which is be- lieved to be the C. aromaticum, though certain knowledge upon this point is wanting. Sensible Properties. Ceylon cinnamon is in cylindrical fasciculi, consisting of a congeries of quills, inserted one into another, and, when unbroken, several feet in length; distinct fasciculi being neatly joined end to end, so as to appear as if one piece. This variety is of a yellowish-brown colour, almost as thin as paper, smooth, somewhat shining, pliable, and of a splintery fracture. Its odour is very fragrant, and its taste warm, pungent, sweetish, slightly astringent, and exquisitely grateful. The Chinese variety is in single tubes, of which the finest differ little in appearance from the cinnamon of Ceylon, but by far the greater proportion are larger, thicker, deeper-coloured, rougher, denser, and of a shorter fracture. The pieces are often much rolled upon themselves, but sometimes not completely quilled. The odour and taste are of the same general character; but the former is less agreeably fragrant, and the latter less sweet and grateful, though equally or more pungent, and more astringent. In both varieties, the powder is of a yellowish-brown colour, so characteristic that, when met with in other bodies, it is distinguished by the name of cinnamon colour. Active Constituents. These are a peculiar volatile oil, and tannic acid, of the latter of which the proportion is not large. The oil is separated by distillation with water; being generally prepared in the East, probably from the broken fragments and refuse barks. There aretwo kinds of oil, distinguished as the oil of cinnamon and oil of casHa, the former obtained from the Ceylon, the latter from the Chinese bark. Both oils, as first procured, are of a fine vellow colour; and both become red by age. The flavour of the proper cinnamon oil, however, is sweeter and finer than that of the oil of CHAP. I.] TONICS.—AROMATICS.—CINNAMON. 321 cassia. Both, when oxidized by exposure to the air, yield cinna- mic acid. Cinnamon yields its virtues in small proportion to water, and much more freely to alcohol. 3Iedical Properties and Uses. This bark has in a very high degree the general properties of the aromatics, with some astringency dependent on the tannic acid. It is among those most employed. It is used for all the purposes of the aromatics (see page 313), but most frequently in conjunction with other medicines, to qualify their taste, and render them more acceptable to the stomach. One of its most appropriate applications is to the treatment of diarrhoea, in association with other astringents and with chalk; a purpose to which the tannic acid it contains particularly adapts it. In conse- quence of its peculiarly agreeable flavour, it is used as a constituent of a great number of officinal preparations. Administration. Cinnamon is sometimes administered in powder, in the dose of from ten to twenty grains. It is ofteu, in this state, associated with other medicines given in the same form. The Aromatic Powder of the Pharmacopoeias (Pulvis Aromaticus, U.S.) consists of cinnamon, ginger, cardamom, and nutmeg; a very fine combination of spices. From ten to thirty grains of this may be given for a dose. It is occasionally applied externally in the form of cataplasm, which may be prepared by adding a little heated spirit so as to bring the oil into activity, and rendering the mixture adhesive by honey or other viscid substance. Such a cataplasm may be advantageously applied to the epigastrium in vomiting, and over the whole abdomen in the cholera of children. An officinal Confection (Confectio Aromatica, U.S.) is prepared by incorporating the aromatic powder above referred to with saffron, syrup of orange-peel, and honey. It may be used for the general purposes of the aromatics, in the dose of from ten grains to a drachm. An infusion of cinnamon may be made by macerating two drachms in a pint of boiling water, and given in the dose of one or two fluidounces; and the bark may be added to other substances in infusion in the same proportion. When added to decoctions, it should be introduced at the end of the boiling, but while the liquid is still boiling hot. The Oil of Cinnamon (Oleum Cinnamomi, U. S) is never used alone, in an undiluted state; as, independently of its extreme pun- gency, it might endanger serious irritation, if not inflammation of the stomach. In over-doses it may prove fatal. Mitscherlich killed vol. i— 21 322 GENERAL STIMULANTS. [PART II. a dog in forty hours with two drachms, and in five hours with six drachms. But made into emulsion with gum Arabic, loaf sugar, and water, it will produce all the effects of cinnamon except those dependent on its astringency; and may be frequently administered advantageously as a stomachic and carminative. It is, however, more frequently employed in solution, in one of the following forms. The dose of it is one or two drops. Cinnamon Water (Aqua Cinnamomi, U.S.) was formerly made by distilling water from cinnamon; but is now much more con- veniently prepared by dissolving the oil in water, through the in- tervention of carbonate of magnesia, as described under the general head of aromatics (see page 316). Although only thirty minims are employed to two pints of water, the resulting solution is too strong for ordinary purposes, unless diluted. It is chiefly employed as a menstruum or vehicle for other medicines, given in liquid mix- ture or solution; but, when used for this purpose, it should gene- rally be diluted with an equal measure or double its measure of water. The dose of this aromatic water is from half a fluidounce to a fluidounce. Spirit of Cinnamon (Spiritus Cinnamomi, Lond.) is prepared by dissolving two fluidrachms of the oil in an imperial gallon of proof spirit. The dose is one or two fluidrachms. A simple Tincture of Cinnamon (Tinctura Cinnamomi, U.S.) and a Compound Tincture (Tinctura Cinnamomi Comp., U.S.), the latter prepared with the addition of cardamom and ginger, afford agree- able means of obtaining the effects of the aromatics, with the astrin- gency of the cinnamon, when alcohol is not contraindicated. The dose is from one to four fluidrachms. The two following barks, though little used, are noticed in most works on Materia Medica, and, as appears to me, can be nowhere more appropriately considered than as subordinate to cinnamon. 1. CANELLA. U.S., Lond., Ed., Dub. This is the bark of Canella alba, a large tree growing in Jamaica and other West India islands. The bark is stripped from the branches, deprived of its epidermis, and dried. Sensible Properties. It is in pieces of various size, usually thicker and larger that the coarsest cinnamon, either completely or par- tially quilled, often twisted, of a pale-orange or light reddish-yellow colour on the outer surface, nearly white on the inner, brittle with CHAP. I.] TONICS.—CANELLA.—WINTER'S BARK. 323 a short fracture, and yielding a yellowish-white powder. Its odour is aromatic, its taste warm, bitterish, and very pungent. Active Constituents. A peculiar volatile oil is the main active in- gredient; but there is also a bitter substance, and an aromatic resin, which are probably not without influence. The bark yields its virtues imperfectly to water, but readily and wholly to alcohol. Medical Properties and Uses. Canella has the properties of the aromatics generally, with a greater degree of pungency than most of them, and some tonic power. It is well adapted to atonic states of the stomach and bowels; but is seldom used except in conjunc- tion with other medicines, of which it may cover the taste, and correct any nauseating or griping property. The dose of. the powder is from ten to thirty grains. Associated with aloes, it forms the Powder of Aloes and Canella (Pulvis Aloes et Canells, U. S), which was formerly so much esteemed as to have received the name of hiera picra, or sacred bitter, though now comparatively little used. Whatever its virtues may be, they must be ascribed almost exclusively to the aloes, of which the canella is merely a corrective. Canella is also an ingredient in the Wine of Aloes of the London Pharmacopoeia, in the Compound Tincture of Gentian, and Wine of Gentian of the Edinburgh, and in the Wine of Rhubarb (VlNUM Rhei, U.S.) of our own, and all the British officinal codes. 2. "WINTER'S BARK.—WlNTERA. U.S. This is the bark of Drimys Winteri ( Wintera aromatica, Willd.), an evergreen tree, growing in the southern extremity of the Ame- rican continent, along the straits of Magellan, and thence northward to Chili and Brazil. As found in commerce, the bark is in quills about a foot long by an inch in diameter, or in larger flat pieces. On the outside it appears as if it had been scraped or rubbed, and has a pale yellowish or reddish-gray colour, with red elliptical spots; the inner surface is reddish-brown or cinnamon coloured. Its powder resembles that of Peruvian bark. Its smell is fragrant, its taste hot, pungent, and spicy. Its chief active constituent is a peculiar volatile oil, with which there is also a somewhat acrid resin, and sufficient tannic acid to cause the infusion to be dark- ened by the salts of iron. Winter's bark was first made known by Captain Winter, who commanded one of the vessels in Drake's famous expedition, and, on his return to England, in 1579, brought some of the bark with him. It has often been confounded with canella, which it resembles 324 GENERAL STIMULANTS. [PART II. in appearance; but it may be distinguished by its dark inner sur- face, while that of canella is white, and by affording with reagents evidence of containing tannic acid, which canella does not. Its medical properties are essentially the same as those of canella, and it may be used for the general purposes of the aromatics; but it is seldom to be found in the markets of the United States, and is little employed. The dose of the powder is about half a drachm. ■♦■ III. CLOVES. CARYOPHYLLUS. U.S.,Edn Dub.—Caryophyllum. Lond. Origin. Cloves are the dried unexpanded flower-buds of Cary- ophyllus aromaticus, a small and beautiful tree, inhabiting the Mo- lucca Islands, in the East Indies, whence it has been successfully transplanted to various parts of the world, as the Isle of France, Singapore, Sumatra, and Cayenne in South America, in which places it is now cultivated to a considerable extent. Sensible Properties. Cloves have the form of a small nail, being on the average somewhat more than half an inch long, with a round head, having four spreading points beneath it. When pressed with the finger-nail, if of good quality, they exude oil. Their colour is dark brown, their odour strong and fragrant, and their taste hot, pungent, aromatic, and lasting. The powder is dark and oily. Chief Constituents. The active principle of cloves is a volatile oil, which may be separated by distillation. When first procured, it is colourless, but gradually becomes yellowish by time, and ultimately reddish-brown. It has the odour and taste of the cloves; but is relatively less pungent. It is heavier than water. Besides the oil, there are two crystalline principles, called respect- ively caryophyllin and eugenin, and a little tannic acid; but the first two are insipid, and the last is of no practical importance. Cloves yield their active matter only in small proportion to water, but freely and entirely to alcohol. The alcoholic extract is excess- ively fiery, but becomes insipid when distilled, while the oil which comes over is relatively mild. Distillation would appear, then, to have produced some change in the oil, which renders it less active. 3Iedical Properties and Uses. Cloves were made known to Europe by the Arabians, but were not largely used until after the discovery of the passage to India by the Cape of Good Hope. They possess, CHAP. I.] TONICS.—CLOVES.—NUTMEG. 325 in a high degree, the characteristic properties of the aromatics, and may be used for all the purposes mentioned in the general observa- tions on this subdivision of the tonics. They are, however, much more employed as a condiment in cookery, than as a medicine. Oc- casionally they are given to correct nausea, relieve flatulent pains, and stimulate the languid digestion; but their chief medicinal em- ployment is as an adjuvant to other medicines, and they form a subordinate ingredient in several officinal preparations. The dose of the powder is from five to twenty grains. The offici- nal Infusion (Infusum Caryophylli, U.S.) is made with two drachms of the cloves to a pint of boiling water, and given in the dose of two fluidounces. The French Codex directs a tincture, of which the dose is a fluidrachm. The Oil of Cloves (Oleum Caryo- phylli, U.S.) is occasionally employed, either alone, in the dose of from two to six drops, properly diluted, or as an ingredient in pur- gative pills, to prevent nausea or griping. It is also used to relieve toothache, by being introduced, upon cotton, into the carious hol- low. It relieves the pain by blunting the sensibility of the part through excessive irritation. IV. NUTMEG. MYRISTICA. U.S., Lond,, Ed., Dub. Origin. Nutmeg-is the kernel of the fruit of Myristica moschata, a handsome middle-sized tree, originally confined to the Moluccas, but now cultivated in Sumatra, Java, Singapore, Cayenne, Brazil, and other intertropical countries. The product, however, is said nowhere to attain such perfection as in its native islands. The fruit, about the size of a small peach, has an outer covering or hull; and within this is a red membrane with slits, through which is seen a chestnut-coloured nut. The shell of the nut being broken, the kernel is obtained, and, having been steeped in a mixture of lime and water, and afterwards cleaned, is prepared for market. Sensible Properties. The appearance of .the nutmeg is too well known to require description. When broken, or cut through, it presents a yellowish surface, with dark, branching veins, in which volatile oil abounds. It is not very easily pulverized by pounding, and is reduced to powder by grating or grinding. It has a fragrant odour, and a warm, spicy taste, and is among the 326 general stimulants. [part ii. :i most grateful of the aromatics. It yields its virtues much more readily, and in larger proportion, to alcohol than to water. Chief Constituents. The most interesting constituents of nutmeg are a volatile and fixed oil, the former of which is obtained by dis- tillation with water, the latter by expression with heat. The vola- tile oil is lighter than water, colourless, or of a pale straw-colour, with the odour of nutmeg, and a pungent, aromatic taste. It is the active principle of the medicine. The fixed oil, often though erro- neously called oil of mace, concretes, after expression, into a soft, unctuous solid, of a yellowish or orange-yellow colour, often more or less mottled, and of the smell and taste of the nutmeg, owing to a proportion of the volatile oil contained in it. Medical Properties and Uses. Nutmeg seems not to have been known to the ancients. The Arabians were acquainted with it; but it was little employed in Europe until after the discovery of the maritime passage to India. It has the ordinary properties of the aromatics, and, in large doses, is somewhat narcotic. In the quantity of two or three drachms, it has produced delirium and stupor; but no danger need be apprehended from it in the ordinary medicinal doses. It is more used as a condiment, or to give flavour to ordinary drinks, than as a medicine; and, in the latter capacity, it is chiefly employed to cover the taste and qualify the action of other substances. It is an excellent addition to farinaceous drinks used as a diet by the sick. The dose of the powder is from five to twenty grains. The Vola- tile Oil (Oleum Myristics, U.S.) may be used, for any of the pur- poses of the aromatics, in the dose of two or three drops. There is an officinal Spirit (Spiritus Myristics, U. S), prepared by dis- tilling proof spirit from bruised nutmeg. In the quantity of from one to four fluidrachms, it forms an elegant addition to tonic and purgative infusions, when the stimulus of alcohol is not forbidden. The expressed oil is sometimes used as a gentle rubefacient in local rheumatism and palsy, and is an ingredient in the Emplastrum Picis of the London and Edinburgh Colleges. 3Iace (Macis, U. S) is the membrane above referred to as sur- rounding the nut in the fruit. It is in flat longitudinally slit pieces, of a rather soft consistence, of a reddish colour, and an odour and taste recalling those of nutmeg, but different and peculiar. Like nutmeg, mace contains a volatile and a fixed oil. It may be used for the same purposes as that spice, but is much less agreeable, and proportionably less employed. CHAP. I.] TONICS.—AROMATICS.—BLACK PEPPER. 327 V. BLACK PEPPER. PIPER. U.S.—Piper Nigrum. Land., Ed., Dub. Origin. Black pepper consists of the dried unripe berries of Piper nigrum, a climbing plant, indigenous in the East Indies, where it is also largely cultivated, especially on the coast of Mala- bar, in the peninsula of Malacca, in Siam, and in the islands of Java and Sumatra. White pepper is the ripe fruit, deprived of its outer coating by maceration in water. It is weaker than the black, and is little used in this country. Sensible Properties. Black pepper is too well known to require description. Its odour and taste are familiar to every one. Chief Constituents. These are a volatile oil, a soft acrid resin, and a peculiar crystalline principle called piperin. The volatile oil may be separated by distillation with water. It is at first limpid and colourless, but becomes yellow by age. Its odour is strong, and resembles that of pepper; but the taste, though warm and pungent, is less acrid than that of the berries themselves. The acrimony resides chiefly in the soft resin, which is semi-fluid, of a deep-green or blackish colour, extremely acrid, insoluble in water and the vola- tile oils, but readily dissolved by alcohol and by ether. Piperin is a crystalline substance, white, inodorous, and tasteless when per- fectly pure; but, as commonly obtained, yellow and acrid. At least this is the statement made by Pelletier; but Dr. Christison says that the whitest and purest crystals he had been able to procure were as acrid as the coloured, and emitted an intensely irritating vapour when thrown on a heated iron plate. It is insoluble in cold water, slightly soluble in hot water, and readily soluble in alcohol, ether, and acetic acid. 3Iedical Properties and Uses. Black pepper has been known as a medicine and condiment from the time of Hippocrates. It has the properties of the aromatics in general, but is much more stimu- lating than most of them, and acts with still greater proportionate energy on the stomach than on the general system. It is thought to have a specially excitant effect on the urino-genital apparatus, and probably stimulates the urinary passages through the direct contact of some one of its ingredients, altered or unaltered, with the mucous membrane of these passages, as it escapes with the urine. In con- 328 general stimulants. [part ii. tact with the skin, it is highly irritant, acting as a rubefacient, and sometimes, it is said, blistering. When taken too largely, it may produce serious irritation or inflammation of the stomach, with general febrile phenomena; and its long continued use in excess endangers a loss of excitability in that organ, with or without chro- nic gastritis. It is much more employed as a condiment than as a medicine. In the former capacity, it not only serves to impart an agreeable flavour, but often facilitates the digestion of substances ordinarily of difficult solution in the stomach, especially fresh vege- tables, when boiled. Care should be taken, however, not to abuse it, for fear of the evil consequences just referred to. As a medicine, it is given occasionally in torpidity of the stomach and bowels, with flatulence, especially in old people, in whom these organs are pecu- liarly apt to be inert. It is thought to act directly upon the mucous coat of the rectum, and thus to prove useful in chronic ulcers of that part, in piles, and fistula in ano. From its influence upon the urinary and genital passages, it has been recommended in gonor- rhoea, gleet, and leucorrhoea; but care should be taken not too much to excite these parts, when there is any tendency to acute inflammation. Much attention has been directed to black pepper from its sup- posed possession of antiperiodic properties. It was recommended in paroxysmal fevers by Celsus and Dioscorides; but, though occa- sionally used in domestic practice in intermittents, it seems for a long time to have been lost sight of by the profession. Louis Frank, in imitation of a practice which he had witnessed in the East, was induced to try it in this complaint, and found it successful in a hundred and seventy cases, which recovered as rapidly as under cin- chona, and with less tendency to relapse. (Trousseau et Pidoux, Trait. de Therap. &c, 4e ed., ii. 465.) Many others followed the example of Frank, and the remedy came into great repute, which it has not yet entirely lost. There is no doubt that it will often cure inter- mittents; and, in cases of great torpidity of stomach, as in drunk- ards, it may with advantage be associated with sulphate of quinia, in order to arouse susceptibility to the action of the latter remedy. When used alone, it should be preceded by a thorough evacua- tion of the bowels; and it is recommended to administer it in the form of whole grains, as less liable than the powder to irritate or inflame the stomach. In reference to its local effects, black pepper is sometimes used, . as a direct application to the mouth or fauces, in paralysis of these CHAP. I.] TONICS.—AROMATICS.—BLACK PEPPER. 329 parts, relaxed uvula, severe toothache, &c. Externally it may often be usefully employed as a rubefacient, for which purpose it may be made into a cataplasm, with or without other irritants. It may be given whole, or in powder. The dose is from five to twenty grains. In intermittents it has been recommended prefera- bly, as already stated, in the whole form; and eight or ten grains of it may be given three or four times a day. There is an officinal Confection (Confectio Piperis, Land), con- sisting of black pepper, elecampane, and fennel-seed, incorporated, when used, with sugar and honey. It has been highly recom- mended in piles, in which it is employed as an officinal substi- tute for an empirical remedy, which acquired much credit, in the treatment of this affection, under the name of Ward's paste. Sir B. Brodie has found it successful in severe eases, and recommends that it should be continued for two, three, or four months. The dose is from one to three drachms, twice or three times a day. It should be accompanied with a laxative, in order to prevent incon- venient accumulation in the bowels; and should not be used when the parts are inflamed. A Fluid Extract (Extractum Piperis Fluidum, U. S) is directed by the U.S. Pharmacopoeia, in which the virtues of the medicine are extracted by ether, and this fluid subsequently evaporated. It contains the volatile oil and acrid resin of the pepper; and, as the piperin is of doubtful efficacy, may be considered as representing the virtues of black pepper. It is a thick, opaque, greenish liquid, having the smell of pepper, and an acrid, burning taste. A prepa- ration, left in the process of preparing piperin, has been kept in the shops, under the name of oil of pepper. It has a black colour, and is essentially of the same character as the fluid extract, though of less uniform strength, and therefore less to be relied on. The dose is one or two minims, which may be given in emulsion, or in connexion with other medicines in the pilular form. Piperin has had considerable reputation in the treatment of inter- mittent fever, having been supposed to be the active principle of black pepper. As found in the shops, it certainly has some effect, and has been used successfully in that complaint. Dr. Meli, an Italian physician, who was the first, I believe, to employ it, consi- dered it superior to Peruvian bark. It has been much employed also in this country, particularly in connexion with sulphate of quinia. As before stated, however, there is much reason to doubt its efficiency when pure. According to Pelletier, the acrid taste, 330 GENERAL STIMULANTS. [PART II. and consequently the medicinal activity of the impure form in which it is commonly found, are owing to a portion of the acrid resin remaining mixed with it. The dose is stated at from one to ten grains. A drachm has been given in twenty-four hours without inconvenience. Meli considers that two or three scruples are suffi- cient to cure intermittents. An ointment, made by rubbing one part of powdered pepper with three or four parts of lard, was formerly employed in scald head, but is little used at present. VI. CUBEBS. CUBEBA. U. S., Lond, Dub. — Cubebs. Ed. Origin. Cubebs are the dried unripe fruit of Piper Cubeba (Cu- beba officinalis of Miquel), a climbing perennial of the E. Indies, inhabiting especially Java and the neighbouring islands. Sensible Properties. The fruit is spherical, about the size of a small pea, and furnished with a short stalk, continuous with a network of raised veins which surround the berry. Their colour in mass is a dark gray, some of the berries being almost black, others much lighter-coloured. The powder is dark and oily, and bears no incon- siderable resemblance to that of opium, which has been fatally mis- taken for it. The odour is peculiar and aromatic, the taste warm, bitterish, and camphorous, imparting a sense of coolness when the air is drawn through the mouth. Water very imperfectly extracts the virtues of cubebs, alcohol and ether completely. They gradually deteriorate by age, and, as this deterioration takes place most rapidly in powder, they should be kept whole, and pulverized as wanted for use. Chief Constituents. These are volatile oil, an acrid resin, and a peculiar principle called cubebin. The volatile oil, which is obtained by distillation with water, is when pure quite colourless, but, as com- monly met with, yellowish or greenish. It is lighter than water, of about the consistence of olive oil, of an odour like that of cubebs, and a warm, aromatic, camphorous taste. The resin is, according to Vauquelin, somewhat acrid, and has a balsamic odour and taste resembling those of copaiba. Cubebin is closely analogous to piperin, and, when pure, quite destitute of odour and taste. The chief active constituent is undoubtedly the volatile oil, the operation CHAP. I.] TONICS.—AROMATICS.—CUBEBS. 331 of which is somewhat aided by the resin. Cubebin is probably inert. 3Iedical Properties and Uses. It is probable that cubebs were known to the ancient Greeks. The Arabians certainly were ac- quainted with them, and by these they were introduced into Eu- rope. Employed for the same purposes as black pepper, they were at once feebler and less agreeable, and fell at length into entire neglect. It is only about forty or fifty years, since the use of them was revived, in consequence of the favourable reports of English physicians in India, as to their efficacy in the treatment of gonor- rhoea, in which they had been long employed by the native practi- tioners. Cubebs have the properties of the stimulant aromatics, with a peculiar direction to the urinary organs. When freely taken, they produce a feeling of warmth in the stomach, increase the frequency of pulse and heat of skin, sometimes occasion giddi- ness or headache, and, in consequence of the absorption of the volatile oil, and its escape through the kidneys, augment the secre- tion of urine, and impart to it a peculiar odour. In excess, they may cause burning in the stomach, nausea and vomiting, griping pains in the bowels with more or less of a laxative effect, irritation or inflammation of the urinary passages, and a general febrile con- dition. Occasionally their operation, in ordinary doses, is attended with a rash upon the surface, somewhat resembling urticaria. Though applicable to the same purposes as pepper, in reference to their cordial operation on the stomach, it is mainly in the treatment of gonorrhoea, and other affections of the urino-genital organs, that they are employed. They are recommended in the earliest stage of gonorrhoea, and, thus given, occasionally produce speedy cures; but they often also fail, and have been accused of in- creasing inflammation, and aggravating any existing tendency to swelled testicle. They should, I think, be used with caution when inflammation exists, beyond that which is an essential constituent of the affection; and it is probable that their greater efficacy in the ear- liest stage is owing to the circumstance, that highly inflammatory symptoms have not yet been developed. They probably operate through a direct alterative influence of the urine, impregnated with their properties, upon the portion of mucous membrane affected. In the advanced or chronic stage of gonorrhoea, and in gleet, though perhaps less efficient, they would be less likely to produce mischiev- ous effects. Upon the same principle as in this complaint, they have been recommended in chronic cystirrhuea, chronic pyelitis, leucor- 332 GENERAL STIMULANTS. [PART II. rhoea, abscess of the prostate, and other conditions of the urinary and genital passages, in which a moderate stimulation of the dis- eased surface is indicated. They are said to have proved useful in piles. Some suppose them to have an alterative action on the mucous surfaces generally, and therefore recommend them also in chronic bronchial affections, attended with copious expectoration, and a relaxed condition of the tubes. Administration. The most Common form of exhibition is that of powder, of which from ten grains to half a drachm is usually given in affections of the bladder, kidneys, and bronchial tubes; but in gonorrhoea the requisite dose is larger, varying from half a drachm to three drachms, three or four times a day. The volatile oil may be employed in emulsion, or dropped on sugar, in the dose of ten drops to begin with, gradually increased till its effects on the urin- ary passages have become evident. The dose has sometimes been increased to a fluidrachm. A Fluid Extract (Extractum Cubeb.e Fluidum, U. S) is directed by the U. S. Pharmacopoeia. It is made by extracting the virtues of the medicine with ether, and then allowing the ether to evaporate. It is a greenish-brown fluid, of variable consistence, and may be given in doses varying from five to thirty minims, either mixed with sugar, or suspended in sweet- ened water. There is an officinal Tincture (Tinctura Cubebs, U.S.) of which the dose is from thirty minims to two or three fluidrachms. I do not know where better to introduce the following medicine, than in a subordinate position to pepper and cubebs, with which it agrees in botanical affinities, and, to a considerable degree, in its effects. MATICO. Dub. This consists of the herbaceous parts, and mora especially of the leaves, of Piper angustifolium (Artanlhe elongata, Miquel), a shrub growing in Peru. The medicine, as imported, usually consists of the dried leaves, spikes, and stalks, mixed to- gether, and closely flattened by pressure. They are of a greenish colour, and, when pulverized, yield a greenish, light, absorbent powder. They have an agreeable aromatic odour, and a strong spicy taste. These properties, as well as their medical virtues, they yield readily to alcohol, and less perfectly to water. Their active constituents are volatile oil, a bitter principle, soluble in alcohol and water, called maticin, and probably resin. They contain nei- ther tannic nor gallic acid. CHAP. I.] TONICS.—AROMATICS.—PIMENTO. 333 Matico has long been used in Peru, externally as a styptic in hemorrhage, and a stimulant to ulcers, and internally as an aphro- disiac, and a remedy in venereal diseases. But it was not introduced into Europe until 1839, when a portion of it was taken to Liver- pool, and prescribed by Dr. Jeffreys, of that place, in various dis- eases. Its effects on the system are those of an aromatic tonic and stimulant, bearing no inconsiderable resemblance to those of pepper and cubebs. It has been employed, with asserted advantage, in chronic inflammation of the mucous membranes, as gonorrhoea, leucorrhoea, catarrh of the bladder, and dysentery, and as a haemo- static in hemorrhage from the nostrils, lungs, stomach, urinary or- gans, and uterus. If useful in these latter affections, it is not through any astringent properties, of which it is quite destitute, but probably by an influence analogous to that of oil of turpentine, which is often an efficient remedy in hemorrhage. Its chief use, given internally, is probably as an alterative to chronically inflamed mucous membranes. As a local styptic, it has been very highly recommended. In this application, it probably acts mechanically, by absorbing the blood, and favouring its coagulation. The dose of the powder is from half a drachm to two drachms, three times a day. An Infusion (Infusum Matico, Dub) is directed by the Dub- lin College, which is made in the proportion of half an ounce to ten fluidounces of boiling water, and given in the dose of one or two fluidounces. The same College directs a Tincture (Tinctura Ma- tico), of which the dose is from one to three fluidrachms. ■♦■ VII. PIMENTO. PIMENTA. U S, Lond, Ed., Dub. Origin. Pimento consists of the dried unripe berries of 3Iyrtus Pimenta (Eugenia Pimenta, De Cand.), a handsome tree, growing in the West Indies, Mexico, and South America, where it is indi- genous, and cultivated in Jamaica, whence the fruit derives the name of Jamaica pepper. Sensible Properties. The berries are similar to those of black pepper, but rather larger, and smoother. They are of a brown colour, a fragrant odour, and a warm, pungent, aromatic, slightly astringent taste. The odour has been thought to resemble that of a mixture of other species; and hence the name of allspice, by which the fruit is generally known. 334 GENERAL STIMULANTS. [PART II. Active Principles. According to the analysis of Bonastre, the active constituents are volatile oil, a green acrid fixed oil, and a little tannic acid. Berzelius, however, thought that the green acrid fixed oil of Bonastre was a mixture of volatile oil, resin, fixed oil, and perhaps a little chlorophylle. This is probably true; so that, as the tannic acid is of little or no account, the berries may be considered as owing their virtues exclusively to their volatile oil. This, when first obtained by distillation, is colourless; but it changes with time, and ultimately becomes reddish brown. It has the fla- vour of the fruit. 3Iedical Properties and Uses. Pimento became known as a spice very soon after the discovery of America. Its effects are those of the aromatics generally, without any special distinguishing pro- perty. It may, therefore, be used for the same purposes as other pure aromatics (see page 313), being preferably prescribed, when its odour and taste are peculiarly agreeable to the patient. It is much more used in cooking than as a medicine. The dose of the powder is from ten to forty grains; that of the Volatile Oil (Oleum Piments, U S) from three to six drops. A Water of Pimento (Aqua Piments, Lond) is made either by distilling water from the bruised fruit, or by simply dissolving the oil in distilled water, and given in the dose of one or two fluidounces. There is also an officinal Spirit (Spiritus Piments, U S), pre- pared by dissolving the oil in diluted alcohol, the dose of which is one or two fluidrachms, or more. VIII. CAR-DAMOM. CARDAMOMUM. U S., Lond., Ed., Dub. Origin. This is the fruit of Eletlaria Cardamomum, a perennial plant, with clustered stems, from six to twelve feet high, and bear- ing its fruit upon a flower-stalk, which springs from the base of the stem, and lies along the ground. It is a native of the mountains of the Malabar coast of Hindostan, where also it has been culti- vated from time immemorial. Sensible Properties. The fruit is a coriaceous capsule, about half an inch in average length, and seldom more than three lines thick, three sided, with rounded angles, somewhat wrinkled longitudinally, of a dirty-whitish or yellowish-white colour, and containing small, CHAP. I.] TONICS.—AROMATICS.—CARDAMOM. 335 angular, irregular seeds, of a deep-brown colour, and appearing as if embossed on the surface. The odour of cardamom is highly fragrant, the taste warm, grateful, pungent, and purely aromatic. The capsular covering has little of the aromatic property, which resides mainly in the seeds. In making, therefore, the preparations of cardamom, the former should be rejected; although, as the seeds keep better in the capsule than when exposed, they should not be separated until wanted for use. Active Principle. The virtues of cardamom reside exclusively in a volatile oil, which is lighter than water, colourless, and highly pungent and aromatic; but it is so liable to deterioration by time, that it is seldom kept separate for use. Water dissolves the oil from the seeds in small proportion; but alcohol is a much better solvent. 3Iedical Properties and Uses. Cardamom was probably known to the ancient Greeks and Romans, and has been employed in India, as a condiment, from the earliest times. It is among the most agreeable and purest of the aromatics, less stimulating than many others, whether locally or generally, and therefore highly useful, as an adjuvant, under circumstances which might forbid the use of a less mild article of the class. Though seldom given alone, it is very much employed to aid or correct the action of other remedies, and enters into a large number of officinal preparations, particularly tinctures. Perhaps no aromatic, on the whole, answers better than this as an addition to tonic and purgative mixtures and infusions, where the object is merely to cover the taste, obviate nausea, and produce a slight cordial impression on the stomach. When used alone, it is most conveniently given in infusion, which may be made with one or two drachms of the bruised capsules to a pint of boiling water; and in the same proportion they may be added to compound infusions. The dose is two fluidounces, or more. There are two officinal Tinctures of this aromatic specially, one simple (Tinctura Cardamomi, U.S.), and the other compound (Tinctura Cardamomi Composita, U.S.); the latter containing cinnamon, caraway, and raisins, and coloured red with cochineal. These are agreeable preparations, especially the compound tincture, which is much used as an extemporaneous addition to stimulant, tonic, and purgative mixtures and infusions, in the quantity of one or two fluidrachms for each dose of the preparation. 336 GENERAL STIMULANTS. [PART II. IX. FEXXEL-SEEU. FCENICULUM. U. S., Land., Ed., Dub. Origin. Fennel-seed is the fruit of Foeniculum vulgare (De Cand.), F. officinale (Merat and De Lens), and possibly F. duke (De Cand.). These are perennial umbelliferous herbs, growing wild in the South of Europe and Asia Minor, and cultivated both in Europe and the United. States. The whole plant, in the different species, has a grateful aromatic odour and taste, on account of which the F. dulce is cultivated in southern Europe; the shoots being eaten raw, or in the form of salad. Sensible Properties. Fennel-seed consists usually of the sepa- rated half-fruits (mericarps) of the plant, usually called seeds. These are oblong-oval, flat on one side and convex on the other, occasionally connected by their flat surfaces, and of a grayish- green colour, with yellowish longitudinal ridges on the convex sur- face. There are two varieties, one smaller, a line or two in length, always in separate half-fruits; the other larger, three or four lines long, of a lighter colour, more prominent ridges, often connected together forming whole fruits, and with a short footstalk. The former comes probably from F. vulgare, the latter from F. officinale. Both have a purely aromatic odour and taste, peculiar and very agreeable. They impart their sensible properties and virtues to water and alcohol, but more largely to the latter. Active Principle. Fennel-seed depends for its activity exclusively on a volatile oil, which is obtained by distillation with water, is lighter than water, colourless or yellow, and of a very grateful flavour. Medical Properties and Uses. The ancients were acquainted with this medicine. It is purely aromatic, mild in its action on the stomach, and scarcely stimulant, in ordinary doses, to the system at large. Being less heating than cloves, cinnamon, ginger, or even car- damom, and yet of a very grateful flavour, it is preferable to these aromatics, when there is an indication at the same time for their pecu- liar influence, and for care to avoid over-excitement, whether local or general. In the form of infusion or of fennel water, it is often employed in infantile cases to relieve flatulent colic, and to obviate nausea. It may sometimes be useful for the former purpose, given as an enema. It is one of the best additions to purgative medi- CHAP. I.J TONICS.—FENNEL-SEED.—CARAWAY. 337 cines, and is often associated with senna, rhubarb, and magnesia, in infusion or mixture. The Infusion may be made in the proportion of two drachms to a pint of water, and given in the dose of two or more fluidounces to an adult, and two or three fluidrachms to an infant. The Volatile Oil (Oleum Funiculi, U. S) may be used in doses of from five to fifteen drops as a carminative or antiemetic; and may be associated with other substances in pill, lozenge, or con- fection, to give them flavour, or enable them to sit better on the stomach. Fennel Water (Aqua Funiculi, U. S) is made by dissolving the oil in distilled water. The dose for an adult is one or two fluid- ounces, for an infant as many fluidrachms. It may also be very properly made the vehicle for medicines given in the form of mixture. There are several other aromatic fruits, the medical properties and uses of which so closely resemble those of fennel, that what is said of one may be nearly as well said of all; one being preferable to another, mainly from its according better with the taste or stomach of the patient. It is unnecessary, therefore, to do more than name them, and very briefly describe their origin and dis- tinctive physical properties. 1. CARAWAY (Carum, U.S.; Carui, EL, Dub) consists of the half-fruits or mericarps, commonly called seeds, of Carum Carui, a small biennial umbelliferous plant, growing wild in many parts of Europe, and cultivated both there and in this country. They are usually separate, about two lines long, rather flat, slightly curved inwards, with five yellowish longitudinal ridges, and intervening spaces of a dark-brown colour. They have an aromatic odour and taste, which depend on a volatile oil. This, when separated by dis- tillation, is at first colourless, but becomes yellow with age, and ultimately brownish. It is lighter than water. The medical pro- perties and uses are the same as those of fennel-seed. An In- fusion is prepared in the same way, and used in the same dose. The Volatile Oil (Oleum Cari, U. S) is likewise used for the same purposes, and in the same manner as that of fennel-seed, in a dose varying from one to ten drops. It is occasionally applied to the relief of toothache, by being introduced upon cotton into the carious cavity. It probably acts by deadening sensibility through vol. i.—22 338 GENERAL STIMULANTS. [PART II. its powerful stimulation. There is an officinal Water (Aqua Carui, Lond), which is used like fennel-water, and an officinal Spirit (Spi- ritus Carui, Lond), which is made by dissolving the oil in proof spirit, and given as a carminative, or adjuvant of other medicines, in the dose of one or two fluidrachms. Caraway was known to the ancients. 2. CORIANDER (Coriandrum, U.S., Lond., Ed) is the fruit of Coriandrum Sativum, a small plant inhabiting Egypt and the South of Europe, and cultivated for use. It is commonly called coriander seed. It is spherical, about the eighth of an inch in diameter, grayish-brown, obscurely ribbed, and separable into two portions or half-fruits. The odour and taste are agreeably aromatic, and must be familiar to all who have eaten the confectionary product called sugar-plums, each of which generally contains one of the fruits. These properties depend on a volatile oil, which, however, is not separated for medicinal use. The fruit may be employed in infusion, and is occasionally added to other substances adminis- tered in this form. It enters into a number of officinal prepara- tions, among which is that excellent laxative, the confection of senna. The dose of powdered coriander is from thirty grains to a drachm. It was known to the ancients, and is mentioned in the Hebrew Scriptures. 3. ANISE (Anisum, U. S., Lond., Ed., Dub) is the fruit of Pirn- pinella Anisum, a small annual plant, native of Egypt and Syria, but introduced into the South of Europe, where, as well as in Germany, it is cultivated for use. Each fruit, commonly called seed, is about a line long, oval, striated, slightly downy, and of a gray yellowish-green colour. It usually has a small footstalk attached. The smell and taste are agreeably aromatic. They depend on a volatile oil, which, when separated by distillation, is lighter than water, colourless, or yellowish, and of the odour and taste of the seeds. Anise imparts its virtues to water, but more readily and largely to alcohol. It is much used for imparting flavour to liqueurs. Its medical virtues are simply those of the aromatics; but it has been supposed to increase the flow of milk, of urine, and the menses, probably without any foundation. The milk, how- ever, is said to acquire the odour of anise when it is taken by nursing women; and it has been asserted to give an unpleasant smell to the urine. The Oil (Oleum Anisi, US) is more em- ployed than the fruit itself. The dose of it is from five to fifteen CHAP. I.] TONICS.—ANISE.—LAVENDER. 339 drops. It is an ingredient in several officinal preparations. There is an officinal Water (Aqua Anisi, Lond., Dub), and an officinal Spirit (Spiritus Anisi, Lond), the former made by dissolving the oil in water, the latter by dissolving it in proof spirit. Anise was' used by the ancients. Poisonous effects have happened in con- sequence of mistaking the seeds of Conium maculatum for aniseed. 1 STAR ANISEED (Anisum Stellatum) is the fruit of Illicium anisatum, an evergreen tree, growing in China, Japan, and Tar- tary. It consists of from five to ten brownish ligneous capsules, four or five lines long, each containing a brown shining seed, and connected together at one end, in a star-like form. It has almost precisely the odour of anise, and yields by distillation a volatile oil, which closely resembles the oil of anise, and is often substituted for it without inconvenience. This is the more singu- lar, as there is no botanical affinity between the two plants. Either the star-aniseed, or its oil may be used for the same purposes as fennel-seed. X. LAVENDER. LAVANDULA. U.S., Lond., Ed., Dub. Origin. Lavender consists of the flowers of Lavandula vera, a small shrub, growing wild in the South of Europe, and cultivated everywhere in gardens. The flowers are arranged around a ter- minal flower-stem, forming long, slender spikes. These are cut, at the commencement of their flowering in August, and tied in bundles, which are sold both fresh and dried. Sensible Properties. The separated flowers are small, blue, and of a remarkably fragrant odour, which they retain long after being dried, sometimes even for years. Their taste is warm, aromatic, and bitterish. Though they yield their virtues in a moderate de- gree to water, alcohol is a much more efficient solvent. Chief Constituents. The flowers contain a volatile oil, a bitter principle, and tannic acid. Though all of these have some activity, the virtues of the medicine depend mainly upon the volatile oil. This is obtained by distillation with water. It is very light, and of a pale lemon-yellow colour, with the fragrance of the flowers, and a burning aromatic taste. Medical Properties and Uses. Lavender has the properties of the aromatics, with a feeble tonic power, and probably a slight stimu- 340 GENERAL STIMULANTS. [PART II. lant influence upon the nervous system. Its odour alone is often refreshing in languor, and general uneasiness; and it is probably more employed in reference to its fragrant properties, than in- ternally as a medicine. Some of its preparations, however, are in considerable vogue. The Volatile Oil (Oleum Lavanduls, U. S) may be given in- ternally in nervous headache and languor, as well as for its cordial aromatic properties, in the dose of from one to five drops. It is, however, much more used in the form of alcoholic solution. The Spirit of Lavender (Spiritus Lavanduls, U S) is made, according to the officinal directions, by distilling alcohol from the flowers; but much more commonly it is prepared by simply dissolving the oil in alcohol, in the proportion of a fluidounce to a gallon. Made in the former method, it is more agreeably fragrant. The lavender water of the shops is usually a solution of this, with some other aromatic oils, in alcohol. Spirit of lavender is useful in the sick room for its grateful and refreshing odour. It may be given internally for the relief of nervous headache, languor, and depression of spirits, in the dose of one or two fluidrachms; but its frequent use might lead to intemperate habits, by originat- ing a fondness for the alcoholic ingredient; and it should not, therefore, be incautiously prescribed. The following, however, is a far more popular preparation. The Compound Spirit of Lavender (Spiritus Lavandula Com- positus, U.S.) is made, according to our national standard, by macerating cinnamon, cloves, and nutmegs, with red saunders to give the preparation colour, in a mixture of the spirit of laven- der and spirit of rosemary. When duly prepared, it is a delight- ful compound of the spices, of which the lavender is not the most important. It is much used in gastric uneasiness, flatulence, colicky pains, nausea, general languor, faintness, depression of spirits, and slight hysterical disorder. But the same caution is necessary in prescribing it, as mentioned in reference to the pre- ceding preparation. It is much employed popularly, under the name of lavender compound, and, it is to be feared, not unfrequently when there is no real occasion. It is one of the best additions to mixtures, in order to recommend them to the taste and the stomach. Its red colour is sometimes of advantage, in otherwise colourless preparations, as in the solution of arsenite of potassa or Fowler's solution, by preventing their being mistaken for water. The dose is a fluidrachm. CHAP. I.] TONICS.—AROMATICS.—ROSEMARY. 341 XI. ROSEMARY. ROSMARINUS. U.S., Ed., Dub. Origin, This consists of the tops of Rosmarinus officinalis, an evergreen shrub, inhabiting the shores of the Mediterranean, and cultivated in the gardens of Europe and this country. As found in our shops, it consists chiefly of the leaves. Sensible Properties. The leaves are distinguished by their linear shape, their length of an inch and more, their breadth about one- sixth of an inch, the faded greenness of their upper and the white- ness of their under surface, and by a singular folding backward of both edges, which causes the colour of their under surface to be concealed on each side by a green border, leaving only a slen- der streak of whiteness in the middle. They have a balsamic odour, and a bitterish and camphorous taste, and yield these pro- perties to water and alcohol, but much more freely to the latter. Active Principle. Rosemary owes its virtues to a volatile oil, which is obtained by distillation with water. It is lighter than water, colourless, of an odour similar to that of the plant, but less agreeable, and a hot somewhat aromatic taste. Medical Properties and Uses. Rosemary, though in some degree aromatic, is more characterized by its stimulant and rubefacient properties. It agrees, however, with the aromatics, in being propor- tionably more stimulating locally, than upon the system at large. Some have considered it as possessing emmenagogue properties; but where it has appeafed to promote the menstrual discharge, it has probably been simply as a general stimulant. In this country it is seldom used internally, except as an ingredient in some officinal preparation, as the compound spirit of lavender. The volatile oil is officinal, as also is a spirit prepared from it. The Oil (Oleum Rosmarini, U.S.) may be given as a carminative, or gastric stimu- lant, in the dose of from three to six drops. The Spirit (Spiritus Rosmarini, U. S) is made by dissolving the oil in alcohol, and is used almost exclusively, either as a perfume, an ingredient in rube- facient liniments, or as one of the constituents of the compound spirit of lavender. 342 GENERAL STIMULANTS. [PART II. XII. PEPPERMINT. MENTHA PIPERITA. U. S., Lond., Ed., Dub. Origin. Peppermint is the herb of 3Ientha piperita, a small, her- baceous perennial, indigenous in Europe, but naturalized in this country, and cultivated largely for use in England and the United States. The herb should be gathered at the flowering period in August. Sensible Properties. Peppermint has a quadrangular stem, branch- ing near the top, from one to two feet long, with leaves opposite, petiolate, ovate, serrate, pointed, dark-green on the upper surface and paler on the under. The flowers are small, purple, and arranged in terminal spikes, which are rounded at top, and interrupted be- neath. All parts of the plant are aromatic, either fresh or dried; but the herb rapidly deteriorates by keeping, and at length be- comes inert. It has a penetrating, grateful, somewhat camphorous odour, and a pungent, glowing, camphorous, bitterish taste, which is followed by a sense of coolness when the air is drawn through the mouth. Active Principles. The virtues of the herb may be said to de- pend exclusively on its volatile oil; for, though there is a trace of tannic acid, and probably a small proportion of some bitter prin- ciple, these are insufficient materially to modify its effects. The volatile oil is obtained by distillation with water. It is at first nearly colourless, but gradually becomes greenish-yellow, and ultimately reddish-brown. Its odour and taste are like those of the herb. It is lighter than water. It is often adulterated, espe- cially with alcohol, which, if in considerable quantity, may be readily detected by agitation with water, which abstracts the alco- hol from the oil, and thus diminishes its bulk. Medical Properties and Uses. Peppermint has all the character- istic properties of the aromatics, and may be used for all their general purposes (see page 313). The fresh herb is sometimes applied externally, well bruised, over the stomach and bowels, in infantile vomiting and colic. It is a good remedy, thus employed, in the earlier stages of cholera infantum. Internally the medicine may be given, in the form of infusion, in colicky pains and flatu- lence; but the preparation almost universally employed in this way is the volatile oil. r CHAP. I.] TONICS.—AROMATICS.—PEPPERMINT. 343 The Infusion, made in the proportion of half an ounce to a pint, may be given in doses of a wineglassful. The Oil (Oleum Menths Piperits, U.S.) is very much used in this country, being almost universally preferred to the herb for obtaining the effects of the medicine by internal exhibition. The dose of it is from one to three drops, which may be prepared for administration by first rubbing it with a little loaf sugar, and then mixing with water. In consequence, however, of its extreme pun- gency, the oil is usually given dissolved in water or alcohol, in one of the following preparations. Tincture of the Oil of Peppermint (Tinctura Olei Menths Pi- perits, U. S), or essence of peppermint, as the preparation is gene- rally called, is made by dissolving two fluidounces of the oil in a pint of alcohol. It is of such a strength as to admit of being taken into the mouth, simply dropped on a piece of sugar. It is a very popular preparation, and often used for the relief of nausea, gastric pains, colic, and flatulence. The dose is from ten to twenty drops. It may be given as above stated, simply dropped on a piece of sugar, or diffused by means of sugar in water. Spirit of Peppermint (Spiritus Menths Piperits, Lond) is a much weaker solution than the last mentioned preparation, contain- ing only three fluidrachms in a gallon of alcohol. It is objection- able on account of the large proportional amount of alcohol, which renders that liquid the chief ingredient. In this country it is scarcely used. Peppermint Water (Aqua Menths Piperits, U.S.), formerly prepared by distilling water from the fresh herb, is now made by simply dissolving the oil in water, through the intervention of car- bonate of magnesia. It is probably more used in this country as a vehicle for substances given in the form of mixture, than any other aromatic preparation. It serves to render the mixture more accept- able both to the palate and stomach, and to obviate any tendency it may have to cause griping. Each fluidounce of it contains about a minim of the oil. It may be given internally, for the ordinary purposes of the medicine, in the dose of from one to three fluid- ounces. Peppermint Lozenges (Trochisci Menths Piperits, U S), con- sisting of the oil, sugar, and mucilage of tragacanth, afford a con- venient form of the medicine for slight cases; as they may be carried in the pocket, and one of them taken as required. They are to be allowed slowly to dissolve in the mouth. They are, how- 344 GENERAL STIMULANTS. [PART II. ever, very feeble; ten of them being scarcely equivalent to a minim of the oil. XIII. SPEARMINT. MENTHA VIRIDIS. U.S., Lond., Ed., Dub. This is the herb of 3Ientha viridis, an herbaceous perennial plant, like the above species a native of Europe, and naturalized in this country, where it is also cultivated for use. The herb differs from peppermint in having lanceolate, nearly sessile, and lighter-coloured leaves, and elongated, pointed spikes of flowers, whence the name of spearmint was derived. The brighter greenness of the leaves probably originated the specific name of viridis or green. The plant is often called simply mint; and, when that term is used without a qualifying epithet, it may be understood as applied to the present species. Its smell and taste are analogous to those of peppermint, but peculiar, and by some preferred. Others, however, and probably the greater number, give precedence to the mentha piperita. The active principle is the volatile oil; though, as in peppermint, there is a small proportion of tannic acid and of a bitter principle. The oil closely resembles that of the other species. The same resemblance extends to the medical properties and uses of the two mints; but the spearmint is thought to be some- what the weaker of the two. The same preparations are used, and in about the same doses. Those of spearmint, recognized by the U.S. Pharmacopoeia, are the Volatile Oil (Oleum Menths Viridis, U. S), of which the dose is from two to six drops; the Tincture of the Oil, or the Essence of Spearmint (Tinct. Ol. Menths Viridis, U. S), of which from twenty to forty drops may be given; and the Spear- mint Water (Aqua Menths Viridis, U. S), used in the same man- ner as the corresponding preparation of peppermint. The London College recognizes a Spirit of Spearmint (Spiritus Menths Viridis, Lond), which might well be dispensed with; and the Dublin Col- lege an Infusion (Infusum Menths Viridis, Dub.) or common mint tea, which is made in the proportion, as near as may be, of half an ounce to the pint, and may be given without special limit. CHAP. I.] TONICS.—AROMATICS.—PENNYROYAL. 345 There are several aromatics of minor importance, consisting of the herb or leaves of plants, which, though not extensively used, are yet sufficiently so to require a brief notice, and may, perhaps, be best introduced in a subordinate position here. 1. EUROPEAN PENNYROYAL (Pulegium, Land., Ed., Dub.) is the herb of 3Ientha Pulegium, a European plant, having properties analogous to the mints above described, though less agreeable as an aromatic, and much less employed. It is used considerably in England as a domestic remedy in amenorrhoea, hysteria, and hoop- ing cough. In this country it is unknown. All the British Col- leges direct the Volatile Oil (Oleum Menths Pulegii), and the Pennyroyal Water (Aqus Menths Pulegii); the Dublin College, an Essence (Essentia Menths Pulegii); and the London a Spirit (Spiritus Menths Pulegii); all of which maybe given in the same doses as the analogous preparations of peppermint. 2. AMERICAN PENNYROYAL (Hedeoma, U. S) is the herb of Hedeoma pulegioides, a small indigenous annual, growing in all parts of the United States, usually preferring dry sterile, or im- poverished fields, and sometimes, from its abundance, scenting the air for a considerable distance. Both fresh and dried, it has an agreeable aromatic odour, resembling somewhat the European pen- nyroyal from which it derived its name, and a warm, pungent, camphorous taste. These properties reside in a volatile oil, which may be separated by distillation. The oil is lighter than water, of a light pale-yellow colour, and a smell and taste similar to those of the plant. The herb imparts its virtues to hot water, but more freely to alcohol. The effects of hedeoma upon the system are very analogous to those of the mints; and, like these, it may be used "to correct nausea, relieve flatulent pains, and cover the taste or correct the action of other medicines. When given in the form of hot infu- sion, in large draughts, it often, like most other aromatic herbs, produces perspiration, and promotes the flow of the menses. Hence, it is considerably employed, in domestic practice, in com- mencing catarrh and rheumatism, and to promote menstruation; the feet being at the same time well soaked in hot water, and the patient covered warmly in bed. There is no doubt that the remedy, thus aided, is not unfrequently successful. As an emmenagogue it is most efficient in recent cases, and given at the regular monthly period, when it comes in aid of the tendencies of the system. It 346 GENERAL stimulants. [part II. has little effect in obstinate cases. It has been used also, like the European herb of the same name, in hysteria and hooping-cough. The Infusion may be made in the proportion of half an ounce to the pint, and given in doses of from two to four fluidounces or more. The Volatile Oil (Oleum Hedeoms, U. S) is officinal, and may be employed with the same objects as the infusion, in the dose of from two to ten drops. It is sometimes used externally as a rubefacient. A water and essence of pennyroyal may be prepared from the oil, in the same manner as the similar preparations of the mints, and used in the same way. 3. HORSEMINT (Monarda, U.S.) is the herb of Monardapunc- tata, an indigenous herbaceous plant, a foot or two high, growing 'preferably in light and gravelly soils, from New Jersey to the Gulf of Mexico. Its odour is aromatic, its taste warm, pungent, and bitterish. These properties depend on a volatile oil, which is ob- tained by distillation, is of a reddish-amber colour, an odour similar to that of the plant, and a hot, very pungent taste. Hot water will extract the virtues of the herb, but alcohol is a better solvent. Horsemint has the aromatic properties of the proper mints, but is more stimulating and less agreeable. It may be used as an anti- emetic and carminative, and as a stimulant to the stomach in lan- guid states of that organ; but is little employed in regular practice. An infusion may be made in the proportion of half an ounce to the pirit, and given in wineglassful doses. Drank warm and freely, it will often induce perspiration, and has been thought to act as an emmenagogue; and, taken cold, it has been supposed to stimulate the kidneys. Hence it has been used in suppression of the menses, and of the urine. The Volatile Oil (Oleum Monards, U.S.) is more used. It may be given as a stimulant and carminative in the dose of two or three drops, mixed with sugar and water; but it has attracted more atten- tion as an active rubefacient. Applied to the skin, it causes red- ness, heat, and pain, and sometimes blisters. In cases not demand- ing a powerful and speedy impression, it should be diluted with olive oil before application. 4. COMMON MARJORAM (Origanum, U. S., Ed) is the herb of Origanum vulgare or common marjoram, a perennial, herbaceous plant, growing wild both in Europe and the United States, and in this country found especially by the road-sides, from Pennsylvania to Virginia. It bears a rather conspicuous summit of pinkish- CHAP, i.] TONICS.—ORIGANUM.—THTME. 347 purple, or rose-coloured flowers, which appear during the summer and early part of autumn. The herb has an agreeable aromatic odour, and a warm pungent taste. For these properties it depends on a volatile oil, which is separated by distillation, and for which alone the plant is now recognized as officinal. The oil as first pre- pared is yellow, but becomes reddish by age, and is said to acquire the same colour when over-heated in distillation; but it may be obtained colourless by rectification. It is lighter than water, has the odour of the plant, and a hot acrid taste. Origanum is a stimulating aromatic, and will answer the same purposes as the mints; but, being less agreeable to the taste, and probably less cordial in its influence on the stomach, is little used. Like pennyroyal and horsemint, it has been supposed to be diaphoretic and emmenagogue; but, like them, probably acts in this way simply as a general stimulant, and when aided with suit- able accompaniments, such as hot water in the form of infusion, and hot pediluvia. The oil is a powerful local irritant, and is some- times employed as such externally, either alone, or in connexion with other medicines. Diluted with olive oil, it is used as a liniment in baldness, rheumatism, sprains, bruises, and paralytic affections. Occasionally it is employed to relieve toothache, being introduced on lint or cotton into the carious hollow. It is an ingredient of the Camphorated Soap Liniment of our Pharmacopoeia, so much em- ployed, under the common name of opodeldoc, as an anodyne and gently rubefacient application. Sweet marjoram (Origanum Majorana) has been used, in powder, as an errhine, but has lost its place in the officinal lists, and is now seldom employed except as a spice in cooking. 5. THYME (Thymus) is the herbaceous part of Thymus vulgaris, a small undershrub, growing wild in the South of Europe, and cultivated in our gardens. It has a characteristic, strong, agreeable odour, which it retains when dried, and a pungent, aromatic, cam- phorous taste. These properties reside in a volatile oil, which is obtained, in the native districts of the plant, by distillation, and is said to be sent into commerce largely, under the name of oil of origanum, by which it is often sold in the shops. It is lighter than water, and has at first a pale-yellow or greenish-yellow colour, which it gradually exchanges for a reddish-brown. Thyme has the medicinal properties of the aromatics, but is much more used in cooking than in medicine. 348 GENERAL STIMULANTS. [PART II. 6. SAGE.—Salvia. U.S. Sage consists of the leaves of Salvia officinalis, or common garden ■sage, an undershrub of two feet or more in height, originally from the South of Europe, but cultivated everywhere in gardens. They have a strong fragrant odour, and a warm, bitterish, aromatic, and somewhat astringent taste. They contain tannic acid, and probably a bitter principle; but their virtues depend mainly on a volatile oil, which exists in them in large proportion. The virtues of sage are those of a gentle tonic and astringent, and an efficient aromatic. In addition to its excitant influence upon the digestive organs and the circulation, it has been supposed also to stimulate the nervous and genital systems, and, when suit- ably aided, no doubt promotes perspiration. By the ancients it was very highly esteemed, and retained its credit as a remedy among the earlier moderfl Europeans, as evinced by the dictum of the school of Salerno, "Cur moriatur homocuiSalviacrescitin horto" It was used as a stimulant tonic in weakness of digestion and general debility, as an astringent in checking profuse sweats, and excessive lacteal secretion, as a febrifuge in paroxysmal fevers, as a diaphoretic in catarrh, and as an antispasmodic in various nervous affections. From these over-estimates of its virtues, it has fallen into probably unmerited disrepute, and has been abandoned by the British authorities, though retained in the secondary list of our own Pharmacopoeia. It may be used with advantage as an anti- emetic, carminative, and gentle stimulant to the stomach and bowels, especially when there is enfeebled digestion, with a tend- ency to diarrhoea. But the chief use now made of it medicin- ally is as a gargle in common sore throat, and relaxation of the uvula, for which purpose it is employed in the form of infusion, and often associated with honey, and alum or vinegar. It is much used as a condiment in cookery, especially in the filling of roasted poultry, and in sausages. As a gargle, and when all its effects on the system are demanded, the infusion should be prepared by macerating an ounce of the leaves in a pint of boiling wa- ter, and the maceration continued till it cools. Two fluidounces may be given for a dose. When wanted to relieve nausea, or as an agreeable drink in febrile affections, the maceration should be shortened, so that the whole of the bitterness may not be extracted." 7. BALM. —Melissa. U.S. Balm is the herb of 3felissa officinalis, a perennial herbaceous plant, a foot or two in height, originally from the South of Europe, CHAP. I.] TONICS.—BALM.—PARTRIDGE-BERRY. 349 but naturalized in this country, and cultivated in our gardens. The leaves have, when fresh, a very agreeable lemon-like odour, which is nearly lost when they are dried, and entirely when they are long kept. In the recent state, they have a feebly aromatic and some- what austere taste; in the dried, impart a slight degree of rough- ness to water. The fresh herb contains a little volatile oil, tannic acid, and bitter matter. Water extracts all its virtues. Upon the system it exerts but a very feeble influence; and it is chiefly employed, in the form of infusion, as an agreeable drink in fevers, and, taken warm, to promote the operation of diaphoretics. The infusion may be made with half an ounce or an ounce of the herb, to the pint of water. The fresh or recently dried herb should be preferred. XIV. PARTRIDGE-BERRY. GAULTHERIA. U.S. Origin. Gaultheria consists of the leaves of Gaultheria procum- bens, an indigenous, small, shrubby evergreen, inhabiting the woods or hill-sides, and dry sandy plains, from Canada to Georgia. It has a creeping, horizontal root, from which, at short intervals, erect stems arise, a few inches high, bearing the leaves near the summit, and a small spherical, scarlet, berry-like fruit. The plant is known by other names, as tea-berry, mountain-tea, winter-green, &c. Sensible Properties. The leaves, which are the officinal part, are ovate or obovate, an inch or more in length, acute, revolute at the edo-es, with a few mucronate serratures, coriaceous, shining, of a bright green colour on the upper surface, and paler beneath. These, as well as the whole plant, including the fruit, have a very peculiar fragrant odour and aromatic taste, very similar to that of the Betula lenta or sweet-birch, and ascribable to a volatile oil, which is the same in both plants, and exists also in some others having similar sensible properties. Besides the aromatic properties above re- ferred to, the leaves have a decided astringency, and the fruit is sweet. Active Principle. The volatile oil is obtained by distillation with water. It is the heaviest of all known volatile oils, having the specific gravity 1.173. When first procured, it is nearly colour- less ; but, as found in the shops, is generally brownish-yellow or 350 GENERAL STIMULANTS. [PART II. reddish. The odour is that of the plant, the taste sweetish, some- what pungent, and very peculiar. 3Iedical Properties and Uses. Gaultheria is a gently stimulant aromatic, and feeble astringent. For these properties, it has been used in some cases of chronic diarrhoea, and with supposed benefit. Like many other aromatics, it has been given as an emmena- gogue; but has no other claim to this title than such as its gently stimulating property may give it. As a stomachic cordial and carminative, and for the relief of the flatulent colic of infants, it may be used like other aromatics, over which, however, it has no superiority. It has been sometimes used by people in the country, in the form of infusion, as a substitute for common tea. Its chief claim to notice, however, rests on its remarkable, and very peculiar flavour, which serves to characterize preparations, into the compo- sition of which either the leaves or the volatile oil enter. The Oil (Oleum Gaultheris, U.S.) is more or less employed throughout the country, dissolved in alcohol in the form of an essence, for the same purposes as the oils of the mints. It may be prepared in the same way, and given in the same dose, as the essence of spearmint. In large quantities, the oil is capable of producing inflammation of the gastric mucous membrane. A case is on record in which half an ounce was swallowed, and occasioned the most alarming gastric symptoms, though the patient recovered. In the quantity of about a fluidounce, it is stated to have caused death in several instances, leaving strong marks of inflammation of the stomach. The oil is an ingredient of the Compound Syrup of Sarsaparilla of the U.S. Pharmacopoeia. XV. GINGER. ZINGIBER. U. S, Lond., Ed, Dub. Origin, Ginger is the root or rhizoma of Zingiber officinale, a biennial or perennial plant, two or three feet in height, a native of Hindostan, and cultivated in various parts of the East Indies, in the West Indies, and at Sierra Leone in Africa. Varieties and Sensible Properties. Ginger comes in several differ- ent states. Sometimes it is imported fresh, and is then called recent ginger. As ordinarily used in medicine, it is in two states; in one, with the epidermis remaining more or less completely, and prepared CHAP. I.] TONICS.—AROMATICS.—GINGER. 351 simply by exposure to the action of boiling water, so as to destroy the life of the root, and prevent germination; in the other, wholly deprived of the epidermis, and often whitened by a bleaching pro- cess. The former is called black ginger, or is designated by the places from which it is derived; the latter is named white ginger, and often Jamaica ginger, from the island of that name, whence this variety was first brought into commerce. Ginger is also imported in the form of a preserve; the tender young offsets from the old roots being selected for its preparation. Recent ginger is flattish, about three inches long, with short obtuse branches- or lobes, on the surface of a light ash colour, internally fleshy and yellowish-white. It will keep for a considerable time, but is apt to germinate in warm weather. Black or coated ginger is somewhat shrunk in drying, with a darkish, ash-coloured, wrinkled epidermis, which in some specimens is absent in spots, where the surface is blackish from exposure, and has thus given name to the variety. Within the epidermis is a brownish and somewhat horny layer; but the central portion is whitish and farinaceous. The powder is of a light yellowish-brown colour. White or Jamaica ginger is wholly destitute of epidermis, more slender and rounder than the preceding, white externally, internally also whitish, and yielding a white or yellowish-white powder. Much of this "variety is now imported from the East Indies; but, as ob- tained from this source, it is not so white as that from Jamaica. The odour of ginger is aromatic and penetrating; its taste hot, pungent, biting, and aromatic. Jt yields its virtues to water and alcohol; but more completely and largely to the latter. It is apt to be injured by worms, when long kept. Chief Constituents. The active principles of ginger appear to be a volatile oil, and a resinous or resino-extractive matter; the flavour probably residing in the former, ancVthe acrid property mainly in the latter. There is also a considerable proportion of starch and gum, which render certain precautions essential in preparing the syrup. 3Iedical Properties and Uses. Ginger was employed by the an- cients. It is a very grateful stomachic stimulant, having some incitant effect also on the circulation, and is one of the most useful of the aromatics. In pure dyspepsia it is often used with much benefit, either alone or in combination; and, when added to tonics, in this affection, it renders them at once more acceptable and effi- 352 GENERAL STIMULANTS. [PART II. cient. In the feeble condition of the digestive organs attendant on atonic gout, it is also an excellent adjuvant to other measures. It is one of the best carminatives; and, in the form of hot infusion, is much employed in simple spasmodic or flatulent colic, especially in children. As a preventive of cholera, its cordial influence upon the digestive organs renders it peculiarly appropriate; and, in the epi- demics of this complaint, it has been among the prophylactic medi- cines most relied on. It is very frequently used in connexion with tonics and purgatives; with the former, to increase their stimu- lant effect; with the latter, to obviate griping; and with both, to cover their taste, and mitigate or prevent their nauseating effects. It is also very much used as a condiment in cookery. Locally, ginger is actively irritant. When chewed, it produces a burning and painful sensation in the mouth, and increases the flow of saliva. Hence it is sometimes employed as a masticatory in toothache, rheumatic affections of the jaws or neighbouring parts, re- laxation of the uvula, and palsy of the tongue, or other part of the mouth or fauces. Snuffed up the nostrils, it produces sneezing, and increases the secretion of mucus, and is, therefore, occasionally used as an errhine. Upon the surface of the body it acts as a rubefacient; and the powder, formed into a cataplasm with warm water, may often be advantageously applied to the cheeks in toothache, the forehead in headache, and over the stomach in irritable states of that organ. Administration. Ginger is given internally, in the forms of pow- der, infusion, tincture, and syrup. The dose of the powder is from ten to thirty grains. In this state it is often combined with powdered columbo, and subcarbonate of iron, and is an ingredient in* the Pulvis Aromaticus of the Pharma- copoeias. The Infusion (Infusum Zingiberis, U. S) is made in the propor- tion of half an ounce of the bruised or powdered root to a pint of boiling water. The dose is one or two fluidounces; but it may be given more freely in urgent cases, especially of flatulent colic. In that affection, a small bowlful, sweetened, may sometimes be drank with advantage. In this form, ginger is much used in connexion with the simple bitters, as gentian, quassia, and columbo, and with cathartics, especially senna and rhubarb. The Tincture (Tinctura Zingiberis, U. S) is, according to the directions of our national code, made very strong, to fit it for the preparation of the syrup; but this concentration has also the advan- CHAP. I.] TONICS.—AROMATICS.—GINGER. 353 tage of increasing the proportion of the aromatic, and diminishing that of alcohol. This is the more necessary, as it is officinal alco- hol, and not diluted alcohol or proof spirit, that is used as the menstruum; the latter causing the tincture to become turbid, in consequence of the quantity of mucilage dissolved. Under the name of essence of ginger, a still more concentrated preparation is made, either by employing a larger proportion of ginger, or preferably by evaporating a portion of the alcohol of the tincture, and filtering. Either of these preparations may be given as a carminative and stomachic stimulant, or added to tonic and purgative infusions, tinctures, and mixtures, in debilitated states of the alimentary canal. The dose of the tincture is from forty minims to a fluidrachm, that of the essence, according to the degree of its concentration, from twenty to forty minims. The Syrup (Syrupus Zingiberis, U.S.) is prepared from the tincture, because, by this method, the starch and gummy matter of the root are avoided, which, if present in the syrup, would dispose it to spoil. The alcohol is drawn off during the process. Syrup of ginger is an excellent addition to tonic and purgative infusions, and to other liquids used for drink, especially to carbonic acid water, when one of the alkaline carbonates or bicarbonates is ex- hibited with it in solution, as these are incompatible with most of the ordinary syrups, in consequence of the acid they contain. It is also a good vehicle for substances in powder, the taste of which it covers while it gives them a suitable consistence for exhibition. Rubbed up with magnesia or its carbonate, it enables that medicine to be readily and uniformly suspended in water; at the same time covering its taste, and obviating its nauseating effect. A fluidrachm of it may be added to every fluidounce or two of the liquid with which it is administered. Ginger lozenges, as prepared by the confectioners, if well made, often answer a good purpose in relieving gastric uneasiness and flatulence; and ginger beer is one of the most wholesome of its class of beverages. In its various forms, ginger is employed, as an adjuvant or corri- o-ent, in a considerable number of officinal preparations. vol. i.—23 354 general stimulants. [part ii. The three following roots appear to me worthy of a brief notice, either for their former reputation, or present use, however limited the latter may be. 1. ZEDOARY—Zedoaria. Two kinds of zedoary are noticed by authors, the round and the long; but it is only the former that is now to be found in the shops. The round zedoary is the root of Curcuma Zedoaria, grow- ing in the East Indies, where it is cultivated. It is usually in slices, which are the halves or quarters of a roundish root, ending in a point. These are marked, on their convex surface, with the sections of circular rings, which in the whole root surround it hori- zontally, and with small projecting points, which are the remains of the radical fibres. The root is grayish-white on the outside, yel- lowish-brown and somewhat marbled on the freshly cut surface, hard, and compact. Its odour is agreeably aromatic, and its taste bitterish, pungent, and camphorous. Its activity resides mainly in a volatile oil; but the bitterness is probably dependent on a distinct principle, which may add a slight tonic influence to the aromatic properties of the root. Its medical properties and effects are essen- tially the same as those of ginger, though weaker. It is at present seldom if ever used in this country. The dose is from ten to thirty grains. 2. TURMERIC—Curcuma. U.S., Ed. This is the root of Curcuma longa, a small perennial plant, indi- genous in the East Indies and Cochin China, and abundantly culti- vated in various parts of Southern Asia. There are two varieties, both produced by the same species of Curcuma, but distinguished by their shape, one being long, and the other round, and therefore named curcuma longa and curcuma rotunda. The former, or long turmeric, is much more abundant in the market than the latter. It is cylindrical, about as thick, but generally not quite so long, as the little finger, tuberculated, and somewhat contorted. The latter, or round turmeric, is round or oval, about the size of a pigeon's egg, or somewhat larger, and marked externally with numerous annular wrinkles. Both are yellowish on the outside, and of a deep orange yellow within, compact, hard, exhibiting, when broken, a wax-like fracture, and yielding a yellow or orange-yellow powder. Turmeric has a peculiar aromatic odour, and a warm, bitterish, somewhat aromatic taste, and tinges the saliva yellow when chewed. Its medi- cal properties probably reside exclusively in a volatile oil, which is chap. i.J TONICS.—TURMERIC.—CALAMUS. 355 yellow and acrid. It contains, however, another interesting prin- ciple, denominated curcumin, on which its colouring properties, and its use as a chemical test, depend. (See U. S. Dispensatory) It formerly had some reputation as an aromatic, resembling ginger in its action on the system, though less efficient, and also less agree- able. It was also supposed to have a special influence upon the biliary organs, probably from its yellow colour, and was used in jaundice and visceral disease. At present, it is scarcely used as a medicine, and probably never in this country. As a condiment, however, it is largely consumed in the East, entering into the com- position of most of the curries so much in favour there. Its chief use here is as a test for alkalies, which change its yellow colour to brown. For this purpose it is employed in the form of tincture, or of turmeric paper. The powder might be exhibited in the dose of from ten to thirty grains. 3. CALAMUS. U S. This is the root (rhizoma) of Acorus Calamus or sweet flag, an in- digenous plant, growing also in Europe and Western Asia, and, in this country, abounding in low meadowy grounds, too wet for the culture of the useful grasses. The plant may be distinguished, by those not acquainted with its botanical character, from the young cat-tails, and coarse grasses with which it is.frequently associated, by the aromatic odour of the leaves when bruised, and their aro- matic taste. The root is horizontal, jointed, somewhat flattened above and below, often several feet long, from half an inch to an inch thick, with numerous fibres or radicles proceeding from its under surface, which are cut off when it is dried, leaving little, round, permanent spots. When dried, it shrinks much. As kept in the shops, it is in pieces of various lengths, wrinkled, yellowish- brown externally, and whitish or yellowish-white internally. In some pieces the exterior cortical part has been removed, leaving the inner portion, while the exposed surface acquires a grayish- white colour. The odour is strong and fragrant; the taste warm, bitterish, pungent, and aromatic. It yields its virtues to boiling water. These may be considered as residing exclusively in a vola- tile oil, which is occasionally separated by distillation, is yellow, and has an odour and taste analogous to those of the root. There is said also to be an acrid extractive matter; but too little is known of it to justify the ascribing to it of any of the virtues of the medicine. Starch is another ingredient. 356 GENERAL STIMULANTS. [PART II. Calamus has been known from ancient times. It has medical virtues closely analogous to those of ginger, for which it might be substituted in most cases, though it is generally much less accept- able to the palate. There is one use of it which I would recom- mend from experience. Having some tenacity, though sufficiently brittle to be easily broken by the teeth, it may be carried in the pocket, and a little of it chewed as wanted. In this way it will often afford great relief to the gastric uneasiness, spasmodic pains, and flatulence so frequently attendant on dyspepsia, nervous gout, and hysterical affections. The dose of it in substance is from twenty grains to a drachm. An infusion made with half an ounce or an ounce of the root to a pint of boiling water, may be taken in the.dose of two fluidounces or more. 4. WILD GINGER.—Asarum. U.S.— Canada Snakeroot. Wild ginger is the root (rhizoma) of Asarum Canadense, a very small,' perennial indigenous plant, growing in wooded grounds, from Canada to Georgia. All parts of the plant have an agreeable aromatic odour, which is strongest in the root. This is in long, somewhat contorted pieces, of the medium thickness of a crow- quill, hard and brittle, externally wrinkled and brownish, inter- nally whitish, and often furnished with short radicles. Its taste is aromatic, bitterish, and grateful, bearing some resemblance to that of cardamom. The active principles are a volatile oil, and a bitter acrid resin. Water extracts them partially, alcohol completely. Wild ginger is a stimulant aromatic, with tonic and diaphoretic properties, somewhat analogous to serpentaria in its operation, but with less of the characteristic effects of the simple bitters, and approaching more nearly the subdivision of tonics in which it is here placed. It may be used as a gentle stimulant and diaphoretic in low fevers; but I should be more disposed to employ it for the same purposes as ginger, for which the country people are said occasionally to substitute it, and its affinity for which is indicated by one of its common names. It might be appropriately used as an adjuvant of tonic and purgative infusions, in debilitated states of the alimentary canal. The dose of the powder is twenty or thirty grains. It may be given also in infusion, made with half an ounce of the root and a pint of boiling water, in the dose of two fluidounces. It would form an elegant tincture, which might be made by macerating four ounces in two pints of diluted alcohol, and used, as an addition to tonic infusions, in the quantity of one or two fluidrachms for each dose. CHAP. I.] TONICS OF MINERAL ORIGIN. 357 III. Tonics of Mineral Origin. There is sufficient ground, in the different properties exercised by the different mineral tonics, for arranging them in three subdi- visions ; one, including those which, so far as their pure and direct tonic action is concerned, operate exclusively on the mucous mem- brane of the alimentary canal; a second, those which act on the system at large, and produce their effects by a direct influence upon the vital properties of the tissues, without entering necessarily into their composition; and a third, those which, though they may pos- sibly operate in the mode just mentioned, are nevertheless pecu- liarly characterized by forming an essential element of some con- stituent of the body, and produce their remedial effects, either by increasing the amount of this constituent, or restoring it when dis- eased to its normal state by supplying a wanting ingredient. In the first subdivision may be ranked the mineral acids, as the sul- phuric, nitric, muriatic, and phosphoric; in the second, the pre- parations of silver, copper, zinc, and bismuth; and in the third, the preparations of iron, 1. Mineral Tonics Acting on the Stomach and Bowels. Mineral Acids. The peculiarity of this subdivision is owing simply to the cir- cumstance that, in consequence of their strong chemical affinities, they seem to be incapable of absorption into the circulation un- changed. Either their disposition to combine with salifiable bases causes them to be neutralized in the alimentary canal, and thus to lose their acid character; or a similar change in their nature takes place by union with one or more of the organic principles they meet with, as albumen for example, with which they readily unite; or they undergo decomposition; or lastly, they remain un- changed in the primaa viae till expelled with the feces. Indeed, this incapability of absorption unchanged, is probably essential to the prevention of poisonous effects from them; as they might very dangerously react on the blood itself through their chemical affini- ties. Their direct effects, therefore, as mineral acids, are confined to the alimentary canal. Various secondary effects result, to which it will be necessary to call attention in considering them severally. 358 GENERAL STIMULANTS. [PART II. These may even be of a tonic character; but the acids are, never- theless, not less distinctly characterized, as a subdivision, by the peculiarity referred to. I. SULPHURIC ACID. ACIDUM SULPHURICUM. U.S., Lond., Ed., Dub. Sulphuric acid was known as early as the seventh century. As found in commerce, it is often called oil of vitriol, and is more or less impure, containing, among other foreign bodies, a small propor- tion of sulphate of lead, which, however, is thrown down when the acid is diluted with water; so that practically its presence is of less importance than might have been supposed. For an account of the chemical properties and characteristics of this acid, the reader is referred to the U.S. Dispensatory. I shall here treat of its relations to the human system, and afterwards of its pre- parations; premising that the strong acid, though much employed as a pharmaceutical agent, and sometimes as a caustic, is never directly prescribed for internal use. Effects on the System. When taken in very small doses, suffi- ciently diluted with water, sulphuric acid produces at first no other observable effect than to increase the appetite. But, after a short time, digestion and secondarily nutrition are found to have been promoted; and a tendency to constipation is sometimes evinced. It is said also somewhat to reduce the frequency and fulness of the pulse, and to diminish the temperature of the body, especially if previously elevated; though I cannot say that I have myself ever noticed these effects. Dr. Christison, in his Dispensatory, states that it is also diuretic, and that it sometimes succeeds in producing an increased secretion of urine in dropsical effusions, when other powerful diuretics have failed. With these properties, sulphuric acid must be considered as tonic, astringent, refrigerant, and diu- retic. If given too freely, it produces uneasiness in the stomach, dis- turbance of digestion, griping pains in the bowels, and often purg- ing; and the same effects may result from its too long continuance in proper medicinal doses. They are the direct consequence of its irritant action on the alimentary mucous membrane. * In large quantities, and even in smaller if taken in the concen- CnAP. I.] MINERAL TONICS.—SULPHURIC ACID. 359 trated state, as not very unfrequently happens by mistake, in con- sequence of the extensive use of the acid in the arts, it very quickly produces burning pain in the mouth, fauces, and stomach, with nausea and generally vomiting of bloody or dark coloured liquids, followed by excruciating pains in the bowels, sometimes attended with constipation, sometimes with purging and bloody stools. The voice often becomes hoarse from inflammation of the glottis; the breath sometimes fetid from the decomposition of the destroyed tissues; and generally, when a corrosive effect has been produced, great prostration comes on, with a cold surface, feeble and irregular pulse, intense anxiety, and incessant jactitation, which soon end in death; the mind remaining unclouded not unfrequently even to the very last. The fatal result sometimes takes place in a few hours, but more frequently at a period varying from twelve hours to two or three days, and occasionally is much longer protracted. When the .quantity has not been sufficient to cause immediate death, the case may run on for weeks or months, with frequent vomiting of membranous flakes, fetid breath, great disturbance of the general system, and gradual emaciation, under which the pa- tient at length sinks. Sometimes the effects are confined to the mouth and fauces; complete deglutition having been prevented by the excessive irritation, or other cause; and great destruction or inflammation of these parts may ensue, from which the patient may or may not recover. The appearances after death are those indi- cative of inflammation and disorganization of the mucous mem- brane. In some places, the surface is reddened by congestion; in others, whitened from a combination of the acid with the albumen of the tissue; and in others again, blackened by its decomposing effect, the blood being coagulated in the surrounding vessels. Death results from the direct action of the acid on the alimentary mucous membrane, and probably in no degree through its absorp- tion into the blood-vessels. Dr. Christison states that the smallest fatal dose of sulphuric acid which he had found recorded was a drachm, or somewhat more than half a teaspoonful. Patients, however, not unfrequently survive the effects of much larger quan- tities. A case of recovery is recorded after six drachms had been swallowed; but such a result must be very rare, and could probably occur only in consequence of a prompt evacuation or neutralization of the poison. From a few drachms of the dilute officinal preparation of the acid, recovery may be reasonably hoped 360 GENERAL STIMULANTS. [PART II. for, if prompt measures of relief are applied, or the immediate occurrence of vomiting has caused nearly all the poison to be thrown off. A patient got well after taking ten drachms of the aromatic sulphuric acid, or elixir of vitriol, which had brought on vomiting and purging of blood. (Lond. 3Ied. Gaz., xxv. 944.) The treatment of poisoning by sulphuric acid consists in the prompt exhibition of substances fitted to neutralize the acid, with diluent drinks to favour the complete washing out of the stomach, and afterwards in the use of measures calculated to allay the inflammation, and support the patient, if necessary, until the recu- perative processes shall have been completed. The best antidotes are magnesia, chalk, and the bicarbonates of potassa and soda; but, in the absence of these, any salifiable base which may happen to be nearest should be at once resorted to, as soap, whiting, or even wood ashes mixed with water. The inflammation may be treated with demulcent drinks, and the ordinary antiphlogistic measures, carefully graduated to the amount of reaction, and the probable future strength of the patient. Where the stomach rejects everything, attempts should be made to support the system by animal broths injected into the rectum. Mode of Operating. The first effect of the acid, given medicinally, is to stimulate the function of digestion. It probably enables the stomach to secrete the gastric juice more freely, upon the applica- tion of its proper stimulus, the food; and there is reason to think that it directly aids the solvent power of the juice itself, especially when, from a debilitated condition of the organ, that fluid may have been produced without the proportion of acid requisite for the due performance of this function. The phenomena which follow its more free exhibition are those purely of irritation of the mucous membrane, or of chemical corrosion. The astringency which it often exhibits, in its action-on the alimentary canal, may result in part from its direct influence on the vital property of con- tractility in the tissues, or from a similar influence of the salts which it forms with salifiable bases, present in the contents of the stomach and bowels. It has long been noticed that this acid is peculiarly apt to give astringency to its salts, more so, indeed, than any other mineral acid, as evinced in the effects of alum and the sulphate of iron. Perhaps another mode in which it proves astringent is by a chemical combination between the acid and the albuminous constituent of the superficial epithelial layers, causing a contraction of the tissue beneath. Something of this kind may CHAP. I.] MINERAL TONICS.—SULPHURIC ACID. 361 occur when it is taken very largely; but, as ordinarly given for medical purposes, in small doses and very much diluted, it is ex- tremely improbable that it produces any such effect. In the prefa- tory remarks on the mineral acids, I have expressed my opinion very decidedly that they never enter the circulation as such. In fact, should they be absorbed, they could exist there only an instant uncombined; for they would immediately be neutralized by the alka- lies or albumen of the circulating fluid. Orfila injected a little diluted sulphuric acid into the veins of a dog, and caused its almost immediate death, with coagulation of the blood. But though, in the uncombined state, it cannot enter the circulation, it is undoubtedly, I think, often absorbed in the state of saline combination; and, as its salts prove astringent in the stomach and bowels, they may exercise a similar influence on the tissues generally, through the blood. Hence, we may account for the supposed efficacy of the acid in the relief of hemorrhages, to the seat of which it can have no direct access. Being, however, offensive to the system, when thus in excess in the blood, the salts are thrown off with the urine; and, in order that this elimination may be effected, it is probable that they have the property of stimulating the kidneys, and thus pro- duce the diuresis, which has been noticed as an occasional result of the exhibition of sulphuric acid. It is not probable that the acid exerts any tonic influence on the tissues generally, other than the indirect promotion of sanguification and nutrition, by the invigor- ation of the digestive process. None of the salts of the acid, ex- cepting those with a tonic base, as the sulphates of iron and zinc, act as tonics; and these metals produce their effects as well without as with the sulphuric acid. The absorption, therefore, of the salts it may form in the bowels, will not be followed by a tonic operation on the system. This is a point of more than merely speculative interest. If the opinion thus given be well founded, it would be useless to prescribe sulphuric acid with the view to a tonic effect, except in so far as it may be desirable to invigorate digestion. Therapeutic Application. Sulphuric acid is admirably adapted by its local tonic powers to cases in which, without organic disease or vascular irritation of stomach, there is a loss of appetite, with languid or inefficient digestion, general debility, and especially nMit-sweats. These conditions are often presented in the conva- lescence from acute diseases, particularly fevers, in which this acid, c-iven alone, or in connexion with the simple bitters, or some pre- paration of Peruvian bark, produces the happiest effects. The 362 - GENERAL STIMULANTS. [PART II. hectic fever of scrofula and consumption, and the advanced stage of suppurative inflammation, often afford similar indications. In pure dyspepsia the medicine is little used; as, though it would seem to be indicated by the state of the digestive process, experi- ence has not pronounced in its favour. To be curative in this affection, a remedy must be continued for a considerable time; and the sulphuric acid, when its use is long persisted in, is apt to be- come irritant to the stomach, though well borne at first. The acid has also been recommended as a tonic in low typhoid and malignant fevers; but I believe that it is of little advantage, and may often prove hurtful in these affections, by a too irritant action on the stomach, and through it indirectly on the system. It is only upon the alimentary canal, as before explained, that it acts directly as a tonic; and a mere gastric stimulant is not what is wanted in these cases. With a view to its conjoint tonic and astringent effect, sulphuric acid has been employed in diarrhoea, cholera, hemorrhage, and colliquative sweats. As a remedy in diarrhoea, connected with a relaxed state of the bowels, or in that complaint in its chronic form, and with a suspicion of ulceration of the mucous membrane, it has long been occasionally employed as an astringent or alter- ative; but it is only of late that it has been introduced, as the main remedial agent, into the treatment of acute diarrhoeas in their earlier stages, and of epidemic cholera. In the London 3Iedical Times and Gazette for January 1852 (page 31), is a communication from Dr. H. W. Fuller, of London, strongly recommending the use of the acid in this affection, and ascribing the first public notice of the remedy to a letter of Mr. Griffiths, which appeared in the Lancet three months previously. In a subsequent communication to the same journal (Oct. 1853, p. 344), Dr. Fuller reiterates his recommendation, based now upon a very large experience of the remedy. He had found it especially adapted to " acute autumnal" or epidemic diarrhoea, and to that form of the disease which pre- cedes cholera; and in all such cases, amounting to upwards of ninety, it had proved invariably successful. In many of the cases there were cold extremities, severe cramps, vomiting and purging, and sometimes even rice-water discharges. He found it of little use in bilious diarrhoeas, and certain chronic cases of the disease. In choleraic diarrhoea, and in cholera itself, in its earlier stages, no remedy is, he thinks, equally efficient. These statements have been confirmed by reports from other practitioners, which have CHAP. I.] MINERAL TONICS.—SULPHURIC ACID. O'JO appeared in the London journals; though, in the hands of some, the remedy has proved of no avail, and has occasionally seemed to be injurious. The mode of exhibiting the acid, is to give from twenty to thirty minims of the diluted sulphuric acid of the Phar- macopoeias, with sufficient cold water to render it palatable, every hour, until its benefical effects are experienced. In some cases, Dr. Fuller recommends that the dose should be repeated every twenty minutes, or even more frequently, during the first hour. " Sometimes after the second dose," says Dr. Fuller, " more com- monly after the third, and almost always after the fourth, the patient experiences a grateful sense of warmth at the epigastrium, heat returns to the extremities, the nausea and vomiting cease, the purging is stayed, the cramps subside, and the countenance re- assumes its natural appearance." The patient goes on amending, and, after a few hours, the remedy may be suspended. If the acid be exhibited at intervals of six or eight, or even three or four hours, the same happy effects are not obtained. Should the liver not act properly after the cessation of the characteristic symptoms, a little blue mass may be exhibited. Some administer aromatic tinctures, opiates, or other adjuvants in conjunction with the acid; but Dr. Fuller prefers it simply diluted with water. In relation to the treatment of cholera itself, in its different stages, it would appear, from the statements in the return of the English Board of Health, that sulphuric acid can, at the best, boast of no superiority over other remedies. (British and For. Med.-Chirurg. Rev., July, 1855, Am. ed., p. 108.) In the hemorrhages, sulphuric acid is occasionally useful; but it does not stand among the most efficient remedies. In hemorrhage from the stomach and bowels, it may do good by a direct action on the bleeding surface; but even here it has found no great favour with the profession generally. In that from surfaces which it can- not directly reach, as in hasmoptysis,,hematuria, menorrhagia, &c, its efficacy has been doubted, upon the ground that it does not come in contact with the bleeding vessels; but it is probable, as before explained, that the saline compounds which it forms in the ali- mentary canal may enter the circulation, and these salts may be as styptic as the acid itself. Nevertheless, sulphuric acid has not sufficient haemostatic power to be relied on exclusively in the treatment of the hemorrhages, and, for the most part, is employed merely as an adjuvant. The incompatibility between it and acetate of lead would forbid its use, in any case, in conjunction with the latter remedy. 364 GENERAL STIMULANTS. [PART II. In colliquative sweats, there are few remedies more efficacious than sulphuric acid. Its use in cases of this kind attending conva- lescence, the hectic of phthisis and scrofula, and the suppurative stage of inflammation, has been already referred to. But whenever excessive sweating occurs, especially if during sleep, and with gene- ral debility, as happens sometimes idiopathically, and often in con- nexion with other diseases, the remedy may be resorted to with a reasonable hope of benefit. Generally, in such cases, it may be advantageously associated with sulphate of quinia. It probably acts either through the astringency of such of its salts as enter the circulation, or, what seems to me more probable, by a sympathetic propagation of its action on the bowels, through the nerve centres, to the surface of the body. From its supposed possession of refrigerant properties, it has been recommended, in fevers generally; but 1 have never seen it useful in cases where the prominent indication was to reduce the pulse and heat of the body; and I have, therefore, much doubt as to the existence of any property of this kind, at least in a sufficient degree to justify its use upon that ground alone. The saline com- pounds which it formed in the primse vise may, when absorbed, prove somewhat refrigerant, as the neutral alkaline salts generally are known to do; but if such an effect is produced in fevers, it is more than counterbalanced by the tendency of the acid to disturb the stomach, already but too prone to irritation. The phosphatic lithiasis, or that condition of the system, and of the urinary organs, in which there is a disposition to an excessive formation and deposition in the urine of the earthy phosphates, is often treated with the mineral acids; and, among them, with the sulphuric. One object in the treatment of this affection is to main- tain a due acidity of the urine, by which the phosphates are held in solution; and another, to give tone to the digestive organs, which are often in fault. Now, it was supposed that these objects would be accomplished by acid medicines, possessing, like the one in ques- tion, tonic powers; the supposition being entertained that the acid would pass out through the kidneys, and thus impregnate the urine. But the mineral acids are not absorbed as such; neither are they thrown off as such by the emunctories. As before stated, it is in the form of salts that they enter the circulation, and are eliminated. Nevertheless, experience has proved them to be among our best remedies, if not the best, in this affection; and, though they do not directly acidify the urine, it is very possible that they may do so CHAP. I.] MINERAL TONICS.—SULPHURIC ACID. 3Go indirectly. In the contents of the bowels, and in the blood, are salts, from which the acid matter normally contained in the urine is probably separated. The sulphuric acid introduced into the sto- mach must, in order to form salts, decompose some saline substance which it meets with in the primae viae; and the liberated acid may either be absorbed, and escape with the urine, or, in its turn, disen- gage from some one of the salts of the blood an acid to be thrown off by the kidneys. Sulphuric acid had at one time some reputation as a remedy in colica pictonum, and is still considered a good prophylactic against that complaint, under certain circumstances. It was supposed to act by forming an insoluble and inert salt with the lead, and thus to remove the cause of the disease. But the preparations of lead do not produce colica pictonum, while lying loose in the alimentary canal, or even precipitated upon its surface. They must enter the circulation, and come into direct contact with the nervous tissue which they affect. Now, sulphuric acid cannot follow them into the circulation and the tissues; and, even if, in the form of soluble sulphates, it should do so, the formation of an insoluble compound of lead in these situations, from which it could not be readily re- moved, would not, it appears to me, be the best method of expel- ling the poison. So far as the acid can do good by combining with any lead in the stomach and bowels, thus far it may be useful in colica pictonum, by preventing the further absorption of the poison. It may, therefore, prove prophylactic, if habitually used as a drink by those who are exposed to the necessity of swallowing small quantities of lead with their saliva, or antidotal in those who may accidentally take the poison into the stomach in larger quantities; but all that it could do chemically in such cases, could be as well done, and with less liability to injury, by the use of one of the soluble sulphates. It must, therefore, act by some other than its mere chemical properties, if it have any special usefulness in the poison of lead; but that it has such usefulness, remains yet to be satisfactorily proved. The acid has been used externally in eruptive affections, as liclien, prurigo, obstinate urticaria, and psora, and in indolent or ill-con- ditioned ulcers. It is also employed as a gargle in ulcerated sore- throat, and the anginose affection of scarlatina, and as a caustic application to diphtheritic exudation in the mouth and fauces. But for all these purposes, its place has been supplied by more efficient or more convenient remedies; and it is now little em- 366 GENERAL STIMULANTS. [PART II. ployed. When used, it should be much diluted. The precise strength will be mentioned under the preparations. Incompatibles. If the special action of sulphuric acid is wanted, it should not be given with metallic iron; with salifiable bases, with which it forms salts; with the carbonates, or salts of vege- table acids; with soluble nitrates, chlorides, iodides, or sulphurets; or with the soluble salts of lime, baryta, and lead, which it decom- poses, forming insoluble or nearly insoluble sulphates of these bases respectively. Sometimes, possibly, it may be appropriately admin- istered in connexion with one or more of these substances; but this should never be done, unless with a view to the reactions which must follow. Preparations of Sulphuric Acid. As kept for internal medical use, sulphuric acid is always in one of the following forms. In relation to its external use as a caustic, it will be treated of under the escharotics. 1. DILUTED SULPHURIC ACID.—AciDUM SULPHURICUM Dl- lutum. U. S., Lond., Ed., Dub. This consists simply of concentrated sulphuric acid, diluted with thirteen measures of water to one of the acid. After the mixture, a white substance gradually separates and subsides, if the com- mercial acid is used in the preparation. It is the sulphate of lead previously contained in the strong acid, which is thus got rid of. Even in this state of solution, the acid is still corrosive, and re- quires to be much more diluted before it can be borne by the palate. When thus diluted, it is intensely sour, and will set the teeth on edge, if it come in contact with them. When taken, therefore, it should either be sucked through a quill, or other tube introduced far into the mouth; or, what I think is ordinarily a better plan, it should be swallowed rapidly, and the mouth, immediately after- wards, well and repeatedly washed out with water, or a weak solu- tion of one of the alkaline carbonates. Without some precaution of this kind, the teeth may be seriously injured. The dose of the diluted acid is from ten to thirty drops, to be repeated, for ordinary purposes, three times a day, or more fre- quently. To be efficient in hemorrhages, it must be given every two hours. The dose should be taken in one or two wineglassfuls of water, sweetened or not, as the patient may prefer. When used as a drink in hemorrhages or fevers, the same quantity may be added to half a pint or a pint of water. CHAP. I.] MINERAL TONICS.—SULPHURIC ACID. 367 For a gargle, in ulcerative affections of the throat, a fluidrachm may be added to a pint of water; for application to the skin, double the quantity. When intended for pseudo-membranous patches in the mouth or fauces, this preparation may be used undiluted, and should be applied by a brush directly to the affected part, and no other. Compound Infusion of Roses (Infusum Ross Compositum, U.S.) is an infusion of red roses, containing about three fluidrachms of the diluted sulphuric acid in two and a half pints. The prepara- tion acquires a slight astringency and a red colour from the roses; but its efficacy depends altogether on the acid. It is considerably used in Great Britain, as a drink in hemorrhages and colliquative sweats, and as a vehicle for saline medicines, especially sulphate of magnesia, the taste of which it in some measure conceals. The dose is from two to four fluidounces. It is also used as a gargle. 2. AROMATIC SULPHURIC ACID. —AciDUM SULPHURICUM Aromaticum. U.S., Ed., Dub.—Elixir of Vitriol. This preparation, which is very generally known under the name of elixir of vitriol, is a simplification of Mynsicht's acid elixir. Made by macerating ginger and cinnamon in alcohol, and adding the resulting tincture to a mixture of alcohol and sulphuric acid, it may be considered as a tincture of the aromatics mentioned mixed with the acid; though some chemical reaction has no doubt taken place between the several ingredients. It contains one part of the acid to about nine parts by measure of alcohol, and is there- fore considerably stronger than the preceding preparation. As the drop, however, is smaller, the dose is about the same as given in drops. It is a reddish-brown liquid, of a peculiar agreeable odour, and, when diluted, of an acid not unpleasant taste. In this country, it is the form generally preferred for the internal administration of sulphuric acid. The dose of it is from ten to thirty drops, given in one or two wineglassfuls of water. It is very often used as an addition to sulphate of quinia to render it soluble in water; and is an ingredient in the Compound Infusion of Peruvian Bark of the U. S. Pharmacopoeia, in the preparation of which it enables the water to extract all the virtues of the bark, while it agreeably qualifies the taste of the infusion. 3. OINTMENT OF SULPHURIC ACID. This ointment was until recently an officinal of the Dublin Col- lege. It was made by rubbing together a drachm of the acid and an ounce of lard. Reaction took place, which altered the colour of 368 GENERAL STIMULANTS. [PART II. the ointment; but it was still merely a dilute preparation of sul- phuric acid for external use. Mixed with an equal quantity of lard, it was employed as a remedy for scabies, lichenous ringworms, prurigo, and other obstinate cutaneous eruptions, and, still further diluted, as a rubefacient in paralysis, chronic inflammation of the joints, rheumatism, &c. II. NITRIC ACID. ACIDUM NITRICUM. U. S., Land., Ed., Dub. Origin. This acid, according to Dr. Pereira, was known to Geber in the seventh century. In commerce it is usually denominated aquafortis, and in technical language sometimes azotic acid. It is prepared by heating together a mixture of nitrate of potassa and sulphuric acid, and condensing in a receiver the vapours which are given off. For an account of its composition, chemical relations, the tests of its purity, &c, the reader is referred to the U. S. Dis- pensatory. It is here to be considered mainly in its direct medical relations. Properties. Two forms of the acid are kept in the shops, distin- guished as the nitrous and nitric acids. Nitrous acid of the shops is characterized by its orange colour, which is sometimes very deep, and by the orange-coloured fumes which it gives off. This peculiarity is owing to its impregnation with nitric oxide or deutoxide of nitrogen, by reaction between which and a portion of the nitric acid, the proper chemical nitrous acid is generated, which imparts its colour to the mixture. But, when the liquid acid is diluted with water, the orange-coloured nitrous acid is decomposed again into nitric acid and nitric oxide, the latter of which escapes, assuming an orange colour when in contact with the air, and leaving a colourless diluted nitric acid-; and, as the medicine must be diluted before being administered, it follows that the nitrous acid of the shops has nothing to distinguish it, in relation to medical effect, from the purer form. This ob- servation is necessary, as peculiar virtues have been ascribed to it. Nitric acid, when quite pure, is a colourless liquid, but, as often kept, is slightly yellowish. If duly concentrated, it gives out white fumes. As directed by the U. S. Pharmacopoeia, it has the sp. gr. 1.42; but is of variable strength as found in the shops. It has a CHAP. I.] MINERAL TONICS.—NITRIC ACID. 369 peculiar odour, and, when so far diluted as to be borne in the mouth, an intensely sour taste. When in contact with the skin, it stains the cuticle yellow; and the colour remains until the cuticle itself is gradually removed; a property which serves to distinguish the stain from that produced by iodine and bromine. The colour, moreover, may be distinguished by becoming brighter under the application of ammonia or soap. Effects on the System. Nitric acid, in the smallest medicinal doses, excites the appetite, promotes digestion, and secondarily invigorates the general nutritive process. It is, therefore, a tonic, acting specially on the stomach and bowels, and in this respect resembles sulphuric acid, from which, however, it differs in being without astringency. It is said also to be refrigerant, and to have alterative properties which render it useful in peculiar morbid states of the system. On these points more will be said directly. It is thought to have sometimes induced ptyalism; but, at best, this result is very rare. Too largely taken, and in the ordinary medicinal doses if con- tinued too long, it is apt to cause disturbance of the stomach, gastric pain or spasm, and sometimes severe attacks of intestinal colic. Swallowed very copiously, and even in smaller quantities if con- centrated, it produces poisonous effects so much like those resulting from sulphuric acid that it is unnecessary to repeat them. (See page 359.) With the nitric acid, however, the inside of the mouth is stained yellowish instead of whitish; and yellow stains on the skin of the face will often serve to distinguish the poison. The antidotes and remedial treatment are absolutely the same as in the case of poisoning from sulphuric acid. 31ode of Operating. Nitric acid is a direct stimulant to the alimentary mucous membrane, becoming irritant in over-doses. It is probably never absorbed in the acid state; but combines in the stomach and bowels with the albumen, and the salifiable bases which it always encounters there, and in this state of combination may enter the circulation, in order to be thrown off immediately by the kidneys. Now the alkaline salts of nitric acid are remarkably refrigerant and sedative to the circulation when absorbed, especially the nitrates of potassa and soda; so that, as one of these salts will be likely to be formed by the nitric acid in the bowels, we may readily account for the refrigerant effect asserted to be produced by the acid. As to its supposed alterative action, so far as such an effect has been experienced, it may be explained in a somewhat similar manner. Muriatic acid frequently exists in the stomach. It is VOB. I.—21 370 GENERAL STIMULANTS. [PART II. possible that, by reaction with this, the nitric acid may sometimes generate that peculiar combination called nitromuriatic acid, which undoubtedly has an important alterative action on the system. This view is rendered the more probable, as it is only occasionally that nitric acid is found to exercise the alterative influence ascribed to it; and it is only occasionally that the reactions can occur which produce the nitromuriatic acid. We may explain in the same wajr the reported occurrence of ptyalism in some instances; as one of the admitted characteristic properties of nitromuriatic acid is fre- quently to act on the gums. , In the concentrated state, nitric acid decomposes the tissues through its chemical affinities, and thus causes the death of the part, acting as an escharotic. Therapeutic Application. The use of nitric acid as a tonic is very nearly the same as that of sulphuric acid. Like that, it is pecu- liarly applicable to the debility of convalescence, with want of appetite, and a disposition to sweat at nights; though not perhaps equally efficient in correcting excessive perspiration. I have occasionally met with cases of fever, from which the recovery seemed very slow; the pulse remaining rather frequent, especially in the latter part of the day, the tongue somewhat furred, and the appetite feeble or wanting; and this state of things continuing for days with little or no change. Under such circumstances, nitric acid, given in small doses every two or three hours, has seemed to answer an excellent purpose in hastening and confirming the convalescence. It has also been used with asserted advantage in fevers generally, being prescribed partly as a tonic, and partly as a refrigerant in those of feeble action, and as a refrigerant alone, in such as require no supporting treatment; but, in cases of this kind, having little faith in its peculiar efficacy, I have not been in the habit of using it; and can, therefore, say nothing from experience of its virtues. I have already explained how it is possible that it may produce a refri- gerant effect. Some have supposed it to have an alterative influence on the liver, and to be useful in chronic inflammation of that organ. Gene- rally it has altogether failed of making any useful impression in such cases, and certainly cannot be relied on. Nevertheless, it may occasionally do good, through the generation of nitromuriatic acid in the primae viae. Of its asserted specific virtues in secondary syphilis, scrofula, and various eruptive affections characterized by a depraved blood, as CHAP. I.] MINERAL TONICS.—NITRIC ACID. 371 impetigo, ecthyma, rupia, &c, I have seen nothing which might not be ascribed to its simple tonic action upon the digestive organs, and to the consequent improvement in sanguification and nutrition. Nevertheless, there may possibly result from its chemical reactions within the system, substances having in some degree the peculiar virtues referred to; and the statements as to its efficiency made by some reliable practitioners would tend to confirm this view. It is, however, acknowledged to be inferior to other medicines in the cure of the affections mentioned, and, if used at all, should be so as an adjuvant merely. In diarrhoea and dysentery, and the ordinary forms of cholera, it has been highly recommended; and, in the form of what is called Hopds mixture, was at one time in great repute. This consisted of nitrous acid, camphor water, and laudanum. Much stress was laid upon the choice of nitrous preferably to nitric acid. I have already shown that this preference was unfounded. I have employed this mixture in the affections above referred to, but generally with little greater effect than could be ascribed to the laudanum and camphor water. The acid often provoked irritation and pain in the stomach or bowels. Nevertheless, there are cases of bowel affections in which the acid appears to do good. I consider it wholly inapplicable to acute cases, with severe pain in the bowels, and febrile symptoms. The circumstances under which it has appeared to me useful, are a certain degree of general debility of system, without heat of skin, with no considerable pain, and evidences of a feeble or relaxed con- dition of the mucous membrane, which disables it from resuming its healthful functions. In such a condition, whether the affection may be in the early or advanced stage, aud whether it may have the form of diarrhoea or of dysentery, the combination above re- ferred to may prove useful; but it is, I think, in cases of dinrrhoza following cholera infantum that it has proved most beneficial in my hands. In ordinary cholera morbus, other methods are so uni- formly successful, that I have never considered myself justified in omitting them in order to try nitric acid. Epidemic cholera has also been treated by nitric acid, but I be- lieve with no peculiar success. In hooping-cough it was recommended by Dr. Arnoldi; and Dr. Geo. D.Gibbs considers it as a most efficient remedy. In a treatise by the latter, published in London, A.D. 1*.~>1, he states that ''it not only arre.-ts the paroxysms, and removes the hoop, but shortens the disease almost as effectually as quinine does intermittent fever." 372 GENERAL STIMULANTS. [PART II. [Lond. Med. Times and Gaz., July 1854, p. 118.) Dr. Arnoldi adds as much of the acid to water, sweetened with sugar almost to the consistence of syrup, as will give it the sourness of pure lemon juice. Of this preparation he gives to a child one year old a des- sertspoonful every hour, to an adult a tumblerful during the day. It is useless to speculate upon the mode of action of the remedy, till further experience shall have established its efficacy. Hooping- cough is sometimes protracted in consequence of a state of debility into which the patient is apt to fall, and which is relieved by tonics. Thus far nitric acid may no doubt prove useful; but much more is claimed for it by the practitioners above referred to. Several cases of spasmodic asthma very promptly yielded to the use of the acid, in the practice of Dr. T. S. Hopkins, of Bethel, Georgia. Most if not all of the cases were of. young children. He gave from three to five drops of the acid three times daily. (Am. Journ. of 3Iecl. Sci., N.S., xx. 549.) As an antilithic, the remarks made upon sulphuric acid, are pre- cisely applicable to the nitric. It will be remembered that it is in the phosphatic diathesis that the remedy is specially indicated. As a local remedy, nitric acid has been used to stimulate feeble ulcers, to remove the callous edges of the obstinate, and to correct the morbid action of the ill-conditioned and phagedenic. Sir B. Brodie succeeded in dissolving a phosphatic calculus, by injecting into the bladder, every two or three days, for a time varying from fifteen to thirty minutes, water acidulated with nitric acid, in the proportion of two and a half minims to a fluidounce. Administration. The dose of the officinal acid is from three to seven drops; but, as kept in the shops, it is often of less than the officinal strength; and no precise rule can be given under these circumstances. I have found, however, that the above quantity of the officinal acid makes a large wineglassful of water rather dis- agreeably sour; and enough, therefore, of any specimen employed should be added to water to produce this effect. In the uncertainty as to the strength of the acid, a small dose should be given at first, to be gradually increased until it produce some sensible effect upon the stomach, a little pain for example, and then to be somewhat diminished. The water may be sweetened, if so preferred by the patient. Special care should be taken to avoid injury to the teeth. (See Diluted Sulphuric Acid, page 366.) As a wash for ulcers, from twenty to forty minims of the. strong acid may be added to a pint or a quart of water. CHAP. I.] MINERAL TONICS.—MURIATIC ACID. 373 Incompatible. The acid should not be administered with sub- stances in a metallic- state, with alkalies, alkaline earths, or their carbonates, nor with soaps or sulphurets. Caution should always be observed not to drop it into a silver spoon, as it would thus form nitrate of silver, or lunar caustic. It should be administered from a glass or porcelain vessel. Diluted Nitric Acid (Acidum Nitricum Dilutum, U. S) is an officinal preparation. Our pharmacopoeia directs one part by mea- sure of the acid of the sp.gr. 1.42 to six parts of water; but, in order that the preparation may be of a uniform strength, the apothecary, if unable to obtain a strong acid of the officinal specific gravity, should make the requisite allowance, and increase the proportion of the acid sufficiently to compensate for its feebleness. This he will be enabled to do by consulting the table of Dr. Ure (see U. S. Dispensatory), from which he can learn the quantity of* strong acid in any specimen of a given specific gravity. The dose of the diluted acid is from twenty to forty drops, which should be taken in a large proportion of water. The preparation may be ap- plied undiluted, by means of a camel's hair pencil, to pseudomem- branous exudations, and certain indolent and insusceptible ulcers; care being taken not to allow the application to extend beyond the surface affected. An ointment of nitric acid was formerly officinal; but has been omitted in recent editions of the pharmacopoeias. It was made, according to the Dublin process, by melting together a pound of olive oil and four ounces of lard, and adding, upon the commence- ment of concretion, five and a half drachms of the acid. The result- ing ointment, which was yellow and of a firm consistence, was used in cutaneous affections, more especially porrigo and impetigo. M + 1 III. MURIATIC ACID. ACIDUM MURIATICUM.. U.S., Ed., Dub. — Acidum Hydro- CHLORICUM. Lond. Syn. Hydrochloric Acid. — Chlorohydric Aoid. Origin. Muriatic acid was described by Basil Valentine in the fifteenth century. To the older chemists it was known by the name of spirit of sea-salt; when better understood, but before its compo- sition had been discovered, it was called muriatic acid; at present, 374 GENERAL STIMULANTS. [PART II. chemists usually denominate it hydrochloric or chlorohydric acid. In the U. S. Pharmacopoeia the name of muriatic acid has been retained as sufficiently expressive, and best adapted for a medical and pharmaceutical title, until chemists shall adopt one upon which all can unite. The term is applied to the liquid acid obtained by acting upon chloride of sodium with sulphuric acid and a little water, and receiving the hydrochloric acid gas given off in dis- tilled water, which condenses it. The U. S. Pharmacopoeia directs that it should have the sp.gr. 1.16. Properties. Muriatic acid when pure is a colourless liquid, but is often somewhat yellowish as in the shops. It emits a vapour which forms a white cloud in contact with the air. Its smell is strong, pungent, and peculiar; its taste, when diluted, extremely sour. It yields with nitrate of silver a white precipitate, insoluble in nitric acid, but readily dissolved by solution of ammonia. Un- diluted, it is corrosive or escharotic. Effects on the System. So far as regards its action upon the digestive function, it closely resembles sulphuric and nitric acids. Like them, too, when given largely, it produces heat and pain in the stomach, and occasionally disturbs the bowels. In very large quantity, or in a concentrated state, it operates as a corrosive poison, with symptoms similar to those produced by the acids just named; but distinguishable, it is said, by the emission of its pecu- liar odour from the mouth. At least this effect has been observed, when it has been given in poisonous quantities to the lower animals. The treatment of its poisonous effects is the same as that indicated for the other mineral acids. (See page 360.) Therapeutic Application. Muriatic acid may be used as a tonic to the digestive organs, and indirectly to the system, under the same circumstances as the sulphuric and nitric. From the circum- stance that, mixed with gastric mucus, it will dissolve food, and from the supposition, at one time entertained, that it was an essen- tial agent in the solution of the food in the stomach, the inference seemed reasonable, that it would prove peculiarly useful in facili- tating digestion when impaired. It certainly has this effect occa- sionally ; but experience has not proved it to possess any supe- riority over the other mineral acids. Dr. Paris considers it, when taken in connexion with strong infusion of quassia, as one of the best preventives of the reproduction of worms, after they have been ex- pelled from the bowels. The acid has been much used in typhus, malignant scarlatina, and other fevers of a malignant character, CHAP. I.] MINERAL TONICS.—NITROMURIATIC ACID. 375 partly under an impression of its antiseptic qualities; and much has been said of its efficiency in these affections. It has also been considered specially useful in scrofulous and syphilitic complaints and cutaneous eruptions. But there may be some doubt whether it acts in all these cases by any other than its tonic powers. It has been used, like the other mineral acids, to correct the phosphatic urinary deposits, and probably acts in a similar manner. Administration. The dose of the undiluted acid is from five to twenty drops, which may be given in half a tumblerful of sweet- ened water, and repeated more or less frequently according to the nature of the case; every two or three hours, for example, in acute cases, and two or three times a day in chronic. The same caution should be observed as with the other acids, to prevent injury to the teeth. (See^or^e 366.) To the incompatibles, mentioned under nitric acid, may be added, for the muriatic, the soluble salts of silver and lead. This acid is sometimes used locally. Applied carefully, without dilution, to diphtheritic or pseudomembranous surfaces, it will effectually change the morbid action ; but, though strongly recom- mended for this purpose by Bretonneau, it is probably in no respect superior to the nitrate of silver, while it is less convenient. In ulceration of the mouth and fauces, it has been used, largely diluted, as a mouth wash or gargle. For this purpose, from one to two fluidrachms may be added to eight fluidounces of water. There is an officinal Diluted Muriatic Acid (AcidumMuriaticum Dilutum, U.S.), containing one part by measure of the strong acid to three parts of distilled water. The dose is from fifteen to sixty drops. IV NITROMURIATIC ACID. ACIDUM NITROMURIATICUM. U. S., Dub. Onfin, d-c. This combination first attracted notice as a solvent for gold,' whence it received the name of aqua regia. It is said to have been known to Geber, who lived in the seventh century; but its introduction into medicine dates only from the early part of the present. According to the strict chemical nomenclature of the day, it is named nitro-chlorohydric, or nitro-hydrochloric acid. It is prepared by mixing one part by measure of nitric acid with two narts of muriatic acid. When the acids are of sufficient strength, 376 GENERAL STIMULANTS. [PART II. a reaction takes place, which Davy supposed to result in the pro- duction of nitrous acid, water, and chlorine. But M. Baudrirnont found, upon collecting the vapours rising from the mixture, that they did not consist of chlorine, but of a combination of this ele- ment with hyponitrous acid, in the proportion of two equivalents of the former to one of the latter; and he gave the name of chlora- zotic gas (chloronitric gas) to the new compound. Gay-Lussac after- wards investigated the subject, and states as the result of his examination, that two new products are formed, consisting of nitric oxide and chlorine, which may be deemed to have been produced, the one from hyponitrous acid by replacing one equivalent of its oxygen with one of chlorine, the other from nitrous acid, by a similar substitution of two equivalents of chlorine for two of oxy- gen; but Gay-Lussac admits also the evolution of free chlorine. It is seen, therefore, that the compound is no longer a mixture of the nitric and muriatic acids, but of certain new substances, having distinct chemical properties, and probably an entirely different physiological action. As the medicine is officinally prepared, it contains a considerable excess of nitric acid; so that its effects must be those conjointly of that acid and the new products. • It is a fact worthy of particular attention, that nitric and muriatic acids will not react on each other so as to produce the changes above referred to, which are essential to the distinctive medicinal character of the compound, unless in a certain degree of concen- tration. If the acids employed be weak, they will still remain nitric and muriatic acids in the mixture, and will exercise on the system only the effects of these acids. It is probably from this cause, in part at least, that the disappointment in the effects of nitromuriatic acid has proceeded, which has led to its abandonment by many practitioners, and to the slighting notices of it given by some of the recent English writers. I have used it much, have taken care to guard against this source of failure, and have had every reason to be satisfied of its great efficiency. Indeed, I con- sider nitromuriatic acid as among our most valuable remedies. When the strong acids cannot be obtained, reaction may be speedily brought about by the addition of a little sulphuric acid, which probably operates by concentrating the weak acids through its affinity for water. At present there is little occasion for this expedient, as the acids are generally to be found of sufficient strength; but it was not always so; and I have repeatedly made this addition with satisfactory results. CHAP. I.] MINERAL TONICS.—NITROMURIATIC ACID. 377 Properties. When reaction has but partially taken place between the constituents, the colour of the mixture is yellow; but it deepens as the changes go on; and at length, when they are completed, is reddish or orange. The odour closely resembles that of chlorine, but is somewhat different. The taste, upon dilution so as to render the medicine supportable in the mouth, is intensely sour and somewhat peculiar. Care should be taken that the preparation is kept in a cool place, and excluded from the light. Effects on the System. Nitromuriatic acid promotes the appetite, and in other respects operates as a tonic to the digestive function, in the same manner as nitric acid. Like that acid, too, it is irritant to the alimentary mucous membrane in over-doses; and, when swallowed in great excess, or in a concentrated state, acts as a cor- rosive poison, with the same phenomena as those already described as the result of poisoning "by the mineral acids. The antidotes and remedies are also the same. (Seepage 359.) But this medicine produces other and very important effects upon the system. It is certainly not absorbed precisely as admi- nistered; for the nitric acid, which, as before stated, is contained in it in excess, probably never enters the circulation unchanged. There can, however, scarcely be a doubt that one or more of the new bodies, resulting from the reaction of the ingredients, is really absorbed. This can scarcely be the chlorine; for the che- mical affinities of that element are so powerful, that it could not remain long enough in the primae viae, or in contact with the tissues through which it must pass, without satisfying those affini- ties by union with some other bod}' elementary or compound. May it not be, that the new compound noticed by M. Baudrirnont, or one or both of those which offered themselves to Gay-Lussac's research, are capable of absorption, and of producing all the pecu- liar effects of the medicine upon the blood, and upon the tissues to which they are conveyed by the blood. An evidence of this action through the circulation is presented in the increased secretion of bile, causing not unfrequently bilious evacuations from the bowels, and in the fact that this occurrence takes place as well from the external as from the internal use of the medicine, proving that it is not merely an irritation propagated from the intestinal mucous membrane through the gall-ducts to the liver. Another evidence of the same kind is the occasional saliva- tion and sore mouth which follow the use of the medicine, whether swallowed or applied to the skin; effects, to the reality of which, 378 GENERAL STIMULANTS. [PART II. though they are by no means constant, I can myself bear witness. Further proofs are offered by the therapeutical influence of the me- dicine in correcting fetid breath, and modifying the urinary secre- tion so as to prevent the elimination of oxalate of lime. It probably acts, in both of these instances, by decomposing and destroying sub- stances in the blood which cause these morbid phenomena, while it leaves the normal constitution of that fluid unaffected. It is in vain to speculate upon the precise method in which these purifying effects are produced. We have not yet light enough to justify even an attempt to form an explanatory theory on the sub- ject ; though we may reasonably appeal to facts for proof of the reality of the effects referred to. Therapeutic Application. Like the mineral acids generally, the nitromuriatic may often be used advantageously in general debility with enfeebled digestion. For the special affections in which it may be thus employed as a tonic to the digestive organs, the reader is referred to the therapeutic applications of sulphuric acid. (See page 361.) The condition under which, in these affections, it may be employed preferably to other acids, is when, with the general debility, and that of the stomach in particular, there is conjoined a torpid condition of the liver, as evinced by the want of bile or its deficiency in the feces. In other respects, acting in these casts probably through the excess of the nitric ajcid it contains, it is identical in its effects with that remedy separately administered. I am much in the habit of using nitromuriatic acid in certain cases of diarrhoea, chronic enteritis, and dysentery, and find it occa- sionally extremely useful. The disease, after lingering long under various treatment, speedily begins to amend, and goes on regularly to convalescence, under the use of the remedy, which I generally give combined with an opiate. That the result is not due exclu- sively to the latter, is proved by the fact that it has been given previously, and in other forms of combination, without any cura- tive effect. The cases referred to are unattended with fever or heat of skin, and are characterized by a relaxed condition of the system, and apparently of the alimentary canal, which appears to indicate a tonic treatment. I am disposed to think, however, that the remedy operates, in these cases, not only as a tonic, but also by an alterative influence on the mucous surface, and perhaps upon the blood, the nature of which is not yet understood. The applicability of nitromuriatic acid to the treatment of dis- eases of the liver was a beautiful discovery of Dr. N. Scott, of Bom- CHAP. I.] MINERAL TONICS.—NITROMURIATIC ACID. 379 bay. That practitioner, having obtained very beneficial effects from nitric acid in hepatic affections, and made known the results of his treatment, and being surprised at a want of coincidence in the experience of other practitioners with his own, was led to make particular inquiries into the cause. He found that the nitre, out of which the acid employed by him in India was prepared, contained a considerable proportion of chloride of sodium, and consequently yielded muriatic acid along with the nitric; so that in fact he had been using nitromuriatic acid in his cases, and not the pure nitric. He was, therefore, induced to try the compound acid, and found his conjecture verified by the result. Nitromuriatic acid appears to act as a stimulant to the secretory function of the liver, and as an alterative in its morbid conditions, very much in the manner of mercury, though in an inferior degree. It differs from that remedy in being wholly inapplicable to acute inflammatory affections, or high vascular irritation, with active con- gestion of the organ. But when the secretory function is deficient, or wholly suspended in consequence of mere torpor or debility of the gland, nitromuriatic acid acts often very advantageously; and if, with this condition of the liver, there are conjoined considerable general debility, an anemic or otherwise depraved state of the blood, and depression of the digestive function, it should even be preferred to the mercurials, as it tends to repair, instead of aggravating, as the latter remedies too often do, the coincident affections. In chronic inflammation of the liver, also, the remedy is peculiarly useful, under the same circumstances. In cases, moreover, in which mercury has been tried without satisfactory results, or insurmountable prejudice exists against it, or idiosyncrasy of the patient forbids its use, nitro- muriatic acid should be resorted to as the best substitute. In the suppurative stage of acute hepatitis, the same remark is applicable. Of course, in the jaundice, dropsical affections, and general cachectic state of system, so often associated with, and in great measure de- pendent on hepatic disease, much good may be expected from the remedy, properly employed, and sufficiently long continued. One practical remark is applicable in all these cases; namely, that nitro- muriatic acid and mercury, however apparently coindicated, should never be administered together, at least with any quantity of the mercurial larger than a small fraction of a grain; for there is dan- cer of the production of corrosive sublimate, and, consequently, of all the mischief which that poison is capable of producing. I have been informed, on what I deemed sufficient authority, of a case of 380 GENERAL STIMULANTS. [PART II. death which speedily followed the joint exhibition of nitromuriatic acid and calomel, with violent pains in the stomach and bowels, vomiting, purging, &c. As a purifier of the blood, nitromuriatic acid may be used ad- vantageously in depraved states of health, attended with ulcerative affections of the skin, or certain eruptions, as ecthyma, rupia, porrigo, &c.; in the purulent infection consequent on the absorption of de- graded and disintegrated pus, and in the somewhat similar condition of the system in gangrene. In all these cases, it probably acts jointly by the tonic influence of its acid ingredient on digestion, and the general alterative influence of the portion absorbed. In the oxalic lithiasis it is certainly an admirable remedy. Sug- gested first, I believe, by the late Dr. Bird, of London, instead of the nitric acid recommended by Dr. Prout, it has come into general use, and certainly often produces the happiest results. I have re- peatedly used it in cases characterized by an abundance of oxalate of lime in the urine; and, I believe, in no instance have known it to fail in correcting, or much diminishing that symptom; while, at the same time, the constitutional symptoms have undergone a simi- lar amelioration. There is a special morbid condition, which I have occasionally met with, and have for many years been in the habit of combating, by means of this remedy, with the happiest success. I do not know that I can convey an accurate idea of this condition to the reader, but it is sufficiently well characterized to my own observation. There is a failure of the appetite, a slight fur upon the tongue, which, however, remains moist, a tendency to constipation, a cool, moist, and relaxed surface, and a pulse rather feebler, perhaps, than in health, sometimes a little accelerated, but not strikingly abnormal in any way. With these symptoms are frequently conjoined an offensive breath, general languor, and a remarkable and apparently causeless depression of spirits, with perverted feeling, sometimes almost approaching insanity. I have attributed this condition to a depraved state of the blood, dependent probably on defective digestion and assimilation. It may continue for weeks without abatement; but, under the use of nitromuriatic acid, begins to im- prove in a few days, and in two or three weeks yields entirely. Since the practice of chemical and microscopical investigation of the urine has come into vogue, circumstances have prevented me from investigating the state of this secretion in the affection, and I CHAP. I.] MINERAL TONICS.—NITROMURIATIC ACID. 3S1 cannot say whether there is, or is not, any special connexion be- tween it and the state of the system. Administration. The dose of the acid is from two to ten drops, according to its strength. About five drops is a medium dose, which may be given in from two to four fluidounces of sweetened water, and repeated two, three, or four times in twenty-four hours. As the medicine, in large doses, is apt to induce colicky pains, it is best to begin with a small dose, and increase till it evinces some sign of acting. The same caution should be observed as with the other acids, to guard the teeth against injury. Care should be taken, in opening the bottle in which the acid may be contained, to avoid exposing the face to the jet of gaseous vapour, which some- times suddenly escapes, especially when the bottle has been kept in a warm place, and which may endanger the eyes, if not guarded. When the patient, or a nurse, mixes the acids, particular direction should be given that they should not be dropped into water before they have been mingled, and full time has been allowed for mutual reaction. In fact, it is best that the mixture should be made by the apothecary, and, after sufficient reaction has taken place, should be diluted before being dispensed. I frequently thus prescribe the remedy, directing it to be diluted with camphor water, in such pro- portion that a tablespoonful of the preparation shall constitute a dose, to be afterwards further diluted by the patient. To this mixture a portion of laudanum may be added, whenever indicated. The incompatibles are so numerous, that the safest plan is to give the acid without other accompaniments than those just mentioned. So far as concerns the effects of the medicine on the liver, it has been thought that its external use is scarcely less efficient than the internal. At least, the two methods may often be advantageously conjoined; or the outward application may be resorted to when the medicine operates offensively on the alimentary canal. It may be employed outwardly in the form of a lotion, footbath, or full bath. For the purpose first mentioned, it may be added to water, in the proportion of two fluidrachms to a pint, and applied by means of a sponge. In pediluvium, from one to two fluidounces may be used to the gallon of water; for a bath, about one fluidounce to the same quantity. Both the bath and footbath should be at the tem- perature of about 96° F., and should be prepared in wooden ves- sels. The application may be continued from ten to thirty minutes, or till a tingling or pricking sensation begins to be felt in the skin. It may be repeated daily, or twice a day. 382 GENERAL STIMULANTS. [PART II. V. PLIOSPHORIC ACID. ACIDUM PIIOSPHORICUM. Origin. This acid was discovered about the middle of the last century. A solution of it, under the name of Diluted Phosphoric Acid (Acidum Phosphoricum Dilutum, Lond), has been adopted as officinal by the London College. This is prepared, according to the directions of the college, by carefully heating together phos- phorus, nitric acid, and Avater. The phosphorus is oxidized and converted into phosphoric acid at the expense of the nitric acid; and, having been obtained in a somewhat concentrated liquid form, is afterwards diluted with water to the officinal strength. Its spe- cific gravity, as recognized by the college, is 1.064. Properties. In this state it is a colourless liquid, without smell, extremely sour, and possessed of strong acid properties. Though much less corrosive, even in a concentrated state, than sulphuric acid, it is yet capable, in that state, of destroying life. Orfila has seen fatal gastritis produced in a dog by 30 grains of it dissolved in a very little water. 31edical Uses. As a medicine, it has been more used on the con- tinent of Europe, particularly Germany, than either in Great Britain or this country. Having never prescribed it, or seen it prescribed, I am not entitled to give an authoritative opinion upon its proper- ties or value as a medicine; but, from all that has been written upon the subject, though some writers claim for it special and extraordi- nary virtues, there seems to be good reason to believe that it re- sembles the other acids in its effects, and can do little more than they. It is thought especially to resemble sulphuric acid in tonic virtues, and, though not so energetic, has the advantage that its taste is somewhat more agreeable, and its tendency to produce gas- tric and intestinal irritation less. It may, therefore, be employed to promote the appetite and invigorate digestion in debilitated states of the system. Scrofulous affections, passive hemorrhages, colli- quative sweats, excessive suppuration, low febrile diseases, caries of the bones, ulcerous and eruptive affections with depraved blood, are complaints in which it has been recommended, and in which its tonic properties may have rendered it useful. Its property of dis- solving phosphate of lime out of the body has led to its employ- ment in ossification of the heart and blood-vessels, and in cases of CHAP. I.] MINERAL TONICS.—CARBONIC ACID WATER. 383 phosphatic deposits in the urine, in the hope that it might dissolve the abnormal bony matter, and calculous formations within the body. In the urinary affection, it may operate beneficially in the same manner as sulphuric acid. It has been supposed to possess the power of greatly reducing vital irritability, and has been em- ployed, in reference to this property, in hysteria and convulsive disorders. On the contrary, from an imagined excitant influence over the generative organs, it has been used in impotence in males. As a local application, it has been especially recommended in caries, in which it corrects the fetor, dissolves and aids in the separation of the dead portions of bone, and otherwise favours the healing process. It is said also to have proved beneficial in offensive cancerous ulcers. The dose for internal use is from ten minims to a fluidrachm, which should be given largely diluted with water. For external use, the officinal acid may be diluted with nine or ten times its bulk of water. CARBONIC ACID WATER. AQUA ACIDI CARBONIC! U.S. Syn. Artificial Seltzer Water.—Artificial Mineral "Water. Preparation. Carbonic acid water is prepared, according to the U. S. Pharmacopoeia, by forcing into water five times its bulk of carbonic acid gas, obtained by the reaction between marble and dilute sulphuric acid. Water under the ordinary atmospheric pressure, and at ordinary temperatures, absorbs about its own volume of carbonic acid gas, and may be made to take up any additional quantity that may be required by increasing the pressure; the quantity absorbed being directly proportionate to the augmentation of the pressure. Thus, if with the pressure of the atmosphere it will absorb itsown volume, with a pressure double that of the air it will absorb two volumes, with triple the pressure three volumes, &c. As kept in the shops, the solu- tion has not always the officinal strength; being sometimes stronger and sometimes weaker. I am told that the preparation generally kept by the druggists of Philadelphia contains about seven or eight times its bulk of the acid gas. This statement, however, applies only to the water first drawn from the fountains; as, being driven out by the pressure of its own escaped air, it gradually becomes weaker as the fountain is exhausted, and towards the close must 384 GENERAL STIMULANTS. [PART II. be much more so than at first. The colder it is, the more gas is it capable of containing. To maintain its proper strength, it must be kept under steady pressure; and hence the best plan is to have it bottled by the manufacturer; in which case, it retains an equable strength for an indefinite length of time, if well secured. Properties and Impurities. Carbonic acid water is an effervescing, sparkling, colourless liquid, of an acidulous, pungent, agreeable taste; often producing, when swallowed, considerable irritation in the fauces. It reddens litmus paper, and precipitates lime-water. From the mode in which it is prepared and kept, it is liable to two impurities, which very much interfere with its beneficial operation. Not unfrequently the fountains or reservoirs containing it, are furnished with a leaden tube of exit, so that a portion of the water, drawn at any one time, must have been for a longer or shorter period in contact with lead, and is liable to be more or less impregnated with the carbonate of that metal. Should it be fre- quently drawn, there will be no appreciable quantity of the salt of lead; but if not, the impregnation may be considerable. The water which has remained over night in the exit pipe often contains it; and I have known of two instances of colica pictonum induced by the habit of drinking every morning the first draught of the water from the fountain. Another impregnation is copper, derived from the fountain, which is usually made of that metal. The copper fountains are, it is true, tinned in the interior; but the process is not always well performed, or the tin coating is worn off in spots; and thus it very frequently happens that more or less copper is dissolved. Sometimes the solu- tion is so strong as to be obvious to the taste. It is highly important, for medical purposes, that the water should be quite free from these impurities. Their presence may easily be detected. If lead is contained in the preparation, it will be evinced by the production of a dark discoloration on the addi- tion of hydrosulphate of ammonia; if copper, by a brown precipi- tate with ferrocyanuret of potassium. This latter test is so delicate, that one part of copper, dissolved in 56,000 parts of the water, may be detected by the reddish tinge it produces. 3Iedical Effects and Uses. Carbonic acid is locally irritant. This is perceived on attempting to inspire the pure gas, when a strong irritant impression is felt in the throat and air-passages, so strong, indeed, that the glottis closes spasmodically, and refuses to admit it unless diluted. Applied to the skin for a short time, it produces CHAP. I.] MINERAL TONICS.—CARBONIC ACID WATER. 385 a feeling of warmth and tingling or prickling, sometimes positively painful. When the strongly impregnated liquid is swallowed, it is often so irritant to the fauces, as with some persons to render it almost impossible to take a large draught of it without interruption. It exercises a similar excitant influence on the stomach itself, and this is probably the main cause of its medicinal effects. In other words, it is a gentle gastric stimulant, operating in a manner more analogous to that of the milder aromatics than of any other medi- cines. It is said to be refrigerant, and to excite perspiration and diuresis. But I believe it owes these effects to the water with which it is taken; and one of its advantages is that, by the gentle stimula- tion of the acid, it prevents injurious effects from the large draughts of very cold water swallowed with it. I do not think that of itself it is either stimulant to the secretions, or in any degree sedative. It is probably not absorbed into the circulation as carbonic acid from the alimentary canal, for the tendencies of the blood are every- where to give out rather than to take in that substance. The gently stimulant action of carbonic acid water renders it useful as a tonic in dyspepsia and other states of gastric debi- lity, if not used so largely and so frequently, as on the one hand to produce inflammation of the stomach, and on the other to ex- haust its excitability. The dyspeptic patient will find advantage in taking a moderate draught of it twice a day. Another great advantage is the one, already referred to, of obviating too great a depressing effect from cold water, and of rendering it acceptable to the stomach, when it might otherwise prove oppressive, possibly excite gastric spasm, or be rejected. Hence, when heated and per- spiring, we may much more safely take a draught of cold carbonic acid water, than an equal amount of equally cold water not simi- larly protected. Hence, too, in febrile diseases, carbonic acid water very cold may be given happily as a refreshing and refrigerating drink, when cold water in the same quantity might oppress the stomach. It thus, too, enables the liquid to act as a diluent and by entrance into the circulation, and passing off with the secretions to relieve febrile excitement. But the most useful remedial effect of carbonic acid is the relief of nausea and vomiting. There are few means more efficient for this purpose, when the nausea is not dependent on positive inflam- mation of the stomach. It is one of our very best resources in the irritable stomach of fevers. More frequently, perhaps, the effect of carbonic acid, under these circumstances, is obtained through the VOL. I.—25 386 GENERAL STIMULANTS. [PART II. medium of the effervescing draught; because there is usually, at the same time, an indication for the diaphoretic and refrigerant influence of the citrate of potassa. But the carbonic acid water is also much used, and is very efficient. The best method of employ- ing it is to have a number of small bottles, each containing about two fluidounces, filled with the liquid, then well closed, and kept in ice-cold water. The contents of one of these may be taken, as wanted, every half hour, every hour, or less frequently; and the preparation remains unimpaired; while, if the liquid is used in suc- cessive draughts from one large bottle, the strength of it becomes exhausted before the bottle is emptied. It is not only the nausea of febrile disease that may be thus treated; but that also of cholera morbus, cholera infantum, and all other disorders in which the affection is properly gastric, and not positively inflammatory. As a vehicle for laxative, diuretic, and diaphoretic medicines, in order to obviate any nauseating effect from them, and to render them acceptable to the stomach, carbonic acid is much used. It is an excellent menstruum for sulphate of magnesia, citrate of magnesia, or any other of the more soluble saline cathartics, of the citrates of potassa and ammonia as diaphoretics, and of the alkaline carbonates as diuretics and antilithics. It is also sometimes useful as a solvent for substances not soluble in water alone. The carbonate of iron and carbonate of magnesia, are soluble to a certain extent in car- bonic acid water, which thus offers the means of agreeably admin- istering these substances in solution. The dose of the preparation is not precise. The patient may, in general, be left to his own discretion; but it is best on the whole to give it in small quantities, as of a wineglassful, repeated frequently, than very largely at once. Seldom more than from four to eight fluidounces should be taken at one draught. It is often advisable to flavour it with some agreeable syrup; as, in febrile cases, with lemon syrup, and in dyspepsia with ginger syrup; but in nausea and vomiting, it is usually more effective when taken alone. Considerable use has been made of carbonic acid topically as a gently stimulant agent. Applied by means of a stream of the gas, or a fermenting poultice, or of cloths wet with the solution, it has been used advantageously in cancerous, sloughing, and other ill-conditioned ulcers, of which it relieves the pain, improves the secretions, and checks the gangrenous tendency. The gas has been injected into the rectum, and thrown up the vagina, with asserted CHAP. I.] MINERAL TONICS. 387 advantage, in painful ulcerative affections, and, by the latter method, has been employed as a remedy in dysmenorrhcea. In obstinate scrofulous ophthalmia, a stream of the gas has been directed upon the inflamed membrane with supposed benefit. Many natural mineral waters contain carbonic acid gas, which adds greatly to their usefulness, by rendering them more palatable, and more acceptable to the stomach. 2. Mineral Tonics acting on the Si/stem generally, through its Vital Properties. It is at present no longer doubted that the medicines belonging to this subdivision enter the circulation, and thus come into con- tact with all the tissues. They operate primarily on the alimentary mucous membrane, in a manner closely analogous to that of the mineral acids; that is, they moderately stimulate or excite the function of the membrane, or, in other words, act as tonics. But they are all, moreover, somewhat astringent, causing a contraction of the tissues, like alum or acetate of lead, though in a less degree; for a very energetic contraction would interfere with the functions of the membrane, and thus prevent the proper tonic effect. It is highly probable that they operate, in a manner precisely analogous, upon the various tissues of the body which they reach through the blood. Producing a slight increase of the vital cohesion of the molecules of the tissues, they give them greater power, while, by a gentle excitation, they call this power into a somewhat higher exercise. But, while thus generally tonic and astringent, they are disposed to act more especially upon the nervous centres; or, to speak more precisely, the organized nervous substance of these centres seems to be peculiarly susceptible to be impressed by them, and to take on, under their influence, a condition of greater firmness or compactness, which enables them, if previously weakened, to perform their proper function more efficiently. Here we have the secret of one of the most important therapeutic effects of this set of tonics; that, namely, of controlling the irritability of the nervous centres, and thus obviating various nervous disorders, and especially muscular spasm. From their influence in this way, they have not unfrequently been considered as antispasmodic, and been so deno- minated. Spasm, as well as most other irregular nervous pheno- mena, depends upon a disturbance in the nervous centres, produced 388 GENERAL STIMULANTS. [PART II. generally from some source extraneous to themselves. The more movable or excitable these centres are, the more liable will they be to give rise to these irregular phenomena under irritating influ- ence. Now the tonics here referred to, by increasing the vital cohesion of their molecules, and rendering their structure firmer, enable them better to resist disturbing causes; at the same time supporting due action in them by a gentle stimulation. The dis- ordered phenomena cease; and, by a sufficient persistence in the use of the remedy, the centres may acquire a permanent capacity of resistance, which may lead to a permanent cure. Hence it is in the various nervous diseases, such as hysteria, chorea, and epilepsjr, that these tonics have acquired the highest reputation, and are most extensively used. Some suppose that they act by entering . into chemical combination with the constituents of the tissue, and thus forming a part of the organization itself; and that their effects are to be explained by the new qualities which the tissues acquire through this change of structure. They support this opinion by the fact, that the metallic ingredient of these medicines is found in the very substance of the organs, from which it can be separated after death, supposing the patient to have died while under their influence. But this is no proof whatever, and scarcely even, in any degree, confirmatory of the notion of a chemical union. The metal may be in the capillaries of the organ; it may be deposited in the very substance of the tissue; it may even be there combined with some organic principle derived from the blood or from the tissue; but even admitting all this, it does not follow that it is chemically combined with the constituents of the tissue in their organized state; and it is not easy to conceive how a foreign body, thus thrust into the constitution of the nucleus or cell, which per- forms the office of the tissue, would enable it to perform that office more effectively. We may conceive that a metallic substance may possibly enter into such a union; but it would be to impair, not to improve the function; it would be to produce the effects of a poison, and not those of a remedy. Indeed, it is not improbable that some metallic poisons operate in this way; but more positive proof must be adduced,' before we can admit that medicines pro- duce their curative effect through such a combination, and espe- cially medicines whose immediate operation is to improve and to invigorate. 4 CHAP. I.] MINERAL TONICS.—NITRATE OF SILVER. 389 I. SILVER. ARGENTUM. U.S., Lond., Ed., Dub. Metallic silver is quite inert, and may lie for a long time in the alimentary canal without sensible effect. It is only in chemical combination that it becomes efficient. As all the constitutional effects of its preparations can be obtained by the exhibition of the nitrate, and as this is generally preferred in practice, it may conve- niently represent the metal in its relations to the system at large; and all that it is necessary to say, in reference to the operation and uses of silver as a medicine, may be included in our consideration of that salt. Afterwards, nothing need be noticed, in relation to the N other preparations, except what may be peculiar to them severally. NITRATE OF SILVER. —Argenti Nitras. U.S., Lond., Ed,—Lunar Caustic. Origin. This salt has been known since the times of Geber, who described the mode of preparing it. I propose to treat of it, in this place, solely in reference to its internal use. As an external remedy, it is among the most valuable; but the consideration of it, in this capacity, belongs to another part of the work. (See Escharotics) It is kept in two forms; one, that of cylindrical sticks, adapted for topical use, and frequently called lunar caustic; the second, that of crystals, which are preferred when the medicine is to be given internally. It is to the latter that the following remarks apply. The crystals of nitrate of silver are prepared by dissolving silver in nitric acid with a little water, and then evaporating, so that crys- tallization may take place upon the cooling of the liquid. They should be kept in well-stopped bottles, from the interior of which everything organic should be excluded. Composition. Crystallized nitrate of silver consists of one equiva- lent of nitric acid and one of protoxide of silver, without water of crystallization. • Properties. The crj^stals are colourless, transparent, and in the form of rhomboidal plates. They are inodorous, but of a strong, bitter, metallic, peculiar, extremely disagreeable, and adhesive taste. Water and alcohol dissolve them freely, especially the former, which takes up its own weight of the salt. At a moderate heat they melt, and at a strong heat are decomposed. In contact with the smallest portion of organic matter, they blacken on exposure 390 GENERAL STIMULANTS. [PART II. to light; but remain unchanged, even by the sun's rays, in the entire absence of such matter. Their solution in pure distilled water is similarly unaffected by sunlight, unless organic matter is present, in which case it is darkened. The change of colour is owing to a partial reduction of the silver. Incompatibles. Nitrate of silver is decomposed, with the forma- tion of insoluble products, or such as are but slightly soluble, by the alkalies, alkaline earths, their carbonates, and soap; by sul- phuric, muriatic, hydriodic, phosphoric, hydrosulphuric, and tar- taric acids, and all the soluble salts formed by the reaction of these acids with salifiable bases, consequently by the soluble sulphates, muriates, phosphates, tartrates, chlorides, iodides, and sulphurets; and by astringent vegetable infusions, in consequence of their tan- nic acid. With albumen and fibrin it unites, forming compounds insoluble in water; but it is a fact of some importance, in explana- tion of the operation of the salt on the system, that the albuminate of the nitrate of silver thus formed is soluble in an excess of albu- men. Of like significance is also the fact, that the insoluble chloride of silver, which is found whenever the nitrate comes into contact with muriatic acid or a soluble chloride, is rendered soluble by an excess of chloride of sodium or potassium.* In consequence of the great number of substances which decom- pose the nitrate, or combine with it, and the constant presence in the stomach of one or more of these substances, especially albumen, muriatic acid, or a chloride, it is scarcely possible that it can long retain its integrity after having been swallowed; though it may do so sufficiently long to exert a direct influence on the mucous coat. That it should enter the small intestines as nitrate of silver, appears to me to be clearly impossible, unless it be so incorporated with other substances in the form of pill, that, in this shape, it may pass through the stomach before the pill is broken up, and its interior exposed to the reagents there existing. Effects on the System. Locally, nitrate of silver is powerfully irritant, and, in a concentrated state, acts as an escharotic by com- bining with the albuminous matters of the tissues, and thus disor- * Some doubt is thrown upon the uniform occurrence of the chemical reaction here referred to, by an experiment of Professor Procter, performed at my request. A drop of solution of nitrate of silver was made to fall into a solution of chloride of sodium, and produced a precipitate; yet, after long contact of this precipitate with the supernatant solution, the latter, when filtered off, gave no evidence of the presence of silver when applied to bright copper, and touched with bright iron; and the taste was purely saline. CHAP. I.] MINERAL TONICS.—NITRATE OF SILVER. 391 ganizing them. When in contact with the mucous membranes, with ulcers, or with the skin deprived of the cuticle, it combines with the albumen of the secreted matters, and often with that of the tissue itself, forming a white and insoluble compound, which covers the surface; and this happens as well in the gastric and in- testinal mucous membranes, as in those visible from without. Ap- plied to the skin, it soon produces a black stain, in consequence of the partial reduction of the silver by reaction with the cuticle. This black stain usually remains until the cuticle separates, either gradually, or at once completely, as in vesication. It may be re- moved, however, by applying to the spot the tincture of iodine, and following this by a solution of hyposulphite of soda. Another agent which speedily removes the stain is a solution of cyanuret of potassium. These remarks, in reference to the local effects of nitrate of silver, will be enlarged upon in a subsequent account of the escharotic and protective operation of the salt. At present, they seemed necessary to explain the effects of the medicine upon the stomach. In very small doses, repeated two or three times a day, nitrate of silver produces no other observable effects than those of a gentle tonic and astringent; as improved appetite, invigorated digestion, and perhaps a tendency to constipation. Taken more largely, it causes warmth of stomach, and some gastric uneasiness, indicating an irri- tant action, which, upon a still further increase of the quantity, is evinced by gastric pains, sometimes nausea and vomiting, and occa- sionally also by griping pains in the bowels, with either diarrhoea or constipation. As to the degree of irritant effect, much depends on the mode of its administration, and the condition of the stomach at the time. It has been repeatedly observed that, in the form of pill, large doses produce little irritation; while a smaller quantity will violently irritate, if given in solution. Dr. Powell found that he could sometimes give fifteen grains in pill, while five grains in solution could rarely be borne by the stomach. (3Ied.- Chir. Trans., ix. 238.) The result is obviously owing, in the instance of the solution, to the whole quantity being brought at once into contact with the surface of the stomach, before time has been allowed for decomposition; while, in the pilular form, dissolving gradually, it acts also gradually, and is more liable to decomposition before it can act at all. When the stomach is full of food, the medicine would be much more exposed to decomposing reagencies than when it is empty, aud would consequently be less likely to irritate; 392 GENERAL STIMULANTS. [PART II. for all the insoluble substances resulting from the chemical changes of the nitrate in the stomach are much less irritant than the salt itself. Thus, the chloride of silver, which must be among the most common products, may be given in large doses, without observable effect. How far nitrate of silver would operate as a deadly poison, in excessive amount in the human subject, is left very much to infer- ence; for few cases of acute and fatal poisoning from this substance have been recorded. Boerhaave mentions the case of a phar- maceutical student who, having swallowed a portion of lunar caustic, died from gangrene of the first passages. But this is the only case of the kind that I have met with in the books. In the Bulletin Generale de Therap. (Sept. 1839) the case of a young man is related, who, after having taken a large quantity of the salt in solution, an ounce, according to his own account after recovery, was carried to the Hospital St. Louis, in Paris, quite insensible in all parts of the body, with convulsive movements of the face and upper limbs, jaws firmly closed, eyes rolled up, and pupils dilated and insensible to light. Common salt was given freely, and after- wards emollient drinks. When sensibility began to return, the patient suffered from violent epigastric pains. He ultimately recovered without serious consequences. The effects upon the nervous system may have been sympathetic with those upon the stomach, which was, no doubt, intensely irritated. (See Am. Journ. of 3Ied. Sci., xxvi. 239.) Orfila found that from twenty to thirty- six grains, introduced into the stomach of a dog, caused death with the phenomena of corrosive poisoning, and that ulceration in the alimentary canal was produced. The fact probably is, that large doses may be borne without immediately fatal consequences, partly from the rapid chemical change which the salt undergoes, and partly from its superficial caustic operation, by which an extremely thin layer of epithelium is disorganized, and, forming with it an impermeable film, protects the deeper and more vital parts of the membrane from destruction. But, admitting this, it must be allowed that a frequent repetition of these large doses might gradually corrode into the deeper structure; and death ensue at last from the slow and continued operation of the poison. Esquirol mentions a case, in which nitrate of silver was given freely during a period of eighteen months, at the end of which time the patient died, and the stomach was found destitute of the mucous coat over CHAP. I.] MINERAL TONICS.—NITRATE OF SILVER. 393 one-half of the inner surface, with several points of corrosion to the peritoneal coat. Nitrate of silver, therefore, must be ranked among the corrosive poisons. In acute cases of its poisonous operation, the treatment should consist in the use of common salt, or, if this is wanting, of the white of eggs, and a thorough washing out of the stomach by diluent drinks, or other means if necessary. Opiates should afterwards be administered, in the form of enema, to quiet irrita- tion ; and the resulting inflammation treated on general princi- ples; care being taken not to exhaust the patient by too copious depletion. Hitherto I have treated only of the local operation of the medi- cine on the alimentary canal. It acts also on the system at large, through the circulation. Of its absorption, or rather of the absorp- tion of the metal in one form or another, there can be no reasonable doubt. Leaving out of view the statements made as to the discovery of metallic silver in the pancreas after death, we have Orfila's de- claration that he has found it in the liver of animals to which the nitrate has been administered for some time (see Lond, Med. Times and Gaz., March, 1852, p. 279); and, in addition to this, the indis- putable evidence of the discoloration of skin produced by it. In any dose in which it is ordinarily given, its physiological influence upon the general functions is not striking. There may possibly be some increase in the frequency or force of the pulse, and the gene- ral temperature; but these results are much less observable than from the more powerful of the vegetable tonics. Salivation is said to have been sometimes produced, and writers speak of an erup- tion upon the skin; but I am not certain that I have witnessed either. One effect, however, is very striking. When the medicine is given in large doses, and long persevered with, a darkening of the skin is sometimes produced, which gradually deepens, till the whole surface of the body assumes a bluish-slate colour, extremely disagreeable to the eye, as totally differing from any natural tint. The discoloration is deepest in the parts exposed to light; but is said also to have been observed in the interior tissues, and in one instance to have pervaded the whole body; though this last state- ment may be considered as wanting confirmation. It is asserted that, in many instances, it does not occur until months after the medicine has been discontinued, and its favourable effects experi- enced. (Sigmund, London Lancet, March 31, 1838.) In connexion with this fact, it may be stated that Orfila found silver in the liver 394 GENERAL STIMULANTS. [PART II. of animals, to which the nitrate had been given, six months after its administration, showing that it is apt to become fixed in the tissues. In seven months, however, it had disappeared, and he could find no evidence of its existence in any part of the body. (See Lond. Med. Times and Gaz., March, 1852, p. 279.) So far as any inference can be drawn from this fact, it is that a patient can- not be considered free from the danger of discoloration in less than seven months after the omission of the medicine. The discolora- tion is generally permanent; but is said to have in some instances diminished with time, or under the operation of certain remedial measures. The seat of it is the true skin; for it remains unaffected when the cuticle is removed by a blister. The obvious explana- tion of the phenomenon is, that the preparation of silver circulating with the blood, when it enters the tissue of the true skin, and is thus exposed more or less to exterior-influences, as of light and the air, undergoes decomposition, with the deposition of the partially reduced metal, probably in the state of a suboxide. This being insoluble in the blood, or in any liquid which the parts can gene- rate, remains unabsorbed in the tissue. Happily, before the skin begins to exhibit this hue, a similar dark discoloration usually appears upon the gums and tongue and in the fauces, and serves, if observed, to put the practitioner upon his guard. It is said that the discoloration has disappeared under a steady course of cream of tartar. Dr. Pereira states, in his work on Materia Medica (3d ed. page 886), that he has been informed of a case in which washes of dilute nitric acid diminished it. Iodide of potassium has been pro- posed as a remedy; but has proved ineffectual. Perhaps the gal- vanic forces, said to have recently succeeded in eliminating metals from the system, may have some effect in this case. From what has been already said of the facility with which nitrate of silver is either decomposed, or otherwise rendered insoluble by chemical reaction, it is highly improbable that it ever enters the circulation without change. There are, however, two known states of combination, in which the metal may possibly be absorbed when the nitrate is administered. One of these is in the compound of nitrate of silver with albumen, which is soluble in an excess of albumen, and consequently in the blood, and the other in the double compound of chloride of silver and sodium, which is said to be soluble in water. (See page 390.) As the albuminate under- goes the darkening process out of the body on exposure, it is highly CHAP. I.] MINERAL TONICS.—NITRATE OF SILVER. 395 probable that it undergoes the same change in the tissue of the skin, with a less degree of the same exposure. Therapeutic Application. Besides the uses of the nitrate as an external remedy, which will be noticed elsewhere, it is employed for two distinct purposes; the one, for its direct influence on the alimentary mucous membrane, the other, for its effects upon the system at large through the circulation. 1. For its influence on the stomach and bowels, it might be employed, in minute doses, as a tonic, in debilitated states of their functions; but other remedies answer the indication so much more conveniently and effectively, that it is very seldom used for this special purpose. Still, as it has been supposed to exercise a pecu- liar influence over the nervous tissue, it has been recommended in certain painful affections sometimes dependent on dyspepsia, as gastrodynia and pyrosis; and has been found useful in morbid sensitiveness of the stomach. But it is vastly more beneficial, given rather freely, through its alterative action upon the mucous membrane in a state of chronic inflammation or ulceration; and has been strenuously recommended even in active irritation or acute inflammation of the same tissue. In chronic gastritis of the worst kind, I know of no remedy so effectual as nitrate of silver. Recommended originally, so far as I am aware, by Dr. Hudson, of Dublin, in this affection, it has been employed by me habitually since the first published notice, and with the happiest effects in most obstinate cases. I am not in the habit of using it in mild cases, which yield readily to a regulated diet, with other suitable hygienic measures, and with little aid from medicine; but, in those severe and obstinate forms of the affection, which have set all ordinary means at defiance, I have found it a most valuable resource. The cases in which it has appeared to me to do most good are those attended with incessant vomiting of food, and often with a smooth dryish tongue, apparently destitute of the papillary structure. I have used it, too, whenever I sus- pected the existence of ulcers in the stomach. One case of yeasty vomiting, 'of a most obstinate character, and probably dependent on an ulcer near the pylorus, yielded in the course of two or three months to this remedy. One most striking instance, in which I have little doubt that it was the means of saving life, was that of a female patient in the Pennsylvania Hospital, who had been reduced to the last degree of emaciation and debility, and whose death I was looking for from hour to hour. The stomach had long refused 396 GENERAL STIMULANTS. [PART II. to retain food, and the slightest nutriment induced vomiting. I directed that nothing whatever should be taken into the stomach, except a little cold water, and pills of nitrate of silver with opium, repeated three or four times a day; life being sustained by the injection of rich soups with laudanum into the bowels. The vomit- ing ceased under this treatment; in a few days a disposition for food returned, which was very cautiously indulged; and the patient went on gradually improving, until her health was perfectly re- established after many months of illness. I believe the remedy acts, in these cases, very much as it does upon the visible mucous surfaces when inflamed. Combining with the outer layer of the epithelium, or of the ulcerated surface, it forms a thin coating which protects the diseased tissue beneath from irritating matters in the stomach, whether derived from its own secretion or from without, and at the same time by its astringent and tonic properties, imparts a healthy contraction and tone to the expanded vessels. To pro- duce this effect, it must be in the state of the nitrate. The oxide or the chloride will not at all answer as a substitute. Hence the importance of giving the medicine upon an empty stomach, when it will be less likely to encounter decomposing substances, and will thus be enabled to exert its full influence on the diseased mem- brane. In these cases, I have never administered large doses of the salt. Beginning with one-quarter or one-third of a grain, combined with from an eighth to half of a grain of opium, repeated three or four times a day, I have very gradually increased, if the symptoms otherwise refused to yield, up to one grain at each dose; but have never exceeded that quantity. In chronic enteritis, also, great benefit is said to have accrued from the nitrate of silver; though in the trials I have made with it, the results have been much less favourable than in the gastric cases. It probably seldom enters the small intestines, or at least penetrates far into them, without being decomposed, and thus rendered unable to act on the surface of the bowel in the method above referred to. In ulcerative affections and chronic inflammation of the small intestines, it has appeared to me less effective than sulphate of copper. Nevertheless, much testimony might be adduced in its favour, not only in chronic, but even in acute inflammation of the alimentary mucous membrane. Trousseau strongly commends its use in acute dysentery, giving half a grain of the nitrate of silver, and the same quantity of nitre, made into a pill with starch, repeated every half hour till it begins CHAP. I.] MINERAL TONICS.—NITRATE OF SILVER. 397 to purge; at the same time administering, twice a day, an enema composed of a pint of distilled water holding from three to ten grains of the salt of silver in solution. (Traitede Therap. Trousseau et Pidoux, 4e ed. i. 354.) The latter part of the treatment, that, namely, by injection into the rectum, has been imitated with great asserted success in some severe cases of the disease; though the measure has failed in many others. Of the use of nitrate of silver by the mouth, in this complaint, I have had no personal experience. The same practitioner has found the medicine very useful in infantile diarrhoea. In cases attended with tormina, and glairy or bloody stools, he gives morning and evening an enema consisting of eight ounces of distilled water with one or two grains of the nitrate, according to the age; in other cases, characterized by nausea, and serous, green, or lienteric passages, he administers by the mouth from the twentieth to the fifth of a-grain dissolved in sweetened water. (Ibid., p". 355.) The same practice has been employed with success in our indigenous cholera infantum, when there was good reason to suspect the existence of ulceration of the bowels; and it is certainly among the measures to which the pru- dent practitioner would be justified in resorting, in obstinate cases of the disease. By M. Boudin, of Marseilles, the nitrate was recommended so long since as the year 1836 (Gazette 3Ied., No. 51, 1836), in enteric or typhoid fever, with a view to its curative influence upon the intestinal ulceration of that affection. He gave it either by the mouth or by the rectum, according as the disease appeared to be seated higher or lower in the alimentary canal; and sometimes he united both methods. He administered from a quarter to half a grain by the mouth, in the form of pill, and three or four grains, by enema, night and morning, dissolved in six fluidounces of water. This practice' has been imitated by other physicians, but has not been generally adopted. I entertain strong doubts of its efficacy; as I do not believe that the nitrate, when swallowed, will reach the seat of the local disease unchanged; and they who are familiar with the position of the ulcerated surfaces, extending often throughout the whole length of the ileum, would scarcely admit that six ounces of fluid, thrown into the rectum of an adult, would come in contact with them. In the diarrhoea of phthisis the medicine has been used with sup- posed advantage; but experience has not proved it to be more effi- cacious in this affection than other medicines habitually employed. 398 GENERAL STIMULANTS. [PART II. The late Dr. J. F: Peebles, of Virginia, found it remarkably efficient in certain cases of jaundice connected with an irritated condition of the stomach and small intestines. He gave from three-quarters of a grain to a grain twice a day, on an empty stomach. (Am. Journ. of 3Ied. Sci, N. S., xviii. 59.) In reference to the cathartic effect which the nitrate of silver sometimes produces, it was recommended by Boerhaave in dropsy; and the medicine is said to have been used advantageously in worms; but these applications of it are now seldom or never made. 2. For its effects upon the system at large, nitrate of silver has been employed chiefly in nervous affections. In some of these it has been carried to an enormous extent, with the effect probably sometimes of seriously injuring the coats of the stomach, and, in not a few instances, two of which at least have come under my own observation, of producing the indelible discoloration of the skin already described. Nor does this excessive use of the medicine, probably, contribute to the end in view. When given largely, the very irritation of the mucous membrane induced must interfere to some extent with its absorption; and by far the largest proportion is converted into chloride of silver, and passes out with the feces in this state, as proved by the experiments of Dr. Heller. In one instance, a boy aged thirteen, took twelve grains daily for three months, without any effect on the system, or discoloration of the skin; and no trace of silver could be discovered in the blood or the urine; while the whole amount of the metal was found in the evacuations from the bowels. (See Am. Journ. of Med. Sci., N. S. xii. 476.) Nevertheless, that the silver does occasionally enter the circulation is, I think, certain; and it may be presumed to do so generally, though in minute quantities. As the absorption depends upon the solubility of the compound of silver formed in the bowels, and as this probably depends on the presence of an excess of albumen or an alkaline chloride in the alimentary canal, the less the amount of the nitrate given, the greater will be the excess of the solvent agents, and the consequent probability of its absorption. The practical inference from these views is, that the physician should limit himself to moderate doses of the medicine, as being at once safer, and likely to prove not less effectual. I have before endeavoured to explain the nature of the action, by which this me- dicine, and others belonging to the same subdivison, prove useful in nervous diseases. (See page 387.) It will be sufficient to repeat, in this place, that the silver probably acts by increasing the vital power CHAP. I.J MINERAL TONICS.—NITRATE OF SILVER. 399 of resistance of the nervous centres to irritant influences, and thus preventing the effects of their irritation, as exhibited in spasms and other irregular movements, and in neuralgic pain. The long period during which, according to the experiments of Orfila before referred to, silver continues to adhere to the tissues after its admi- nistration has been omitted, may serve in some measure to explain the permanency of its effects in nervous diseases. Epilepsy is that one of the nervous affections in which the nitrate of silver has been given most frequently, and in the treatment of which it has the highest reputation. It is certainly among the remedies which have proved most effectual, so far as testimony can avail to decide the question. Every one knows that epilepsy, from the very nature of its sustaining cause, is often quite incurable. That the nitrate of silver, therefore, should very frequently fail, is nothing more than might be expected. The great obstacle to its general use is its liability to cause discoloration of the skin, which is even more objectionable to most persons than the disease itself. The physician, dreading the responsibility of such a result, if he employ the remedy at all, is apt to do so inefficiently; either using it in too small a quantity, or not continuing it sufficiently long. Upon this point, however, he should always guard himself, by informing the patient or his friends of the possible result, and leaving the decision with them. The risk of the discoloration may be considered as extremely small, when proper precautions are taken. These will be mentioned. Other nervous affections, in the treatment of which nitrate of silver has enjoyed considerable reputation, are chorea and angina pectoris. The former disease, however, is so readily curable by other less objectionable remedies, that it would not be justifiable to expose the patient to the risk, however small, of the cutaneous dis- coloration. But in angina pectoris, as in the case of epilepsy, the choice may well be left to the patient; though the chances of a cure from the remedy are so slight, that little encouragement should be offered. To its use in hysteria, asthma, and pertussis, in which it might be considered as indicated by its influence on the nervous centres, the liability above alluded to should be deemed an all-sufficient objection. Administration. When the effects of nitrate of silver upon the system generally are desired, it should be given preferably in the form of pill; as a larger dose can thus be taken, without irritating the stomach, than in solution. The same form is also preferable 400 GENERAL STIMULANTS. [PART II. when it is given by the mouth for intestinal affections; as there may be some hope that it may thus, in part at least, escape decom- position by the gastric contents. For its alterative influence on the stomach, it may be given in either form; but the solution would probably be most effective if well borne. When taken in pill, it should be mixed up with flour, starch, or powdered gum with syrup. The crumb of bread, often used, is objectionable on account of the common salt it contains. If given in solution, distilled water should be employed as the menstruum; the taste being covered, if deemed advisable, by a little oil of mint or peppermint. In either case, the preparation should not be long kept before being used. The dose to begin with, at least in delicate states of the stomach, should not exceed one-quarter or one-third of a grain, three times a day, which may be gradually increased to one, two, or even three grains, should no irritant effect be experienced. Some have pushed the medicine much further, even so far as fifteen or twenty grains, and with impunity; for there are generally in the stomach sub- stances, especially the chloride of sodium, which render it inert by decomposition; and it might unite with the albumen of the mucus, or even superficially with that of the epithelium itself, without serious injury. But these decomposing substances might be want- ing, or the mucous coat might be unprotected by its ordinary secretion, and the medicine come into contact with some exposed point with too great intensity; in short, experience has shown that the salt may prove highly irritant, and even poisonous; and there is no occasion to incur any risk, for, as before stated, these large doses are almost wholly decomposed, and pass out of the bowels; a very small portion only being absorbed; so that, when not mis- chievous, they will probably be useless. The great point will be to guard against the discoloration of the skin. For this purpose, the mouth should be carefully and fre- quently observed, and the least appearance of a dark blueness in the gums should be considered as a signal for discontinuing the medi- cine until this has disappeared. As the nitrate in solution mioht have the effect of darkening the surface of the mouth by its direct contact, the discoloration thus produced must not be mistaken for that resulting from the absorption of the medicine. Dr. James Johnson states that no case of discoloration is on record, in which the use of the medicine has not been continued beyond three months. It would, therefore, be a good rule, after having employed it conti- nuously for that length of time, to suspend it for a period, say one CHAP. I.] MINERAL TONICS.—OXIDE OF SILVER. 401 or two months; and there is some ground for this suspension in the long retention of the medicine in the tissues, as shown by the experiments of Orfila; so that, though it should be omitted, that already taken and absorbed might still be acting. The medicine should be taken on an empty stomach, and the caution should be observed that nothing containing common salt, or any other substance having the property of decomposing the nitrate, should be swallowed within a short time, either antecedent or subsequent to its administration. The following are preparations of silver derived from the nitrate. 1. OXIDE OP SILVER.—Argenti Oxidum. U.S., Dub. This is prepared by adding solution of potassa to a solution of nitrate of silver, the oxide being precipitated. It is an olive-brown powder, inodorous, nearly tasteless, and very slightly soluble in water; consisting of one equivalent of silver and one of oxygen. Though used as a medicine, on the continent of Europe, during the last century, it attracted little notice until proposed by Dr. Butler Lane, as a substitute for the nitrate, in the various diseases in which that remedy has been used. Oxide of silver acts locally as a slight irritant and astringent, but is wholly destitute of the property, which renders the nitrate so valuable, of combining with the tissues. Taken into the stomach, it is either absorbed, or forms soluble compounds which are ab- sorbed; for it produces occasional soreness of the gums and sali- vation, and has even caused discoloration of the skin. It was substituted for the nitrate as a milder remedy, and capable of producing its constitutional impression, with less danger of affecting the skin; but the want of the property of combining with the superficial part of the tissues, incapacitates it for those local alterative effects on diseased surfaces which give its highest value to the nitrate; and, in proportion as it may be less liable to dis- colour the skin, it will probably prove less efficacious as a medicine; the liability to produce that effect being incidental to the absorp- tion of the silver, no matter in what form it may be taken up, and consequently in some degree a test of its constitutional influ- ence. It seems to me, therefore, that little is gained by the substi- tution. Nevertheless, the oxide has been found useful, by Dr. Lane and others, in gastralgia, pyrosis, enteralgia, dysentery, diarrhoea, idio- pathic night-sweats, dysmenorrhea, leucorrhcea, and uterine hemorrhage. In the last-mentioned affection, the favourable report of Dr. Lane is supported by the experience of Dr. Golding Bird; and Dr. vol. I.—26 402 GENERAL STIMULANTS. [PART II. Thweatt, of Petersburg, Va., has published several cases of menor- rhagia, in which the medicine appears to have proved efficacious. (Am. Journ. of Med. Sci., N.S., xviii. 69.) The oxide would seem to promise most fairly as a substitute for the nitrate in epilepsy, and other spasmodic complaints; but, though it may probably be given with less risk in large doses, experience has not proved that it pos- sesses superior advantages as a remedy. It is said to have been used successfully in taenia. The dose is a grain, repeated twice or three times a day, which may be gradually increased to two grains. In the larger quantity, it sometimes occasions a little tormina and tenesmus, which may be checked by an anodyne enema. (Thweatt, ibid.) The same caution is requisite, in relation to the continuance of the dose, as when the nitrate is employed. It may be given in powder or pill. The oxide has been used also externally, in powder or ointment, in ophthalmia, excoriated nipples, irritable ulcers, and venereal sores; and, smeared on a bougie, has been employed in gonorrhoea. The ointment may be prepared with a drachm of the powder and an ounce of lard. 2. CHLORIDE OP SILVER. —ARGENTI CHLORIDUM. This is made by adding muriatic acid, or a solution of chloride of sodium, to a solution of nitrate of silver. The chloride of sil- ver is precipitated as a white curdy substance, which, when washed and dried, is ready for use. Though white at first, it soon begins to darken on exposure. It is insoluble in water. The circumstance that nitrate of silver is often converted into the chloride in the sto- mach, has led to the employment of the latter, as likely to produce the same effects on the system, while much less irritant. Many years since, I was induced myself, by this consideration, to try it in epilepsy; but, meeting with no encouraging success, I soon aban- doned it. Dr. Perry used it in the Blockley Hospital of Phila- delphia, and obtained advantage from it in chronic dysentery. It has been employed also in syphilis, and in other diseases in which the nitrate is recommended; but it has not come into general use. The dose is from one to three grains, or more, three or four times a day. Twelve grains have been given daily for three months, with- out unpleasant symptoms. A dose of thirty grains has produced vomiting. 3. IODIDE OP SILVER—ARGENTI IoDIDUM. This may be prepared by mixing solutions of nitrate of silver and iodide of potassium; the iodide of silver being thrown down CHAP. I.] MINERAL TONICS.—COPPER. 403 as an insoluble, greenish-yellow powder. Dr. Charles Patterson, of Dublin, having convinced himself, by experiment, that this prepara- tion does not change colour on exposure to the light, even in contact with organized matter, conceived that it might be advantageously substituted for nitrate of silver, on the ground that it would not be liable to cause discoloration of the skin. In order to determine how far it might possess the therapeutic virtues of the nitrate, he tried the medicine in various diseases; and, though he succeeded in curing a gastric affection of the Irish peasantry, in which the nitrate had been found useful, in ameliorating pertussis, and in relieving a case of dysmenorrhoea, his experience was certainly not, upon the whole, very satisfactory; and a much more extensive series of ob- servations would be necessary to establish the claim of the iodide of silver to be used as a substitute for the nitrate. Nor is it by any means certain that it might not cause discoloration of the skin; for though, if absorbed unchanged, it might not thus act, the proba- bility is that, before entering the circulation, it would be chemically altered, and that the compound of silver really absorbed would be liable to the same changes in the system, as that which enters the blood-vessels when the nitrate is administered. Nevertheless, the iodide is perhaps worthy of further trial; as, if found to be pos- sessed of the virtues of the nitrate, without its disadvantages, it would be a most valuable addition to the Materia Medica. From one to three grains may be given three times a day, and gradually increased till some disagreeable effect upon the stomach or bowels is produced. II. COPPER. CUPRUM. In the metallic state, copper is quite inert. Instances are on record in which copper coins have remained long in the stomach without any observable effect; and animals which have been made to swallow filings of the metal, to the amount even of an ounce, have in no degree sensibly suffered from them. Yet other eases have occurred, in which local injury to the stomach, or some derange- ment of the system has followed, under similar circumstances. The result in these instances has, no doubt, depended on chemical changes, by which the metal has been oxidized, and converted into a salt through the agency of the gastric acids; so that it was not 404 GENERAL STIMULANTS. [PART II. the copper itself, but one of its soluble compounds, probably the chloride, that acted. Copper may generally be detected in minute quantities in the blood of persons in health, and has been repeatedly found in the tissues, when no preparation of the metal was known to have been taken. It has hence been inferred that, like iron, it forms an essential constituent of the blood; and Millon supposed it to enter into the normal constitution of the red corpuscles. But so much copper is taken into the system in various ways with our food, that the exceedingly minute portion which a delicate chemical analysis can detect, has its origin probably in this source, and is only accidentally present in the blood, which would in no degree suffer from the want of it, as it does from the want of iron. Wacken- roder has confirmed this view by showing that the blood of domes- tic animals, living on pure vegetable food, is quite destitute of it; while it may readily be discovered in the blood of the same animals and of man, when fed on a mixed diet. (Chem. Gaz., May 1, 1854, p. 175.) It may be inferred, however, from these facts, that a proportion of copper large enough to be sensible to chemical research, may exist in our economy without impairing health. Effects on the System. The preparations of copper are locally irritant, and most of them, in a concentrated state, corrosive. Taken internally, in moderate doses, they operate as gentle excit- ants to the mucous surface of the stomach, increasing the appetite, and producing other effects characteristic of tonic medicines. In over-doses they become irritant; but happily provoke vomiting very promptly; so that, being discharged from the stomach, time is not allowed them to produce serious and permanent effects, unless taken very largely. In this latter event, as will be seen directly, they are capable of producing fatal inflammation and corrosion of the alimentary mucous membrane. Like nitrate of silver, they decompose the superficial parts of the tissue, forming compounds with albumen, which are of a greenish-blue colour, and, according to Mialhe, soluble in an excess of the salt, when its acid is of vegetable origin, but not when it is mineral. But the preparations of copper also act on the system generally. This they are enabled to do by the facility with which they enter the circulation. They appear, indeed, to be among the metallic substances most easily absorbed. After one of the salts of cop- per has been taken for a short time, the metal may be sought for in vain in the alimentary canal, but will be found in the blood, CHAP. I.] MINERAL TONICS.—COPPER. 405 the substance of the liver, and other tissues. When absorbed, moreover, it holds its place in the organism with great tenacity. Orfila states that it may be detected in the liver, intestinal coats, and bones, eight months after having been taken into the stomach. (Lond. 3Ied. Times and Gaz., March, 1852, p. 279.) No observable effects upon the system, in health, are produced by small medicinal doses of the salts of copper; but their results in disease prove that, even in these quantities, they are not without efficiency. Their action appears to be that of a tonic, especially on the nervous centres, which they strengthen against irritating in- fluences, as explained in the general observations on this sub- division of mineral tonics. (See page 387.) When taken too largely or too long, they give unmistakable evidence of their effects, which may even be poisonous, independently of their direct action on the alimentary mucous membrane. The poisonous operation of the salts of copper is of two kinds, either rapid from a large quantity given at once, or slow from too long a continuance of relatively small quantities. In both of these modes of action, moreover, there appears to be a union of a local influence on the alimentary mucous membrane, with a general influence dependent on absorption. 1. Acute poisoning from a large quantity is attended with a cop- pery taste in the mouth, nausea, incessant vomiting, violent pains in the stomach and bowels, purging sometimes profuse, severe headache, cramps in the lower extremities, and, in fatal cases, con- vulsions, palsy of the limbs, and coma. In the lower animals, Orfila noticed, among the last phenomena before death, rigidity of the muscles, and even tetanus. Occasional salivation is also men- tioned, and jaundice is not uncommon, generally appearing during life, but sometimes not until after death. The first series of the symptoms here detailed are evidently the direct result of the irritant action on the stomach and bowels; those which succeed depend on a systemic influence directed more especially to the nervous centres, but sometimes exerted on the salivary glands, and not unfrequently upon the blood, as evinced by the jaundice, which probably arises from the destruction of the red corpuscles, and the alteration of their colouring matter. That the nervous symptoms are not merely sympathetic with the gastric disorder is proved by the facts, first, that after death the mucous membrane of the stomach and bowels is, in some instances, found to all appearance quite healthy, especially after speedy death; secondly, that the nervous 406 GENERAL STIMULANTS. [PART II. symptoms sometimes precede the gastric and intestinal, and thirdly, that similar phenomena have resulted from the poison injected into the veins, or applied to a wounded surface. The ordinary post- mortem phenomena are the signs of severe inflammation in the stomach and bowels, gangrenous patches here and there, corrosion and sometimes even perforation of the intestinal mucous mem- brane, and green discoloration of the tissue to a greater or less extent. The lungs are said also to have been seen inflamed; but this may have been an accidental coincidence. 2. The slow poisoning, according to Dr. Corrigan, of Dublin, who has drawn up his summary from an observation of several cases, is attended with emaciation, a cachectic appearance, muscular weak- ness, colicky pains, cough without discoverable pectoral disease, " and a peculiar characteristic retraction of the gums, with a purple, not a blue edge;" without the severe colic, constipation, and local palsy, which result from lead. (Braithwaite, xxx. 303, from Dub. Hosp. Gaz., Sept. 1854, p. 232.) Besides these phenomena, loss of appetite and diarrhoea are mentioned by other observers. I have seen no account of death from this slow poisoning. The symptoms are probably due partly to a chronic irritation of the alimentary canal, partly to a direct action upon the system. Poisoning by copper sometimes results from the accidental swallowing of one of its preparations used in medicine or the arts, but more frequently from food or drink prepared or kept in copper vessels, which, even though protected by tinning, are nevertheless apt to lose this protection, and to communicate deleterious proper- ties to substances contained in them, especially when these sub- stances are in any degree acid. There is reason to believe that much injury has thus been produced in the digestive organs, if not in the general system, by the habitual use of carbonic acid water, prepared and long kept in copper fountains. The treatment of the acute poisoning consists mainly in the free use of the white of egg mixed with water, which forms an insolu- ble compound with the poison, and at the same time facilitates the cleansing of the stomach. Should this not be at hand, recourse may be had to milk, or even wheat flour mixed with water. Ferrocyanuret of potassium has also been recommended as an anti- dote. Should free emesis not take place, the stomach should be thoroughly washed out by the stomach-pump. Afterwards the antidote should be administered with a cathartic, in order that it CHAP. I.] MINERAL TONICS.—SULPHATE OF COPPER. 407 may reach any portion of the poison that may have entered the bowels. The irritation of the stomach and bowels may then be quieted by opiates; and the case otherwise treated on general principles. The therapeutic applications of copper will be most conveniently treated of, under the heads of its several preparations. I. SULPHATE OF COPPER.—CuPRi SULPHAS. U.S., Lond., Ed,, Dub. — Blue Vitriol. Origin. Sulphate of copper exists in solution in the water run- ning from copper mines, from which it is obtained by evaporation and crystallization. But it is more frequently prepared artificially; and the method usually employed in this country is by the direct action of sulphuric acid on copper or its oxide. Composition. It consists of one equivalent of oxide of copper, one of sulphuric acid, and five of water of crystallization. Properties. Sulphate of copper is in fine, large, deep-blue, trans- parent crystals, inodorous, of a strong, harsh, styptic, metallic, and very disagreeable taste, very soluble in water, and insoluble in alcohol. It is slightly efflorescent on exposure. By heat it melts, and loses its water of crystallization, becoming white and opaque; and by an intense heat it is decomposed. On the addition of am- monia to its solution, a precipitate is first thrown down, which is dissolved by a further addition of the ammonia, with the production of a beautiful deep azure-blue colour. Incompatibles. The fixed alkalies and their carbonates, the alka- line earths, the soluble salts of lead, lime, and baryta, acetate of iron, bichloride of mercury, nitrate of silver, borax, tannic acid, and the astringent vegetable substances containing it, yield precipi- tates with the solution of sulphate of copper, and are therefore in- compatible in prescription. Effects on the System, The effects of this salt are those already described of the preparations of copper in general, with the addi- tion of astringency, in which it much exceeds the others. In short terms, it may be said, in relation to its action on the alimentary canal, to be tonic, astringent, powerfully emetic, highly irritant, and corrosive, according to the quantity swallowed; in relation to its effects upon the system, to be, in medicinal doses, tonic to the nerv- ous centres, and in excessive doses poisonous by an overwhelming influence upon those centres. Death, with coma and convulsions, has resulted from two drachms of it swallowed. Besides the anti- 408 GENERAL STIMULANTS. [PART II. dotes mentioned under the head of copper generally, magnesia has been recommended as specially useful in poisoning by the sulphate. Therapeutic Application. Sulphate of copper is thought to have been employed as a medicine by the ancients. In reference to its emetic operation, I shall treat of it under the emetics, and as an external remedy, in which capacity it is much used, under the escharotics. It is here considered solely in reference to its tonic, astringent, and alterative action on the stomach and bowels, and its general influence on the system. 1. It is seldom employed for its tonic action on the stomach; but has been highly. recommended in chronic diarrhoea and dysentery from a supposed astringent effect. In certain cases of this kind, it is certainly an admirable remedy. No doubt its astringency ren- ders it useful in some of these cases; but I ascribe its efficacy chiefly to a stimulant and alterative influence upon the ulcerated surfaces, similar to that which it exerts upon old and indolent ulcers externally. It has the great advantage, in intestinal affections of this kind, over nitrate of silver, that it may pass undecomposed through the stomach into the bowels, and thus come into contact with the ulcers. The particular condition in which I have found it specially useful, and in which, so far as my experience has gone, it is equalled by no other remedy, is a kind of chronic enteritis, attended with diarrhoea, distressing pains in a particular part of the abdomen, with or without tenderness on pressure, emaciation, great depression of spirits, a pulse often though not necessarily frequent, and a moist tongue. In such cases, I have been disposed to ascribe the obstinacy which they often exhibit, and sometimes in an extra- ordinary degree, to the existence, within a comparatively small ex- tent of the bowels, of a chronic, indolent ulceration, which requires a strongly excitant and alterative impression to enable it to take on a healing tendency. I have seen them, after being treated by a diversity of remedies, opiates, astringents, &c, and lingering month after month, without permanent relief, yield most happily to the persevering use of this remedy, combined with a little opium to render it less offensive to the stomach. A beneficial change is usu- ally experienced in a few days, and afterwards regularly advances to a cure. The only adjuvants which have seemed to me advisable, besides the small proportion of opium, are a diet exclusively of milk and farinaceous substances, and the daily use of the hot salt bath. In somewhat larger doses than are necessary in the affec- CHAP. I.] MINERAL TONICS.—SULPHATE OF COPPER. 409 tion just mentioned, I have no doubt that the remedy would prove highly useful also in certain obstinate cases of chronic dysentery, with ulceration of the large intestines. In the former affection, one- quarter of a grain of the sulphate, with the same quantity of opium, or even less, may be given four times a day, and gradually increased, if necessary, till the stomach is disturbed; in the latter, one-half a grain may form the commencing dose, to be similarly increased. The necessity of the larger dose in the dysenteric affection is that, the seat of ulceration being lower in the bowels, the medicine will have been to a greater degree diminished by absorption before reaghing it. Dr. Pereira states that he has, in an old dysenteric case, increased the dose to six grains three times a day, and con- tinued this for several weeks, with no other obvious effect than slight nausea, and amelioration of the disease. (Mat. 3Ied., 3d ed. p. 802.) 2. For its effects on the nervous system, sulphate of copper has been employed in epilepsy, hysteria, and other spasmodic, convul- sive, or nervous affections; but for these purposes it is generally less esteemed than the ammoniated copper, to which the reader is referred. It has also been recommended in intermittents, and might d priori be deemed useful in these complaints, from its corroborative influence upon the nervous centres, rendering them, like quinia, in- sensible to the irritant impressions which give rise to the paroxysms. Though much less efficient than quinia, it might be used as a sub- stitute for that remedy when circumstances prevent or forbid its use; and I have occasionally employed it as an adjuvant in obsti- nate cases.* Besides the diseases mentioned, sulphate of copper has been recommended in dropsy, worms, chronic catarrh with excessive secre- tion of mucus, and catarrh of the bladder; but I have had no expe- rience with it in these affections, and should have little faith in its efficacy. Administration. The dose of sulphate of copper, to begin with, is one-quarter of a grain, three or four times a day, which may be gradually increased, if the stomach will bear it well, to two grains. In doses of from three to five grains, it would be apt to vomit. It * The prescription I have employed was as follows. Take of sulphate of cop- per one grain, sulphate of quinia eight grains, opium one grain. Form with syrup of gum arabio into a mass, to be divided into four pills. One to be taken four times a clay. 410 GENERAL STIMULANTS. ■ [PART II. is most conveniently given in the form of pill, which may be made with crumb of bread, or with a mixture of gum and syrup. II. AMMONIATED COPPER.—CUPRUM AMMONIATUM. U.S., Ed. — Cupri Ammonio-SULPHas. Lond., Dub. Origin. This is made by rubbing together carbonate of ammonia and sulphate of copper. A reaction takes place, attended with the escape of carbonic acid, and resulting in the formation of a moist deep-blue mass, which, when dried, constitutes the preparation in question. Composition. Different opinions have been held as to the precise composition of this salt. The most probable is that which considers it a compound of one equivalent of sulphate of ammonia, and one of cuprate of ammonia, the oxide of copper performing the part of an acid in the latter salt. Properties. It is in the form of a coarse powder, having a beau- tiful deep azure-blue colour, the smell of ammonia, and an astrin- gent metallic taste. It is readily soluble in water. On exposure to the air, it is gradually decomposed, giving out ammonia, and assuming a greenish colour. It should, therefore, be kept in well- stopped bottles. Incompatibles. These are the same as in the case of the sulphates, with the addition of the acids. Effects on the System. Ammoniated copper has the physiological properties of the preparations of copper in general; being less astringent and irritant than the sulphate, but supposed to act more energetically on the nervous centres. In over-doses, it is capable of producing poisonous effects. Therapeutic Application. This preparation has been chiefly used, in reference to its effects upon the nervous system, in various spas- modic, convulsive, and neuralgic affections. In epilepsy, it has been considerably employed, and is among the remedies which have been most effectual, and are at present most relied on. In these respects, it probably stands next to nitrate of silver, over which it has the great advantage of not discolouring the skin. To sulphate of cop- per it is preferable, from being somewhat less disposed to irritate the stomach, and perhaps somewhat more effective as an antispas- modic. It should be persevered in for a long time, care being taken to guard against any obvious injurious effects on the system. In chorea, hysteria, pertussis, spasmodic asthma, and neuralgia, it has been recommended, and may be resorted to upon failure with other less CHAP. I.] MINERAL TONICS.—ZINC. 411 irritant substances. It has also been used in intermittent fever, in dropsy, and against worms in the bowels. Administration. The dose is half a grain, three or four times a day, to be increased, if necessary to obtain its curative effects, to four or five grains, unless it should prove irritant to the stomach. It is most conveniently given in pills, made like those of the sul- phate; and may often be usefully associated with assafetida. A solution of it in water has been used as an injection in gonor- rhoea and leucorrhcea, a collyrium in opacity of the cornea, a wash in prurigo, and as a stimulant application to indolent ulcers. According to. the effect desired, the strength of the solution may vary from one to thirty grains to the fluidounce of water. III. ZINC. ZINCUM. U.S., Land., Ed., Dub. Metallic zinc is without influence on the system; and it is only in chemical combination that it becomes active. The effects of its preparations are closely analogous to those of the preparations of copper, though less energetic. In relation to their visible topical effects, they are, according to their degree of solubility and concen- tration, either mildly excitant and astringent, or actively irritant, or escharotic. Taken internally, they operate directly on the ali- mentary mucous membrane, and, through absorption, on the system at large. In reference to the former of these seats of their action, they are, in small doses, simply tonic and astringent; in larger, promptly and powerfully emetic; in still larger, highly irritant, and even escharotic, sometimes causing death by inflammation or de- struction of the mucous membrane. This higher grade of action is exercised only by the soluble preparations. Upon the system at large, when given in small and repeated doses, they produce no sensible effect in health; and it is only by the relief or cure of cer- tain morbid conditions, that they are inferred to exercise a tonic or corroborant influence on the nervous centres, analogous to that of silver and copper. That they are absorbed, has been proved be- yond question. After having been swallowed, they have been found in the secretions and the solid tissues. Dr. Michaelis, in his experiments on the lower animals, noticed that, though zinc was found in the urine, after the internal exhibition of the oxide, it was 412 GENERAL STIMULANTS. [PART II. more largely eliminated with the bile. (Arch. Gin., 4e sdr., xxx. 481.) Taken in poisonous doses, together with the local injury of the primae vise, the preparations of zinc sometimes occasion symp- toms evincive also of an action on the nervous centres, as coma, con- vulsions, and paralysis. It has been a question, the decision of which is of considerable importance, whether the slow and continued introduction of zinc into the system is capable of materially deteriorating the health; in other words, of inducing a state of chronic poisoning, as the preparations of lead and some other metals are known to do. The general impunity under the long use of zinc as a medicine, and the comparatively little inconvenience experienced by those engaged in the various manufactures or applications of the metal, would seem to determine this question in the negative; but facts have been brought forward, which appear to me to place beyond doubt the occasional action of the preparations of zinc in the way referred to. Thus, a patient who took twenty grains daily, for several months, of the oxide of zinc, for the cure of epilepsy, became pale, ema- ciated, and almost idiotic, with a furred tongue, constipated bowels, tumid abdomen, cold extremities, oedema of the lower limbs, dry, shrivelled skin, like parchment, and a slow, small, very feeble pulse; symptoms, however, which quickly disappeared upon the omission of the medicine, and the use of cathartics, with a tonic and support- ing treatment. (Brit, and For. 3Ied. Rev., July, 1838, p. 221.) Several men employed in barrelling oxide of zinc, and exposed for several days to an atmosphere loaded with the powder, experienced, from the beginning, loss of appetite, clammy taste in their mouths, and colic; and, after ten days, were attacked with vomiting, constipa- tion, and violent colic, not unlike the affection produced by lead, and which, as that usually does, yielded to purging and opiates. (See Chem. Gaz., viii. 362.) In another instance, workmen exposed to the powder arising from beaten zinc, were affected with general depression, sore throat, angina, ulceration of the tonsils, white pel- licles on the gums, salivation, fetid breath, nausea, colic, and diar- rhoea. The symptoms subsided, upon the abandonment of the occupation, in less than a week. (Ibid) In these instances, it is obvious that large quantities of the powdered oxide must have been swallowed; and it was probably from this source that the symptoms proceeded. They were mainly such as result from a direct irritation of the alimentary canal; and, though it is probable that some of them arose from the absorption of the metal, they CHAP. I.] MINERAL TONICS.—SULPHATE OF ZINC. 413 were of little importance. They moreover disappeared rapidly, on the removal of the cause, leaving no permanent effect behind. It is very satisfactory that the evil from this cause is so trivial, when compared with that from exposure to the influence of lead, for which zinc is in a course of rapid substitution as a material for painting. In poisoning from large quantities of the soluble salts of zinc, the treatment should consist of the use of magnesia or one of the alkalies as an antidote, of free dilution with demulcent drinks, of opium to quiet irritation of the stomach and bowels, and of mea- sures to combat inflammation corresponding with the exigencies of each particular case. Of the therapeutic application of zinc it will be sufficient to treat under its several preparations. Of these, I would here ob- serve, that for internal use all might well be spared except the sulphate and oxide, from which every curative effect can be obtained which the others are capable of producing. 1. SULPHATE OF ZINC—ZlNCl SULPHAS. U.S.,Lond.,Ed,, Dub.—White Vitrio I. Origin. This was known so early as the middle of the sixteenth century. It is prepared by acting upon metallic zinc with dilute sulphuric acid. The metal is oxidized at the expense of the water, the liberated hydrogen escapes, and the oxide of zinc formed unites with the acid, to produce the sulphate, which is then obtained by evaporation and crystallization. Composition. The crystallized salt, which should always be se- lected for use, consists of one equivalent of sulphuric acid, one of oxide of zinc, and seven of water. On exposure, it partially effloresces, and loses much of its water. Properties. The crystals are small, slender, transparent, four- sided prisms, and in mass very closely resemble those of Epsom salt, for which they have sometimes been mistaken. They are inodorous, of a styptic, metallic, disagreeable taste, very soluble in water cold or hot, and insoluble in alcohol. By heat they are dissolved in their own water of crystallization, which gradually escapes, leaving the salt in the form of a white opaque powder. By an intense heat they are decomposed. Incompatibles. Sulphate of zinc is decomposed, with insoluble precipitates, by the alkalies and alkaline earths and their carbonates, by the soluble salts of lead, of lime or calcium, and of baryta or 414 GENERAL STIMULANTS. [PART II. barium, by sulphuretted hydrogen and the soluble sulphurets, and by astringent vegetable infusions through their tannic acid. Effects on the System. These are such as have been described in the general remarks on zinc, and do not require to be repeated particularly here. It is sufficient to state that this is the most astringent of the salts of zinc, and one of the most energetic in its effects on the system, whether medicinal or poisonous. It has been frequently taken, by mistake for sulphate of magnesia, in doses of an ounce or more, and sometimes, though very rarely, with fatal results. Happily, the powerful emetic properties of the salt usually cause the whole of it to be rejected, before it has had the oppor- tunity to produce a caustic effect upon the coats of the stomach. In a case of the kind which fell under my knowledge, one of the severest symptoms was a feeling of excessive constriction of the mouth, throat, and oesophagus; but the patient, who was a young woman, recovered without any serious consequences. Generally, along with incessant vomiting and retching, there is violent gastric and intestinal pain; and, in the fatal cases, there have been observed, in addition, purging, anxiety, restlessness, great prostration, and ultimately convulsions. The treatment required in such cases has been already stated. Therapeutic Application. As an emetic, sulphate of zinc will be considered particularly with the class of emetics. First, I shall treat of its internal, and afterwards of its external use. 1. For its direct effects on the alimentary canal, the salt has been used in dyspepsia,, diarrhoea, dysentery, and colica pictonum. As a gentle tonic, in very small doses, it is sometimes beneficial in sim- ple indigestion; but is seldom used in that affection. To diarrhea it is adapted by its strong astringency; but it is too irritant for the disease in its acute form, unless associated with great intestinal relaxation. It is to chronic diarrhoea that it is best adapted, and especially to those cases in which there may be a suspicion of ulcers in the small intestines. In these cases, associated with opium in small doses, it is sometimes very useful, though less effective, I think, than the corresponding salt of copper. In acute dysentery it should not be used by the mouth, except, sometimes, in the very advanced stages; but it may at any time be tried in the chronic form of the disease, when the tongue remains moist, and the ordi- nary measures have been employed in vain. There is a condition of dysentery in which it may often be used with very great benefit. I allude to cases in which the rectum is the part mainly affected, CHAP. I.J MINERAL TONICS.—SULPHATE OF ZINC. 415 whether the case be subacute or chronic. In instances of the latter kind, the patient will often suffer long with the most harassing tenesmus; and though, from the want of constitutional sympathy, his general health may suffer less than when the higher portions of the large intestines are inflamed or ulcerated, yet the local distress and inconvenience are so great that life is rendered burthensome. The remedy should here be used by injection, so as to bring it into direct contact with the ulcerated surface. I have been for many years in the habit of resorting to this measure in the class of cases mentioned, and, though they may have been of several months' duration, and in one instance which I remember, had continued a year, they have speedily begun to improve, and generally marched on steadily to convalescence. I usually direct from four to eight fluidounces of water, holding two grains of the sulphate in solution for each fluidounce, with the addition of thirty or forty drops of laudanum, to be thrown up the bowel twice a day. With the use of the salt in colica pictonum, I have no experience; and I should not be disposed to rely on it, while medicines known to be efficient are at command. 2. In reference to its tonic effects upon the system generally, and on the nervous centres more especially, the medicine has been given in most of the chronic nervous diseases, to which the metallic tonics are thought to be peculiarly applicable. Epilepsy, hysteria, hooping- cough, and asthma are among these complaints; but the one in which it has the highest reputation, and in which experience has shown it to be most efficacious is chorea, or St. Vitus's dance. It is certainly among the remedies which I have found most effectual in that complaint, especially when used in connexion with occa- sional purging. Upon the same principle, it will sometimes succeed in interrupting the paroxysms of intermittent fever, though probably less efficacious in this affection than sulphate of copper, and incom- parably less so than sulphate of quinia, or the arsenical prepara- tions. It is asserted to have proved useful in obstinate chronic gleet and leucorrhcea; and Dr. Christison, in his Dispensatory, states that, in the dose of from three to six grains twice or thrice daily, he had frequently been successful with it in such cases. It would appear to operate by something more than a mere astringency. It may possibly exert an alterative influence over the mucous membranes, and thus prove useful also in chronic bronchitis with profuse expecto- ration, in which it has been recommended. Administration. The dose, to begin with, is one or two grains, 416 GENERAL STIMULANTS. [PART II. twice or three times a day, which may be gradually increased, if requisite, as the stomach is found to tolerate it without inconve- nience. Dr. Babington has increased to thirty-six- grains three times a day; but this can rarely be necessary; and it is probable that all that the medicine can effect may be obtained from much smaller quantities. It may be given in pill or solution. External Use. There are few more valuable medicines for ex- ternal use than sulphate of zinc. Being at once excitant and decidedly astringent, it serves to stimulate enfeebled surfaces, and, by contracting their blood-vessels, to obviate inflammation in them. But there is something, also, in its mode of operation, which we do not exactly understand, by which it changes the condition of parts even specifically diseased, and disposes them to take on a healthy action, to which otherwise they would have no tendency. In other words, it is alterative, as well as tonic and astringent, in its local influence. It has been used as a simple styptic to bleeding surfaces, though probably inferior in this respect to some other astringents, such as alum and acetate of lead. As a collyrium in the very commencement of inflammation of the conjunctiva, in slight affections of the kind at any stage, in chronic cases or the declining stages of the acute, and whenever the blood- vessels appear to be merely passively dilated, it is among the safest and most efficient remedies. For this purpose, it may be dissolved in rose-water, or in pure distilled water, in the proportion of one grain to the fluidounce, or even less when the eye is very sensitive. The solution may be applied twice a day, and gradually strength- ened, if requisite. In very slight cases, which, however, are some- times troublesome by interfering with the use of the eyes, a single application often proves sufficient. In gonorrhoea, in any stage, unless when the inflammation is very high, and involves more than the mucous membrane, it is a very efficient remedy if properly used. At the very commencement of an attack, it will sometimes almost immediately arrest the affection. The strength of the solution should not at first exceed two grains to the fluidounce of water, and it may be even weaker in very sen- sitive conditions of the urethra. To be successful, the injection must be very frequently repeated, so as not to allow the impression to subside before it is renewed; every three or four hours for ex- ample, or six or eight times in the twenty-four hours. In leucorrhcea the same injection will often prove highly useful, CHAP. I.J MINERAL TONICS.—SULPHATE OF ZINC. 417 employed two, three, or four times in the twenty-four hours; but little good can be expected from it when the discharge is sustained, as it too frequently is, by organic disease. In chronic inflammation of the rectum, with mucous discharges, it is an invaluable remedy; whether this condition be original, or a mere accompaniment or consequence of dysentery. The method of administration has been mentioned in the remarks made on the use of the remedy in that affection. Chronic purulent discharges from the ears, and the same affection of the nostrils, known under the name of ozsena, are other complaints in which the sulphate of zinc is often extremely useful. In these cases, the strength of the solution, at first only two or three grains to the fluidounce, should be increased, as the parts will bear it, to five or even ten grains. Whenever the immediate seat of the dis- charge can be seen, as sometimes when an ulcer exists, even a stronger solution than the strongest mentioned, may be directly applied to the diseased surface by means of a camel's hair pencil, leaving the sound parts untouched. But perhaps the local affections most amenable to the remedy, are ulcers and pseudomembranous patches in the mouth and fauces. Whenever the surface of the ulcers, in these positions, is covered with a whitish exudation, whatever may be their duration or size, from the small superficial aphthous ulceration to the obstinate and destructive cancrum oris, the solution of sulphate of zinc will, ac- cording to my observation, effect a cure. I do not include in this category the gangrsena oris, which I believe to be a different affec- tion, and which is more effectively treated by more active escha- rotics, as nitrate of silver or sulphate of copper, nor syphilitic ulcers, in which corrosive chloride of mercury is more effectual. The solution should have the strength of fifteen or twenty grains to the fluidounce of water, and should be applied daily or twice a day, by means of a brush or hair-pencil, exclusively to the dis- eased surface, and continued until the whitish exudation, before alluded to, gives way to a red surface, after which it should be omitted. As soon as this change takes place, the ulcer speedily heals. A much weaker solution, say of two or three grains to the fluid- ounce, may sometimes be used in obstinate cases of the infantile thrush, or muguet of the French, with great benefit. The same remedy is applicable to all ulcers, wherever seated, which, in consequence of a loose, flabby, debilitated state of the old VOL. I.—27 418 GENERAL STIMULANTS. [PART II. tissue, or of the new granulations, refuse to take on the healing pro- cess ; and especially when the ulcers are attended with a copious purulent discharge. The strength of the solution must, in these cases, vary so much that no precise rule can be given. It may con- tain from two to twenty grains to the fluidounce. Certain cutaneous eruptions yield to the local use of this solution. I have found it specially beneficial in that brownish superficial disco- loration, which sometimes spreads over large portions of the surface, to the great anxiety of the patient, and which has been differently named ephelis and pityriasis versicolor. Made in the proportion of from two to five grains to the fluidounce, and thoroughly applied morning and evening, the solution has, I believe, invariably within my recollection, effected cures. Sometimes a mixture of acetate of lead and sulphate of zinc in solution, has been employed as a collyrium, and as an injection in gonorrhoea, preferably to the sulphate alone. In this case, a double decomposition takes place, with the production of sulphate of lead, which is precipitated, and of acetate of zinc, which remains dis- solved. If the liquid, therefore, be employed clear, it is the latter salt which is the real agent; if it be agitated, the insoluble sulphate of lead is applied at the same time. It is possible that this salt may add something to the curative effect by affording a sort of protect- ive covering to the mucous surface. When it is the effect of the acetate of zinc alone that is wanted, recourse should be had pre- ferably to a solution of the pure salt. The proportion of the two salts employed is usually three grains of the acetate of lead to two of sulphate of zinc, in a fluidounce of water. II. ACETATE OF ZINC—ZiNCl AcETAS. U. S., Dub. This is prepared by exposing metallic zinc to the action of a solution of acetate of lead. The zinc takes the place of the lead in the solution, while the latter metal is deposited in the pure state. The liquid being now evaporated, and allowed to stand, yields acetate of zinc in crystals. The salt consists of one equivalent of acetic acid, one of oxide of zinc, and seven of water. It is in soft, white, shining, micaceous crystals, which effloresce in a dry air, are inodorous and of an astringent metallic taste, and are very soluble in water, and soluble also in alcohol. The effects of this salt are essentially the same as those of the preceding, but milder, and less astringent. Though capable of doing injury in excessive doses, it is much less poisonous than the sulphate. It may be given internally for the same purposes, CHAP. I.] MINERAL TONICS.—CARBONATE OF ZINC. 419 but is seldom used in that way. It is chiefly employed, in the form of solution, as a collyrium in ophthalmia, or an injection in gonorrhoea.. The dose for internal use would be one or two grains. The solu- tion for topical application may contain from one to three grains to a fluidounce of water. III. VALERIANATE OF ZINC—ZlNCI VALERIANAS. Dub. This may be made by double decomposition between valerianate of soda and sulphate of zinc, dissolved separately in boiling water, and then mixed. Upon evaporation, the valerianate of zinc, being less soluble than either of the other salts, is formed, and separated in the shape of crystals, which float on the surface, and are removed as they appear. The salt is in white pearly scale-like crystals, which have a feeble odour of valerianic acid, and a styptic, metallic taste. It is of difficult solubility, requiring 160 parts of cold water, and 60 of alcohol. Its effects on the system are essentially the same as those of the sulphate, though less astringent. It was introduced into use under the impression that valerianic acid might impart to it greater anti- spasmodic efficiency than belongs to the preparations of zinc gene- rally. It has proved useful in various nervous diseases, such as those for which the other preparations of zinc are employed; but experience has not satisfactorily shown that it has any superiority over them. The dose is one or two grains, several times a day. It is usually administered in the pilular form. IV. PRECIPITATED CARBONATE OF ZINC—ZlNCI Car- bonas Pr^ecipitatus. U. S. —Zinci Carbonas. Dub. — Car- bonate of Zinc. The U. S. Pharmacopoeia directs this to be made by double decomposition between sulphate of zinc and carbonate of soda, mixed in boiling hot solution. It has been introduced among the officinal preparations as a substitute for calamine, or impure car- bonate of zinc, which, as found in the shops, is often a wholly sur- reptitious substance, containing no zinc whatever, and therefore not to be relied on. The officinal carbonate of zinc is really a sub- carbonate; the oxicle of zinc being in considerable excess, in consequence of the escape of carbonic acid during the reaction of the two salts used in its preparation. Precipitated carbonate of zinc is a soft, light, white powder, insoluble in water, and without smell or taste. It is, however, soluble in most acids; and, when applied locally to a secreting sur- 420 GENERAL STIMULANTS. [PART II. face, may be considered as undergoing solution in very small proportion in the extravasated liquid, through the instrumentality of an acid contained in it, or some other chemical reagency. Therapeutic Application. This is exclusively topical and ex- ternal. Probably in consequence of the slight solution, just referred to, which it may be supposed to undergo in the moisture of the surface to which it is applied, it may acquire a very mode- rate degree of the excitant and astringent properties which charac- terize the soluble preparations of zinc, and thus produce a positive impression, such as it could not produce in a perfectly insoluble state. But it probably also acts, when in the form of powder, by absorbing the irritating secretions of the diseased surface, and thus in some degree correcting their influence; and, whether in powder or ointment, has some effect by the exclusion of atmospheric air. It is used in excoriations, whether from the chafing of opposed surfaces, as in fat persons and particularly children, from acrid secretions as of the upper lip in coryza, or from superficial injuries; also in chapped hands and sore nipples, and sometimes in scalds and blisters. It is applied in the form of powder dusted on the part, or in that of cerate (Ceratum Zinci Carbonatis, U. S) made by incorporating two drachms of the powder with ten drachms of simple ointment. CALAMINE. — CALAMINA. U. S. This, when genuine, is an ore of zinc consisting chiefly of the carbonate of that metal. It is in hard masses, which are first heated, then pulverized, and afterwards submitted to the processes of levigation and elutriation, in order to reduce it to the state of fine impalpable powder, in which state it constitutes prepared cala- mine. Prepared Calamine (Calamina Pr^eparata, U.S., Lond., Ed., Dub) is in the form of a powder of various colours, according to the particular specimen of ore from which it may have been ob- tained, either pinkish, yellowish, or brownish. It is inodorous and tasteless, and quite insoluble in water. Sometimes it is in small pulverulent lumps. The sophisticated article often found in the shops is generally of a pink colour. Calamine has the same properties, and is used for the same purposes, and in the same manner as the precipitated carbonate. There is an officinal cerate called Calamine cerate (Ceratum Calamine, U.S.) or Turner's cerate which is made by mixing prepared calamine with yellow wax and lard melted together. CHAP. I.] MINERAL TONICS.—OXIDE OF ZINC. 421 V. OXIDE OF ZINC. — ZlNCI OxiDUM. U.S. Origin and Properties. The oxide of zinc is prepared either by burning the metal, and condensing the vapours, or by heating the carbonate of zinc strongly, and thus driving off the carbonic acid. Procured by the former method, it has been called flowers of zinc. In composition it is a protoxide, consisting of one equivalent of each of its ingredients. It is a white powder, without smell or taste, unalterable in the air, insoluble in water, but readily dis- solved by most of the acids. Effects on the System. Oxide of zinc is probably inert in its un- combined state; but, as there is very often free acid in the alimentary canal, with which it may react so as to form soluble salts, it is capable of producing the characteristic effects of the pre- parations of zinc on the system. The experiment of Orfila, who gave to a small dog from three to six drachms, without producing any other observable effect than vomiting, is not to be received as a sufficient proof of the inactivity of the oxide; for there may have been no acid present in the stomach, or too little to generate any considerable proportion of soluble salt. Given largely to men, it is said sometimes to have produced vomiting and purging; and even giddiness and intoxication have been mentioned among its effects. As already stated, in the general remarks on the metal, it is capable of acting injuriously when used freely and for a long time. Having recently been largely employed as a substitute for white lead in painting, in consequence of retaining its white colour when exposed to the action of sulphuretted hydrogen, it is a very happy circumstance that, if not absolutely innoxious, it should have proved so much less injurious than that paint. Its general effects on the system, so far as it acts at all, may be considered as identi- cal with those of the preparations of zinc already described. Therapeutic Application. This medicine has been used in all the nervous affections to which the preparations of zinc are deemed applicable; namely, epilepsy, catalepsy, chorea, hysteria, hooping-cough, neuralgia, and gastric spasm; but it is in the treatment of epilepsy that it has enjoyed the highest reputation. If some accounts which have been published of its efficacy are to be relied on, it is capable of curing a very considerable proportion of cases; but they who are familiar with this disease, and know how obstinately, when once established, it resists every variety of treatment, are prepared, when they read such reports, to make many allowances for failure 422 GENERAL STIMULANTS. [PART II. in diagnosis, for the deceiving effects of preconception, and for the fact, almost universally noticed, that the paroxysms of epilepsy are often suspended, and sometimes kept long at bay, by anything calculated to excite the hopes, and occupy the attention of the sufferers. When the disease is purely functional, it may often, no doubt, be cured, if submitted to treatment at an early stage; and there is as little doubt that it has not unfrequently given way under the use of oxide of zinc; but the number of failures, taking all the cases into consideration, will probably greatly exceed the cures effected by this remedy. It has the advantage over the sulphate, that it is less disposed to irritate the stomach and bowels; and it may, therefore, be used preferably when these organs are pecu- liarly delicate. The dose is from two to eight grains or more, given three times daily. It should not be indefinitely increased; as conditions' of the alimentary canal, in which it may be innocent at one time, may be so changed that it shall prove highly irritant at another. I do not think that the dose of twenty grains should be exceeded; and, should irritant effects be experienced, the smaller doses mentioned should be diminished, or withheld for a time. It may be given in pill, or in powder mixed with syrup. External Use.. As in the case of the carbonate, this preparation may possibly be dissolved, in minute quantities, in the liquid secre- tion proceeding from diseased surfaces, and thus rendered posi- tively efficient in its action on such surfaces. In the form of powder or ointment, the oxide has been much used as an absorbent, desiccant, and alterative, in cutaneous eruptions characterized by copious liquid extravasation, as in eczema and impetigo, in excoria- tions of all kinds, superficial burns, blisters, chapped hands, lips, and nipples, and profusely secreting ulcers. In chronic ophthalmia, it has been recommended in the form of a collyrium, made by diffusing a drachm of the powder equably in three or four fluidounces of mucilaginous liquid; and the same method of preparation has been recommended in cutaneous affections, and for Ejections in gonorrhoea and leucorrhcea. Ointment of Oxide of Zinc (Unguentum Zinci Oxidi, U. S) is made by mixing one part of the oxide with six parts of lard. It was intended as a substitute for the old tutty ointment (unguentum tutias) prepared in the same manner from tutty, which is an impure oxide of zinc, of uncertain strength, formerly much used, but now nearly abandoned. CHAP. I.] MINERAL TONICS.—CHLORIDE OF ZINC.—BISMUTH. 423 VI. CHLORIDE OF ZINC—ZlNCI Chloridum. U. S., Dub., Lond. The mode of preparing, and the properties of this compound, will be considered under the head of escharotics, to which it belongs by its most important application. It is sufficient here to state that it is a soft, greenish-white, translucent substance, deliquescent on exposure, and soluble in water, alcohol, and ether. Its consistence has gained for it the name of butter of zinc. It is locally irritant and caustic, and, in its effects upon the sys- tem, corresponds with the soluble salts of zinc already mentioned. In over-doses, it is an irritant poison, producing nausea, vomiting, gastric and intestinal pains, cramps in the limbs, and great prostra- tion, with paralysis of the extremities, convulsions, and coma. An instance of death from it, in a child, is on record. Introduced by Papenguth into medicine, it has been occasionally used by other practitioners, particularly on the continent of Europe, in scrofula, epilepsy, chorea, and neuralgia. It has no advantage, that I can appreciate, over the sulphate or oxide, while it is more likely to injure the stomach and bowels. The dose is from half to three- quarters of a grain, to begin with. Its local uses will be more conveniently detailed under the escha- rotics ; and, among them, its disinfectant property. IV. BISMUTH. BISMUTHUM. U.S., Lond., Ed., Dub. As only one preparation of bismuth is used, all that is requisite to be said of the metal may be introduced under that preparation. SUBNITRATE OF BISMUTH.—BlSMUTHI SuBNITRAS. U.S., Dub. — Bismuthi Nitras. Lond. — Bismuthum Album. Ed. — Wh ite Od,ide of Bism u th. — Magistery of Bismuth. Origin. This is prepared by dissolving the metal in nitric acid, and pouring the resulting solution into water. Two salts are formed; one a supernitrate, with great excess of acid, which re- mains dissolved, the other a subnitrate, which is thrown down. The latter is the preparation in question. Pro/it rties. Subnitrate of bismuth is a heavy, white powder, without smell or taste, very slightly soluble in water, but readily 424 GENERAL STIMULANTS. [PART II. dissolved by nitric acid. It becomes grayish on exposure to the air, and blackens under the influence of sulphuretted hydrogen. Effects on the System. Ordinarily, when given internally, the oxide produces little observable effect; and very large quantities have been exhibited with perfect impunity. These facts might lead to the suspicion that former observers were mistaken in ascribing active irritant properties to the medicine. But the apparent dis- crepancy is explained by reference to the very feeble solubility of the salt in water, and to its ready solubility in some of the acids. Whether, therefore, it shall prove nearly inert, or powerfully irritant, may depend on the absence or presence of an acid in the primae viae, capable of dissolving it. An instance of death is recorded, which resulted from swallowing two drachms of the subnitrate with a little cream of tartar. It produced the ordinary symptoms of inflammation of the mucous membrane of the stomach and bowels, as pain, vomiting, purging, swollen abdomen, hiccough, &c.; and, besides these, cramps and coldness in the limbs, intermittent pulse, laborious breathing, swelling of the hands and face, suppression of urine, salivation, and delirium. Some of these symptoms were clearly the result of the absorption of the medicine. The patient, who was a man, died on the ninth day. Dissection showed marks of inflammation and gangrene throughout the alimentary canal. (Christison on Poison) It is quite possible that the accompaniment of bitartrate of potassa may have had some influence in the result, by rendering the salt of bismuth more soluble. Bismuth has not been detected in the urine of persons using it. The effects of the medicine on the system are quite equivocal; but it may probably be ranked with the metallic tonics of the present section more safely than elsewhere. Therapeutic Application. Subnitrate of bismuth was introduced into medicine by Dr. Odier, of Geneva. It has been supposed to have a peculiar influence over painful affections of the stomach, either directly blunting the sensibility of the nervous tissue of the organ, or operating through the nervous centres. It has been more especially recommended in gastralgia, gastric spasm, cardialgia, and pyrosis; and has been found also to allay nausea and VQmiting. At a comparatively recent period, it has been very much employed in different forms of diarrhoea, with great asserted advantage. It is not impossible that the small portion dissolved may operate as an astringent; but it is not in this way that the extraordinary effects claimed for it can be explained. Perhaps, as suggested by M. Mon- CHAP. I.] MINERAL TONICS.—IRON. 425 neret, it may act by being deposited upon the inner surface of the membrane, and thus protecting it against the irritant action of the contents of the stomach and bowels. Hence, it is recommended by that practitioner in very large quantities, not less than two or three drachms in a day. It has been specially recommended, as extra- ordinarily efficient, in the diarrhea of phthisis, that of enteric or typhoid fever, and the chronic diarrhea of children. I can say little of the remedy from my own experience. Having almost constantly failed with it in the gastric affections in which it was originally recommended, I have long ceased to employ it. The dose, as for- merly given, was too small. From five to twenty grains may pro- bably be administered with safety, under all circumstances, to the adult. The caution should be strictly observed, not to accompany its use with that of nitric acid, or indeed any other acid. 3. Reconstructive Mineral Tonics. It will be remembered that these are tonic substances which enter essentially into the constitution of the system. The only medicines which have been satisfactorily proved to belong to this subdivision of the mineral tonics, are the preparations of iron. IRON. FERRUM. It has long been known that iron is a normal constituent of the blood; and comparatively recent researches have shown that it exists exclusively in the colouring matter of the red corpuscles, of which it forms an essential constituent, and, as is generally believed in definite proportion.* Without it, the red corpuscles could not exist, nor life be supported. In what state of combination it is contained in the colouring matter, has not been ascertained. It is certainly held by a powerful affinity; for it is altogether insensible to the tests by which iron can be detected in all other combina- * According to M. Le Canu, about 1 part of it exists in 4400 of blood, and 7 parts in 100 of hematosin. For the blood, the proportion is necessarily variable as that of hematosin itself is variable; for the hematosin, it is fixed, the combination being definite. (Archives de Physiol, de The'rap., et d'lli/g. de Bouchardat, Oct. 1S54 pp 144 and 147.) 426 GENERAL STIMULANTS. [PART II. tions. The probability is, that it is united, in an elementary con- dition, either directly with the other elements of the colouring matter, or with some peculiar organic principle, having for it an affinity beyond that of any other body in nature, and capable of being overcome, through chemical agency, only by the destruction of that principle. Hence, it may be found either by burning blood, in which case it is left in the ashes, or by the instrumentality of chlorine, which destroys the animal principle referred to. The part which iron acts in the economy is wholly unknown. The theory of Liebig, which supposes it to be a carrier of oxygen from the lungs to all parts of the system, entering the respiratory organs as a pro- tocarbonate, there becoming sesquioxidized with the escape of the carbonic acid, and afterwards carried away with the arterial blood to supply oxygen to all the functions, and be reconverted into the protocarbonate, though very beautiful, has not been authenticated, and at present must be regarded as at best a plausible conjecture. That iron is the real colouring matter of the blood, has long been regarded as highly probable; nor did the discovery of hematosin as a distinct principle serve in any degree to invalidate this opinion; but if it be true, as asserted by M. Sanson, that hematosin can be deprived of iron without losing its colour, the opinion must be abandoned. Nevertheless, M. Le Canu, on repeating the process of M. Sanson, did not succeed in obtaining the same result; so that it may be considered as a yet unsettled point, whether iron is or is not the colouring principle. (Quevenne, Arch.de Physiol., Oct. 1851, p. 147.) That it has the property, when taken internally, of in- creasing the redness of the blood, is a familiar fact. A reference to the above physiological points seemed to be a necessary intro- duction to the consideration of iron as a therapeutic agent. Effects on the System. Whether metallic iron has any direct influ- ence on the system, is not certainly known; for, though very decided effects follow its introduction into the stomach, it is supposed that the metal is oxidized and combined with an acid before it operates. Nevertheless, it is by no means certain that the finely powdered metal may not find, among the constituents of the gastric juice, the organic principle with which it is combined in hematosin, and, uniting with this, enter into the blood at once in a state suitable for the part it has to play in the formation of the red corpuscles. This idea does not by any means preclude that of its absorption, and existence in the serum in other forms of combination. In fact, it serves to explain the double action of the metal; that of a tonic CHAP. I.J MINERAL TONICS.—IRON. 427 in the blood, like any other absorbed medicine of the same class; and that of a reconstructive agent, serving to increase the red cor- puscles, by affording an essential constituent in a due state of pre- paration. The operation of the chalybeates, or preparations of iron, must be considered in reference, first, to their local effects upon the tissue with which they are primarily brought into contact; and secondly, to their effects upon more or less distant parts, or on the system generally. 1. In regard to their local operation, when in any degree soluble, or capable of being rendered so by the reagencies to which they are exposed, they act as excitants and astringents; the degree in which they produce such effects being very different in the different pre- parations, and in some measure proportionate to their solubility. If used in small doses, they produce on the stomach only that de- gree of excitation which is called tonic, increasing the appetite, and invigorating digestion; while their astringent operation is evinced by a tendency to constipation, and the smaller, dryer, and harder stools, which are apt to follow. If carried too far, they cause irri- tation of the stomach and bowels, with a sense of heat, weight, or. uneasiness in the epigastrium, sometimes nausea and vomiting, and not unfrequently griping pains and diarrhoea. Some of the soluble salts, as the sulphate, sesquinitrate, and chloride, are capable of producing even dangerous if not fatal inflammation, and thus acting as irritant poisons. The local effects of the chalybeates, applied externally, either to the mucous surfaces or the skin, are of the same nature; but, in the latter instance, the cuticle serves as a pro- tection, and the irritant influence is much less felt. A phenomenon resulting from the use of iron, though not a part of its physiological operation, is the black colour of the stools which almost invariably attends it. This is caused probably in part by the combination of the sesquioxide with the tannic acid often contained in the food, as in tea and coffee for example, and in part by the formation of the sulphuret of iron through the reagency of sulphuretted hydrogen in the bowels, or one of the soluble sulphu- rets. A knowledge of this fact is important; as otherwise wrong inferences might be drawn from the colour of the stools, and lead to improper practice. Instances of this I have myself witnessed. Not unfrequently also the preparations blacken the tongue, in con- sequence probably of the simultaneous use of astringent substances; 428 GENERAL STIMULANTS. [PART II. and care must be taken not to confound this appearance with the blackness of tongue resulting from disease. 2. The effects upon the system, or on parts more or less remote from the surface, are next to be considered. These depend upon the absorption of the iron, and are usually not exhibited until a considerable time after its introduction into the system. That iron is absorbed has been proved by numerous experiments. Tiedemann and Gmelin found it in the serum of the blood of the mesenteric and portal veins of a horse, to which they had six hours previously given a solution of sulphate of iron. M. Quevenne has shown that, if iron passes with the urine at all in the normal state, it is in ex- tremely small proportion; and that, after the use of the ferruginous preparations for a short time, the quantity, though still very small, is appreciably increased; proving that, while the kidneys are not the avenue by which the metal is mainly eliminated from the system, it must have been absorbed in order to produce the slight increase ob- served. (Archives de Physiol., Oct. 1854, p. 104.) It is said also to have been found in the milk, perspiration, and bile. In what state it enters the blood is uncertain; but it is highly probable that, in part at least, it does so, as before stated, in union with an organic principle, and that, in this condition, it contributes directly to the construction of the red corpuscle. Another portion may circulate in the serum in other soluble forms, and simply act as a tonic and perhaps astrin- gent upon the tissues. After iron has been taken in the ordinary medicinal doses for a few days, often in less than a week, its effects on the system may be seen in an increased redness of the complexion, the lips, and the tongue, a fuller and stronger pulse, and a general exaltation of the organic functions. These results proceed from a greater richness of the blood, in which the proportion of the red corpuscles is in- creased. If the use of the medicine be continued, a plethoric con- dition may be induced, indicated by fulness or dull pains in the head, sluggishness of mind, a full strong pulse, increased heat, and a heightened colour of the surface. It is said that pustules of acne are apt to appear on the face, breast, and back. This is a morbid condition, predisposing to active congestion, hemorrhage, and pro- bably inflammation. Hence the danger of an excessive and long continued use of the natural chalybeate waters, against which they who frequent watering places should be placed upon their guard. These effects are scarcely sufficient to rank iron among medicines which are poisonous to the constitution. They are but an exalta- CHAP. I.] MINERAL TONICS.—IRON. 429 tion of the healthy powers and functions, such as may result from an abuse of food and other agents essential to life. The only mode in which any of the preparations of iron can become poisonous,, is, as before mentioned, by irritating and inflaming the stomach and bowels. Therapeutic Application. Iron has been immemorially employed in medicine. It has two modes of therapeutic action; one, by a gentle excitement of the functions, and a somewhat constricting effect on the tissues, evinced in the surfaces to which it is directly applied, whether external or internal, and in distant organs or the system generally, through which it circulates in the serum of the blood ; and the other, as a reconstructive agent, by affording the material and the influence necessary for the production of new blood-corpuscles, to supply the place of those which may have been lost. In the first method, it operates as ordinary tonics possessing some astrin- gent power; in the second its influence is quite peculiar and cha- racteristic, unless, as some assert, it may be imitated by manganese. Some therapeutists believe that this reconstructive operation is essentially and purely tonic; that is, that the iron taken as a medi- cine acts simply by a gentle exaltation of all the blood-making functions, enabling them to form the red corpuscles more abund- antly, not by furnishing the material, but by increasing their power of assimilating nutriment. Others, again, think that it acts simply by furnishing an essential constituent of the corpuscles, and that in fact it is nothing more than an article of food. It is probable that the truth embraces both these opinions; and that the chalybeates, in augmenting the red corpuscles, really stimulate the functions, while they render the material more accessible, and furnish it in a state more readily to be acted on, than as it exists in the ordinary diet. In referring to the several diseases in which iron is used, I shall endeavour to keep the two methods of operating here de- scribed in view, though they are often conjoined in the same dis- ease. 1. As a mere tonic, iron is much and very advantageously used in debility of the digestive organs. Connected with laxatives and aromatics, it is among the most useful remedies in dyspepsia, and its associated and dependent affections. When no effect on the system at large is required, and the indication is simply to stimulate the mucous membrane of the primae viae, one of the soluble prepara- tions should be preferably selected. Unless the medicine is given too largely, the tendency is to produce constipation; and hence the 430 GENERAL STIMULANTS. [PART II. propriety of administering laxatives at the same time. Should irritation of stomach or bowels be induced, the inference is that too much has been given, and the dose should be diminished within the irritating point. Not unfrequently, in these cases, the chalybeate is associated with one of the simple bitters, as well as with a laxa- tive and aromatic; and these may be combined, in the form of pill, powder, infusion, or tincture, to. suit the particular necessities of the case. The astringency of the preparations of iron renders them, in con- nexion with their tonic property, advantageous also in chronic diar- rhea attended with relaxation of the mucous tissue. The saline preparations are preferred for this purpose, especially the sulphate, and the solution of the nitrate, the latter of which was introduced into use chiefly for its supposed efficacy in this complaint. Great care should be taken not to give them in irritating doses ; and they may often be usefully associated with opium, or one of its prepa- rations. Passive hemorrhage from the stomach or bowels is sometimes beneficially treated with the chalybeates. To the active hemor- rhages from these parts they are inapplicable, in consequence of their excitant property. Even in the passive kinds, they should not be trusted to exclusively in threatening cases; their astringency being too feeble; and at best they are usually prescribed rather to meet some coexisting indication, than simply as haemostatics. Through the circulation they are supposed to operate beneficially as tonics and astringents in passive hemorrhages, and various ex- cessive secretions, as in haemoptysis, menorrhagia, hsematuria, bron- chorrhea, leucorrhea, spermatorrhea, &c.; but, though they are often useful in these affections, it is probably more by their influence upon the blood than their direct action on the tissues. They should never be exhibited when the complaint is associated with a ple- thoric condition of the circulation, and a sound state of the blood. General debility, independently of any special deficiency of blood, affords an indication for the use of iron as a tonic. But discrimi- nation is necessary. To the cure of acute debility, such as occurs in low fevers, the chalybeates are quite inadequate; operating both too slowly and too gently for the wants of the system. The pre- parations of Peruvian bark and serpetitaria among the tonics, are much more effectual here. But in the chronic weakness resulting from deficient food, enfeebled digestion, the depressing emotions, previous disease, &c, they act beneficially by gently stimulating CHAP. I.J MINERAL TONICS.—IRON. 431 the organic functions through the circulation ; and when with the debility is connected a special relaxation of the tissues, as in scro- fula, and various nameless cachectic conditions of the sj^stem, their astringency gives them additional efficacy. But the conditions of debility in which they are indicated, in reference to their tonic and astringent properties, are almost always associated with a defective or depraved state of the blood, in which their reconstructive power is wanted; so that it will be most convenient to consider the several affections under that head. 2. As a reconstructive agent, iron is used whenever the red cor- puscles are relatively deficient; and such is the case in all instances of impoverished blood. This condition of the blood has received the not altogether appropriate name of anaemia. In women it is often called chlorosis. Some authors make a distinction between these affections. I have been able to discover none that is essen- tial. In the female, chlorosis sometimes comes on without any appreciable cause, possibly from some derangement of the assimi- lative functions essentially connected with the peculiarities of the sex; but it is also frequently produced in them, as well as in males, from obvious causes; and there is no difference that I have been able to appreciate in the results. The symptoms are the same, the mode of treatment is the same; and the obscurity of the cause in certain instances is not a sufficient ground for assuming a distinct character in the affection. The varieties under which anaemia appears are almost infinite. Sometimes it is a pure, original, idio- pathic affection ~ but much more frequently it is associated with other diseases, as their effect, their cause, or a coincident effect of the same cause. In whatever shape it may appear; so far as the anaemia itself is concerned, iron is indicated. It may not always succeed; but it should always be tried when it is desirable to cor- rect the anaemia. Not impossibly, this condition of the blood may sometimes be intended as a safeguard against other affections, per- haps of a hemorrhagic, perhaps of an inflammatory character; and to correct it may involve the patient in the risk of mischief greater than the evils of anaemia itself. In such cases, caution should be observed, in the use of the chalybeates, not to carry them too far; but to endeavour as nearly as possible to preserve a due balance, so that the aims of nature may be effected, without incurring danger in the opposite direction. Simple anaemia from the loss of blood, excessive secretion, de- fective supply of food, or inefficient assimilation, is a very common 432 GENERAL STIMULANTS. [PART II. affection, and in general easily recognizable by the paleness of the face, lips, and tongue. For its characteristic symptoms, the reader is referred to works on the practice of medicine. It may be men- tioned here, as having a special therapeutic bearing, that, instead of the depressed state of the various functions, which might, a priori, have been anticipated, there is, on the contrary, as a general rule, much and very prominent disturbance of them, even more so than in the opposite condition of the blood. A frequent pulse, palpita- tion of the heart, panting respiration, and varied nervous agitation, are often striking phenomena; and it is of the utmost importance not to mistake these, as they were formerly often mistaken, for evi- dences of an over-excitement requiring depletory treatment. There are too, very generally, especially in females, bellows murmurs in the heart and large blood-vessels, to be heard by pressing the ear or the stethoscope upon them, which might lead an incautious observer to suspect the existence of organic cardiac disease. Some- times, when the disease is not yet fully developed, the characteristic paleness of the cheeks may be wanting, and there may even be in the female something of the rose yet remaining. In this condition, those apparent anomalies above referred to, the palpitations, the pantings, the hysterical disorders, and especially the cardiac and vascular murmurs, become diagnostic symptoms, by which the nature of the case may often be determined. In all these cases of anaemia, iron is the great remedy; and, were it of no other use as a medicine, it would, from the possession of its extraordinary power over this complaint, be of inestimable value. Not only is the anaemia with its immediate symptoms corrected; but evils of great magnitude, which are apt to flow from a perseverance of the affec- tion, such as dropsy, sterility, organic heart affection, and ultimate death from the unresisted attacks of other diseases, are prevented. A sufficient dose of the chalybeate, repeated three times a day, and continued for six or eight weeks, will very generally cure the complaint entirely. In the course of a week or two the colour will begin to return to the lips and cheeks, the pulse to acquire more stability, the appetite and digestive function to improve; the amelioration of the symptoms will advance regularly; and, at the end of the time specified, a wan, wasted, and desponding girl, apparently in the last stage of debility, and quite incapacitated for the performance of any active duty, will have been converted into a cheerful, rosy, plump, and vigorous young woman, full of energy and hope, and prepared to enter zealously upon the duties of her CHAP. I.J MINERAL TONICS.—IRON. 433 station. This change has been effected merely by restoring the healthy proportion of red corpuscles to the blood. The remedy should be omitted when the cure is effected, for fear of inducing plethora. The only caution necessary is that an observant eye should be upon the individual for some months; and, upon the least sign of a return of the symptoms, the chalybeates should be again recurred to. There is a peculiar form of anaemia, different in its origin from the preceding, in which iron is scarcely less effectual. I allude to that condition of system often left behind by miasmatic fevers, cha- racterized by a sallow paleness of the surface, general languor and weakness, mental depression, feeble digestion, and often more or less dropsical effusion, sometimes only anasarcous, but sometimes also in one or more of the serous cavities at the same time. There may or may not be attendant disease of the viscera. I believe this condition to be a pure anaemia, resulting from the destruction of the red corpuscles of the blood by the miasmatic poison; the yel- lowness being attributable to a changed condition of the liberated hematosin. The same condition often follows yellow fever, pro- bably from the same cause. It is delightful to see how rapidly this condition, serious if not relieved, will yield to the conjoined use of iron and quinia. Slight cases will often get well in a week or two, the worst generally within two months. When there is consider- able dropsy, however, bitartrate of potassa, to the amount of an ounce, taken through the day, should be associated with the other medicines. In a large number of diseases, iron is given with a view mainly to the correction of the anaemia with which they are associated. The following list embraces most of them. When, in any one of them, there is an additional indication for the use of the medicine, the fact is mentioned. Scrofulous affections are often attended with a poverty of the blood which serves to sustain the diathesis, and aggravate the complaint. But there is often also a relaxation of the tissues in these affections, which calls for a joint tonic and astringent action in the remedy. Iron answers both indications; and is very often, therefore, given in the different forms of scrofula. It has, however, no specific in- fluence over the disease, and is used only as an adjuvant to the alterative remedies, such as iodine and cod-liver oil. The iodide of iron is generally preferred, on the presumption that the effects of the iodine may be obtained along with those-of the chalybeate. VOL. i.—28 434 GENERAL STIMULANTS. [PART II. Phthisis may be ranked among the scrofulous diseases, and might be supposed to call for the remedy equally with the other forms. But there is a consideration connected with this affection, which ren- ders caution in the use of the chalybeates necessary. The anaemia in phthisis is a provision of nature for bringing the blood into a due relation with the capacity of the lungs. If, with the progressive destruction of these organs, the blood should remain unimpaired, the quantity passing through the lungs would be more than could be duly oxidized, or indeed carried through the remaining pulmo- nary vessels. Congestion of the lungs, with hemorrhage, and other evils from a want of due aeration of that fluid, would take place. The use of iron, if successful in-its object, might counteract this purpose of nature, by inducing a relative plethora. Nevertheless, the anaemia is often carried far beyond the point essential for its useful purpose; and, in such cases, the chalybeates would be useful, by lending the support of good blood to the exhausted functions; and even, in co-operation with other measures, by obviating in some degree the disposition to tuberculous deposition. But they should be omitted, as soon as the blood may be deemed to have become as much enriched as the condition of the lungs will permit, without risk of mischief. Various nervous affections afford indications for the use of chaly- beates. Disorders of the nervous system are often nothing more than results of that irritation of the nervous centres, sustained by the constant call made upon them by the functions when suffering from the want of blood. Placed as points of communication be- tween all the functions, and the various agencies intended for the supply of these functions with the means of support, they are con- stantly receiving impressions, and sending forth influence; and the degree of their excitement being in proportion to the amount of impression received, they are consequently most excited when the wants of the functions are the greatest. Hence, in an anaemic con- dition of the blood, when all the functions are suffering under the deficiency of this essential pabulum, the nervous centres are neces- sarily over-excited, and exhibit their irritation by various violences throughout the system. By correcting the condition of the blood, the functions are quieted, the nervous centres are relieved, and the existing obvious disease, so far as it depended on their irritation from this cause, ceases. Hence the use of iron in these complaints. But it operates also on the tonic principle of giving strength to the nervous centres, and enabling them, in a certain degree, to resist CHAP. I.] MINERAL TONICS.—IRON. 435 the irritative impressions made upon them; though, in this mode of action, it is inferior to the preceding section of mineral tonics, including the preparations of silver, copper, and zinc, which have the advantage over the chalybeates, of a special influence upon these centres, not possessed by the latter remedies, or, at all events, in a much less degree. The chalybeates, therefore, while they are much more energetic and more relied upon in the nervous diseases, when dependent on or aggravated by anaamia, than the other metallic remedies mentioned, are inferior to them under other circumstances. The'rational practitioner, guided by this principle, will know when to rely mainly on the chalybeates in these complaints, when to use them as adjuvants of the other metallic tonics, and when to abstain from them as useless or possibly injurious; for, of course, they could do only harm in irritation of the nervous centres dependent on or aggravated by plethora. Hysteria is one of the affections in which chalybeates are often used beneficially on the principles above stated. Neuralgia is also frequently benefited by them; and, in many instances of this complaint, they are among the most effectual reme- dies. In neuralgia of the face, or tic douloureux, they enjoy a very high reputation; but, no matter what may be the seat of the com- plaint* provided it can be traced to anaemia as the sole or a co-ope- rative cause, they will prove equally beneficial. In gastralgia,-they sometimes act very favourably. They are often associated with the narcotic extracts, as belladonna, stramonium, and conium; and there is probably, on the whole, no more effectual combination in the treatment of neuralgia. Chorea, associated with anaemia, will often yield to the chalybeates when other remedies fail; though, as a general rule, they are inferior in this affection to some other metallic tonics. In epilepsy, they may be tried under similar circumstances; but little reliance can be placed upon them for the cure; as this fearful malady has roots much deeper than an impoverished condition of the blood. In sp>asmodic asthma, hooping-cough, and amaurosis, they have been recommended, and may be used to meet their special indication when presented. In the special diseases of various organs, attended with anaemia, iron is a most valuable adjuvant. In chronic hepatitis, or the shattered state of system left behind by it, the chalybeates are very useful. Invalids from tropical cli- 436 GENERAL STIMULANTS. [PART II. mates often find their health greatly promoted, or quite restored by a residence at chalybeate springs, and the use of the waters, espe- cially when, as in the case of the Cheltenham waters in England, the iron is associated with saline laxatives. I am disposed to think that the chalybeate, in these cases, does good also by a direct tonic action on £he liver. A similar combination of iron and saline laxa- tives, with the various pleasures of a watering-place, is among the most effectual means of cure in certain cases of jaundice, which, having yielded in a great degree to other measures, continue after- wards to resist for a long time the best directed efforts of the phy- sician. In enlarged spleen, attended with anaemia, and especially when originating under miasmatic influence, the preparations of iron are highly useful; and, in conjunction with quinia and purgatives, offer the best means of curing that often very obstinate affection. Iron is thought to act specially on the spleen as an astringent, and, as before stated, is said to reduce the bulk of that organ in animals which are kept under its use for some time. In organic diseases of the heart, the attendant anaemia serves often to aggravate the affection, by sustaining an excessive action of the organ. The functions, defectively supplied with blood, call on the nervous centres, and they, in obedience to the call, stimulate the heart, in order to supply, by the rapidity with which the blood is sent, the deficiency in its quality. The flaccidity of the heart, too, in anaemia, renders it more expansible by the forces to which it is subjected. Hypertrophy is aggravated by the former influence, and dilatation by the latter. Without being able to cure either of these conditions, the preparations of iron, by improving the state of the blood, may tend to moderate or control the increase of both; and, in the case of dilatation, may possibly, by their tonic and astrin- gent action on the tissue, even favour a contraction of the organ. Brighfs disease of the kidneys is almost characteristically attended with anaemia, which contributes to the accompanying dropsy, and, when the affection consists in fatty degeneration of the organ, fatally promotes the evil by lowering the vital forces which best resist that destructive process. Iron is here indispensable, and acts powerfully, in aid of cream of tartar and digitalis, in the relief, and sometimes, I believe, in the cure of the complaint. Diseases of the genital organs, with anaemia, are occasionally bene- fited by the chalybeates. Independently of their influence on the blood, they may act as tonics on the organs, and by some are sup- CHAP. I.] MINERAL TONICS.—IRON. 437 posed to exercise over them a special influence, peculiarly over the uterus. They have not unfrequently relieved sterility in women; and the story is told that they first came into vogue by curing the son of an ancient monarch of impotence. Their supposed powers in spermatorrhoea, leucorrhcea, and the passive forms of menor- rhagia have already been noticed. In amenorrhea, they are among the remedies most relied on. Combined with aloes, they probably restore the suppressed, or increase the deficient menses, in a greater number of cases than any other medicine, or association of medi- cines. Some suppose them to act as a direct emmenagogue; others, merely by improving the blood. It is probable that they have no specific emmenagogue power, and that their main influence is owing to the change they produce in the blood; but, nevertheless, they probably tend, by their tonic power, to which the uterus seems peculiarly susceptible, to put that organ into a healthy condition when relaxed or debilitated, and thus enable it to perform its func- tions duly. In this way, they may be readily conceived to be em- menagogue in one instance, and to relieve excessive menstruation or uterine hemorrhage in another. It remains onlyto consider the chalybeates in their relation to diseases consisting in a depraved condition of the blood, as distinct from a mere deficiency of one of its normal ingredients. Such a condition exists in many low febrile diseases, and is supposed by not a few to be the .main pathological lesion in those affections. The corpuscles are not essentially deficient in quantity here, but they, as well as the fibrin, are supposed to be diseased, poisoned pro- bably by the absorbed cause of the fever. Now, it is not an improba- ble supposition that iron, so useful in the construction of the red corpuscles, may also possess some efficacy in their repair. Hence, it has recently been introduced into use as a remedy in some of these affections. Attention has of late been prominently called to this appli- cation of iron by Dr. Bell, of Edinburgh, who speaks in the highest terms of the efficacy of the tincture of the chloride iii erysipelas. His practice has been imitated by many others, not only in this complaint, but in some of analogous character, particularly scarla- tina. But it is probably in the passive hemorrhages, that the chalybeates prove most useful upon the principle of action now under considera- tion. Though operating in these diseases also by their astringency, they owe the great efficacy which they sometimes evince much more to their influence on the blood. In the class of hemorrhages 438 GENERAL STIMULANTS. [PART II. here referred to, the red corpuscles, though not wanting in amount, are apparently diseased, and unable to supply that stimulus to the capillaries which is essential to the support of their healthy vital contractility, while the plasticity of the fibrin is so much diminished that it coagulates imperfectly. Hence the vessels allow the escape of blood; and the means of spontaneous cure possessed in other kinds of hemorrhage, through the ready coagulability of the fibrin, are deficient or wanting there. The chalybeates have a tendency to correct this condition, by improving the character of the corpus- cles, and probably also, indirectly, that of the fibrin; as there is every reason to suppose that this principle proceeds in part from the corpuscles, and must therefore partake of their qualities. Iron may be given in any hemorrhage of this kind; but it has probably proved, upon the whole, most efficacious in menorrhagia. Choice of Preparations of Iron. For many of the facts upon which the following conclusions rest, I have pleasure in acknowledging my indebtedness to a memoir by M. Quevenne, published in Bouchardat's Archives for October, 1854, in which are presented the results of a vast number of experiments, made by the author, upon the mode in which iron enters the system. These experiments were performed chiefly on dogs, in the stomachs of which an artificial opening had been made, allowing of the examination of their con- tents, and of the changes going on in them from time to time. Almost all the ferruginous compounds, soluble in the gastric liquors, are capable of contributing to the formation of the red cor- puscles, and of producing the general effects of iron upon the sys- tem. Two striking exceptions are afforded in the ferrocyanuret and ferridcyanuret of potassium (yellow and red ferroprussiate of potassa), both of which are soluble, but neither is capable of exer- cising the characteristic influence of iron on the system. They are absorbed with great facility into the blood, but they pass out un- changed with the urine; at least the only change produced is the conversion of the red salt into the yellow before elimination. Solubility in the gastric liquids is essential Jto the activity of a chalybeate; and the degree of its solubility may be considered as an approximate measure of its absorbability, and therefore of its power. But the solubility or insolubility of the chalybeates in water, is no criterion of their relation to the gastric liquids in this respect. On the contrary, some of the preparations most insoluble in water are most readily dissolved in the stomach, as, for example, powdered iron, and the protocarbonate. Indeed, the soluble salts CHAP. I.] MINERAL TONICS.—IRON. 439 of iron almost always undergo precipitation in the stomach, before final solution in the gastric liquids. The precipitate is probably formed by reaction with the organic principles either of the food or of the mucus; and, in the absence of acid in the stomach, would remain undissolved. Acids do not ordinarily exist in the stomach while fasting; but, on the introduction of food, and probably of substances excitant to the stomach, though not nutritive, they are secreted with the gastric juice, to the efficiency of which they seem to be essential. The chalybeate, if introduced into the empty sto- mach, may possibly excite it to the production of these acids; if introduced with the food, must encounter them in the liquid by which this is dissolved. Though precipitated, therefore, it is always subsequently in a greater or less degree dissolved in the liquor of the stomach. Quevenne ascertained that, if the gastric liquid thus holding iron in solution, be treated by an alkali, a portion at least of the chalybeate is thrown down; and this precipitate was always found, on decomposition, to yield nitrogenous products, proving that it contained an organic principle. This was probably albumen. Mitscherlich inferred, from his experiments, that in the stomach albumen unites with the salts of iron to form compounds, of which those containing the protoxide are soluble in water, those contain- ing the peroxide are insoluble; but both are dissolved by the gas- tric acids. It is probably, then, in this state of combination with albumen, that the chalybeates, taken, into the stomach, finally enter the circulation. Of the changes which the absorbed iron undergoes in the blood, in order that it may be fitted to form a part of the red corpuscles, we know nothing; and conjecture is futile. The above considerations are calculated to aid us in the choice of chalybeates. In reference to their effects on the system, their mere solubility in water is of no advantage. In fact, it is some- times otherwise; for until they are precipitated, they may act as irritants to the stomach, and thus interfere with absorption, and with their own further exhibition. Besides, Quevenne has shown that, as a general rule, they yield a less proportion of metallic iron than the insoluble preparations to the gastric liquors. Of these latter, however, the sesquioxide of iron, as represented by the pre- paration officinally denominated subcarbonate, is an exception ; as it gives a less proportion of the metal to that liquor than any other chalybeate in use. Upon the whole, then, when the object is to affect the system through the absorption of iron, as soon and with as little inconvenience as possible, it is advisable to select one of 410 GENERAL STIMULANTS. [PART II. the insoluble preparations, as the powder of iron, or, if a soluble one is chosen, to employ the mildest and least irritating, as the tartrate of iron and potassa. Should a compound insoluble preparation be chosen, one of the proto-compounds should be preferred to those in which the iron is of higher equivalent value; as the protocar- bonate, for example, to the sesquioxide. If the object be solely to act on the mucous membrane of the primae viae, as upon the stomach in dyspepsia, or on the bowels in diarrhoea, then recourse should be had preferably to one of the more active of the soluble salts, as the sulphate, or the chloride. The best period for exhibiting the chalybeate is also a point for consideration. When the aim is to introduce the iron into the circulation, the preparation should be given at the commencement of a meal; as it is then better borne by the stomach, and is placed under circumstances most favourable for solution by the gastric acids. Quevenne ascertained that a dog could bear twice as much, given with food, as upon an empty stomach. A dose which would vomit or purge under the latter circumstances, caused no incon- venience under the former. But, when the operation of the chaly- beate is to be confined to the mucous membrane, it should be given on an empty stomach; as it will thus operate with greater prompti- tude and certainty, while, as the quantity of metal that may enter the circulation is now a matter of indifference, the dose can be regulated according to the effects without inconvenience. Another fact ascertained by Quevenne is, that the quantity of a chalybeate absorbed is increased somewhat with the increase in the quantity given, but by no means proportionably; so that, in esti- mating the relative value of two preparations for affecting the system, one yielding iron largely to the blood, the other sparingly, we cannot supply the deficiency of the latter, so as to bring the two upon an equality, by increasing its quantity. The great multiplication of the chalybeate preparations is unfor- tunate, as it tends to embarrass the student and young practitioner, without affording him any equivalent advantage; for all the good that can be obtained from the whole catalogue, whether an regard to diversity of effect, or facility of administration, can be equally obtained from one-third, or at most one-half of the number. I seldom find occasion to prescribe any others than the powder, the protocarbonate (pill of carbonate of iron, U.S.), and the subcarbonate, among the insoluble preparations; and the sulphate, the tartrate of iron and potassa, the tincture of the chloride, and the solution of the CHAP. I.J MINERAL TONICS.—POWDER OF IRON. 441 iodide, among those which are soluble. I believe that all the remedial effects which iron is capable of producing can be obtained from these chalybeates, which afford also opportunity for every desirable diversity in the form of exhibition, whether in powder, pill, mixture, or solution in water or alcohol. The preparations may be arranged under the heads of 1. those in the metallic state, 2. the oxides, 3. the salts consisting of an oxide and acid, and 4. the haloid salts. 1. Preparations of Iron in the Metallic State. I. POWDER OF IRON. — Ferri PuLVlS. U. S., Dub.— Quevenne's Iron. This is prepared by passing hydrogen over sesquioxide of iron heated to redness. The hydrogen abstracts oxygen from the ses- quioxide, and escapes as watery vapour, leaving the iron in a metallic state. This is powdered, and kept in well-stopped bottles. Properties. It is a dark iron-gray powder, without smell or taste. A little of it, struck with a smooth hammer upon an anvil, forms a scale having the metallic lustre. Thrown into a dilute acid, it produces effervescence, with the escape of hydrogen. It rapidly oxidizes on exposure to the air, from which it should be as much as possible excluded. If quite black, and but feebly effervescing with dilute acids, it may be looked on as not having been fully reduced, and consequently imperfect. Effects on the System. Powdered iron produces all the character- istic effects of the metal on the system, but has little action on the stomach locally. Nevertheless, in very large doses, it sometimes disturbs the bowels, and has been known to cause vomiting. When there is any acid in the stomach, it is rapidly dissolved, being probably first oxidized at the expense of the water, and then combining with the acid. From the experiments of Quevenne, it appears to yield a larger proportion of iron to the gastric liquor than any other preparation of the metal, given in the same quantity. Therapeutic Application. This particular form of powdered iron was first introduced to the notice of the profession by MM. Que- venne and Miquelard, of Paris, and has now come into general use. Its want of taste, the smallness of its dose, and the mildness of its action are valuable qualities; but the facility of its solution in the gastric liquids, and of its absorption into the system, constitutes its great recommendation. It may be employed with advantage in all cases, in which the object is to introduce iron into the system 442 GENERAL STIMULANTS. [PART II. through the circulation. Perhaps no chalybeate is superior to it in this respect. It has been specially employed in anaemia, and acts with great efficiency in this affection, in all cases which are amenable to the influence of iron. An objection has been urged against all the forms of metallic iron, that they occasion unpleasant flatulence, by the hydrogen liberated in the stomach. But, in refer- ence to this particular preparation at least, the objection is rather theoretical than practical; the dose being too small to produce any great effect of the kind. Three grains of it could evolve only abont one-tenth of a grain of hydrogen. It is not adapted to those cases, in which the indication is to act exclusively or specially on the mucous membrane of the stomach and bowels by direct contact. Administration. The dose is from three to five grains twice or three times a day, which may be increased if necessary. From fifteen to thirty grains of the powder prove irritant, disturbing the bowels, and more or less incommoding the stomach, though very rarely vomiting. It may be given mixed with syrup, or in the form of pill. II. IRON FILINGS. —Ferri Ramenta. U.S.—Ferri Li- MATURA. Ed. These were formerly much more used than at present. As kept in the shops, they are too often the mere refuse of the workshops, and are consequently impure, not unfrequently containing particles of copper and other metals. The French Codex directs them to be beaten in an iron mortar with an iron pestle, and then sifted, in order to free them from adhering oxide. They may, in some degree, be further purified by drawing them through a sieve with a mag- net, which attracts the iron, leaving the isolated particles of other metals, and at the same time the coarser particles of iron itself. But this method answers only imperfectly; and the only method of securing them, fit for medical use, is to prepare them directly by filing from a piece of pure soft iron. They should be kept quite dry, in well-stopped bottles, to prevent oxidation, and should have a bright and clean appearance. I have no doubt that iron-filings, or steel-dust as they were often called in old times, are an efficient chalybeate. The flatulence they may occasion is but a trifling inconvenience, while their mildness, and facility of entrance into the system through the action of the gastric acids, are positive recommendations. The great objection to them is their frequent impurity. They have, CHAP. I.J MINERAL TONICS.—BLACK OXIDE OF IRON. 443 however, at present, been entirely superseded by the reduced pow- der of iron, which has all their advantages, in a still higher degree, without their disadvantages. The dose of iron-filings is from five to fifteen grains. They may be taken in powder with syrup, or in the form of pill. Porphyrized iron is a preparation directed by the French Codex, made by rubbing pure iron-filings into the state of impalpable pow- der by means of porphyry. Its colour is black, probably owing to a partial oxidation. The dose is the same as that of the preceding preparation, or somewhat less. 2. Preparations of Iron in the State of an Oxide. I. BLACK OXIDE OF IRON. —Ferri Oxidum Nigrum.— Martial Ethiops. Under this name, several preparations have been introduced into use, all of analogous composition, and probably identical medical properties, but differing somewhat in the proportion of their ingre- dients. They consist of the two oxides of iron, the protoxide and sesquioxide, in different proportions, with or without water. The oxides are combined chemically, the sesquioxide acting the part of acid, and the protoxide that of base; and it is in consequence of this combination that they undergo no change on exposure. If they were mixtures of the two oxides, the protoxide would gradu- ally absorb oxygen until converted into the sesquioxide. Three of them merit particular notice; 1. the scales of iron, 2. the hydrated oxide of the Edinburgh Pharmacopoeia, and 3. the magnetic oxide of the Dublin Pharmacopoeia. l. scales OF IRON.—Squama Ferri. This is the true old 3Iartial Ethiops. It consists of the scales which fall from heated iron when hammered on the anvil. These are first powdered coarsely, then purified by the magnet, and finally brought to the state of an impalpable powder by levigation and elutriation. They are of variable composition; the sesquioxide seeming to unite with different equivalent quantities of the prot- oxide, forming different definite compounds, which are then mixed in uncertain proportions. 2. HYDRATED BLACK OXIDE OP IRON. — OxiDUM FERRI Nigrum IIydratum.—Ferri Oxidum Nigrum. Ed. This is prepared by precipitating, by means of ammonia, mixed solutions of the sulphates of the protoxide and sesquioxide of iron. The two bases are thrown down, combined with water. According 444 GENERAL STIMULANTS. [PART II. to Wohler, who originally proposed this preparation, it consists of two equivalents of protoxide, one of sesquioxide, and two of water. 3. MAGNETIC OXIDE OP IRON. —OXYDUM FERRI MAGNETI- cum. Dub. The Dublin College prepares this in a method analogous to that of the Edinburgh College, excepting that the proportions of the two sulphates are different, and caustic potassa is used as the pre- cipitant instead of ammonia. There is in this preparation one equivalent of each of the oxides; the same as in the native magnetic iron ore, of which it is an imitation. Properties. In all these forms, the black oxide is a blackish or grayish-black powder, inodorous and tasteless, with decided mag- netic properties, and insoluble in water. The stronger acids dis- solve it without effervescence, showing that it contains no metallic iron. It is unchangeable in the air. 3Iedical Uses. The black oxide has all the effects of the chaly- beates upon the system, and is very mild in its operation. It is more readily dissolved in the stomach than the sesquioxide, but not so readily as the reduced iron above described. It may be used whenever it is desirable to bring the system generally under the influence of iron. The dose is usually stated at from five to twenty grains. II. SESQUIOXIDE OF IRON.—FERRI SESQUIOXIDUM. The proper chemical sesquioxide of iron consists of two equiva- lents of the metal, and three of oxygen. It constitutes the sole or chief ingredient of several officinal preparations, of which the hy- drated sesquioxide, the dry sesquioxide, the rust of iron, and the sub- carbonate of iron of the U. S. Pharmacopoeia require special notice. The first three will be considered here; the last, from its compara- tive importance, will be treated of distinctly, in an article imme- diately succeeding the present. 1. HYDRATED SESQUIOXIDE OP IRON. —FERRI OxiDUM Hydratum. U.S. — Ferki Peroxydum Hydratum. Dub. — Fer- RUGO. Ed. This is prepared by dissolving sulphate of iron in water, adding sulphuric acid, and boiling; then adding nitric acid in small por- tions successively, boiling after each addition, until a dark colour is no longer produced; and, finally, precipitating with ammonia in excess, and washing the precipitate with water. The object of the first part of the process is to convert the protoxide of the sulphate CHAP. I.] MINERAL TONICS.—SESQUIOXIDE OF IRON. 445 completely into sesquioxide, which is done at the expense of the oxygen of the nitric acid. The precipitated sesquioxide, after having been washed, is introduced into a bottle, and kept in a moist state under water. This preparation consists of one equivalent of the sesquioxide, and two of water of combination, which it retains when carefully dried. Properties. Hydrated sesquioxide of iron, as officinally prepared, is a moist, reddish-brown mass or pulp, inodorous, of a slightly styptic taste, nearly insoluble in water, but readily dissolved, by most acids. Dried carefully, it is still dissolved by acids, though . less rapidly. By standing long, even under water, it acquires a new molecular condition, which, though it does not render it abso- lutely insoluble, very much impairs its solubility. Heated to red- ness, so as to be deprived of all its water, it is dissolved very slowly by the dilute acids. Medical Effects and Uses. As this preparation, in the moist state, or when carefully dried, is dissolved with considerable facility by acids, it would no doubt be taken up by those of the stomach, and act on the system efficiently as a chalybeate; but it is not used for this purpose. It was introduced into the Pharmacopoeias as an antidote for arsenious acid; and there can be little doub't, I think, that it possesses great efficiency in this respect; often saving life, and perhaps always, if properly employed, unless the injury already done is fatal. It acts by converting the poisonous arsenious acid into an insoluble and inert subarseniate of the sesquioxide of iron. It is true that it will not produce this effect on the undissolved arsenious acid; but it is not in this condition that the poison acts; and if, as it dissolves, there is enough of the antidote present to neutralize the dissolved portion, it prevents evil effects, until the whole of the arsenic can be evacuated from the stomach, and sub- sequently from the bowels. To prove successful, however, it is ne- cessary that the antidote should be employed in great excess; not less than twelve times as much as the arsenious acid taken beino- required; and some advise thirty times as much, or even more. As the chalybeate produces no injury, except perhaps a slight irri- tation, infinitely less deleterious than the effects of the poison, it should be given very freely; and attention to the precise quantity is unnecessary. It becomes much less efficacious when dried or long kept even in the moist state; and should, therefore, if possible be obtained freshly precipitated when wanted for use. 446 GENERAL STIMULANTS. [PART II. 2. ANHYDROUS SESQUIOXIDE OP IRON. — FERRI "IpEROX- YDUM. Dub.— Colcothar. This may be prepared by drying the hydrated sesquioxide above noticed, and afterwards exposing it for a short time to an obscure red heat; or by calcining the sulphate of iron. In the former case, the water of the hydrate is simply driven off, leaving the dry ses- quioxide; in the latter, the protoxide of the sulphate is sesqui- oxidized at the expense of the sulphuric acid, which is partly converted into sulphurous acid, and partly escapes in the anhy- drous state. It is a reddish-brown powder, inodorous and tasteless, insoluble in water, and dissolved very slowly and with difficulty by the dilute acids. Medical Uses. Taken internally, this oxide is almost inert, as regards any effect on the system, in consequence of its very difficult solubility in the acids. The Dublin Pharmacopoeia employs it in the preparation of the plaster of iron, or strengthening plaster. 3. RUST OP IRON. — RUBIGO FERRI. This is made by exposing iron, in the shape of wire or filings, to the action of air and water. The metal becomes in time covered with a powder, which is rubbed off by trituration under water, and, being suspended in the liquid, is poured off with it, and subsides. It may be afterwards brought to an impalpable state by levigation and elutriatiori. It is chemically a sesquioxide of iron, containing, according to Berzelius, 14.7 per cent, of water. Sometimes, at least, it contains also a minute proportion of the carbonate of the protoxide of iron, to which it probably mainly owes any efficiency which it may possess as a chalybeate. The probability is that, in the process of rusting, when the iron becomes protoxidized, a por- tion of the protoxide combines with the carbonic acid of the air or water, and, though it very soon parts with most of this on becom- ing further oxidized, retains a small proportion for a long time, perhaps indefinitely. Rust of iron is in the form of a light yellowish-brown powder, or of small, pulverulent, conical lumps, into which it has been formed when drying. It is inodorous, nearly or quite tasteless, in- soluble in water, and slowly dissolved by the dilute acids. 3Iedical Uses. It was formerly very much employed to obtain the effects of the chalybeates on the constitution; but, as it was very slow in its operation, in consequence of its difficult solubility in the weak acids, and uncertain, either from the variable quantity CHAP. I.J MINERAL TONICS.—SUBCARBONATE OF IRON. 447 of acid present in the stomach, or its own variable proportion of carbonate of the protoxide, it has been to a considerable degree abandoned. The following preparation is more elegant, and has almost universally superseded it. The dose is from five to thirty grains. III. SUBCARBONATE OF IRON. — FERRI SuBCARBONAS. U.S.—Ferri Sesquioxidum. Lond. — Ferri Oxidum Ru- brum. Ed. — Ferri Carbonas. Dub. — Ferri Garbonas Pra>- cipitatum.—Crocus Martis. — Safran de Mars aperitif. Paris Codex. — Precipitated Carbonate of Iron. This was introduced into practice as a substitute for the old rust of iron. Its claim to the title of subcarbonate cannot be sustained on chemical grounds. Only one compound of carbonic acid and iron is known, and this consists of equivalent proportions of the acid and protoxide. There is, therefore, no known subcarbonate. The preparation under consideration consists mainly of hydrated sesquioxide of iron, with which is associated a variable proportion, always, however, small, of carbonate of the protoxide. In the U.S. Pharmacopoeia it was denominated subcarbonate, partly be- cause it had previously held the name of precipitated carbonate, which, when its true nature came to be known, was considered quite inappropriate, and partly under the impression that its vir- tues were, in great measure, ascribable to the small proportion of carbonate contained in it, which could not, therefore, it was thought, be appropriately excluded from a share of the title. The term subcarbonate may, in this sense, be considered as simply signifying that it contains carbonic acid, but not in quantity equivalent to the- basic matter. This preparation is made by precipitating a solution of sulphate of iron with carbonate of soda, and afterwards washing and drying the precipitate. By reaction between the two salts, carbonate of protoxide of iron is formed, which, though of a bluish-white colour when deposited, rapidly changes on exposure to the air, and, before the close of the washing and drying, is converted mainly into ses- quioxide of a reddish-brown colour. The protoxide of iron has so strong an affinity for oxygen that, whether separate or combined with an acid, it quickly becomes sesquioxidized on exposure; and, if previously combined with carbonic acid, gives so much of it off as was united with the portion converted into sesquioxide. In the present preparation, however, a small proportion of the carbonate 448 GENERAL STIMULANTS. [PART II. precipitated remains unchanged. It is said that the manufacturer sometimes calcines it to improve its colour, thus driving off the water, and probably converting the small residue of carbonate into sesquioxide, very much to the detriment of the preparation. Unless it effervesce somewhat when dissolved in muriatic acid, its fitness for medicinal use may be doubted. Properties. The subcarbonate of iron is a fine reddish-brown, or somewhat chocolate-coloured powder, inodorous, of a slightly styptic and ferruginous taste, insoluble in water, and soluble with difficulty in the acids, except the muriatic, which dissolves it with some effervescence, owing to the escape of carbonic acid. Effects on the System. It has little local action on the stomach, and may be taken to an almost unlimited amount, with no other effect than to occasion feelings of epigastric weight and oppression, and sometimes probably slight nausea and vomiting. It may, too, when taken excessively, accumulate in the bowels, and produce some mechanical inconvenience. By far the larger portion passes out of the bowels with the stools, which it blackens. Of a consi- derable number of chalybeate' preparations examined by Quevenne, this gave to the gastric liquor the least proportion of iron. As it can impart to the circulation only so much of the metal as it yields to that liquor, it must be inferred to be among the feeblest in its effects on the system. Nevertheless, experience has shown that it is capable of producing all the general effects of the chalybeates; and, though it must be given in larger doses than most other pre- parations, it is yet well borne by the stomach, so that the disadvan- tage of its relative feebleness is in some degree counterbalanced. These large doses are rendered necessary by the small proportion it contains of the carbonate, which, probably, is the ingredient through which, mainly, it is capable of affecting the system. Therapeutic Application. Little good can be expected from the subcarbonate by its direct action on the stomach and bowels; and it is seldom given for such a purpose. But, in reference to its effects on the system, before the discovery of the protective power of sugar over carbonate of iron, and the consequent adoption of that salt, and while yet the extraordinary chalybeate virtues of the powder of iron reduced by hydrogen were unknown, this was among the most popular of the ferruginous preparations, partly from its ascertained efficiency, and partly from its innocence, even in very large doses; and it is still employed to a considerable extent for special purposes. It is unnecessary here to repeat an4 CHAP. I.] MINERAL TONICS.—SUBCARBONATE OF IRON. 449 account of the diseases to which the chalybeates in general, and consequently this particular preparation, are applicable. For this the reader is referred to the general remarks upon the subject of iron. It will be sufficient here to call attention to the special pur- poses just referred to. The therapeutic application for which the subcarbonate is most highly esteemed is to the cure of neuralgia. More than thirty years since, Mr. B. Hutchinson, in a pamphlet on the subject, called the notice of the profession to several cases of tic douloureux, which had been successfully treated by this remedy. The practice was quickly imitated by others, with results so frequently favourable, that the confidence of the profession in its efficiency became esta- blished. I have frequently employed it myself in this painful and often very obstinate affection, and do not think that I have obtained so much advantage from any remedy, as from a joint use of the sub- carbonate of iron and the narcotic extracts, especially that of bella- donna. Many cases certainly will resist the influence of this remedy, and others may succeed where this has failed; for there are few affections having a greater diversity of origin, or requiring greater diversity of treatment than neuralgia; but it may, I think rank among the most efficacious. Its usefulness in this disease suggested its employment in other obstinate nervous affections; and it has been given in a considerable number of cases of trau- matic tetanus with asserted success. It has also been employed advantageously in chorea, and in the second stage of hooping-cough, when its nervous character has begun to predominate. As a remedy in these nervous affections, particularly neuralgia and tetanus, the doses employed are much larger than those ordinarily administered merely for the improvement of the blood. From half a drachm to three drachms are given three times a day; and, in one case of tetanus, it was carried to half an ounce every two or three hours. Care should be taken, when these large doses are given, that the bowels should be duly evacuated; and I have generally combined the chalybeate with a little ginger, to obviate its disagreeable effects on the stomach. How the medicine operates in the nervous diseases, whether merely as a chalybeate, by improving the blood, and exercising a tonic influence directly on the nervous centres, or by some addi- tional and peculiar influence, it is difficult to determine. If upon the former principle alone, the same effects ought to be produced by other chalybeates, still more efficient than it in obviating anaemia. vol. I.—29 450 GENERAL STIMULANTS. [PART II. I cannot help suspecting that the operation of its mere mass on the interior surface of the stomach and bowels may have something to do with the result, probably through the sympathies connecting the alimentary canal with the brain and spinal marrow. Another purpose for which this preparation may be employed is to act as an antidote to arsenious acid. Though not equal to the freshly precipitated hydrated sesquioxide, it has considerable efficacy, and should be resorted to when the other cannot be ob- tained. But if previously exposed to a red heat, it becomes inap- plicable to this purpose, in consequence of the same molecular change which renders it insoluble in dilute acids. It may be given ad libitum. ' The dose for the ordinary purposes of the chalybeates is from five to thirty grains, three times a day. It may be administered in the form of an electuary mixed with syrup or molasses, and may often be usefully associated, to meet special indications, with aromatic, tonic, and laxative powders, as ginger, columbo, and rhubarb. The Iron Plaster (Emplastrum Ferri, U. S) is rnade from this preparation, by incorporating it with lead plaster and Burgundy pitch, previously melted together. Under the impression that this plaster serves to strengthen debilitated parts, it has commonly been called strengthening plaster, and employed in weakness of the loins and joints. But there is no reason whatever to suppose that the chalybeate can penetrate the cuticle so as to reach the part affected; and the notion of the strengthening influence of the iron is probably quite illusory. Nevertheless, the plaster may prove useful in some cases of chronic rheumatism, or other inflammatory affection of these parts, through the revulsion effected by the gentle irritation it sustains upon the surface; and the muscles or joints, being thus relieved of the disease which interferes with their function, seem to be strengthened. 3. Preparations of Iron in the State of a Salt. I. PILLS OF CARBONATE OF IRON. —Pilule FERRI Carbonatis. U.S.—Ferri Carbonas cum Saccharo. Lond. —Ferri Carbonas Saccharatum. Ed., Dub. — Vallefs Fer- ruginous Pills. The protoxide of iron has so powerful an affinity for oxygen, that it cannot remain an instant in contact with air, or water con- taining air, without undergoing a partial change into sesquioxide; CHAP. I.] MINERAL TONICS.—PILLS OF CARBONATE OF IRON. 451 and a brief exposure is sufficient to render that change complete. The same property is evinced when it is combined with acids, and especially with carbonic acid. Hence, as soon as the carbonate of the protoxide is precipitated from a solution of the mixed salts out of which it is formed, it begins to absorb oxygen, and give out car- bonic acid, until, as explained in the foregoing article, it is almost wholly converted into sesquioxide. Now it is believed that the protoxide and its compounds find a readier entrance into the system than the sesquioxide and its com- pounds; and the fact is beyond all doubt in relation to the car- bonate, which experience has shown to be much more efficient, in bringing the system under the influence of iron, than the sesqui- oxide resulting from its exposure. The difficulty, however, was to preserve the carbonate unchanged till it could be administered. It had been discovered that sugar had the singular property of impeding, if not preventing the oxida- tion of iron; and the idea suggested itself to a German physician of the name of Becker, that this property might be taken advantage of for medicinal purposes. The idea was carried into effect by Klauer, a German chemist, who prepared a carbonate of iron so protected by sugar that it resisted the tendency to sesquioxidation. M. Vallet, of Paris, improved the process; and hence, the prepara- tion adopted by the U. S. Pharmacopoeia, and most used in this country, goes commonly by the name of Valleys ferruginous pills. Preparation. According to the U. S. process, sulphate of iron and carbonate of soda are dissolved in separate portions of sweetened water; the solutions are mixed in a bottle which they just fill, and which is well stopped to exclude the air; the precipitate of car- bonate of iron thus formed is separated, and washed with sweetened water; and, lastly, having been allowed to drain, the mass is in- stantly mixed with honey and sugar, and evaporated to a consist- ence fit for the formation of pills. The British Colleges simply mix the two salts dissolved in water, and, after washing the precipitated carbonate, mix it with sugar, and evaporate till the powder becomes dry. As the slightest exposure of the carbonate is attended with change, it is desirable that the protecting influence of the saccharine matter should be present in every step of the process; and that, until it is completed, there shall be no avoidable exposure to the air. These conditions are fulfilled in the U. S. process, adopted from 452 GENERAL STIMULANTS. [PART II. Vallet; and the resulting preparation, therefore, is the unchanged carbonate of the protoxide simply incorporated with sugar. In the British formula, Oxidation is going on from the commence- ment of the process to the moment when the sugar is finally added; and consequently a considerable proportion of the carbonate is changed into sesquioxide. It is obvious, therefore, that of the two preparations, viz., the pilular mass of the U. S. Pharmacopoeia, and the powder of the British Colleges, the former is to be preferred. Properties. The U. S. preparation is a soft mass, of such a con- sistence as to be readily made into pills. It is black, of a sweet and strongly ferruginous taste, and readily and wholly soluble in muriatic acid, with brisk effervescence. The British preparation is a grayish-green powder, having a similar taste, and in like manner soluble in muriatic acid. The former consists exclusively of car- bonate of protoxide of iron with somewhat more than half its weight of sugar; the latter has the same ingredients with an uncer- tain proportion of sesquioxide of iron. Medical Uses. This preparation is little used for obtaining the direct effects of the chalybeates upon the primae viae, for which it is not adapted. But, in reference to its effects on the system, it is one of the best chalybeates, probably upon the whole inferior to none; being at the same time perfectly mild in its action on the stomach, which it very seldom offends, and readily and wholly solu- ble in the gastric liquids, and therefore absorbable into the circula- tion. Abundant experience has proved both its gentleness and efficiency. I am in the constant habit of using it, and calculate with the utmost certainty upon the desired effects from it, so far as these depend on the impregnation of the system. In the Penn- sylvania Hospital there is a constant succession of patients, espe- cially in the autumn, in the most pitiable state of anemic debility, often complicated with oedema of the limbs, to whom a dose of this medicine three times a day, with a little quinia and a nutritious diet, in the course of from two to four weeks, and sometimes even a shorter period, restores healthy colour and strength. Indeed, whatever can be accomplished by any one of the chalybeates towards improving the blood may be expected from this. There are others preferable for some special purpose, or on particular occasions from their solubility, or in reference to a direct action on the mucous membrane of the primae viae, but none, I believe, as a reconstructive agent, to build up a debilitated system by the resto- ration of red corpuscles to the blood. CHAP. I.J MINERAL TONICS.—COMPOUND PILLS OF IRON. 453 The dose of the pilular mass is from three to ten grains three times a day. Five grains may be given in a pill without incon- venience. More than fifteen grains would be liable to produce irritation of the stomach or bowels. Of course, if continued so as to produce plethora, the medicine may occasion headache and other unpleasant symptoms. There are two officinal preparations which may be most conve- niently noticed here, because the aim in them, so far as their chaly- beate ingredient is concerned, is to produce the carbonate of iron, though, from the deficiency of sugar, this undergoes a somewhat rapid change into sesquioxide. The preparations referred to are the Mistura Ferri Composita, and the Pilulse Ferri Compositae of the U. S. Pharmacopoeia. 1. COMPOUND MIXTURE OP IRON. — MlSTURA FERRI Com- posita. U. S., Lond., Ed., Dub. This is prepared from sulphate of iron, carbonate of potassa, and myrrh, with spirit of lavender and a little sugar to flavour it, and rose water as the vehicle. When freshly prepared, it is greenish, and may be kept so if perfectly excluded from the air; but the least exposure changes its colour, in consequence of the sesqui- oxidation of the protoxide of iron of the carbonate, which results from the mutual reaction of the two saline ingredients. A large addition of sugar would have a tendency to prevent this change. It is an imitation of the antihectic myrrh mixture of Dr. Griffith, which at one time had considerable celebrity. It combines the effects of myrrh with those of the chalybeates, and may therefore be given in anemic states of the system, with amenorrhoea, and chronic catarrh; but should never be administered in inflamma- tory conditions of the gastric mucous membrane. I have seldom found much benefit from it in phthisis, in which it was formerly employed. The dose is one or two fluidounces two or three times a day. 2. COMPOUND PILLS OF IRON. — PlLUUB FERRI COMPOSI- TE. U. S., Lond. These pills are made with sulphate of iron, carbonate of soda, myrrh, and syrup sufficient to form a pilular mass. Carbonate of iron results from the double decomposition of the two salts, but by time and exposure is converted into the sesquioxide. The pills are no doubt useful as a tonic and emmenagogue; but, since the introduction into use of the pills of carbonate of iron, have no 454 GENERAL STIMULANTS. [PART II. sufficient end to answer. Their intended effects would be better obtained by combining the latter preparation with myrrh, in such proportions as might seem best adapted to the particular occasion. The dose is from two to six pills, equivalent to about six and eighteen grains of the mass. 3. NATURAL CHALYBEATE WATERS. These belong to the present head, as they generally owe their virtues to the carbonate of irOn they hold in solution. Carbonate of iron is insoluble in water, but is dissolved by water impregnated with carbonic acid gas. Water which has been exposed to the air always contains a small proportion of carbonic acid, sufficient to enable it to dissolve a portion of the carbonate. Hence ordinary spring or river water, remaining long in contact with ores of carbonate of iron, would be more or less impregnated; but when waters highly carbonated are similarly exposed, they become of course much more strongly chalybeate. All chalybeate waters, when exposed freely to the atmosphere, gradually part with their iron; the protoxide of the carbonate being converted into the sesquioxide, which, being insoluble, and incapable of uniting with carbonic acid, is deposited. Hence the yellowish-brown deposit in springs of this kind, and the track of a similar colour, which marks the course of a chalybeate streamlet. The pure chalybeate waters act upon the system in the same manner as the officinal carbonate, and probably, from the dis- solved state of the salt, with still greater facility. They are admir- ably adapted to produce all those beneficial changes in the system for which the chalybeates are generally given; especially when drank at their native sources in mineral springs, where they are often aided by the invigorating influence of pure air, exercise, and agree- able association. They may, however, be abused; and it is neces- sary to be cautious in their use in health, and not to continue them too long in debility, lest plethora should be induced, with its risk of hemorrhage and inflammation, or fever. The natural chalybeate waters appear to be occasionally diuretic, and are thought to have proved useful in chronic nephritic diseases. Artificial chalybeate water may be made by dissolving a mixture of sulphate of iron and bicarbonate of soda in carbonic acid water. Ten grains of each of these salts, powdered and intimately mixed, and then dissolved in a tumbler of the water, will afford a lively drink, containing four grains of carbonate of iron, with a little sulphate of soda, and an excess of the bicarbonate. The whole quantity may be taken at once, morning and evening. • CHAP. I.] ' MINERAL TONICS.—SULPHATE OF IRON. 455 II. SULPHATE OF IRON.—Ferri Sulphas. U.S., Lond., Ed., Dub.— Green Vitriol. Preparation. For medical purposes, this salt should be prepared by heating together dilute sulphuric acid and iron wire. The iron is oxidized at the expense of the water, hydrogen escaping with effervescence; while the acid unites with the oxide to form the sul- phate of the protoxide, which remains in solution. In order that there may be no admixture of the sesquioxide, which it is desirable to avoid, the iron should be in excess, and, after the resulting solu- tion has been poured off, a very little sulphuric acid should be added; care being taken, in the subsequent filtration, evaporation, and crystallization, to exclude atmospheric air as much as possible. This is the process of Bonsdorff, which has been adopted in the U. S. Pharmacopoeia, and affords a pure sulphate of the protoxide. Composition. Crystallized sulphate of iron consists of one equiva- lent of sulphuric acid, one of protoxide of iron, and seven of water. Properties. Obtained in the manner above described, the crys- tals are of a fine bluish-green colour. If quite green, they contain a considerable proportion of sesquioxide. They are inodorous, of a strongly astringent, inky or ferruginous taste, very soluble in water, and insoluble in alcohol. A moderate heat drives off their water of crystallization, and reduces them to the state of a whitish powder. By an intense heat they are decomposed, sulphurous and sulphuric acids being given off, and the red sesquioxide remaining. Prepared by the method of Bonsdorff, they undergo little change i on exposure, in consequence of a minute quantity of uncombined sulphuric acid contained in them; but, as ordinarily found in the shops, they effloresce in the air, and at the same time absorb oxygen, with the production of a red subsulphate of the sesquioxide. In consequence of this change, they first become quite green, and afterwards more or less covered with a whitish or reddish-brown powder; the latter colour predominating after long exposure. This solution, which reddens litmus, is at first bluish-green, but afterwards becomes successively green, greenish-brown, and red- dish, in consequence of the absorption of oxygen, and the gradual conversion of the protoxide into sesquioxide; the latter being partly deposited in the state of an insoluble subsulphate of the sesquioxide, and partly remaining in solution as the neutral sul- phate of the same oxide. When the liquid has assumed a clear red colour, this change may be considered as complete, and no 456 GENERAL STIMULANTS. [PART II. protoxide is left. The solution, however, may be kept in the original state, by means of iron wire, which appropriates the oxygen as fast as absorbed; and sugar has the same effect by its peculiar influence in preventing the oxidation of iron. The sul- phate of iron of the shops almost invariably contains more or less of the sesquioxide. Incompatibles. This salt is decomposed by the alkalies, the alka- line carbonates, soaps, lime-water, the soluble salts of lime, lead, and baryta, the borate and phosphate of soda, nitrate of silver, the soluble sulphurets, and ferrocyanuret of potassium. When a per- fectly pure sulphate of the protoxide, it is not affected by tannic acid, or the vegetable astringents; but, as kept in the shops, it always affords a black or bluish-black precipitate with these re- agents, in consequence of the sesquioxide of iron contained in it. But, though it yields precipitates with the above substances, it does not follow that they are all medicinally incompatible. On the con- trary, it is often given in connexion with an alkaline carbonate, with a view to the production of the carbonate of the protoxide, which is a milder salt, and may be more advantageously employed when the object is to affect the general system. The officinal com- pound mixture of iron, and compound pills of iron, are prepared on this principle. (Seepage 453.) Effects on the System. Sulphate of iron is locally excitant and actively astringent. On the stomach, in moderate doses, it operates often very kindly as a tonic, and in the bowels is apt to produce constipation by its astringency. In larger quantities it becomes irritant, causing heat and uneasiness in the stomach, and, in exces- sive doses, nausea, vomiting, and diarrhoea, with griping pains. In great excess, it may even prove poisonous by inflaming the stomach and bowels. Orfila found two drachms to kill a dog; and Dr. Christison states that he has met with a case, in which half an ounce seemed to have proved fatal in a child. (Christison s Dispen- satory) It is no doubt capable of bringing the system under the influence of iron; but it is probably never absorbed as a sulphate; undergoing decomposition in the stomach, and forming new com- pounds before it is dissolved by the gastric juice. In the mean time, it exercises its excitant influence upon the mucous membrane of the stomach; and, if given freely, with a view to the impregna- tion of the system, it endangers unpleasant symptoms of gastric and intestinal irritation. Therapeutic Application. From the above considerations, it may CHAP. I.J MINERAL TONICS.—SULPHATE OF IRON. 457 be inferred that sulphate of iron is useful as a tonic in dyspepsia, and as a joint tonic and astringent in relaxed states of the bowels attended with diarrhoea. In the defective appetite and feeble diges- tion of convalescence, especially when accompanied with an atonic diarrhoea, it is particularly indicated; and it may be used with hopes of benefit in passive hemorrhages from the stomach or bowels. It has often, moreover, been employed, with a view to its operation through the circulation, in anemic affections, amenorrhoea, passive hemorrhages generally, colliquative sweats, diabetes, excessive secretion from the mucous membrane of the urinary passages, leucorrhoea, and chronic catarrh with exhausting expectoration; but, for reasons stated in the preceding, paragraph, it is not so well adapted for the chalybeate impregnation of the system as some of the milder preparations, and has been nearly superseded by them. It has also been used in intermittent fe^rs, and for the destruction of the tape worm; but is of little real service in either of these affections. Administration. It may be given in pill or solution. If in the former method, it should first be deprived of its water of crystal- lization; as, if made from the crystals, the pills would be apt to crumble from the efflorescence of the salt. The Edinburgh and Dublin Pharmacopoeias direct it in this state under the name of Dried Sulphate of Iron (Ferri Sulphas Exsiccatum, Ed). In solu- tion, it maybe given dissolved in sweetened water, in order to pro- tect it from oxidation, or in carbonic acid water, which aids its tonic effect in dyspepsia. The dose of the crystallized sulphate is from one to five grains, of the dried from half a grain to three grains. External Use. Sulphate of iron has been considerably used as a topical remedy. In the aggregate solid state, in powder, or in strong solution, it has been used to check the oozing of blood from he- morrhagic or wounded surfaces; in weaker solution, as a collyrium in ophthalmia, and an injection in gleet, leucorrhcea, and prolapsus ani; and, in the same form, as a wash in indolent or flabby ulcers, and cutaneous eruptions, especially in the lichenous or herpetic ringworm of the face. The strength of the solution may vary, according to the purposes for which it is used, from one to twenty grains to the fluidounce of water; the feeblest proportion being used in ophthalmia, the strongest to arrest hemorrhage, or with a view to a powerful alterative influence on limited surfaces, as those 458 GENERAL STIMULANTS. [PART II. of diseased ulcers, and patches of chronic cutaneous eruptions. Velpeau has found it the most efficacious local remedy that he has used in erysipelas, which it never fails to cut short in one or two days. He uses preferably a lotion consisting of about half an ounce of the salt dissolved in a pint of water, which is to be ap- plied by compresses, frequently wetted so as to keep the skin con- stantly moist, (Lond. 3Ied. Times and Gaz., March, 1855, p. 239.) III. SOLUTION OF NITRATE OF IRON.—LlQUOR FERRI Nitratis. U.S. — Ferri Ternitratis Liquor. Dub. Preparation. This preparation, first made known as a remedy by Mr. William Kerr, of Scotland, in 1832, has been adopted as officinal in the U. S. and Dublin Pharmacopoeias. As made by the process of Mr. Kerr, and according to the officinal directions, by simply dissolving iron wire in nitric acid, with the addition of water to give it a certain strength, it is a solution of the mixed nitrates of the protoxide and sesquioxide of iron, and consequently, on ex- posure to the air, is apt to become turbid by the further oxidation of the protoxide, and the deposition of a subnitrate of the sesqui- oxide. Mr. Kerr obviated this effect by adding to the solution a little muriatic acid, which dissolves the sesquioxide as fast as formed. Professor Procter suggested, for the same purpose, an alteration in the U. S. formula, which consists in adding the iron in separate portions to the diluted nitric acid, allowing each portion to be dis- solved before adding the next, and, after filtration, heating the solu- tion to 160° F., and carefully dropping in nitric acid, with constant agitation, until the liquid acquires a clear red colour, and yields, when tested with ammonia, a red precipitate without any dark tint. This improvement has been adopted in the late reprint of the U. S. Pharmacopoeia (A. D. 1855), as essential to the correct result of the process. The preparation thus made is a solution of the pure nitrate of the sesquioxide, without any admixture of the protoxide. Properties. The solution, as made by the former process, is of a dark colour, and apt to become turbid; by the improved me- thod, is bright red and permanent. The taste is ferruginous and very astringent, but not corrosive. All substances are incompati- ble with it, which form insoluble compounds with sesquioxide of iron, and soluble compounds with nitric acid; consequently, ferro- cyanuret of potassium, phosphate of soda, and the alkaline sulphu- rets; and with all the vegetable astringents it affords copious black precipitates. The alkalies and alkaline earths precipitate the base. CHAP. I.J MINERAL TONICS.—PHOSPHATE OF IRON. 459 Medical Use. This preparation operates like the soluble salts of iron in general; that is, locally as an astringent, and either a mode- rate excitant or irritant, according to the dose, or the strength of the solution employed; and upon the system at large, as a tonic and reconstructive agent; though, in these latter respects, much inferior to the protosalts of iron, or the metal itself in impalpable powder. It would no doubt prove useful in debilitated states of the stomach and bowels, in the absence of inflammation; and will occasionally cure diarrhoeas connected with this condition of the. alimentary canal. It was as a remedy in diarrhoea that it was introduced into practice; and much testimony has been adduced in its favour. From the trials I have made with it, I do not consider it superior to the other soluble chalybeates for this purpose, especially the sul- phate, when care is taken not to administer that remedy in an over- dose. From the experiments of Quevenne, it may be inferred that it must be decomposed and undergo precipitation in the stomach, like the other soluble salts of iron, and consequently does not reach the seat of its operation in the small intestines, in the state of nitrate. The very blackening of the stbols is alone evidence of decomposition. The dose is from five to thirty drops, from two to four times a day, which may be gradually increased, if necessary, while borne without inconvenience. In an overdose it will irritate and inflame, if not corrode the stomach and bowels. It has been locally used as an injection in leucorrhcea, diluted so as to produce only a slight smarting sensation; but it is probably inferior, in this and other mucous discharges, to the sulphate of iron, as being less astringent. IV. PHOSPHATE OF IRON. — Ferri Phosphas. U.S. Phosphate of iron is prepared, according to the directions of our officinal code, by mixing solutions of sulphate of iron and phos- phate of soda. A double decomposition takes place, resulting in the formation of sulphate of soda, which remains in solution, and phosphate of iron, which is precipitated. This is then washed and dried. If the salt of iron employed be a pure sulphate of the pro- toxide, the resulting phosphate will contain the iron in the same condition, and will be white when thrown down; but this almost never happens; and if it do, oxygen will be quickly absorbed, and the salt assume its characteristic colour. Composition. As employed, this salt always consists of a mixture of the phosphates of the protoxide and sesquioxide of iron, which 460 GENERAL STIMULANTS. [PART II. are in variable proportion. As the phosphoric acid is tribasic, the composition of the protosalt, which greatly predominates, is two equivalents of protoxide of iron, one of water, and one of the acid; that of the sesquisalt, two equivalents of sesquioxide, three of water, and three of acid. Properties. Phosphate of iron is a bluish-white powder, nearly tasteless, insoluble in water, but soluble in the acids. 3Iedical Use. Its operation is that of the insoluble chalybeates generally; that is, it produces the usual effects of the chalybeates on the system, without much affecting the mucous surface of the stomach. It was brought prominently before the notice of the pro- fession by Mr. Carmichael, of Dublin, in his work on cancer, pub- lished in 1809, as a remedy in that disease, in which he employed it both internally, and as an application to the ulcerated surface. In a treatise on diabetes, published in 1825, Dr. Venables speaks highly of its usefulness in that disease; and Dr. Prout confirms his favourable estimate, stating that he regards it as an excellent re- remedy. (Stom. and Ren. Dis., Lond. 1848, p. 50.) The late Dr. Thos. T. Hewson, of Philadelphia, was in the habit of using it for the general purposes of the ferruginous preparations; and, at his recommendation, it was introduced into the Pharmacopoeia of the United States. It is no doubt a good chalybeate, capable of doing what can be accomplished by iron in the improvement of the blood, and of the general health, and is thus far useful in cancer and dia- betes ; but it has no special power over these formidable diseases, and is altogether inadequate to their cure. It is probably in no de- gree superior to the pill of carbonate of iron, if equal to that excel- lent preparation. The dose is from five to ten grains, which may be given in the form of powder, pill, or electuary. Locally, it may be applied to cancerous ulcers, either by being dusted over them, or in the form of a lotion suspended in water, or mixed with water to the consistence of a thin paste, and spread over the surface. Other combinations of phosphoric acid and oxidized iron have been recommended; but there is probably no one which surpasses the officinal phosphate, either in mildness or efficiency. V. TARTRATE OF IRON AND POTASSA. — FERRI ET Po- tass^e Tartras. U.S. — Ferri Potassio-tartras. Lond.— Ferrum Tartarizatum. Ed., Dub. — Tartarized Iron. This is among the most valuable of the chalybeates. It is pre- pared, according to the method of Soubeiran, which has been adopted in the U. S. Pharmacopoeia, and by the British Colleges, by CHAP. I.] MINERAL TONICS.—TARTRATE OF IRON AND POTASSA. 461 adding gradually to a heated mixture of bitartrate of potassa and water, the recently precipitated hydrated sesquioxide of iron (see page 444), constantly stirring, until the latter ceases to be dissolved; then filtering, evaporating to the consistence of syrup, and drying in thin layers. Composition. It is probable that, in the above process, half of the tartaric acid leaves the bitartrate of potassa, and combines with the sesquioxide. According to Soubeiran and Capitaine, the salt con- tains 30.49 per cent, of the sesquioxide. It may be supposed to consist of one equivalent of tartrate of potassa, and one of basic tartrate of sesquioxide of iron (one eq. of acid and one of base F203), chemically combined; the latter ingredient probably acting the part of an acid in the compound. But other views have been taken of its chemical nature; and its insensibility to certain re- agents which ordinarily act strongly on iron in its soluble forms, would seem to show that its metallic constituent is in a peculiar state of combination. Properties. As above prepared, the salt is in translucent scales, of a ruby-red colour, and permanent in the air; but, as formerly made, and still frequently found in the shops, it is in the state of a dark-greenish or olive-coloured powder, slightly deliquescent on ex- posure. The preparation is inodorous, of a mild, sweetish, slightly chalybeate, and not disagreeable taste, freely and wholly soluble in water, slightly so in alcohol, and considerably in diluted alcohol or wine. Its watery solution is not rendered blue by ferrocyanuret of potassium, nor precipitated by the alkalies at ordinary tempera- tures, nor sensibly affected by the ordinary acids. Astringent vegetable infusions, however, affect it in the same manner as other ferruginous solutions. 3Iedical Use. In one or another form, this chalybeate has long been in use; but is not at present, I think, employed as much as it deserves to be. With little disposition, notwithstanding its solu- bility, to irritate the stomach, and almost destitute of astringency, it is yet capable of readily imparting its iron to the system, and produces all those effects upon the blood and the tissues which cha- racterize the ferruginous preparations. Without, therefore, being a very efficient remedy in dyspepsia, diarrhoea, or hemorrhages from the primae viae, in which it is inferior to other soluble salts, it may be employed with advantage whenever the object is to improve the blood, or produce a tonic impression directly on the system. With a view to these results, and without reference to a specific or 462 GENERAL STIMULANTS. [PART IL peculiar influence of any kind, I should prefer it to all other soluble chalybeates. It may require to be exhibited in a larger dose than they; but, even in equivalent quantities, in relation to the iron it gives to the blood, it is less irritant to the stomach. Another advan- tage is its less tendency to constipate. Its want of unpleasant taste, as well as its general mildness, admirably adapt it to the cases of young children; and it is wonderful how soon it will restore a health}'" colour to their cheeks, in the lowest states of anaemia, when purely functional. The dose for an adult is from ten to thirty grains, three or four times a day, to be given in solution. Three or four grains of it may be given to a child from two to four years old. Wine of Iron (Vinum Ferri, Lond), which may be considered as a vinous solution of this salt, has been long in use as a chalybeate. The London College directs it to be made by digesting iron wire in sherry wine, for a month. Madeira or Teneriffe wine would be better, containing more of the solvent agent. The iron is oxidized at the expense of the air or water, and then combines with the ex- cess of tartaric acid of the bitartrate of potassa always present in wine, forming a salt which is probably essentially the same, so far at least as medical effect is concerned, with the one above described. It is not improbable, however, that there may occasionally be other acids present, which may aid in dissolving the iron. The prepara- tion is a weak chalybeate, adapted to cases requiring the use of iron, but in which the patient has been in the habit of using wine regularly. The strength of it must of course vary with the quan- tity of acid or of the bitartrate in the wine; and it is, therefore, somewhat uncertain, as well as feeble. A better plan would be to prepare the wine by dissolving in it directly the tartrate of iron and potassa. Such a solution would have the advantage over an aqueous one, of not being liable to the spontaneous decomposition of the organic acid. The dose is from half a fluidounce to two fluidounces, two or three times a day. VI. TARTRATE OF IRON AND AMMONIA.—Ferri ET Ammonite Tartras. Preparation. This is made, according to the process of Professor Procter, by dissolving freshly prepared hydrated sesquioxide of iron in a solution of bitartrate of ammonia, then evaporating, by means of a water-bath, and drying in thin layers, as in the instance of the last mentioned salt. The equivalent in excess of tartaric acid in the bitartrate unites with an equivalent of the sesquioxide CHAP. I.] MINERAL TONICS.—CITRATE OF IRON. 463 of iron, and a double salt is formed, consisting probably of one equivalent of basic tartrate of the sesquioxide of iron acting as the acid, and one of tartrate of ammonia acting as the base, united, ac- cording to Prof. Procter, with four equivalents of water. Accord- ing to Mr. Hemingway, it contains 31.9 per cent, of sesquioxide. Properties. It is in brilliant, dark-brown, almost blackish scales, or small, irregular, angular fragments, like those of the East India kino; but, by transmitted light, it exhibits a garnet redness. The taste is sweetish, moderately ferruginous, very slightly styptic, and not disagreeable. The salt is very soluble in water. In its reagen- cies it resembles tartrate of iron and potassa, with which also it is closely analogous in composition, ammonia taking the place of potassa. 31edical Uses. In medical properties, as well as in chemical na- ture, this salt bears a close resemblance to the preceding; and all that has been said in relation to the tartrate of iron and potassa, of its want of unpleasant taste, general mildness, efficiency as a chaly- beate in its operation upon the system at large, and inapplicability to the treatment of stomachic and intestinal affections, belongs equally to this salt. It may be used in any case in which it is de- sirable to impregnate the system with iron, and in which a soluble preparation is wanted. Another advantage of both these salts is that they may be given with the alkaline carbonates, and generally with other saline medicines, without undergoing decomposition. The dose is from five to thirty grains, three times a day. The first quantity mentioned is sufficient to begin with, unless in urgent cases. VII. CITRATE OF IRON. — FERRI ClTRAS. U.S. The U. S. Pharmacopoeia directs this salt to be made by gradu- ally adding to a heated solution of citric acid, freshly precipitated hydrated sesquioxide of iron (see page 444) until it ceases to be dis- solved, and the acid is saturated. The liquid is then filtered, evapo- rated to the consistence of syrup, and spread out in a thin layer to dry. A direct union takes place between the acid and oxide, result- ing in the formation of a salt consisting of one equivalent of citric acid, and one of sesquioxide of iron. Citrate of iron is an uncrystallizable salt, and, as above prepared, is in translucent laminae of a fine garnet-red colour, of a mild fer- ruginous taste, slowly soluble in cold, but readily in boiling water. It is a mild chalybeate, and may be employed to obtain the gene- ral effects of iron on the system, either in pill or solution, in doses 464 GENERAL STIMULANTS. [PART II. of from three to ten grains, three times a day. It has been con- siderably used in this country. Citrates of the Protoxide and of the Black or Magnetic Oxide of iron have been prepared, but have no special advantage to recommend them. Citrate of Iron and Quinia is the name given to a preparation made by boiling together recently precipitated quinia, citric acid, and citrate of iron, in water, until a solution is effected, then evapo- rating, and drying as in the preparation of the citrate of iron. It is in thin, garnet-red scales, of a bitter, slightly chalybeate taste, and soluble in water. It is a double citrate of iron and quinia; but, as usually found in the shops, contains a large excess of the salt of iron. It may be used as a tonic, and would be especially adapted to that anemic condition of system which so frequently follows our autumnal fevers; but I can see no advantage it possesses over a mixture of the citrate of iron with sulphate of quinia, while it has this disadvantage, that the relative quantity of the two salts cannot be adjusted to the particular indications of the case. The dose is about five grains. VIII. CITRATE OF IRON AND AMMONIA. — FERRI ET Ammonite Citras.—Ferri Ammonio-citras. Lond., Dub. Preparation and Composition. This salt is made by dissolving freshly prepared hydrated sesquioxide of iron in a solution of citric acid, adding solution of ammonia, evaporating to the consistence of syrup, and spreading out in thin layers to dry. An acid citrate of the sesquioxide of iron is first produced, which subsequently yields a portion of its acid to the ammonia, forming citrate of ammonia. The two salts then combine, constituting a double salt, consisting probably of one equivalent of citrate of ammonia, and one of basic citrate of sesquioxide of iron (one eq. of acid and one of base F203), the latter acting the part of an acid in its relation to the former; so that the salt is closely analogous in composition to the tartrate of iron and potassa before described. Mr. Redwood found the salt of commerce to contain variable proportions of the sesquioxide, from 31 to 34.5 per cent. (Pereira, Mat. Med., 3d ed., p. 793.) Properties. This salt is in very thin, shining scales, of a bright, almost ruby-red colour, and of a sweetish or acidulous, slightly chalybeate, very feebly styptic, and not disagreeable taste. It is readily soluble in water, but almost insoluble in alcohol. Ferro- cyanuret of potassium does not change it blue, though caustic potassa and lime-water decompose it, throwing down the sesqui- CHAP. I.] MINERAL TONICS.—ACETATE OF IRON. 465 oxide, with escape of ammonia. It is not decomposed by the car- bonates of the alkalies. I am told that ammonia escapes when it is heated. , 3fedical Uses. All that has been said of the medical applications of tartrate of iron and potassa, and tartrate of iron and ammonia, is equally applicable to this salt, which is closely analogous to them in composition and properties. It is an excellent chalybeate, and may be given whenever it is desired to bring the system under the influence of iron, and a soluble preparation is wanted. It is less calculated than some other soluble salts of iron, to meet the indi- cations for the tonic and astringent effects of the calybeates on the alimentary mucous membrane. The dose is from five to thirty grains, the former being sufficiently large for a commencing dose in ordinary cases. Several other salts of iron have been recommended at different times, and received more or less attention, of which very brief no- tices must suffice; as none of them have come into general use, and probably none are capable of producing effects which cannot, to say the least, be quite as conveniently and advantageously obtained from those already described. 1. ACETATE OP IRON. — FERRI ACETAS. Acetate of protoxide of iron is in small, green crystals, which decompose rapidly on exposure to the air; acetate of sesquioxide of iron is uncrystallizable, and, in the solid state, deliquescent; it is only, therefore, in solution that either of these salts can be con- veniently kept. The Dublin Pharmacopoeia directs a Tincture of Acetate of Iron (Tinctura Ferri Acetatis), which is made by mix- in tr alcoholic solutions of the sulphate of sesquioxide of iron and acetate of potassa. A double, decomposition takes place, resulting in the formation of sulphate of potassa, which is precipitated, and acetate of sesquioxide of iron, which remains in solution. The liquid is then expressed and filtered. It is transparent, of a deep- red colour, and a strong, ferruginous taste. It is an agreeable and efficacious chalybeate, and was a favourite with Dr. Percival, who is said to have introduced it into the Dublin Pharmacopoeia. In this country, it is seldom or never used. The dose is from twenty minims to a fluidrachm. vol. L—30 466 GENERAL STIMULANTS. [PART II. 2. CITRATE OP IRON AND MAGNESIA.—FERRI ET MAGNE- SIA ClTRAS. This is made by dissolving freshly prepared hydrated sesqui- oxide of iron in citric acid, saturating with carbonate of magnesia, evaporating to the consistence of syrup, and drying in thin layers. It is in translucent scales, of a greenish-yellow colour, and an acidu- lous, slightly chalybeate taste, very soluble in water, but insoluble in alcohol. It has the general properties of the ferruginous prepara- tions, and may be given in the dose of five grains or more, in pill or solution. 3. LACTATE OP IRON.—FERRI LACTAS. Lender the impression that lactic acid is ordinarily present in the gastric juice, that it is consequently the form of lactate which the ferruginous preparations introduced into the stomach generally assume, and that in this form they enter the circulation, MM. Gelis and Conte were induced to recommend the use of the lactate of iron in medicine, as more likely than others to find its way readily into the blood, and to produce the required effects on the system. Some trials that were made confirmed their views as to the effi- ciency of the salt, and it was for a time considerably used; but further experience has shown that it is not superior to other salts of iron; and, from the experiments of Quevenne, it would appear that it is no less liable than others to>undergo precipitation in the stomach. It may be made either by digesting iron filings in lactic acid, or by double decomposition between lactate of lime and sulphate of iron. In the former case, the iron is protoxidiz^d at the expense of the water, and then combines with the acid to form a lactate of the protoxide; in the latter, the same salt remains in solution after the precipitation of sulphate of lime. In both, the resulting solu- tion is filtered, evaporated to the consistence of syrup, and then spread thinly on glass or porcelain to dry. Lactate of protoxide of iron is in white crystalline plates, of a mild ferruginous taste, little changed on exposure to the air, slowly and sparingly soluble in water, and scarcely soluble in alcohol. The watery solution becomes yellowish on exposure, in conse- quence of the partial sesquioxidation of the protoxide; and the dry salt is sometimes met with of the same colour, probably from the same cause, or from want of care, in its preparation, to avoid this source of impurity. In its effects on the system, lactate of iron is not unlike the sul- CHAP. I.J MINERAL TONICS.—VALERIANATE OF IRON. 467 phate, but is less astringent. It is capable of exciting, and, in over-doses, of irritating the stomach, and may, therefore, be used as a gastric stimulant in dyspepsia, though less efficient than some others in diarrhoea and hemorrhage from the mucous membrane of the primae viae. It may also be employed to produce the effects of iron on the system at large; but is inferior for this purpose to powdered iron, or the pill of the carbonate, or even to the milder soluble salts, as the tartrate of iron and potassa, and the tartrate or citrate of iron and ammonia, because more liable to irritate the stomach when freely administered, and consequently incapable of imparting so much iron to the circulation within a given time. The dose is one or two grains, three times a day, which may be gradually increased so as to amount to twelve grains daily. It may be given in powder, pill, or syrup. 4. VALERIANATE OF IRON. — FERRI VALERIANAS. Dub. This has been recently introduced into the Dublin Pharmacopoeia, probably under the impression, that the valerianic acid contained in it might superadd to the tonic action of the iron, in chlorotic cases, the peculiar antispasmodic influence of the oil of valerian. It is, however, so easy to mix a little oil of valerian with one of the pre- parations of iron, that, even admitting the peculiar additional virtue supposed to be acquired, it is scarcely a sufficient reason for in- creasing the already overburthened catalogue of the chalybeates. The salt is made by double decomposition between the sulphate of sesquioxide of iron and valerianate of soda; sulphate of soda being left in solution, and valerianate of sesquioxide of iron precipitated. The latter is then washed, dried, and kept in well-stopped bottles. The salt is composed of three equivalents of acid and one of ses- quioxide. It is in the form of a loose, dark-red powder, with a slight odour and taste of valerianic acid, insoluble in cold water, soluble in alcohol, and deprived of its acid by boiling water. It is also decomposed by the acids, which liberate valerianic acid, recog- nizable by its peculiar, very offensive odour. The preparation is thought to be specially adapted to anemic cases associated with hysteria. One grain is mentioned as the dose, to be repeated three or four times a day. 46S GENERAL STIMULANTS. [PART II. 4. Preparations of Iron in the State of Haloid Salt. I. TINCTURE OF CHLORIDE OF IRON. —TlNCTURA Fer- ri Chloridi. U.S. — Tinctura Ferri Sesquichloridi. Lond, — Ferri Muriatis Tinctura. Ed.—Muriated Tincture of Iron, Preparation. This is prepared by dissolving subcarbonate of iron (U.S. Pharmacopoeia) in muriatic acid, and, after filtration, adding alcohol to the solution. As the subcarbonate of iron of the U. S. Pharmacopoeia consists mainly of sesquioxide of iron, and this, by reaction with muriatic acid, is converted into sesquichloride, there is obtained by this process a solution of sesquichloride of iron in alcohol, with only so much water as was contained in the muriatic acid used. But there is usually, in the subcarbonate above referred to, a small, though uncertain proportion of carbonate of protoxide of iron, producing with the muriatic acid a corresponding propor- tion of protochloride, which remains in the solution. But proto- chloride of iron, exposed to the air, is converted, by the absorption of oxygen, into sesquichloride and sesquioxide, the latter of which, being insoluble, has a tendency to render the preparation turbid. If there be an excess of muriatic acid present, it will dissolve the sesquioxide as fast as formed, and thus preserve the liquor clear; but, as this is not the case in the U.S. formula, the tincture is apt to become turbid on standing. A precipitate is slowly produced, which forms crusts on the bottle, and in this state is insoluble in an excess of muriatic acid, probably from its peculiar state of aggrega- tion* Another inconvenience to which the preparation is incident is that, in consequence of the muriatic acid of the shops falling short of the officinal sp. gr. 1.16, the whole of the subcarbonate directed is not dissolved, and the resulting tincture is, therefore, too weak. If the strong acid cannot be obtained, this defect may be obviated, as sug- gested by Mr. A. P. Sharp, of Baltimore, by passing a little muri- atic acid gas, from some liquid muriatic acid heated in a Florence flask, through a bent glass tube, into the mixture of the subcar- bonate and acid, until a perfect solution is effected, and then pro- ceeding as directed in the officinal process. (Am. Journ. of Pharm. xxvii. 103.) Properties. The tincture of chloride of iron is a deep-brown liquid, * Prof. Procter ascertained, at my request, that this was not an oxychloride of iron, for it was dissolved by sulphuric acid without the evolution of muriatic acid. It is, therefore, probably sesquioxide, rendered, as suggested in the text, insoluble in excess of muriatic acid by its peculiar molecular condition. CHAP. I.J MINERAL TONICS.—TINCTURE OF CHLORIDE OF IRON. 469 which, in very thin layers, is yellowish, and, applied to white paper, produces a yellow stain. It has a sour, very astringent, and strongly chalybeate taste, and'an odour resembling that of muriatic ether, a little of which is probably generated by reaction between the mu- riatic acid and alcohol. It is sensible to the ordinary tests for iron. The following substances produce precipitates with it; namely, the alkalies, alkaline earths and their carbonates, acetate and subacetate of lead, nitrate of silver, astringent vegetable infusions, and mucilage of gum Arabic. Effects on the System. This preparation is locally excitant and astringent, and, in excess, highly irritant. Swallowed in moderate doses, it acts as a tonic and astringent upon the alimentary canal, increasing the appetite, promoting digestion, and causing constipa- tion of the bowels. More largely used, it irritates the stomach, and, in great excess, acts as a poison by inflaming the gastric and intes- tinal mucous membrane. Christison, in his treatise on poisons, mentions a case in which death appeared to result from swallowing a fluidounce and a, half of the tincture. There were symptoms of inflammation in the stomach and bowels during life, and the marks of it after death. Upon the system in general it produces the ordi- nary effects of the chalybeates, and is thought, moreover, by some, to operate as a diuretic, and to exert a peculiar influence on the urinary organs. Though I have used the medicine considerably, I have not noticed the latter effects; but I do not wish to be under- stood as denying them. Attention has recently been called to an extraordinary power of coagulating the blood, possessed by a strong watery solution of the sesquichloride, when injected into the blood- vessels; and the tincture would probably have a similar effect. Therapeutic Application. The tincture may be used with advan- tage as a tonic in dyspepsia, and a joint tonic and astringent in diarrhoea of relaxation, and in passive hemorrhage from the sto- mach and bowels. It may also be used with a view to bring the system under the influence of iron, and is with many a favourite remedy for this purpose; but it has the disadvantage of being liable to irritate the stomach, if given somewhat too freely; and is inferior, I think, for this purpose, to the powder and carbonate, and to the milder soluble salts, as the double tartrate, or ammonio-citrate. There are, however, special purposes which it may be better calcu- lated to fulfil than those preparations. Through the chlorine in its composition, it has been considered as having alterative properties, which render it more efficient in scrofula than the chalybeates gene- rally ; and it has, therefore, been associated with other chlorides, as 470 GENERAL STIMULANTS. [PART II. those of barium, calcium, and sodium, in the treatment of that affection, when complicated with anaemia. It is supposed also to be more efficacious than most of the chalybeates, in checking hemor- rhage from the uterus and urinary passages. It has, indeed, enjoyed considerable reputation, in consequence of the special influence ascribed to it over the urinary organs. In anemic cases of dropsy, in which chalybeates are indicated, it might be selected preferably to others, from its supposed possession of diuretic powers. Some surgeons of eminence have found it peculiarly efficient in spasmodic stricture of the urethra, in which it must be used more freely than for other purposes-; ten minims being given every ten minutes until it produces the desired effect or nauseates. It has also been recom- mended in dysury from weakness of the muscular coats of the bladder, in chronic mucous discharges from the same viscus, and from the pelvis of the kidney, in leucorrhcea, gleets, and the ad- vanced stages of gonorrhoea. A new application has, within a few years, been made of the tincture by Mr. C. Hamilton Bell, of Edinburgh; to the treatment, namely, of erysipelas. He gives it internally, in doses of from fifteen to twenty-five drops every two hours, continued night and day, throughout the complaint, employing no other treatment, ex- cept to operate freely on the bowels in the beginning, and after- wards to keep them regularly open. He has used the remedy for twenty-five years, with invariable success. (Ed. 3Ionth. Journ. of Med. Sci., A.D. 1851, p. 498.) Other practitioners have employed the remedy, and reported favourably of its effects. I have myself used it in several cases, which all terminated in health at the usual pe- riod ; but I presume that the same result would have happened under other modes of treatment; for, within my observation, this complaint has almost always ended favourably, unless in indi- viduals previously broken down by intemperance or disease. Dr. H. L. Byrd, of Savannah, Geo.,- has employed a similar treat- ment, with great supposed advantage, in scarlet fever, and considers the remedy, from his experience with it in twenty cases, as superior to all others in that complaint. He gave it in doses varying, accord- ing to the age, from half or three-quarters of a drop for an infant six or seven weeks old, to ten drops for a child eight years old, and at intervals varying from four to eight hours. (Charleston Med. Journ., ix. 165, March, 1854.) The dose of the tincture for ordinary purposes is from ten to thirty minims, which may be increased to one or two fluidrachms, two or three times a day. CHAP. I.J MINERAL TONICS.—AMMONIATED IRON. 471 Externally the medicine has been employed as a stimulant and astringent application to venereal warts, and cancerous and fungous ulcers; and as a styptic to bleeding surfaces. A strong watery solution of the sesquichloride of iron has of late been suggested as an injection into varices and aneurismal tumours. Some trials made with it show that it acts powerfully in coagulat- ing the blood. M. Pravaz, a surgeon of Lyons in France, found that, through the influence of a few drops of it thrown into an artery or vein, all the blood for an extent of somewhat more than an inch, was coagulated, in the course of a few minutes, into a firm clot. It remains to be seen whether this fact is susceptible of useful practical application. For varices, a solution has been recommended containing about one part of the salt to two parts of water, for aneurisms about one part to four. The sesquichloride may be obtained by a careful evaporation of the tincture, and may then be dissolved in water. II. AMMONIATED IRON. — FERRUM AMMONIATUM. U.S.— Ferri Ammonio-Chloridium. Lond, — Ammonio-Chloride of Iron. When the subcarbonate of iron of the U. S. Pharmacopoeia (ses- quioxide of iron) is digested with muriatic acid, a reaction takes place, by which the sesquichloride of iron is formed in solution. If now a solution of muriate of ammonia be added, and the mixed liquids evaporated to dryness, we obtain the preparation under consideration. It is probably nothing more than a mixture of ses- quichloride of iron and muriate of ammonia, the former amounting only to about 15 per cent. Ammoniated iron is in crystalline grains of a fine reddish-orange colour, and sharp, saline, and chalybeate taste. It is deliquescent, and soluble in water and alcohol. Its incompatibles are the same as those of the preceding article. Under the name of fiores martiales or martial flowers, a prepa- ration closely analogous to this has long been known, since the times, indeed, of Basil Valentine, which was procured by subliming a mixture of sesquioxide of iron and muriate of ammonia. The sesquioxide was probably converted, at the expense of a part of the muriatic acid of the muriate of ammonia, into sesquichloride of iron, which then chemically combined with the remainder of the muriate. The preparation differed from that now officinal in having a vellow colour, and a slight peculiar odour. Medical Uses. The great predominance of the muriate of ammo- 472 general stimulants. [part II. nia renders this a feeble chalybeate, while it imparts aperient, and, as some suppose, alterative properties, which give it a somewhat peculiar character. It is particularly applicable to cases, which offer indications at once for the influence of iron and of a deob- struent agent. Such are presented in anemic states of the system, with swollen lymphatic glands as in scrofula, with enlarged liver, or with chronically hepatized lung. At present, however, it is little used. The dose is ten or twelve grains to begin with, which may be given in pill, solution, or electuary. The London College directs a tincture, which is an altogether useless preparation. III. IODIDE OF IRON.—Ferri IODIDUM. U.S. Preparation.- Iodide of iron is prepared by simply mixing the two ingredients together, with the presence of water, which dis- solves the resulting compound, and, after filtration, yields it by evaporation. The iron is employed in the state of filings, or of wire; but the latter is preferable, as it is in general purer. The preparation consists of one equivalent of iron, one of iodine, and five of water; but, if considerable heat is employed in drying it, the proportion of water is smaller. It should be kept in a well-stopped bottle. Properties. When the solution of iodide of iron is very carefully evaporated, with the exclusion of atmospheric air, the salt is ob- tained in the form of green, transparent, tabular crystals; but, as ordinarily prepared, it is a greenish-black substance, of an astrin- gent chalybeate taste, very deliquescent, and very soluble in water and alcohol. At a moderate heat it melts, and on cooling solidifies i into a dark-gray, crystalline mass, of a metallic lustre. At a higher heat, with exposure to the air, it is decomposed; the iodine escaping, and the iron absorbing oxygen, and remaining behind as the ses- quioxide. Upon the slightest exposure to the air, even at ordinary temperatures, the iron attracts oxygen and passes into the state of sesquioxide, while the iodine becomes free. Analogy would lead to the supposition that, as in the case of the protochloride of iron, the metal would be divided between the oxygen absorbed, and the principle previously combined with it, forming the sesqui-iodide and sesquioxide; but that iodine is liberated is shown by the fact, that the altered substance colours starch blue. This change has almost always happened, in some degree, with the iodide of iron of the shops, which, on that account, is seldom entirely soluble in water. A solution of the iodide undergoes this change much more CHAP. I.] MINERAL TONICS.—IODIDE OF IRON. 473 rapidly than the solid salt, quickly depositing the sesquioxide, and thus becoming weakened as a chalybeate. There are, however, two means of protecting the solution against this change; one by introducing into the bottle containing it some iron filings, or a coil of iron wire, the other by incorporating it with a considerable pro- portion of sugar. A solution protected in the latter method is officinal, and will be described below. In the former method, the free iron immediately takes all the oxygen which that of the iodide absorbs from the air; and the protiodide, therefore, remains un- changed in the solution. Incompatibles. Precipitates are produced in the solution of iodide of iron by the alkalies and their carbonates, lime-water, magnesia, soaps, hydrosulphuric acid and the soluble sulphurets, ferrocyanuret of potassium, the soluble salts of lead, copper, silver, and mercury, but not those of zinc, by the soluble phosphates, all the astringent vegetable infusions, and many other organic substances. Effects on the System. Iodide of iron has both the topical and constitutional effects of the other soluble salts of the metal, in- creasing the appetite, improving digestion, enriching the blood, and operating generally as a tonic; but it is less astringent than the sulphate, and probably less so than the nitrate or chloride; and, moreover, possesses peculiar properties quite distinct from its powers as a chalybeate, and attributable to the iodine it contains. These are evinced in its alterative, diuretic, and laxative effects. Dr. A. T. Thomson states that, shortly after its administration in large doses, both iron and iodine may be found in the urine; but it is not mainly in the form of iodide of iron that it is thus thrown off. The experiments of Quevenne show that but a small portion of the metal passes by the kidneys, while the iodine passes abun- dantly; proving that the two constituents are separated in the system, and most of the iron retained. (Arch, de Physiol, &c, de Bouchardat, Oct. 1854, p. 104.) We can thus explain the two classes of effects produced, one belonging to the chalybeate ingre- dient, the other to the iodine. In over-doses the iodide of iron proves irritant to the stomach and bowels, causing epigastric un- easiness, nausea, vomiting, purging, and griping pains. Very largely taken, it would probably induce serious gastro-intestinal inflammation; though I have seen no account of positively poison- ous effects. Therapeutic Application, This medicine was first employed by Dr. Pierquin so early as in the yeax 1S24. It is now among the 474 GENERAL STIMULANTS. [PART II. most popular of the chalybeates, though employed chiefly in a special class of cases. It may be used as a gastric tonic in dys- pepsia, or with a view to the general effects of iron on the system, as in simple chlorosis, or in the anemic condition attended with amenorrhoea, leucorrhcea, &c.; but its best effects are displayed in cases of scrofulous disease, and other forms of local tumefaction or induration, in which there is at the same time an indication for the improvement of the blood. It is only in the absence of all febrile excitement and gastric inflammation, that it should be resorted to in such cases; but, when properly accommodated to the state of the system, it is an excellent remedy. In swellings of the lympha- tic glands external or internal, diseases of the bones, ligaments, and joints, and ulcerative and eruptive affections of the skin, when these can be traced to a scrofulous taint; in chronic enlargement of the thyroid gland, mamma, testicle, ovary, liver, and spleen; in various subacute or chronic swellings and indurations without spe- cial seat, or known peculiarity of character; in all these affections it may be considered as indicated, when they exist conjointly with an anemic state of the blood, and a general deficiency of vital force. Without this associated condition, and in all cases in which the excitant properties of the chalybeate on the system may be contraindicated, some other preparation of iodine, especially iodide of potassium, should be preferred. Iodide of iron has also been used with advantage in secondary syphilitic affections, in like man- ner, connected with anemic debilit}'. A solution of it containing from one to two drachms in a pint of water, has been employed locally as an injection in gonorrhoea and leucorrhcea, and as a lotion in ulcers. Administration. The dose of the iodide of iron is two or three grains three times a day, which may be increased to ten grains, if not found to disturb the stomach. The administration of it, in the pilular form, is attended with some difficulty, in consequence of its deliquescent property, and extreme proneness to chemical change. Various modes of obviating these objections have been proposed. Perhaps the best method would be to evaporate to a pilular consistence the officinal solution of the»iodide, which is pro- tected from change by sugar; or the preparation might be directly incorporated with sugar when made into pills; or, as suggested by Prof. Procter, a little reduced iron might be added to the mass with the same view. But, even though protected against oxidation, the pills would still be liable to deliquescence. To obviate both disad- CHAP. I.J MINERAL TONICS.—FERROCYANURET OF IRON. 475 vantages, they might be covered with a coating of impervious matter, by dipping them into a chloroformic solution of caoutchouc and drying them. But, upon the whole, it might be better to avoid altogether this mode of exhibition, and employ only the solution. Pflls of Iodide of Iron (Pilule Ferri Iodidi, U. S) are ordered by our officinal code to be made by incorporating sulphate of iron and iodide of potassium with sugar and a little tragacanth. Either before or after entering the stomach, an interchange of principles takes place, resulting in the formation of sulphate of potassa and iodide of iron; and the sugar has a tendency to protect any portion of the latter which may be produced prior to the exhibition of the pills. The taste of the pill is disagreeable, its consistence apt to be friable, and altogether the preparation is not an eligible one. The pills should be made only when wanted for use. Each one con- tains somewhat more than a grain and a half of iodide of iron, and two of them may be given two or three times a day. Solution of Iodide of Iron (Liquor Ferri Iodidi, U.S.— Syrup of Iodide of Iron, Syrupus Ferri Iodidi, Lond) is directed by the U. S. Pharmacopoeia to be prepared by dissolving iodine and iron filings together in water, with the aid of a gentle heat, filtering the solution upon a certain proportion of sugar, in a bottle, and then adding distilled water so as to fill up the required measure. There is scarcely sufficient sugar in the U. S. preparation to preserve it effectually, and more might be appropriately added.' Should the solution not keep well, a coil of iron wire might be introduced for further security. The solution or syrup is transparent, and of a pale green, or yellowish-green colour, with occasionally a little sediment. By ex- posure to light in a closely stopped bottle, it becomes nearly colourless. It is the common form for the administration of iodide of iron, and is greatly preferable to the pill. When it is swallowed, care should be taken to wash out the mouth well, in order to avoid possible injury to the teeth. The dose of the U. S. preparation is from twenty to fifty drops, which should be diluted with water, but only at the moment of exhibition. IV. FERROCYANURET OF IRON. — Ferri FERROCYANU- retum, U.S.—Ferrocyanide of Iron. — Pure Prussian Blue. Preparation. As the Prussian blue of commerce is always more or less impure, this preparation should be made specially for medi- cal use. The U. S. Pharmacopoeia directs that a solution of sesqui- 476 GENERAL STIMULANTS. [PART II. sulphate of iron should first be prepared, in the same manner as in the process for hydrated sesquioxide of iron, that to this a solution of ferrocyanuret of potassium should be added, and that the preci- pitate produced should be washed on a filter, and dried. Portions of the iron of the sesquisulphate, and of the potassium of the fer- rocyanuret, change places, so as to form sulphate of potassa and ferrocyanuret of iron, of which the former either remains in the solution, or is dissolved oufin the washing, leaving the latter pure. Composition. Ferrocyanuret of iron consists of three equivalents of ferrocyanogen (which contains one equivalent of iron and three of cyanogen), four equivalents of iron, and six eqs. of water; the last ingredient being essential; as it cannot be separated without decomposing the salt. The compound, however, as in the case of other haloid salts, may be looked on as consisting of a hydracid and an oxide of iron, the hydrogen of the water going to the ferrocyanogen, and the oxygen to the iron. In this view, the salt would be a hydroferrocyanate of the sesquioxide of iron, and would consist of three eqs. of hydroferrocyanic acid (each containing one eq. of ferrocyanogen and two of hydrogen), and four eqs. of sesqui- oxide of iron. Commercial Prussian blue always contains, besides the above compound, a portion of uncombined alumina and ses- quioxide of iron. Properties. The pure salt is in the form of a rich deep blue pow- der, inodorous anct tasteless, insoluble in water and alcohol, and unaffected by the dilute acids. Strong sulphuric acid dissolves without decomposing it, concentrated nitric and muriatic acids decompose it, and the alkalies separate sesquioxide of iron. Effects on the System, From the insipidity of Prussian blue, its insolubility even in dilute acids, and the fact that it is formed whenever the ferrocyanuret of potassium meets a salt of iron in the body, even in the circulating liquor sanguinis, a fair inference is, that it would probably have no other effect on the system than such as might result mechanically from the presence of an insolu- ble powder in the stomach and bowels; and this view would seem to be supported by the experiments of M. Coullon, who found it without action in several different species of animals. (Merat et de Lens, ii. 531.) Therapeutic Application. Notwithstanding, however, its presumed inertness, it has been much commended by some practitioners. Dr. W. Zollickoffer, of Maryland, first called the attention of the pro- fession to it as a remedy in intermittent and remittent fevers, in which CHAP. I.] MINERAL TONICS.—FERROCYANURET OF IRON. 477 he was induced by his observations to consider it superior to Peru- vian bark. (Am. Med. Recorder, July, 1822, v. 540.) Dr. Samuel Jackson, late of Northumberland, employed it with success in a large number of cases, but found it to fail in many. (Am. Journ. of 3Ied. Sci, ii. 336, A.D. 1827.) Dr. Hasse, a German physician, found it effectual in an epidemic intermittent which prevailed at Gastrow in the spring of 1827; but he gave doses of a grain of the salt with a scruple of pepper, the latter of which was probably much the more efficacious of the two. (HufelancVs Journ., quoted by Merat and de Lens, ii. 531.) Dr. Eberle speaks of it favourably from his own observation and experience. (3Iat. 3Ied. and Therap., 4th ed., i. 321.) Many other physicians have borne a somewhat hesitating or equivocal testimony in its favour. I tried it myself in a number of cases, soon after it first came into notice, with some success, but with so many failures that I soon abandoned it. The medicine has been given with supposed success also in chorea and epilepsy, but associated generally with others, so as to leave the real agent of cure doubtful, and sometimes in such doses as to leave no doubt as to the inefficiency,of the Prussian blue. Thus, M. Burguet, of Bor- deaux, gave from one-eighth of a grain to four grains a day; and Dr. Kirckhoff, of Ghent, supposed that he cured epilepsy with from half a grain to six grains in the day. Dr. Bridges, of Philadelphia, em- ployed it in a case of obstinate facial neuralgia, with considerable relief, after the ordinary remedies had been tried with little or no effect. It will have been observed that all these diseases, in which efficiency has been claimed for it, are of a character to be readily affected through the mind; and in which anything will occasion- ally effect apparent cures in which the patient may have confidence, or even strong hope. I am not prepared, however, to say, that the mere presence of an insoluble agent in the primae viae, acting only mechanically on the mucous surface, may not prove useful in nervous diseases, and local affections of the membrane itself. The dose, as given by different practitioners, varies extremely. Generally, from four to six grains have been given several times a day. Instances are mentioned above in which the dose was reduced to the eighth of a grain, and Dr. Jackson, late of Northumberland, gave in some cases two drachms during the interval in intermittents, finding it to lie easily on the stomach. This latter fact tends strongly to favour the idea of its inertness, in reference to any direct in- fluence on the system in general. 478 GENERAL STIMULANTS. [PART II. SECTION SECOND. Diffusible Stimulants. Under this division of General Stimulants are included those which act quickly and energetically, but only for a comparatively short period. In the degree in which they possess the stimulant property they differ much among themselves; but, as a general rule, they greatly exceed, in this respect, the permanent stimulants, em- bracing the astringents and tonics, which have just been under con- sideration. One of the laws of all stimulation, whatever may be its degree, is that it is followed by a depression proportionate, at least approximately, to the previous exaltation of the function or func- tions excited. Hence, the remedies belonging to the present section, as they exceed the astringents and tonics in rapidity and extent of stimulant action, leave behind them a more speedy and greater depression. General Therapeutic Remarks on Diffusible Stimulation. The condition to which this therapeutic process is applicable, is obviously that of general depression of the actions or powers of the system. To a considerable extent, the observations made upon tonic stimulation in reference to the possible injury from its abuse, and to the conditions of depression or debility admitting and calling for its employment, are applicable also to this variety, and need not be repeated. A few remarks more particularly bearing on the subject at present under consideration will be appropriate. As a general rule, the diffusible stimulants may be resorted to in cases of considerable, and especially of rather sudden or acute prostration, which tonics and nutritious food are either too slow in action, or too feeble in stimulant power to counteract. But some cautions are necessary. Sometimes there is great prostration of the vital actions, de- pendent on the concentration of blood and nervous power in some large organ, or extensive structure in the interior of the body, in a state of high inflammation. This may without caution be mistaken CHAP. I.J DIFFUSIBLE STIMULANTS. 479 for real debility, and fatally treated under that impression. It occurs usually at or near the commencement of the inflammatory ' attack, and will in general be readily diagnosticated by the evi- dences of the existing inflammation, if the practitioner be on his guard. In these cases, bleeding is the great remedy, if it can be employed; the system reacting as the interior organs are unloaded, and the pulse rising under the lancet. But sometimes the least amount of blood lost so far impairs the powers of the heart as still further to depress the pulse. Under such circumstances, stimula- tion may become necessary in order to excite the heart, and rouse up the circulation generally, so that loss of blood may be borne, until the relief of the internal congestion shall remove the depress- ing force. But it is obvious that the stimulation must be such as will not be likely to continue into the period of reaction, as it would much aggravate the danger of inflammation. Therefore, reliance should mainly be placed on external stimulation, which can be withdrawn at any moment when desirable; and, if this should prove insufficient, the stimulants of briefest action should be pre- ferred, as heat, the ammoniacal preparations, and those of ether. Another analogous condition, in which precisely the same cautions should be observed, is that collapse -of system which generally attends violent concussion of the brain, and not unfre- quently occurs after any severe shock upon the system, as from accidental injury, or a surgical operation. The nervous centres are here prostrated, and all the vital functions fail in consequence. Sometimes reaction never takes place; but when it does, inflam- mation and fever almost always ensue, and might be greatly aggra- vated by the previous injudicious use of stimulants. But these are sometimes essential to assure reaction. The external, and those of brief action are here also indicated; and those especially should be avoided which would peculiarly stimulate the organ likely to become the seat of inflammation, as the brain in concussion. Again, collapse calling loudly for diffusible stimulation some- times occurs in the cold stage of febrile diseases, particularly those of a typhous and malignant character, and the exanthematous. Here also reaction will take place if the patient survive; and, although equal caution in regard to prolonged stimulation is not necessary as in the former instances, the reaction itself being often tainted with debility, yet injury may be done by a too zealous em- ployment of the measure, and the stimulants of long-continued action, and greatest influence on the brain, should be resorted to 480 GENERAL STIMULANTS. [PART II. only when it becomes obvious that external and brief internal stimulation will not answer. But when debility occurs in the course of acute disease, as in the various febrile affections, diffusible stimulation may be employed without scruple, and usually in a degree exactly corresponding with the apparent call for it. Here there is no danger of subse- quent reaction. The prominent indication is to support the system until the depressing agency shall have ceased, and either the system have recovered its energies, or the disease run its course. Even the coexistence of inflammation does not, under such cir- cumstances, altogether contraindicate the use of stimulants, though it should dispose to greater watchfulness not to exceed the neces- sary point. Various inflammations occur in the course of fevers of the low or typhoid character, in which the blood and nervous force are both greatly impaired, and often will-not sustain life unless by the aid of the diffusible stimulants. Local measures, even moderate cupping or leeching, fomentations, blisters, &c, and the careful use of the mercurials, may be employed for the inflamma- tion, while stimulants may be freely used to support the functions, and nutritive matter to supply a better blood. This remark, too, is applicable even when the inflammation may have been the original affection, provided the symptoms of typhous debility, and a depraved or poisoned blood supervene. Examples of this kind we have in typhous pueumonia, typhous dysentery, malignant sore throat, and the prostrate or malignant forms of scarlet fever, small- pox, and erysipelas; and there is scarcely one of the exanthematous fevers, or of the local inflammations to which the remark will not apply. Another condition of debility often demanding the free use of the diffusible stimulants, is that which attends acute febrile affection or inflammation occurring in persons previously worn out by enfee- bling disease, bad living, or habits of intemperance. In the latter case, it is generally necessary, even when the lancet may be em- ployed for the cure of the inflammation, to administer stimulants to support the heart and nervous centres, which would refuse to act without them. This is an important therapeutic principle in the treatment of habitual drunkards, and even of those who have been long in the habit of using ardent spirits in great excess, though never obviously intoxicated. Agaiu, when the system is exhausted by profuse evacuations, as in the hemorrhages, cholera, diarrhoea, &c, by long continued CHAP. I.] DIFFUSIBLE STIMULANTS. 481 disease of almost any kind, or by copious suppuration, the result of antecedent inflammation, or is prostrated under the influence of gangrene from the same or some other cause, diffusible stimulants are often necessary to support life, until the system recovers its powers, or the processes referred to shall have terminated, as they usually have a tendency to do, in health. Often, in these cases, tonics and a nutritious diet, or even the latter alone, may be suffi- cient; but frequently also the diffusible stimulants are essential. Whenever, moreover, the blood becomes so impaired by an absorbed or otherwise introduced poison, as to be incompetent alone to the support of the vital functions, diffusible stimulants must be freely used, in order to sustain life as long as possible, in the hope that the poison may be thrown off, or that the blood and solid tissues may pass through the series of morbid changes set on foot by the poison, and return to the sound condition. Thus, puru- lent infection, the state of system resulting from poisoned wounds, as in dissection, and the poisonous condition produced by the bites of serpents and other venomous animals, will sometimes recover under potent stimulation, when the patient would perish without it. Finally, there are diseases in which the nervous centres appear to be prostrated, without any observable vitiation of the blood, and without at first any considerable failure in the actions of the heart; in which, however, powerful stimulation is sometimes essen- tial. Not to mention delirium tremens, in which this condition of the nervous centres results from the withdrawal of a wonted stimulus, and which often imperiously demands stimulation to save life, there are tetanus, and various other violent spasmodic and nervous affections, among which mania may be sometimes included, in which the same remedial measure is often of great importance. Division of Diffusible Stimulants. Most of the general excitant influences, though they may in a greater or less degree affect the whole system, are characterized by having a preferable tendency to some one of the subordinate systems rather than to another; and hence the stimulants belonging to this section are divided into the arterial, the cerebral, and the nervous, according as they exhibit a tendency to excite more especially the circulation, the brain, or the nervous tissue generally. To this rule, however, there is one striking exception. Heat is a vital stimulus essential to the support of every function in its normal state, and capable, therefore, when operating in excess, of produc- VOL. I.—31 482 GENERAL STIMULANTS. [PART II. ing over-excitement in all parts of the body. It is a universal stimulant, and is capable of being remedially employed as such with very great advantage. The consideration of it as a remedy falls within the scope of this work, and, in relation to its stimulant powers, belongs especially to the present section. Having, how- ever, other therapeutic properties, it will, in reference to these, be treated of in connexion with the several classes to which it may belong, as the diaphoretics, rubefacients, epispastics, and eschar- otics. The following observations apply only to its properties and uses as a diffusible stimulant. HEAT AS A DIFFUSIBLE STIMULANT. It is only when of higher degree than the temperature of the body, or of that part of the body to which it may be applied, that heat is used therapeutically. No precise degree, therefore, can be fixed, at which it will take rank among remedies; for the temperature of the body which must determine this point, is itself variable. But, as a general rule, it may be said that a heat of 95° Fahr. or up- wards, may be remedial; for this is above the average temperature of the surface of the body; and a decided sensation of heat will be excited by the contact of a conducting substance, at that tem- perature, with the skin. But, should the surface be very cold, a much lower temperature than that mentioned might prove stimu- lant; and, on the contrary, should it be very hot, a higher heat might be applied without any effect of the kind. It will be remem- bered, therefore, that when precise degrees may be mentioned here- after, they are to be considered not as fixed, and applicable under all circumstances; but merely as an average, and of course to be varied with the particular condition of the body at any given time. It will be found also, in the progress of these observations, that the mode in which heat is applied influences very much the degree at which it will act as a remedy. 1. Effects of Heat on the System. The first effect of heat is to excite its own peculiar sensation in the seat of application. In a moderate degree, this may not be unpleasing; indeed, when the temperature has been depressed below the normal standard, it is often highly grateful; but, if increased, it begins at length to become painful, and in its higher CHAP. I.J DIFFUSIBLE STIMULANTS.—HEAT. 483 degrees is often extremely so. The excitant influence is speedily extended to the capillaries, which dilate under the stimulation, admitting a larger amount of blood, and thus reddening the sur- face, and producing a greater or less distension of the tissue gene- rally. The blood of the part, thus increased in amount, and at the same, time flowing more rapidly with the increased action of the vessels, receives an increment of heat from without, which it car- ries through the system, to produce everywhere a degree of the same stimulant effect first produced upon the surface of application. The impression upon the nerves, moreover, is transmitted to the cerebral and spinal centres, exciting them to increased action. A universal stimulant influence is thus exerted. The heart beats more rapidly and energetically; and the pulse is consequently fuller, stronger, and more frequent. The respiration is hurried. The general temperature, under the universal excitation, is elevated in a degree much greater than would result from the mere addition of caloric from without. The secretions are promoted; all of them probably at first, under a gentle operation of the stimulant; but, when the heat is considerable and continued, the mucous mem- branes and the kidneys appear to be irritated beyond the point of free secretion, as indicated by a dryish state of the mouth, aud diminished discharge of urine; while the secretory functions of the liver and skin are promoted, so that there is usually a freer flow of bile, and greater or less increase of perspiration. An explanation of this difference in effect, and of its uses, will be given hereafter under the head of'diaphoretics. At present it is sufficient to ob- serve that, in some instances, even the liver and skin appear to be so much irritated as to be unable to perform their function, and the patient consequently suffers with hepatic congestion, and gene- ral heat and dryness of the surface. Along with the exaltation of the organic functions, the nervous also become excited. A mode- rate influence of the cause is usually attended with agreeable effects. Sensibility is rendered more acute, muscular motion invi- gorated, and the intellect, imagination, and feelings more or less exalted. But these functions, under a higher degree of the excita- tion, become deranged, and at a still higher are impaired; so that a feeling of fulness and even painful distension of the head, vertigo, and other abnormal cerebral sensations, and hebetude of the intel- lectual and emotional functions, are often experienced. This result is simply in conformity with the general law, that, by moderate over-excitation or irritation, the functions are increased in a normal 484 GENERAL STIMULANTS. [PART II. direction, by a greater amount of it, are deranged, and by a still greater, are diminished or suppressed. The generative functions obey the same general law; and the sexual feelings are excited, the menstrual act promoted, and the capacity for conception proba- bly increased, under the genial influence of a moderately elevated temperature; while they may be perverted or suppressed by its excess. Should the heat be very considerable, or continued too long, a universal acute derangement of the functions may take place, constituting fever. As in the case of every other stimulant, the excitement produced by heat in the functions, is followed by a proportionate depression. The excitability, exhausted by excessive exercise, now fails to re- spond to the ordinary vital stimuli, and action is of course dimi- nished. As before stated, this may be considered as a universal law of stimulation. Hence the soft, compressible, and often feeble pulse, the cool, pale, and relaxed skin, the muscular debility, the lassitude or indisposition to exertion, the mental languor, and the tendency to sleep, after the subsidence of the general excitement produced by the hot bath. Hence, too, the enfeebled state of sys- tem, the habitual languor and lassitude experienced after a pro- longed exposure to the heats of summer, or a residence of some months in a tropical climate. 2. General Therapeutic Application. Two main purposes are fulfilled by heat acting as a stimulant; first, to elevate the depressed, or support the failing functions; and secondly, to equalize the distribution of the blood and nervous energy, by attracting them away from parts where they may exist in excess towards the seat of its own immediate action. These two indications not unfrequently exist in the same case, and are fulfilled by the same application of the remedy; as in those in- stances of great prostration, with concentration of the blood in the interior, which are presented in the initial or cold stage of malig- nant fevers. Here the stimulant influence of heat applied to the surface, rouses the prostrated nervous centres and the heart, while it calls forth the accumulated blood from within, and unloads the oppressed vital organs. Frequently also the two purposes are separately fulfilled; as when heat is applied, in one instance, to aid internal stimulants in supporting the sinking system in the advanced stage of febrile diseases, and, in another, to draw excite- CHAP. I.] DIFFUSIBLE STIMULANTS.—HEAT. 485 ment away from the brain or lungs, towards the lower extremities in threatened apoplexy or pulmonary congestion. But it will be most convenient to treat of the special uses of the remedy, in con- nexion with the several modes of applying it, which are next to be considered. 3. Modes of Applying Heat Therapeutically. Of the heat generated within the body by exercise, stimulation, a rich diet, friction, &c, I shall not here treat, because it is -a result of other measures, and, though it may be one of the means by which those measures prove remedial, it cannot be itself considered in the light of a remedy. There are two modes of obtaining the direct influence of heat; first, by preventing the escape of the natural heat of the body, and thus causing its accumulation,, and secondly, by imparting it to the body from other heated substances. 1. Confining the Heat of the Body. This is effected by surround- ing the person with a badly conducting medium in the form of clothing, or bed-covering at night, or in that of a dry atmosphere, which is a very slow conductor. a. Clothing. Much may be done in the management of morbid tendencies, and even of disease itself, by a proper regulation of the clothing. Furs, feathers or down, and wool are the worst conduct- ors of heat; tissues made of raw silk are, perhaps, next in order; then tissues of cotton, and after this linen, which is the most rapid conductor of all the materials used for clothing. It is obvious that, when the object is to keep the surface warm, a selection should be made from these substances, whether for body clothing, for bed- ding and bed-covering at night, or for occasional use under extraor- dinary exposures to cold, according to the degree of protection wanted; the worst conductors being chosen when it is most im- portant to confine the animal heat. Upon the whole, the most suitable under-clothing for keeping up an equable temperature of the body is flannel, or the elastic woollen tissue now so much worn, which has the advantage over flannel that it shrinks less by wash- ino-, and is not apt to become so hard and stiff. When it is spe- cially important to preserve an equable temperature, this should be worn through the whole year, summer as well as winter; the quality being accommodated to the degree of heat. The fabric may be had of every diversity of texture, from the coarseness of 486 GENERAL STIMULANTS. [PART II. the heaviest flannel, to the fineness almost of gossamer; and the lightest should be chosen for summer wear. It is scarcely less important in the warm than the cold season; for the changes of summer are very great, and the surface is even more susceptible to cold than in winter, in consequence of its frequent relaxation under a high temperature. Should even the lightest woollen fabric be insupportable in the most intense heat of the season, a similar tissue made of raw silk may be substituted, or, if this cannot be had, of cotton; but, in cases of delicate health, where the preser- vation of the temperature is important, linen should never be worn next the surface of the body, unless when the skin is excessively irritable; and, in that case, wool, silk, or cotton should be worn over it. Persons in whom this kind of caution is essential, should be peculiarly careful to keep the feet warm and dry, either by woollen stockings, or, what is sometimes preferable, double stock- ings, one pair of silk, and the other of cotton. Occasionally, woollen hose keep the feet in a constant perspiration, which moistens the covering, and serves to convey away the heat; so that these parts arc always cold. This evil may often be corrected by wearing the double hose just referred to. In wet weather, the boots or shoes should always be water-tight, when the person is exposed out of doors; but they should be exchanged for others within doors, as they confine the perspiration, and cause the feet to be cold by making them damp. The outer covering should always be propor- tioned to the degree of cold, when the body is necessarily exposed to it. Some delicate individuals think they can harden themselves against cold, by habitual exposure; and hence encounter the severest weather with insufficient covering. This is a great mistake. They frequently, I believe, expose themselves in this way to the great danger of aggravating a morbid diathesis into positive disease. The proper rule is never to allow one's self to become chilled for any length of time. An excellent mode of preventing the evil results of the present mode of open dressing over the chest, is to suspend from the neck, under the shirt, a piece of doubled silk with cotton wadding quilted within, or a dressed rabbit's skin. At night, equal attention is necessary to preserve a due degree of warmth. The covering should be sufficient to render the person comfortable; and, with delicate persons, it is better to err on the side of excess of warmth than that of cold. The habit of using mattresses in summer is very well; but feather beds should be em- ployed, in winter, by all persons in whom the indication for sustain- CHAP. I.] DIFFUSIBLE STIMULANTS.—HEAT. 487 ing a warm temperature of the body exists. I think I have known the most serious evils result from an attempt, on the part of indi- viduals of scrofulous predisposition, to harden themselves to the influence of cold; and carelessness on this point may be equally injurious. It will be observed that I am not applying these re- marks to the healthy and robust. For these, equal caution is not necessary; though even they would do well to exercise some care in the point under consideration. The predispositions and affections to which these observations are especially applicable are those of a scrofulous or tuberculous character. A continued depression of the temperature beneath that of full health is peculiarly injurious in all the forms of tuberculosis, whether before or after the deposition, and in all cases of a stru- mous character or tendency. Hence the advantage, on the part of such individuals, of a residence in warm climates; but, when this is impossible, much can be done by a due attention to clothing, by day and by night, and at all seasons. I do not say that temporary exposures to cold may not sometimes be useful in these persons, through the tonic influence of the reaction. But such exposures should always be purposed, not accidental; should be employed in a remedial capacity,.and not left to the caprices of chance; and, when they are resorted to, the utmost care should be taken that due reaction shall ensue. When this takes place with difficulty, they should be at once abandoned. The above remarks may seem trivial to the unexperienced; but those who have seen much of dis- ease know, that influences of the kind here alluded to are quite as important as medicines, and will agree with me in the necessity of attention to them. But it is not in the scrofulous cachexia only that a due preserva- tion of warmth is important. All low forms of disease, and espe- cially the low fevers, are promoted by constant chilliness; and no fact is more universally admitted in medicine, than that change of temperature, and especially exposure to cold after heat, is one of the most fruitful causes of the various inflammations. The pre- servation of a moderate warmth of surface, not sufficient to induce perspiration, is one of the great hygienic rules which should be attended to under all circumstances. b. Dry Air. Another method of sustaining the warmth of the body is to surround it with dry air, which is a very bad conductor. But dry air favours greatly the evaporation of liquids, and thus tends to act injuriously, in many instances, on the mucous membrane of 488 GENERAL STIMULANTS. [PART II. the air-passages, and on the skin. It is, therefore, only under pe- culiar circumstances that it can be resorted to remedially. It is indicated in patients of a debilitated habit, with a disposition to excessive moisture of the surface, and excessive bronchial secretion from chronic disease of the air-passages. In certain cases of pitui- tous catarrh, or humoral asthma as it was formerly called, with a cool perspiratory state of the surface, confinement to such air may prove useful. This is readily accomplished, in winter, by warming the cold dry air from without by ^passing it over heated surfaces, without supplying water to moisten it in its passage into the cham- ber. Great facility for this purpose is afforded by the present plan of heating houses from furnaces in the cellar. 2. Imparting Heat to the Body. The methods of accomplishing this object are numerous, and each requires a special notice. They may all be included in two divisions; the first embracing those in which the heating body used is dry, the second those in which it is moist. There is an important difference between these two methods. By the first we obtain the effects of heat alone; in the second, the sedative influence of moisture, and the conducting power of water, modify these effects often very materially. These influences will be considered when we come to the methods of applying moist heat. a. Dry Heat. This is imparted either by radiation, or by the direct contact of the heated medium. Insolation, or exposure to the rays of the sun, is,the most effective mode of obtaining the influence of radiant heat. It is sometimes agreeably stimulant to the old, feeble, and paralytic, and appears to act as a restorative in the debility of convalescence. As the com- bination of heat and light, in the direct rays of the sun, is essential to the perfect development of vegetables, so it is probably also to that of animals; and there is little doubt that this is one of the influences which, combined together in a journey through the coun- try in the warmer seasons, tend so powerfully to build up a system dilapidated by disease, worn out by over-exertion, or languishing from the confinement, impure air, and in-door dwelling of a town life. To the scrofulous and consumptive, exercise in the pure sunny air is peculiarly beneficial; and the direct warmth of the sun, by a positive stimulation and invigoration of all the vital pro- cesses, contributes considerably, I have little doubt, to the favour- able influence of a residence in warm climates over a tuberculous diathesis. An excess of it may, of course, be injurious, and must be guarded against, especially its immediate action on the brain. CHAP. I.] DIFFUSIBLE STIMULANTS.—HEAT. 489 The radiant heat of a fire may be used as a substitute for insola- tion in the old and feeble, during winter. The same mode of heat- ing is often used for equalizing the temperature in cases of cold hands and feet; and, in attacks of spasmodic colic, or of subacute and neuralgic rheumatism from exposure to cold, a thorough heat- ing of the feet, before a good fire, will sometimes produce a cure. Substances used to impart dry heat to the body by conduction are solid or aeriform. Of the former class are bottles filled with hot water or heated sand; tin vessels made to fit certain parts of the body, and filled in the same manner; metallic bodies, such as flat-irons heated; hot bricks; bags filled with heated oats, sand, or ashes, and shaped so as to lie conveniently along various parts of the body; and towels heated as hot as the skin will bear them, and applied folded to the surface. These means may be had recourse to in the cold stage of febrile diseases; the advanced stage of the same diseases, with general feebleness and coldness of the extremities; the collapse of cholera and other bowel affections; asphyxia, complete or partial; the ex- ternal paleness and chilliness attendant on severe colic, and violent spasms of the stomach, bladder, gall-duct, and ureters; in short, whenever there is an indication for the general stimulation of heat, or its derivative influence from irritated, congested, or inflamed or- gans. In cases of great emergency, when some powerful impression may be necessary to rouse the failing sensibilities of the system, a red-hot coal may be applied to the surface, especially to the epigas- trium. I have known of an instance of this kind in malignant typhus, in which the patient, who had sunk below the reach of all ordinary stimulants, was roused by this means, and, on recovering afterwards, said that the sensation of the burning coal had been positively agreeable to him, in the state of horrible vacancy of feel- ino- to which he had been reduced. When the solid bodies above enumerated are brought into contact with the surface, care must be taken that they are not hot enough to burn the skin; and this caution is the more necessary, because the patient is often himself too insensible at the time to give notice of the danger. It is some- times advisable to wrap them in flannel, in order to interpose a slow conductor between them and the skin. Heated air may be employed for the same purposes. The body will support a much higher temperature of the surrounding air when it is dry than when moist, because in the former state it is a much worse conductor. Persons have even remained, for a short 490 GENERAL STIMULANTS. [PART II. time, in chambers heated considerably above the boiling point, without suffering material inconvenience. According to MM. Ber- ger and Delaroche, when the temperature is between 150° and 190°, a smarting sensation is produced in the surface, particularly in the conjunctiva and nostrils, the veins swell, the skin becomes burning hot, the pulse is very greatly accelerated, even to 160 in a minute, the respiration is laboured, and vertigo, headache, and other disordered cerebral phenomena are experienced; but very soon a copious per- spiration breaks out, and tends in a considerable degree to obviate the unpleasant effects. (Forbes, Cyclop, of Pract. 3Ied., Am. ed., i. 286.) It is very seldom necessary, however, in order to obtain any desirable stimulant effect, that the temperature should exceed 150°; and often a much lower heat will answer. The stimulation is greatest when the patient is wholly immersed in the hot air, so as to inhale it into the lungs; but it is a safer and equally effectual plan, for all prac- tical purposes, to allow the hot air to be applied only to the surface of the body, while the patient breathes air of the ordinary tempera- ture. As, in many of the cases to which the remedy is applicable, there is an indication for revulsion from the interior to the surface, the latter plan is preferable on this account. For the modes of preparing the hot air-bath, the reader is referred to page 72 in the first part of this work. The hot air-bath is probably more frequently used with a view to produce perspiration than as a mere stimulant. For the latter purpose, however, it may be resorted to with much benefit in certain cases of prostration, with coldness of the surface, to which more particular reference will be made when the therapeutic applications of the hot water-bath are considered. As the latter cannot always be commanded, the former, which can generally be quickly pre- pared and applied with facility, may often be substituted for it with advantage. b. 3Ioist Heat. In moist heat, two quite distinct agents are com- bined, which must be considered severally before their joint influ- ence can be well understood. Heat is purely stimulant; water, purely sedative; and the result of their combined action will depend on the proportion in which they respectively exist in the combination. The influence, too, of cold, that is, of the diminution of heat below the normal standard of the surface of our bodies, must be taken into account. This is sedative; but differs in this respect from the sedative influence of water, that its depressing effect is always attended with a disposition to reaction, which is wanting in the operation of the CHAP. I.] DIFFUSIBLE STIMULANTS.—HEAT. 491 latter. The sedative properties of cold and water will be more fully considered in a more appropriate place. They are here alluded to, merely to make more intelligible the properties and effects of heat and moisture combined. Water may be applied to the body, with a view to remedial action, at three different temperatures; below, at, and above that of the surface in health; so as to produce, in the first instance, the sensation of cold; in the second, no sensation either of cold or heat; and in the third, that of heat. It is obvious that, by a bath answering to the first condition, the joint depressing influence of cold and of water would be produced; to the second, the purely sedative influence of water; and to the third, the com- bined sedative influence of water, and stimulant influence of heat. The first two conditions of the bath may be left out of view in this place, as not belonging to the subject of stimulation. It is to the third only that our attention is to be now directed; that, namely, in which the temperature of the bath is above that of the surface, so as to occasion the sensation of heat. Hot Bath. In a bath of this kind, the effects are both stimulant and sedative; and whether one effect or the other shall predominate, must depend on the degree of the temperature above that of the surface of the body. When the elevation is but moderate, the two influences may balance each other; so that neither elevation nor depression of the vital functions shall be perceptible; and this is the condition in which the bath can be longest borne, and which should be aimed at when the mere cleansing effect of water, with as little impression as possible of any kind upon the system, is required. But this equation of effect is obtained only after a short period of immersion. Heat acts more quickly than water; and its excitant influence, even when it is only in very moderate excess, is experienced before the water has fairly begun to operate; so that a short time must elapse before the balance is established. Nor does the exact balance con- tinue long. Under the stimulus of heat, the excitability is impaired, and the excitation consequently gradually ceases, and is at length followed by depression, according to the general law; while the sedative effect of the water is increased, the longer that agent con- tinues to operate. Hence, the short period during which the two are balanced is followed by a period of depression much greater than the antecedent elevation, and increasing with the continuance 0f the agent. The bath, therefore, of which the temperature is but slio-htly above that of the surface, can scarcely be considered as a stimulant agent; the excitant effects being moderate and very brief, 492 GENERAL STIMULANTS. [PART II. and the sedation soon predominating. It is therefore as a sedative remedy that it is almost uniformly employed; and as such it will be considered hereafter, under the name of the -warm bath. The title of hot bath should be confined to that in which the heat is felt at first rather disagreeably, and in which the excitant effect deci- dedly predominates, and continues to predominate for a consider- able time. It is the operation of this variety of the bath that is now to be considered. The limits of the hot bath, as determined by the sensations, may be placed, in reference to the lower extreme, at the point when the heat is merely somewhat uncomfortable; in reference to the higher, at that in which it is barely not insupportable. As indicated by thermometrical degrees, they cannot be fixed precisely; because they vary with the variable sensibility and temperature of the sur- face; but the lowest point may be considered as somewhere between 95° and 100° Fahr., and the highest between 106° and 112°; and it is never advisable to exceed the degree last mentioned. At the mean of 103°, the bath is actively stimulant, producing a strong sensation of heat, reddening and expanding the surface of the body, increasing the frequency, force, and fulness of the pulse, hurrying the respiration, and causing at first an agreeable excitement of the brain, not unlike the effect produced by wine, but ending, if the immersion continue, in painful sensations of fulness, distension, and vertigo. After a time, perspiration breaks out upon those parts of the body not covered with the water; and, if the patient is removed from the bath, and placed in bed, the whole surface usually becomes relaxed, and bathed in a copious sweat. The excitement gradually subsides; and is followed, if the regular succession of events is not modified through some abnormal state of the system, by universal relaxation, with depression of the pulse, muscular weakness, feelings of languor and drowsiness, and ultimately sleep. The immersion may continue from four or five minutes to half an hour, according to the effects; the patient being always removed when unpleasant cerebral phenomena are produced, and never allowed to remain, when the stimulant effect is the main indication, until evidences of depression supervene. The operation of the water in the hot bath is at first, through its conducting power, to hasten the stimulating effects of the heat, but afterwards, by the relaxation it produces, to favour the secondary depression; and the latter result often adds greatly to the beneficial CHAP. I.J DIFFUSIBLE STIMULANTS.—HEAT. 493 influence of the remedy, when it is designed to act rather as a re- vulsive agent than as a general excitant. The conditions indicating the use of the hot bath are 1. coldness of the surface, with either general prostration, or powerful and concentrated internal irritation, inflammation, or congestion; and 2. an abnormal state of system, in which a strong impression is re- quired, to break up long-continued and obstinate morbid associa- tions. The following are affections in which these indications are presented. In the cold stage of febrile diseases, particularly those of a malig- nant or pernicious character, there is sometimes a degree of pros- tration and indisposition or inability to react, which is extremely dangerous. The nervous centres seem to have become almost inert under the violence of the morbid cause, and the most important vital functions are prostrate under the want of their necessary in- fluence. The heart acts feebly, the surface is cold and pale, and the great internal organs are loaded with the venous blood, which accu- mulates in them because the moving forces are unable to carry it forward. Sometimes death takes place without any reaction; some- times feeble and insufficient efforts at reaction are made, and the patient sinks back into the same alarming prostration as at first. .In aid of other stimulant measures, the hot bath may often be re- sorted to, in these cases, with great advantage. Through its pow- erful impression on the surface, it rouses the nervous centres from their torpor, and thus indirectly excites the circulatory and respira- tory functions; by heating the blood passing through the vessels of the skin, it renders that fluid more stimulating to the great interior organs, as the heart, lungs, and brain, into which it is convej^ed; and, while thus acting as a powerful general stimulant, it is no less powerfully revulsive, irritating the whole of the cutaneous capillaries to an active expansion, and drawing into them the blood before ac- cumulated in the central viscera and great venous trunks. It is one of the most efficient agents, in such cases, in bringing about reaction. Typhus fever, pernicious miasmatic fever, smallpox, scarlatina, and epidemic erysipelas are among the diseases, in the initial or cold stage of which, the hot bath not unfrequently proves highly useful on the principles here stated. It has, too, the great advantage over internal stimulants, that it can be at once withdrawn when needed no longer, and does not add, by a prolonged influence, to the vio- lence of the reaction when this is brought about. In the sudden prostration which sometimes occurs in the advanced 491 GENERAL STIMULANTS. [PART II. stages of low fevers, in prolonged asphyxia, in the collapse of cholera, hsematemesis, and melsena, similar indications are afforded by the cold surface, the prostrated vital functions, and the interior con- gestion. In the retrocession of cutaneous eruptions, the hot bath is often use- ful. In some instances, the apparent retrocession is nothing more than a sudden general prostration, in which the actions of the sur- face fail with those of the whole system, and which differs in nothing from the sinking spells of low fevers noticed in the last paragraph; but, in most cases, it is owing to, or connected with the occurrence of severe internal irritation, which it is highly desirable to recall as quickly as possible to the surface. Not unfrequently, a similar condition existing previously to the eruption, retards its appearance, and sometimes it may even keep back the cutaneous affection altogether, to the great detriment of the patient. Under these1 circumstances, the hot bath proves serviceable by powerfully exciting the skin, and making this the seat of afflux for the irrita- tive tendencies. The eruption again appears, or comes forth if not previously existing, and the symptoms of internal disorder cease almost instantaneously. Painful internal spasms are generally more beneficially treated by the relaxing warm bath than by the stimulant hot bath; but sometimes they are so severe, and attended with so much general prostration, that the former remedy is quite inefficient, and it be- comes desirable to have recourse to the greater energy of the latter. Violent attacks of nervous gout in tlie stomach and bowels, of colic, and of spasm of the diaphragm, are examples of this kind. The remedy acts by its powerful revulsive impression on the general surface. Internal inflammation is usually not a proper subject for the in- fluence of the hot bath, which too much excites the circulation, and sends the blood too forcibly into the parts affected; but, in certain cases, the inflammation is so violent and extensive as to concentrate the blood and the nervous energy of the system in its own seat, with the effect of prostrating the general functions, and inducing great apparent debility, for which, indeed, the condition has sometimes been fatally mistaken. The cold and pale surface, and feeble pulse seem to call for active stimulation; while, in fact, prompt and free bleeding is indicated, and is sometimes the only remedy which will save the patient. Generally, under these circumstances, if a vein is opened, the blood will flow, slowly and scantily at first, but with a CHAP. I.] DIFFUSIBLE STIMULANTS.—HEAT. 495 gradually increasing current; and, so far from still further failing, the pulse will rise, and become fuller and stronger as the operation proceeds. This, however, is not always the case; and it is found impossible to continue the bleeding without endangering fatal pros- tration. In such a case, the hot bath is an admirable remedy. By its powerful revulsive action it calls the blood from the interior to the surface, stimulating the heart at the same time; and, though of itself it would be altogether inadequate to the cure, and, if con- tinued, might act injuriously upon the inflamed organ by sending the blood into it too vigorously, yet it prepares the system for the use of the lancet, and thus opens the way for a cure which might not otherwise be possible. It should of course be withdrawn the moment that it has answered its purpose. In cases of this kind, the warm bath, though useful in ordinary internal inflammations, would be quite inert; and might even be injurious by its sedative action on the surface and the heart. Extensive inflammation of the' peritoneum, dysentery of extraordinary intensity, and violent pneumonia in the congestive stage, and occupying both lungs, some- times present the condition referred to. Obstinate chronic enteritis, with little or no excitement of the circulation, and an habitually dry, palish, and cool skin, may also be advantageously treated with the hot bath, repeated every day, especially if made somewhat more permanently irritant to the skin by the addition of common salt; and the same remark will apply to inflammation of other abdominal viscera, presenting the same conditions. In the first mentioned affection, I have found the hot salt bath one of the most efficacious remedies. It was stated above that the hot bath is indicated in some obsti- nate long continued affections, in which it appears to act by breaking up morbid associations. Possibly it may operate by a penetrating stimulation of all the tissues, which are thus roused out of their habit of morbid action into an over-excitement, from which they may afterwards subside into health. In some such method as this, it sometimes proves beneficial in cases of chronic rheumatism and gouj, occupying at the same time various parts of the system, distorting the joints, contracting the tendons, and not unfrequently, to a greater or less extent, paralyzing the muscles. It is not impossible, however, that the diaphoretic action of the bath may add to its efficiency. The bathing at hot springs has proved peculiarly useful in these diseases. Perhaps in the same category may be placed certain chronic and 496 GENERAL STIMULANTS. [PART II. indolent affections of the skin, in which the tissue requires to be roused alike out of its torpor, and out of its morbid habit of acting. Cau- tion is necessary not to use the bath at too early a stage; and if, as often happens with stimulating applications made prematurely, it should be found to excite inflammation or high irritation, it should be immediately suspended. It should also be accompanied with alterative measures, to change the constitutional condition, while the attempt is made to relieve the local disease. Paralytic cases of long standing, in which the original cause, if affecting the nervous centres, has quite ceased to operate, and the disease is sustained by a morbid indolence of the tissues concerned, whether nervous or muscular, some good may be hoped for from the hot bath, in connexion with other measures. The contraindications to the use of the hot bath are a plethoric state of system, determination of blood to the head, active hemor- rhagic tendencies, general vascular irritation with active congestion, aneurisms and hypertrophy of the heart, acute inflammation with well developed fever, the febrile state generally with a hot skin, and a peculiarly irritable state of the nervous system. Local Hot Bathing. Hot water may be employed locally by semi- cupium, coxseluvium, pediluvium, maniluvium, fomentation, or cata- plasm. For an account of these methods of application, the reader is referred to page 71. They act on the same principles as the general hot bath, but are much less powerful, and, with the excep- tion of the semicupium or half-bath, which is usually employed as a milder substitute for the general bath, and in cases where determi- nation to the head or trunk is feared, are used less for general stimulation, than for their excitant effect on some one part or organ of the body, or for their revulsive influence. Thus, the hot hip-bath is used to stimulate the uterus in amenor- rhoea; and the hot foot-bath and hand-bath to act revulsively from the head or interior organs towards the extremities, whenever the latter are cold, and evidences exist in the former of active congestion without fever, and especially when gout or rheumatism has retro- ceded from the extremities, and it is desirable to restore it to its original seat. Hot fomentations or hot cataplasms, are employed to relieve by revulsion either inflammation, spasm, or other irritation of interior organs over which they may be applied, or to stimulate the part to increased action, as when it is desirable to hasten a languid external inflammation onward to suppuration, and through this to a more speedy cure. CHAP. I.J DIFFUSIBLE STIMULANTS.—HEAT. 497 Another form of local application is the hot douche, or stream of water falling from a height, or directed with some force upon the part. This unites the effects of shock and pressure to the stimu- lant action of the heat, and proves sometimes more efficient than the simple application of hot water, in chronic rheumatic and gouty swellings, obstinate local palsies, and indolent tumefactions and indurations of inflammatory origin. Hot Vapour Bath. In some countries there are public vapour baths, in which numbers mav be collected in the same chamber; and this is occasionally so arranged, with seats rising one above another, that persons may be exposed to various temperatures; the heat of the apartment increasing from below upward, because it is the tendency of the vapour to ascend. Thus, upon the level of the floor the heat may be only 110° Fahr., while in the uppermost part of the chamber it may be as high as 160° or 180°. Of course, the patient inhales the hot moistened air, as well as feels its effects upon the surface. The vapour may be introduced into the chamber from without, or by throwing water, within, upon stones heated to red- ness by a furnace beneath. But, in this country, it is only the soli- tary vapour bath which is employed. For the various modes of preparing it, the reader is referred to the first part of this work r. (page 73). It may be so arranged that the patient can, at his pleasure, either breathe the moistened air of the bath, or the cold external air. The heating effect of the former is greater; but its revulsive influence is less; and, as it has a tendency to suppress the pulmonary exhalation, it may sometimes act injuriously when the latter would be quite safe. In consequence of the less conducting power of vapour than of water, the former can be borne at a much higher temperature than the latter; while, for a corresponding reason, the vapour bath may be intolerable at a temperature at which dry air could be borne without inconvenience, the latter being a slower conductor. Ac- cording to Dr. Forbes, the heating effect of the hot bath at from 98° to 106°, is equal to that of the vapour bath, when the air is breathed, at from 110° to 130°, and when it is not breathed, at from 120° to 160° (Cyc. of Pract. 3Ied., Am. Ed. i. 255); and these are the temperatures within which the methods respectively may be employed; though, in all, the heat may be raised with impunity considerably above the highest point mentioned. The effects of the vapour bath, and of the hot bath, are essentially the same in VOL. i.—32 498 GENERAL STIMULANTS. [PART II. reference to stimulation and revulsion; but the former is attended with much more copious perspiration during its continuance than the latter; the contact of water with the surface having great effect in preventing extravasation from the blood. Another difference is that the relaxing or sedative effect of the vapour is less than that of the water; and that consequently the stimulation of the former, though more slowly induced, is longer sustained, and is accompanied with a less degree of soothing influence. The vapour bath may be used for the same purposes as the hot bath, but is, upon the whole, less efficient and less agreeable. In its extempo- raneous form, it may be employed when circumstances may render it impossible, or extremely inconvenient to prepare and apply the bath of heated water. It is also preferable, in some instances, when the indication is to produce profuse perspiration with a stimulant effect, as in certain cases of chronic rheumatism. Local vapour baths may be applied by exposing any part of the body to the steam escaping from boiling water, which may be readily confined by a suitable arrangement of woollen or other cloths. But they are employed more for the relief afforded to in- flammatory, and other painful affections, by the copious perspi- 0 ration they induce in the part, than as stimulant agents. The same may be said of the hot vapour douche, which consists in a jet of heated vapour directed on some part of the surface. It differs from the simple application of steam only in exposiug the part to successive portions of vapour, instead of continuously to the same; and the effect would consequently be somewhat greater. It may be applied by causing steam to pass through a pipe from a vessel of boiling water; or, in relation to the meatus auditorius of the ear, by holding the orifice of the meatus over the small end of a funnel, the larger end of which is placed over a vessel of water boiling hot. In the latter case, the remedy may be used, as a stimu- lant to the ear, in cases of defective hearing from deficiency of nervous power. Finally, heated vapour may be applied exclusively to the' lungs by inhalation, and thus made to act as a stimulant to the bronchial tubes when enfeebled, and disposed to the excessive production of mucus in consequence of this relaxed state; but the measure would require to be conducted with much caution. At a lower tempera- ture, so as to produce, not the stimulant effects of heat, but the soothing and emollient effects of mere moisture, it may often be CHAP. I.] DIFFUSIBLE STIMULANTS.—ELECTRICITY. 499 used with benefit. But this action of the remedy belongs to an- other section. For the modes of applying vapour by inhalation, see page 78. Hot Water as Drink. Hot water has the same stimulant effect, when taken internally, as when applied to the surface; but is almost never used except as a vehicle for other substances, the action of which it often very much promotes. But, even in this mode of administration, it is much less used with a view to its stimulant action, than as a diaphoretic. In cases of great prostration, it may sometimes be advisable to exhibit the stimulant drinks employed, heated rather than cool, as their effects are thus both hastened and augmented. ELECTRICITY AS A STIMULANT. In treating upon electricity as a medical agent, I shall take it for granted that the reader is already acquainted with its chemical and physical properties, and with the prevalent opinions of its nature. In this place it is to be considered only in relation to its physiolo- gical and therapeutical effects, and to the methods of employing it as a remedy. As these effects are materially modified by the modes in which it is developed or excited, and applied, the latter division of the subject must be first treated of, in order that what may be said on the former may be understood. I wish here to express my indebtedness for much which follows to the excellent work of 31. Duchenne de Boulogne, who, by his tho- rough and laborious experimental investigation of electricity in its medical relations, the sagacity with which he has traced the various ramifications of its influence, and the ingenuity and perseverance with which he has applied the knowledge thus obtained to success- ful therapeutic results, has given a precision to the subject which it before much wanted, and has opened a new era in the history of the remedy. 1. Modes of Development or Excitation. For medical purposes electricity is developed or excited in four somewhat distinct methods; 1. by friction, in the form of common electricity; 2. by contact and chemical reaction, in the form of galvan- ism; 3. by magnetic induction, in the form of electro-magnetism; 500 GENERAL STIMULANTS. [PART II. and 4. by a combination of magnetic and galvanic induction, as by the volta-electric apparatus. a. Excitation by Friction. General Observations. Electricity excited by friction is usually denominated static, conveying the idea that it is stationary or not in action, while in the form of galvanism it is said to be dynamic, as being essentially in movement, and exercising power. Though this distinction is not very precise, it may serve at least the purposes of nomenclature. A very great difference exists between the phe- nomena exhibited by these two forms of electricity; the static hav- ing in a high degree the properties of attraction and repulsion, and, when brought into movement, exercising great mechanical power, the dynamic exhibiting its energy more in developing heat and pro- ducing chemical change. It is supposed that this difference de- pends, not on any essential diversity of character, but on the dif- ferent states of the electricity developed in the two methods; that excited by friction having little quantity, but great tension or in- tensity, by which it is able to overcome resistance, while that set in movement by contact and chemical reaction has feeble tension, but large quantity. These terms, however, are rather conventional, in- tended to represent certain qualities in convenient language, than absolutely expressive of the fact; for it is by no means universally admitted that electricity is a distinct substance, to which the term quantity is at all applicable, unless as a figure of speech. Means of Excitation. Static electricity is developed by means of friction between two substances, and this is usually effected by an apparatus called the electrical machine, constructed in different me- thods, for an account of which I must refer to works on chemistry or natural philosophy. To every machine is attached an insulated conducting body called the prime conductor, which receives upon its surface the electricity as it is excited, and retains it for a con- siderable time, in consequence of the non-conducting property of the dry air around it. Thus developed, the electricity acquires a degree of tension, proportionate to the power and working of the apparatus, by which it is enabled to break its way through the re- sisting air to neighbouring bodies, producing a stream of light in its passage, and a very perceptible sound. When the tension is very great, the spark, as" this flash is called, may be many inches long; when very slight it may be even less than an inch. In order that the electricity may escape in this way, the body approaching CHAP. I.J DIFFUSIBLE STIMULANTS.—ELECTRICITY. 501 the conductor must be rounded or flat; as, if pointed, it receives the electricity quietly, and almost insensibly, from the conductor. Silent Conduction. If any part of the body be brought into con- tact with the prime conductor, the electricity passes silently into and through him, or along his surface, into the earth, in search of the equilibrium to which it always tends. Sparks. If, instead of coming into absolute contact with the ex- cited prime conductor, a part of the body be made to approach it within a certain distance, greater or less according to the degree of electric tension, the fluid passes to the body by sparks, which pro- duce a decided sensation as they are received. By means of rods or chains of metal, or other conducting substance, in contact at one end with the prime conductor, and having a rounded knob at the other, the electricity may be conveyed to any convenient distance from the machine, and applied by sparks to any part of the body. These communicating instruments are called directors, and must be insulated from the hand of the operator by some non-conducting substance, such as glass, which may at the same time serve as a handle. Electrical Bath. Another method of applying static electricity is by placing the patient upon a stool, insulated by glass legs, and then connecting him with the prime conductor. His body thus shares the electricity with the conductor, and acquires precisely the same relations towards the machine and other surrounding objects. In this way it may become saturated with the fluid, which escapes very slowly and silently from the hairs, finger and toe nails, and the surface of the body generally; the hairs rising up and standing apart under its repellent force. Sparks may now be drawn from any part of the body by the approach of a blunt conducting sub- stance ; and, by keeping the machine constantly in action, this con- dition may be indefinitely prolonged. By communicating with the negatively excited electric, instead of the positive prime conductor, it is obvious that the body may itself become negatively excited; and, by varying the connexion, the peculiar effects of either of these two modes of the electric influence may be separately obtained. This method of applying electricity is denominated the electric bath. Electric Aura. This is a current of electricity directed to any part of the body, through the air, by means of a pointed insulated director, connected at one end with the excited prime conductor by a chain, and, at the other and pointed extremity, held near, but 502 GENERAL STIMULANTS. [PART II. not in contact with the portion of surface to be acted on. The electricity silently and invisibly issues from the point, and, expand- ing cone-like as it passes through the air, spreads itself out broadly upon the surface. Exactly the reverse takes place, when a similar point is held near the body, itself in a state of electric excitation upon an insulated stool. Little if any sensation is in either case experienced. Leyden Jar and Electric Battery. By these instruments the great- est force of the electricity of friction is obtained. The jar is a broad-mouthed glass bottle, coated within and without by tin-foil, excepting the upper part of both surfaces, where it is bare. With the inner coating is in contact a chain, connected with a metallic rod, which passes upward through a cork, or other material closing the mouth of the bottle, and ends in a round metallic ball at top. When this ball is put in communication with the excited prime conductor of the machine, the inner coating becomes positively charged, while, at the same time, by the laws of electric in- duction, the outer coating passes into the negative or opposite state. If now a conducting substance be connected with the inner coat by means of the knob, and directly or indirectly with the outer, the equilibrium is instantly restored, and the whole force of the movement is exerted upon the connecting material. If this be the body, a shock is felt, proportionate in degree to the extent of the coated surfaces, and the amount of the charge. It may be so slight as to occasion little inconvenience, or so power- ful as to destroy life like a flash of lightning, which, indeed, is nothing more than the spontaneous discharge of an analogous electric arrangement in the atmosphere, or between that and the earth. But to obtain a shock of such extreme violence, it would be necessary to make the bottle of an unwieldy magnitude; and the same end is attained by connecting together a number of bottles by their inner and outer surfaces respectively, so that the whole may be discharged at once. Such an arrangement is called the electric battery, and affords an instrument of immense power. The current of electric force may, with either the jar or battery, be made to penetrate through the skin, and enter deeply into the body; and, by means of directors connected with the opposite excited surfaces, may be conveyed from one end of the body to the other, or through it from side to side, or from one part to another of a limb, or through very limited portions of the body, at the pleasure of the operator. The directors must of course have iso- CHAP. I.] DIFFUSIBLE STIMULANTS.—ELECTRICITY. 503 lated handles, and their knobbed free extremities must be applied at the opposite extremities of the part through which the current is to pass. If the object be to direct the electricity into a single muscle, both extremities, as directed by M. Duchenne, should be applied immediately over the muscle, with the space of an inch or more between them. A repetition of graduated effects may be obtained through the jar, by placing its ball in communication with the excited prime conduc- tor, and its external surface, in any convenient method, with one of Lane's electrometers, in such a manner, that the ball of the electro- meter shall not be in absolute contact with it, but within striking distance of the electrical spark. By means of chains, insulated di- rectors may be connected with the prime conductor and the electro- meter, and their knobs applied at the required points of the surface. ^ When the machine is set in motion, and the jar becomes charged, at the moment of connexion through the body, the electrical current passes between the knob of the electrometer and the outer coating of the jar, to establish the equilibrium. If the intervening space is large, the shock will be necessarily severe, for great tension will be necessary to overcome the resistance of the air; if very small, the shock may be slight; so that its severity may be regulated by regulating this interval, and at the same time attending to the work- ing of the machine. Care should be taken that the jar should be fully discharged before commencing operations; and then the han- dle of the machine should be turned more or less frequently, and more or less rapidly, according to the effect required. b. Excitation by Contact and Chemical Action. Galvanism, or the dynamic form of electricity, is excited by the contact of two metals, or other conducting bodies, with the pre- sence of a fluid capable of chemical action on one only of the two, or on one more than on the other. A change of electrical condition takes place in the one most easily affected chemically; the other as- sumes an opposite condition; and, at the moment of communication between them, whether by the absolute contact of the two, or by means of another metal, an attempt to restore the equilibrium takes place, with the effect of developing electrical phenomena. The ap- parent current of force is from the metal chemically affected, through the liquid, to the one not affected, and then through the connecting material to the point of origin. But as the cause is constantly ope- rating, the electrical condition is constantly disturbed, and no equi- 504 GENERAL STIMULANTS. [PART II. librium is in fact established, but a constant circle of action main- tained until the exciting agency is exhausted. Anything suscepti- ble of change by electrical influence, if placed in the circuit, will feel the effects in a degree proportionate to its susceptibility, and the force developed. From a simple circle, as above described, but slight effect is obtained; yet enough to be very sensible. To increase the effect, these simple circles or elements must be multiplied, so as to form what are called galvanic batteries, or vol- taic piles; and the power developed is in proportion to the number of the elements employed. Numerous methods of attaining this end have been devised, which it is not my object to describe. One thing is common to all of them; namely, that the associated metals, or other conductors, in each pair, and the several pairs themselves always bear the same relation to one another; and the successive pairs must be connected by a conducting medium. The extremes of the arrangement are consequently of opposite character; and, when they are made to communicate, the accumulated force of the whole battery is exerted in the line of communication. These ex- tremes are usually denominated poles, the one at which the metal most acted on is placed being the negative, and the other, towards which the current of force is directed, the positive. Zinc and either copper or silver are the metals usually chosen, and a diluted acid, especially the sulphuric or nitric, the excitant and conducting liquid; but other metals and other liquids, and even non-metallic substances may be substituted, and various other arrangements have been shown to have a similar agency ; chemical action, however, being common to all. As before stated, the tension of galvanic electricity is very slight, and consequently but slight sparks are afforded by approaching the poles, and relatively slight sensation produced; but the influ- ences dependent on quantity are strong, such as chemical decom- position, the development of caloric, and, in the animal system, the production of organic change. Application. The simplest galvanic arrangement may be applied with great facility. A small circular or oval plate of zinc, and a silver coin an inch in diameter, placed in the mouth above and below the tongue, and then allowed to touch, afford evidence of their action to the sense of taste; and a similar pair, soldered toge- ther, may be used for very gentle stimulation to these parts; the saliva acting as the exciting liquid. Another simple arrangement is to place upon two separate parts CHAP. I.] DIFFUSIBLE STIMULANTS.—ELECTRICITY. 505 of the body, between which it is desired to establish a galvanic current, two thin oval or circular plates of zinc and silver, an inch or two in diameter, one on one of the parts, and the other on the other, and to connect the two by means of a delicate wire attached to an eye, upon the outer surface of each plate. The skin beneath should be moist, so as to allow the galvanic influence to penetrate through the cuticle, which is a bad conductor; and for this purpose a layer of any wet conducting substance may intervene between the plates and the skin. Even distant parts of the body may be connected in this way. Galvanic Chains. A series of small hexagonal plates, composed each of a zinc and a silver plate soldered together by one of their surfaces, and connected by wires so as to move freely, forms a sort of chain, which may be worn next the body, and becomes active through the perspiration. The chain of Pulvermacher, made of couples of minute coils of wire around cylinders of wood, and con- nected together by wire, acts with considerable energy. The number of elements may extend to several hundreds. Excited by being steeped in an acid liquor, it continues to act for several hours, and may be usefully employed in the treatment of superficial affections. The advantage of these and other arrangements with small elements is, that the peculiar galvanic stimulation may be obtained with less of the heating effect, which is proportionate, in some degree, to the size of the metallic plates, while the former depend more upon their number. Batteries or piles are made of various forms, and of variable numbers of pairs, according to the amount of effect desired. They are applied by means of wires connected at one end with their opposite poles, and terminating at the other in various modes for convenience of use, by which the galvanic influence is conveyed to the person at any distance from the battery. These conductors must be isolated, in some portion of their course, by glass tubes or otherwise, so that the operator himself may not interrupt the cur- rent. Of the different methods of termination of these conductors more will be said, in connexion with other electric arrangements to be considered immediately. I may mention here that the object is sometimes effected by applying the agency through the medium of water. Thus, both feet may be placed in vessels of water con- nected with the opposite poles, or both hands, or one foot and one hand; and thus the currents varied in their direction through or over the body. Indeed, the whole body may be immersed; 506 GENERAL STIMULANTS. [PART II. so that, when the bath is connected with one pole, and the body with the other, the electric current may diffuse itself through the system, in its attempts to escape at the surface. Disadvantages of the ordinary batteries used for chemical purposes, as Cruik- shank's, Wollaston's, &c, are the disagreeable odour given out in consequence of the decompositions which take place, their un- wieldy size, and the difficulty of suitably regulating their action. They are not, therefore, much employed; though circumstances occasionally arise which render a resort to them advisable. c. Excitation by 3Iagnetic Induction. When a magnet is placed within a coil of wire isolated by being covered with silk thread, the latter assumes a polar condition the reverse of that of the magnet; and, if the magnetic circuit and that of the coil be closed at the same time, a current takes place in the latter in a direction opposite to that of the former. A powerful horse-shoe magnet is thus capable of inducing an electric movement in a coil of wire, which gives rise to sensible phenomena, and with certain arrangements may be made to act with great energy. When the body is connected with the two opposite poles by any conducting material, a slight shock is felt upon the closing of the magnetic circuit, after which no sensation is perceived, and no obvious effect produced, until the circuit is broken, when another sensation stronger than the first is experienced, by the instant alteration of the current before its entrance into repose. If, by any contrivance, this interruption of the circuit be made rapidly, the quick succession of the shocks becomes painful, and the effect may be increased so as to be quite insupportable. Upon this principle it is that the electro-magnetic machine is composed. Electro-magnetic or 31agneto-electric Machine. Different machines of this kind have been devised by different persons. Among them probably those of Clark, Dujardin, and the Messieurs Breton are best known. The current is broken in these instruments by a rotary movement given to the armature of soft wire, by which it is alternately brought into and removed from apposition with the magnet; but the coil of insulated wire, called the intensity coil, is in some of them placed around the armature, and in others around the magnet. This difference is of no <*reat account, as the armature always becomes temporarily a magnet when in connexion with the proper magnet, and consequently CHAP. I.J DIFFUSIBLE STIMULANTS.—ELECTRICITY. 507 induces a current in the coil around it. But M. Duchenne con- siders none of them capable of effecting all the objects attainable by a perfect machine of this order; and has endeavored, by com- bining the best parts of those in use with improvements of his own, to make an instrument approaching nearer to his conception of what is desirable than any one hitherto invented. As this instru- ment has not, to my knowledge, been introduced into this country, I present in a note a figure of it copied from one in M. Duchenne's treatise, with his explanation of its construction and principles. I would here simply state that his chief additions are a graduator of the currents, by which the intensity may within certain limits be increased or diminished at pleasure, and a second superimposed coil of insulated wire, much finer than the first, by which the intensity is greatly increased, and which, though used in the volta-electric machines, has not previously been applied to the electro-magnetic* * Electro-]\feir/nefir, or Magneto-faradic Apparatus (Appareil magneto-faradique) of M. Duchenne de Boulogne. M. Duchenne gives this title to his instrument, in accordance with a nomen- clature which he has adopted, and used throughout his work, in relation to this form of induced electricity. As the term electricity is applied to the static form, and galvanism to that developed by contact, he considers that, in honour of the great chemist who has done so much to advance this branch of science, he is justi- fied in giving the name of farradism to the induced form of dynamic electricity, And. faradisation to its application. The apparatus consists of a magnet; an armature put in motion by a special mechanism; a regulator of the armature, and at the same time moderator of the currents and magnetic tensor; two cylinders formed of copper wires of unequal thickness ; a commutator; a graduator of the two currents; and a regulator of the intermissions.* " a. The magnet consists of two parallel branches, united at one of their extre- mities by a transverse piece of soft iron. Each of these branches, cylindrical in shape, 3.5 centimetres (1.38 inches) in diameter, and 20 centimetres (7.87 inches) long, is divided into three laminae, and is fastened to the soft iron by a screw. The magnet thus formed is placed horizontally on a support three centi- metres (1.18 inch) high, and fastened by a strong screw to the base of the appa- ratus. At its anterior extremity, the magnet is supported by a bobbin (so named from the small cylindrical piece of wood with raised borders, used for winding thread upon), as will be seen further on. " b. The armature (soft iron C), which, by its rotary motion produces the inter- missions of the magnetic current, is 12.5 centimetres (4.9 inches) long, 3 cen- timetres (1.18 inch) high, and 1.5 centimetres (.59 inch) thick. It is traversed * The Messrs. McAllister, No. 194 Chestnut Street, Philadelphia, permit me to say that they will be happy to order either of the instruments here referred to from Paris, should any one wish to ob- tain it. I presume that it could scarcely be made from the description, without an accompanying model. 508 GENERAL STIMULANTS. [PART II. d. Electric Excitation by Galvano-magnetic Induction. If within a coil of insulated wire a piece of soft iron be placed, and a galvanic current be passed through the coil, the soft iron be- in the middle by a horizontal axle, having at its ends a point of very hard steel, received into two pieces likewise of steel, which are screwed into two uprights of copper. These uprights are fixed firmly to a movable and quadrilateral plate of copper (FJ, which rests on the base of the apparatus. Between these two uprights, and at their upper extremity is fitted a large wheel (A\ the shaft of which tra- verses on one side one of the uprights, in which it may perform rotary movements, while the other end, terminating in a point, is received into a piece attached to the second upright. The handle (M) which moves the large wheel, may be withdrawn at will. The diameter of the large wheel (A) is 11 centimetres (4.3 inches); its circumference is divided into 64 teeth, which, by means of a Vaucanson chain, put into motion a small pivot wheel, armed with 8 teeth, and fixed upon the axis of the armature (C), so that, with every turn of the large wheel, this armature turns 8 times upon its own axis, and consequently produces 32 intermissions of the induction current. As it is possible to give two revolutions every second to the large wheel, there may be obtained, of course, 64 intermissions in the same time. " c. Regulator of the Armature. The movable plate F, on which rest the armature C and its motor system, is approached to or withdrawn from the magnet by means of a strong withdrawing screw (N) called the regulator of the armature. This screw turning in a female screw fixed to the apparatus, operates on the base of one of the uprights attached to the plate F, which it draws towards itself or repels. "That the armature may press against the magnet, the screw N is turned, so that the needle shall reach the middle of the arc of a circle (0) called the indicator. When the armature C, placed transversely, is approached to the magnet, and is in perfect contact with its extremities, the instrument is ready for action. "d. Induction Bobbins ( Cylinders). A cylinder 9.5 centimetres (3.74 inches) long, CHAP. I.] DIFFUSIBLE STIMULANTS.—ELECTRICITY. 509 comes magnetized, and continues so as long, and only as long, as the current is maintained. Now this temporary magnet exercises and on which are rolled in spirals 24 metres (about 78 feet) of copper wire covered with silk, and half a millimetre (about ^ of an inch) in diameter, is attached to each arm of the magnet, in such a manner that its anterior border is on a line with the free border of the magnet. The shield which forms the anterior extremity of the bobbin rests on a support which sustains the magnet in a position parallel to the plane of the apparatus. "A second wire of copper, one-third of a millimetre (about ^ of an inch) in diameter, and 600 metres (nearly 2000 feet) long, also covered with silk, is rolled upon the thicker wire. The latter is inductor relatively to the fine wire which covers it. " The two wires are wound in the same direction, and the end of one is soldered to the beginning of the other, while the other ends proceed, that of the wire of the first order (larger wire) to the springs S, which produce the intermissions on the commutator B, and that of the wire of the second order (fine wire) to the buttons to which the excitors (the instruments by which the machine commu- nicates with the person) are attached. The springs S start from the conducting wires which proceed to the buttons Q, which receive the current of the first order (that of the larger wire). " e. Commutator and its Regulator. The commutator is composed of a little bobbin B, and of two springs S. This bobbin of wood is fixed on the axis of the soft iron C. One of the springs, put in connexion with an extremity of the wire of the first order (large wire), rests against a metallic ring, fixed upon the small bobbin. From this ring spring four small teeth, two of which are shorter than the others. The second spring S of the commutator, which communicates with the second end of the wire of the first order (large wire), is put in contact with the four or the two teeth by means of the button a, called regulator of the commutator, attached to the left of the apparatus, and which is turned to the right or left, and vice versd. "f. Graduator of the Currents. Two cylinders of red copper (H) covering the bobbins, which are placed on the arms of the magnet, and united by a transverse piece at their further extremity, are drawn forward or backward, gliding over the bobbins, by means of a quadrilateral stem R. This last, fixed to the transverse piece, which terminates by a button, is equal in length to the bobbins, and is divided into 90 degrees. When the stem enters entirely into the apparatus, the cylinders wholly cover the bobbins, and the currents are at their minimum of intensity. These currents are, on the contrary, at their maximum when the stem is com- pletely without the apparatus. The degrees of intermediate force are in direct relation to the advance of the stem, and vice versd. The stem, therefore, deserves the name of graduator of the currents. "g. Regulator of the Intermissions. A piece of copper is fixed on the base of the apparatus, before and to the left of the large wheel. It is traversed by a screw D, upon which is soldered a spring of brass I. By the aid of this screw, the spring performs a swing-movement, which places it in contact, sometimes with the pegs which are situated on the anterior face of the large wheel A, sometimes with the plate F, by which this is supported. One of the extremities of the wire of second order (small wire) communicates with this plate F. The brass spring I is in com- munication, by a copper wire, with the buttons P and Q. 510 GENERAL STIMULANTS. [PART II. an inductive power on the wire, similar to that produced by a per- manent magnet, and increases the force of the galvanic current in "Theory of the Apparatus. The simultaneous intermissions of the magnetic cur- rent, and of that of the central helix, produced by the rotary movement of the wheel A, which puts in action the armature C, and the commutator B, develop phenomena of induction in the wire of this central helix. The theory of these phenomena is the same as that of all the magneto-faradic apparatuses. • "At the instant when the induction is produced in the central helix, under the influence of the temporary magnetic current, if the conjunction of the two ends of tha wire of the second order (smaller wire) make of it a closed conductor, there is developed in this latter, as is known, a counter-current, the direction of which is in an inverse relation to that of the first order (larger wire). "One extremity of the wire of the first order and of the second order proceeding to the excitor button of the currents, and the other extremity of these helices com- municating with the plate F which supports the great wheel, it becomes necessary to put this wheel in connexion with the second excitor button of the first order or second order. The regulator of the intermissions D perfectly fulfils this condition, since it communicates by a copper wire with the second button P or Q, and is placed in contact either with the plate F, or with the pins of the large wheel A, attached to this plate by means of a swing-movement effected by the screw D of the regu- lator of the intermissions. " Should it be desired to cause rapid currents to pass in the excitors attached to the buttons P or Q, it is evident that the screw should put the spring I in con- nexion with the plate F, which is itself in connexion with one extremity of the two wires. But if the spring I communicates with the plate G only by the pins of the large wheel A, the currents will arrive at the buttons P or Q only four times, or twice, or once with the revolution of the large wheel A. Consequently the excitors attached to the buttons receive four, or two, or one intermission with the revolution of the large wheel, when the spring touches the pins, or else they receive the rapid current (32 or 64 intermissions for each revolution) when the spring touches the metallic plate F. I designate the screw D, which causes the spring to move, by the name of regulator of the intermissions. " For the theory of the graduation of the two currents, I refer to what has been stated in treating of the volta-faradic apparatus of double current. (See forward.) I will explain directly how, with my magneto-faradic apparatus, strong or weak doses can be graduated." M. Duchenne goes on to explain that the double induction discovered by Pro- fessor Henry of this country, which had never before been applied to the magneto- electric apparatus, gives it a vast increase of power, which puts it at least on a level with the volta-faradic (votta-electric) apparatus. The inductive power of his apparatus he thinks greatly superior to those before in use. He ascribes this result partly also to the proportions observed in the thickness and length of the super- posed wires, or to the length of the bobbins or cylinders which cover the amis of the magnet. He states that the current of the first wire is sufficiently powerful to be collected and applied when indicated. Commutator. By means of the mechanism called regulator of the commutator, the intermissions may take place twice or four times for each revolution of the soft iron, according to special indications. Every intermission is attended with two cur- CHAP. I.J DIFFUSIBLE STIMULANTS.—ELECTRICITY. 511 the former. If, over the coil of wire alluded to, another be placed consisting of smaller wire, this also acquires an induced state, of rents in opposite directions. But the current at the commencement of the inter- mission is so feeble that it produces no appreciable effect in man, and it is conse- quently only that which attends the end of the intermission which really operates. (Page 14.) Each revolution, therefore, is accompanied with either 4 or 8 induc- tions or currents, of which two or four are energetic. If two intermissions only are obtained, the two stronger inductions will be in the same direction of the cur- rent ; if four intermissions are obtained, of the four stronger inductions, two would be in opposition to the other two. When, therefore, it is desired that the sensible current should be in the same direction only two intermissions should be obtained ; if the indication is for rapid effects without reference to the direction of the cur- rent ; then four intermissions are desirable; and the regulator enables either of these ends to be attained. Regulator of the intermissions. It is important to be able to lengthen the time be- tween the intermissions at pleasure, so as to give one, or two, or four excitations for each half second, instead of the almost continuous action which is obtained when the full power of the instrument is exerted in this respect. " The action of the regulator of intermissions should be combined with that of the regulator of the commutator. The first is placed so as to produce a very rapid current, and the second so as to touch the four teeth of the commutator. If, on the contrary, the regulator of intermissions is to produce only distant intermissions, the spring of the commutator is placed so as to touch only two teeth. This is the reason. Whilst the spring of the intermissions touches one of the pins of the large wheel, the contact lasts sometimes a little longer, and then it happens that two or four in- ductions are produced in rapid succession at the moment of contact, according to the position of the commutator. If the latter touches the four teeth, the four re- doubled inductions then produced excite a stronger sensation. If, on the contrary, the spring of the commutator touches but two of the teeth, it is evident that these rapid actions cannot take place at the moment of contact with the pins of the large wheel. Consequently, the distant intermissions and the sensations produced by them will be more regular." Graduation of the currents. The graduating cylinder regulates the amount of effect as in the volta-faradic or volta-electric apparatus of M. Duchenne, to which the reader is referred. But the currents are not entirely neutralized by these cylin- ders, and the instrument would be inapplicable to very delicate organs, but for another contrivance by which a moderation of the currents may be effected. Moderator of the currents. The armature and its motor system can be with- drawn about an inch from the magnet by the screw N, at which distance the influ- ence of the soft iron is much diminished. By this means very feeble doses of the electric influence may be administered. If a still slighter influence is wanted, as for delicate experiments on frogs, by turning from right to left the screw at the base of the spring, the current of this helix is prevented from reuniting on the commu- tator, and the induction can then take place only by the influence of the soft iron on the magnet. This is so slight that the current of the apparatus is only appre- ciable by placing the excitors to the lips. Magnetic tension. Magnets in general lose in a short time nmch of their power, and the rapidity of the loss is proportionate to the use made of the instrument. A 512 GENERAL STIMULANTS. [PART II. electric action, and the intensity of the galvanic current is still fur- ther augmented. If, again, the current be interrupted, phenomena are produced of the same character as those already referred to as resulting from a similar interruption of the current in the electro- magnetic apparatus. Upon these principles instruments have been invented for the therapeutic application of electricity, which have of late been much in use, and, together with the electro-galvanic machine, have almost superseded the methods formerly employed. Volla-Electric 3Iachines. Galvano-31agnetic Induction 3Iachines. Electro-Dynamic 3Iachines. A large number of these machines have been contrived in England, France, and Germany, as those of Newman, the Messrs. Breton, Keller, &c. The following are the essential parts of the properly proportioned armature exercises a continuous tensive power upon the magnet. This influence should be sustained during the intervals of the opera- tions. By means of the screw N, the soft iron is brought into contact with the mag- net, and a constant strain upon it is effected by placing some shot in a little cup c, at the extremity of a curved lever, fixed in a hole in the circumference of the screw N. The tendency of the weight of these shot is by turning the screw to separate the armature from the magnet; and this is really effected if the charge of shot be too large. Manner of placing the apparatus in action. The following directions for this pur- pose are given by M. Duchenne, which can be followed, even though the principles of the instrument are not understood. " To put the apparatus in action, the screw N is turned from left to right, until the soft iron no longer rubs against the magnet during the rotary movement. If a rapid current be wanted, the regulator of the intermissions D is turned from left to right, until it can turn no longer. If remote intermissions are necessary, the same screw D is turned in the contrary direction, until the needle of the indi- cator marks the number of intermissions which it is wished to obtain by a revolu- tion of the large wheel. The handle should always make two revolutions in a second. To graduate the currents, it is only necessary to remember that when the stem has wholly entered the instrument, the current is at its minimum. The divi- sion of this stem into 95 millimetres, allows of the electric dose to be proportioned, by fractions, to the degree of excitability, and the therapeutic indication. If the part operated on is very excitable, and it is necessary to administer very feeble doses, the armature must be removed more or less from the magnet, by turning the regulator N from loft to right. Should it be desired to experiment on frogs, the armature is removed as far as possible from the magnet, and the current is pre- vented from reaching the commutator, by turning the little screw placed on the base of the spring S3. When the apparatus is no longer used, the armature is to be put in tension by placing the soft iron transversely, turning the screw at N from right to left till thj needle reaches the middle of the indicator 0, and charging the regulator with its cup of leaden shot. The conducting wires of the excitors shoukl be placed on the buttons of the current of the first order, or those of the second order, according t o the indications." CHAP. I.] DIFFUSIBLE STIMULANTS.—ELECTRICITY. 513 apparatus: 1. a primary and secondary coil or helix of insulated wire; 2. a bundle of soft iron wires to be introduced within the coil; 3. a contact breaker, by which the current is interrupted, and which is made to act through the influence of the galvanic current itself; 4. a galvanic battery or pile, consisting of one or more pairs, which is to furnish the influence by which the whole apparatus is set in operation; and 5. a pair of insulated metallic directors or conductors, which are to be connected with the poles of the apparatus, and by means of which the electricity is applied to the body. The termi- nations of these directors are called by M. Duchenne excitors, and are of various character and form to meet special indications. (See page 518.) To put the machine in operation, the galvanic battery is first made to act, and the electric influence is conveyed to the ends of the larger and inner wire, which thus becomes the connecting medium between the poles of the battery. A galvanic circuit is thus esta- blished, the intensity of which is greatly increased by the reaction upon each other of the spires through which the influence is pro- pagated. At the same time the bundle of wires within becomes magnetized, and the outer wire acquires an induced state of great energy, and in an opposite direction to the original current. It is, however, by the frequently repeated interruption of the currents that they acquire their great physiological and remedial power, as in the electro-magnetic machine. The contact-breaker which pro- duces this effect operates on a very simple principle. A slip of metal movable at one end, and kept in its place by a spring, is so situated that this movable end forms a part of the circuit, which passes through its point of contact. But being also near, though not in contact with the iron which becomes magnetized by the current, as soon as this is established, it is attracted by the magnetic force, and separated from its previous connexion. The circuit is thus broken, the magnet loses its power, the attraction ceases, and the spring forces the movable slip back to its original position. This restores the current, and the same operation is repeated as before; so that there is a constant and rapid succession of intermissions, as long as the machine acts; the contact-breaker producing a sen- sible sound, as it flies rapidly backward and forward between the metallic boundaries of its movements. The wires which serve to convey the influence of the machine to the patient, and which are of course attached to its opposite poles, are often themselves made to increase the intensity of the vol. i.—33 514 GENERAL STIMULANTS. [PART II. current by being thrown for a portion of their length into the spiral form. I shall not attempt to describe the various instruments employed; but present an account of one of the most recent and most perfect, which has been arranged by M. Duchenne. By consulting this account, the reader will be put into possession of all that will be necessary to enable him to understand and apply not only this, but other apparatuses of the same kind.* * Volta-electric, or Galvano-Magnctic Apparatus of M. Duchenne. M. Duchenne calls this apparatus his volta-faradic apparatus with double cur- rent (Appareil volta-faradique a double courant). Of the two following figures, the first is the representation of his apparatus as originally devised, the second, of the perfected instrument. It is necessary to give them both here, because, together, they represent parts of the perfected apparatus which neither figure exhibits alone ; but the reader must bear in mind that it is only the second which is recommended as here described. All the parts mentioned in the text are contained in this instrument, with others for the attainment of objects to which the ordinary machines are inadequate. One prominent-point in which, at the first glance, it is seen to differ from those commonly used in this country, is the inclosure of the pile or battery, by which the galvanism is excited, within the circuit of the instrument. "The pile contained in the lower drawer (Fig. 1) is formed, like that of Bunsen, of a charcoal and a zinc plate. The charcoal 0 is fiat, hollowed at the centre, and filled with powdered coke. The zinc Z has the form of a little flat oblong ferry- boat, in which the charcoal is placed without diaphragm. The drawer in which it is contained is lined with mastic and laminae of glass, so that moisture cannot reach the wood. The bottom of the drawer above the pile is also covered with mastic, which protects it from the vapours disengaged by the pile. Two slips of copper L, N, in contact, one with the zinc, the other with the charcoal plate, communi- cate with the plates of platinum E, G (Fig. 2), by means of the screw-buttons L, N (Fig. 2). " The bobbin (cylinder), composing the system of induction, is formed of wires .of red copper, of unequal diameter, covered with silk thread. The larger wire, half a millimetre (l-50th of an inch) in diameter, is rolled spirally upon a bunch of wires of soft iron. The ends of this wire, which produces the current of first order, communicate with the plates E and G (Fig. 2) and the buttons L, N. The finer wire, a millimetre in diameter, is rolled upon the preceding. It gives birth to the current of the second order, and its ends are soldered to the buttons P, Q (Fig. 2). " The graduator B (Fig. 2), is a cylinder of copper which covers the bobbin, and on the upper part of which is a graduated scale. The button B', at its extremity, is used for drawing it out, and pushing it in upon the bobbin. "The moderator consists of a glass-tube F (Fig. 2), with a metallic base at bot- tom, to which is soldered a button I, and a ferrule at top, from which proceeds a small hook, which serves to place the moderator in connexion with one of the but- tons P or X of the currents. In the upper ferrule is placed a little cork traversed by the stem J of the moderator. The tube is filled with water. "The magnetic reometer (riomltre magne'tique) measures the intensity of the ini- CHAP. I.J DIFFUSIBLE STIMULANTS.—ELECTRICITY. 515 2. Effects of Electricity on the System. As electricity is probably identical under whatever aspect it may present itself, its effects under similar circumstances are pro- tial current, or the degree of magnetization of the soft iron of the bobbin. It is a compass V (Ffg. 1), placed in the upper drawer U. The face of the compass is divided into four parts, each of which is divided into 90 degrees. Fig. 1. " The trembler (contact-breaker) consists of a movable piece of soft iron A and a platinum screw S, against which the iron is pressed by a little spring. " The toothed wheel D (Fig. 2) is fixed without the box, on the base of the ap- paratus, above the upper drawer U. It turns by means of a handle, and presents 516 GENERAL STIMULANTS. [PART II. bably also identical; but, in the different conditions in which it is actually developed, it exhibits striking differences of operation, upon its circumference four teeth, upon which is supported a copper spring D'. The current of the pile passes from the spring into the wheel before reaching the bobbin. " Mode of putting the Apparatus in Action. When newly prepared, the charcoal plate is charged with from 30 to 40 grammes (an ounce to 6 drachms, troy) of nitric acid, which is poured in slowly by the rectangular opening hollowed out in the centre of the charcoal. The acid is quickly absorbed by the powdered coke, and penetrates all its pores. To maintain the power of the pile, it is only necessary from time to time to let fall a few drops of nitric acid on the charcoal. Thus prepared, the charcoal plate is placed in the middle of the boat of zinc, in which preliminarily are poured one or two spoonfuls of water saturated with common salt, which should moisten the whole surface of the zinc. The slip of copper placed over the char- coal is fixed upon the drawer by means of two small points, and the drawer is then closed. " If it is now desired to ascertain the force of the initial current of the pile, the drawer U is opened to the vertical black line traced on its sides, and the appa- ratus is placed so that the needle of the reometer V is directed transversely to the long diameter of the apparatus. The soft iron of the trembler A is fixed by giving to the button of the screw C (Fig. 2) a half turn from right to left, and the cur- rent is closed by turning the two screw buttons L and N, until they are in contact with the plates E and G, by which the current of the pile is transmitted to the extremities of the induction bobbin. Then the needle of the reometer V deviates from the direction of the magnetic meridian, in consequence of the power of the pile. " Should it be wished to obtain the intermissions by the aid of the wheel D, the drawer U is closed, and the handle of the wheel is turned more or less quickly, according to the indications to be fulfilled. " If the intermissions are to be made by the trembler A, the spring which keeps the movable plate of the trembler fixed, is relaxed by turning from right to left the screw C ; and instantly this plate is agitated between the screw and the tem- porary magnet of the bobbin. The more intense the initial current is, the more rapid and noisy is the play of the commutator. "When the graduator B is wholly buried in the apparatus, the currents are at their minimum of intensity. To increase them, the graduator is withdrawn to the degree required. "The apparatus being in action, the conductors (reophores) are attached to the buttons P and Q of the current of second order, or to those of the first order, ac- cording to the indications to be fulfilled. At their free extremities the conductors are attached to the excitors, in their form of cylinder, metallic broom, &c. (See page 518.) "If it be desired to faradise (electrize) very excitable organs, or administer doses infinitely feeble, the upper part K of the moderator F is put into connexion with one of the buttons of the second or first order, and one of the reophores (con- ductors or directors) is attached to its lower extremity I. Then, the more we raise the stem J of the moderator, the thicker is the layer of water through which the current must pass, and the more is the intensity of the apparatus weakened. In this state of weakness, the currents of the apparatus may be divided and mea- sured by the graduating cylinder B. CHAP. I.J DIFFUSIBLE STIMULANTS.—ELECTRICITY. 517 which render necessary the consideration of it, in the present rela- tion, as before in regard to the methods of development, under " In the intervals of operating, the current is interrupted by loosening the screw L or N, in order to preserve the power of the pile. The apparatus will act for twelve hours with the same solution. After the sitting, the zinc and charcoal plates are cleansed, and wiped with great care ; a piece of waxed linen is placed between them, and the pile is replaced in its drawer U. If the apparatus is used but rarely, the zinc should not be left in contact with the charcoal." "Theory of the Apparatus. The pile being inclosed in the apparatus, if no inter- ruption take place, whether by the trembler or the toothed wheel, the current, which is transmitted by the buttons L and N to the wire of the central bobbin, is continuous, and causes no phenomena of induction, but magnetizes the soft iron in the bobbin. It is on the influence exercised by this magnetization on the needle, that the magnetic reometer is founded. The soft iron is magnetized differently at its extremities, according to the direction of the current. Suppose the north pole to be at the end of the soft iron nearest the reometer, the needle, disposed as above indicated, will deviate from the magnetic meridian by the attractive force of the magnet on its south end; and as the strength of the magnetization of the soft iron is in direct proportion to the intensity of the initial current, the degree of deviation of the needle will indicate at once the strength of the magnetization of the appa- ratus, and the intensity of the current of the pile. " In this state of things, if the plate A of the trembler be left at liberty by loosen- ing the screw C, this plate is attracted by the temporary magnet of the bobbin. The current being thus interrupted, the magnetization instantly ceases; the soft iron of the trembler is forced back by a spring against the platinum point of the screw S, and closes the circle anew, which produces a new magnetization. These temporary magnetizations, and these interruptions of the current, succeed each other with extreme rapidity. The theory of the toothed wheel is the same as that of the trembler, only that the intermissions may be accelerated or retarded at the will of the operator. "At the instant when the current of the first order (through the large wire) is interrupted, we observe the physical and physiological phenomena produced in virtue of the two combined forces; namely, the inductive action of the current on itself through the mutual influence of the spires, and the mutual influence of this current and of the magnetized soft iron of the bobbin. "If the ends of the wire which covers the central bobbin (the smaller wire) are put • in communication with a conducting body, a current of the second order takes place, and manifests itself by physical and physiological effects produced upon bodies placed in its circuit." M. Duchenne then develops the progressive steps by which he had perfected his apparatus, which we have not space to insert. But he makes the following prac- tical observation, which may be useful. The charcoal plates, however well made, become at length so saturated with the salts resulting from the action of the pile, say after five or six months, as to inter- fere with the passage of the currents, and thus diminish the force of the pile. Should the trembler cease to act, this would serve as an indication that the pile wants cleansing. The oharcoal plate should then be immersed for several hours in water, which dissolves out the salts, should afterwards be dried, and again charged with nitric acid as at first. The pile thus recovers all its strength. 518 GENERAL STIMULANTS. [PART II. its several distinct forms. Its characteristic effects, as a general rule, are to excite sensation and muscular contraction, and, indeed, to augment the functions of all the organs on which it may be brought specially to act; consequently, under favouring circum- stances, to promote digestion, absorption, circulation, animal tem- perature, secretion, and the nutritive and assimilative processes; in other words, it appears to be capable of acting as a universal stimu- lant, though more especially directed to the vital properties of Excitors, or Terminations of the Directors. Before proceeding to treat of the effects of electricity on the system, it will be expedient to make a few remarks on the different modes of application, by the directors. The form of the terminations of the free ends of the conducting wire or chain, by which the influence is conveyed to the patient, is of some importance. These terminations are called excitors by M. Duchenne. When electricity is to be ap- plied by the aura, they should be pointed; when by sparks, rounded; when by contact, they may be of any form which the practitioner may deem most conve- nient; the mere touching of the excitors by any part of the surface being sufficient. Spherical, olive-shaped, or conical terminations (Fig. 2) are very common. Sometimes cylindrical pieces of metal are used, which the patient can hold in his hand. Some- times a metallic shoe is made to fit the foot, which terminates one pole, while the other is applied to some other parts of the body. The excitors may be straight or variously curved, and, when to be applied by an operator, must as before stated, have an isolating handle. It is often necessary that the surface of the body to which they are applied should be moist, to enable the influence to penetrate through the cuticle. In such instances the ends of the excitors should be covered with buckskin or other simi- lar material, which will imbibe and retain moisture. A sort of hollow cylinder containing a wet sponge (Fig. 1) should be used, when it is desirable to cover some extent of surface. M. Duchenne uses sometimes a bunch of fine wires, in the form of a brush or broom (Fig. 3), the wires being fixed at one end in a hollow cylinder. from which they proj ect at the other, and the cylinder being screwed upon an iso- lating handle. CHAP. I.J DIFFUSIBLE STIMULANTS.—ELECTRICITY. 519 sensibility and muscular contractility. In its influence upon sen- sation, it produces effects corresponding with the functions of the several senses; causing pain, when acting on the nerves of general sensation; the perception of light, when on the organ of vision; a peculiar taste, when on the tongue and palate; smell, when on the olfactory organs; and sound, when on the ears. Muscular contrac- tion is caused by it, whether directed to the muscle exclusively, to the nerves of motion, or to the nervous centres of motion. In the higher exertion of its powers, like some other stimulants, it has the effect of overwhelming the vital functions, and producing ap- parent direct prostration, even to a fatal issue. Witness the effects of a violent shock, and especially of a stroke of lightning, which often destroys life instantaneously, and, when it fails to do this, generally leaves the patient for a time more or less prostrate, sense- less, and paralyzed. a. Effects of Electricity Excited by Friction. The effects of a mere accumulation of electricity in the system have not been satisfactorily determined. We feel often very dif- ferently before and after a thunder-storm. Many persons imagine they can detect by their sensations the approach of certain changes in the weather, before any evidence of such changes is presented by ordinary signs. I know neuralgic persons who suffer much more in certain kinds of weather than in others, though completely protected against any influence of cold or moisture. These results have been vaguely ascribed to the electrical condition of the sys- tem, and possibly with some justice; but it would be difficult to adduce positive proof of the fact; and when we attempt to reduce the phenomena within any general rules, they quite elude our grasp. Silent Conduction. When the body, by contact with an excited prime conductor, becomes the route through which the electric current passes, however powerful may be the machine, and how- ever rapid the current, no observable effect is produced either upon the sensations, or any of the functions. The Aura. This is said to operate as a mild stimulant to the portion of surface upon which it is made to act; and has some- times been employed for this purpose in affections of yery delicate organs, as the eye. But the influence, if any, must be extremely slight. The Electric Bath. Very different statements have been made as to the effects of electricity accumulated in the system, in a state of 520 GENERAL STIMULANTS. [PART II. insulation. Some have found it to increase the frequency of the pulse, and promote the secretions, especially those of the skin, kidneys, and salivary glands, and have obtained great supposed advantages from it in rheumatic neuralgia and paralytic diseases. Giacomini, while admitting that the positive electric bath produces no impression on any one of the interior functions, imagined the negative to be powerfully depressing, and capable of advantageous use as a contra-stimulant agent. It is not impossible that, in cer- tain very susceptible individuals, the bath may have some influ- ence; but I have found no effect from it in my own person, and the same I believe to be the experience of most who have tried it; and, without calling into question the accuracy or trustworthiness of those who have made opposite statements, we are, I think, justi- fied in at least suspecting, that the phenomena observed were really ascribable to the mental state of the persons acted on, and in no degree to the electricity. As to the supposed cures of rheu- matism, neuralgia, and palsy, we know well how powerful mental influence is in many cases of those affections, and how often the favourable changes which have taken place spontaneously with time, have been ascribed to the last remedy used. But, though we may doubt the remedial influence of simple electrical accumulation, yet the bath may be made a means of gentle stimulation to the sur- face, by the sensation produced when the electricity is drawn from the body, under these circumstances, by sparks. Sparks. The spark, whether drawn from an excited prime con- ductor by the body, or from the excited and insulated body by other substances, is attended with more or less sensation, of a sharp, pungent character, very slight when the spark is small, but pain- ful when the electric tension is very great, though seldom so severe that it cannot be readily borne. The electricity scarcely penetrates beyond the surface; yet it in some degree excites the skin, and, if the operation be continued, produces rubefacient swelling, and some tenderness to the touch. It may, therefore, be occasionally used with advantage in this method, as a gentle excitant in inac- tive states of the surface, and as a revulsive in internal diseases of no great severity. It may be concentrated in one spot, or applied extensively over the surface; and, for the latter purpose, the bath probably affords the most convenient means. By the interposition of flannel, which may cover the ball of the director, or be applied to the surface of the body, a great number of minute sparks may be drawn rapidly, with less discomfort to the patient. CHAP. I.J DIFFUSIBLE STIMULANTS.—ELECTRICITY. 521 Ley den Jar. When the body is made the connecting medium between the two surfaces of a Leyden jar, a quick painful sensation is experienced, denominated the shock, which is always disagree- able, and may be so violent as to be quite insupportable. This is attended with a quick, jerking, muscular contraction, and even the deep-lying muscles may be brought into energetic action. If applied to the hands, the sensation is felt chiefly in the wrists, elbows, and breast. If directed so as to reach the nervous centres, the shock radiates through the whole system. When severe, its first observ- able effect, independently of the sensation and spasm produced, is to depress function by overwhelming it. Thus, the skin for a short distance around the point of entrance is whitened, and its temperature lessened, while the follicles project in consequence of the shrinking of the tissue. The part is also more or less be- numbed. If the shock is passed through a nerve of sensation, numbness is apt to be felt in the parts supplied by it; and a severe shock through the brain or spinal marrow, produces, in the former case, mental confusion, forgetfulness, dimness of vision, &c, in the latter, feebleness approaching to paralysis of the lower limbs. The violence of the effect is proportionate both to the electric intensity and quantity. A small jar, highly charged, will produce a greater effect than a larger one feebly charged; but, the intensity being equal, the degree of effect is then proportionate to the quantity, or to the magnitude of the apparatus. The shock from an electric battery is capable of producing temporary insensibility, and probably death. After fatal effects from lightning, streaks of redness are said to be sometimes observed along the surface; and the blood is, in gene- ral, fluid, and the muscles flaccid, as if universal death had taken place immediately. The depression occasioned by the shock from the jar speedily passes off, and is followed by more or less reaction. In this method of application, electricity may sometimes be use- fully employed for exciting parts which lie deeply, and are ex- tremely insusceptible, or in rousing a torpid system by the shock, or for depressing nervous excitement by its first overwhelming effects; but it is impossible to limit its action precisely to any one muscle or part; and there may be hazard, in cases of great depres- sion, of dangerously adding the prostration of the shock to that already existing. Allusion has been before made (see page 503) to a mode of regulating the remedy which will obviate this latter danger. In some instances, the subcutaneous adipose tissue is so thick, or the cellular tissue so edematous, that the dynamic cur- 522 GENERAL STIMULANTS. [PART II. rents will not reach them. In such cases recourse may be had to the jar. b. Effects of Dynamic Electricity. This includes both galvanism, strictly speaking, and the electricity developed by induction. Dynamic electricity differs in its attendant physiological phenomena, materially from the static. It produces sensation, but in a much less degree, in proportion to other effects. Thus, a galvanic battery, capable of powerful chemical action, will give only a slight tingling sensation to the part at which the current enters; while the continuance of the current gives rise to effects which never proceed from a continuous current of machine elec- tricity. The dynamic current causes also contraction of the mus- cles, and even energetic contraction, but without the violent shock to the system produced by the other form. Another important point of difference is that its influence can be directed to a certain part, and in a considerable degree limited to that part; so that a diseased muscle, for example, which may have lost its sensibility, and in which the electric stimulation may be strongly indicated, may be acted on by means of the galvanic or inductive current, with little or no disturbance or injury to neighbouring and more excitable tissue. This alone gives a vast superiority to this form of electricity over the static, as a therapeutic agent. For the me- thods of effectually localizing the action of galvanism, we are greatly indebted to M. Duchenne. Formerly no attempts of the kind were made, or quite ineffectually, until the method of acu- puncture was applied by M. Sarlandiere to this object; but the necessity for this has been superseded by the methods of M. Du- chenne, which, while less unpleasant, are even more effectual. 1. Effects of Galvanism. In the physiological operation of gal- vanism, there are effects produced, which cannot be completely separated, and which often interfere injuriously with one another when the agent is employed therapeutically. The current may be either continuous or intermittent; and the effects of the two modes of application differ materially. The continuous current, while it produces sensation in the skin, exercises also an influence over the organic actions, giving rise to heat, irritation, and inflammation in various degrees, according to its power and continuance, sometimes ending in absolute cauteriza- tion. The most powerful current, if introduced into a muscle, occa- sions but slight, irregular, or partial contractions, while it causes a CHAP. I.J DIFFUSIBLE STIMULANTS.—ELECTRICITY. 523 sense of burning heat, even in the depths of the tissues along its course. In the intermittent current, the organic action of the battery, or its tendency to produce heat, inflammation, and disorganization, is diminished; while its power of exciting sensation and muscular contraction is greatly increased. This difference is readily explica- ble. At every breaking of the current, there are three physiolo- gical actions, one at the entrance of the current, one at its cessation, and a third in the interval. Sensation and muscular contraction are produced chiefly at the entrance, and much less at the moment of interruption, while in the interval, or during the continuance of the current, there is little comparative infl uence on the sensibility, none or scarcely any on muscular contractility, but a strong tendency to provoke inflammation or organic change. It follows, therefore, that, if the current be frequently interrupted, sensation and contraction will be proportionably increased, and organic action diminished; and thus the intermittent current can be more effectively applied to the former purposes, the continuous to the latter. There is one effect which, according to M. Duchenne, the galvanic current produces beyond all other modes of electric action. It has great influence on the organ of vision, and, if made to operate on the face or scalp, where the fifth pair of nerves, which are mainly sensitive, are distributed, it occasions dazzling luminous sensations. These flashes are produced strongly at the entrance of the current, feebly at its cessation, and very slightly, so as to be appreciable only in a dark room, during its continuance. By a rapidly recur- ring intermission of the current, there may be kept up a constant succession of the luminous phenomena. They are produced chiefly on the side to which the application is made, more powerfully as the median line is approached, and on both sides, when the excitors connected with the two poles are both placed at that line. An im- portant inference is deducible from this fact, in determining the therapeutic application of the agency; namely, that galvanism is to be preferred when the indication is to excite the retina, and its ap- plication to the face avoided in the opposite indication. I need scarcely state, that the interruption of the galvanic cur- rent may be effected by withdrawing the excitors, and a succession of intermissions more or less rapid obtained, by their more or less rapid withdrawal and reapplication. But there is much inconvenience in this manual operation; it is almost necessarily effected comparatively slowly and irregularly; 521 GENERAL STIMULANTS. [part II. and, even at best, the continuous current, while it lasts, is exercising its organic influence, and may at times be productive of great in- convenience. While, therefore, the galvanic battery is preferable in all cases in which the object is to excite inflammation or other organic change, it is highly desirable to obtain the means of excit- ing at will the nervous properties of sensibility and muscular con- traction, without endangering the integrity of the tissues. Such means are supplied by the form of electricity developed by induc- tion, whether through the electro-magnetic, or volta-electric instru- ments. 2. Effects of Induced Electricity. In the operation of the instru- ments above referred to, it is at the moments when the circle is closed, and when it is broken, that the effects are produced; no phe- nomena whatever being excited between these two points of time. While the circle remains closed, the electric force appears to be quite quiescent. This is the important point in which the induced electricity differs, in its physiological and therapeutical effects, from the galvanic. That the fact is as stated may be shown by a simple experiment. If a frog's muscle be placed in the electric circle, it contracts instantaneously when the circle is closed, then becomes perfectly quiescent, and continues so until the circle is broken, when it again contracts, and more strongly than at first. But, though there are thus shown to be two actions, one at the closing, and the other at the breaking of the current, it is only the latter which is strong enough to be effective in the human subject; the one occurring at the closure of the circle being scarcely percep- tible, though sufficiently powerful to produce contraction in the muscles of a frog. It is to this power of strongly exciting sensa- tion and motion, without producing inflammation, that the inductive instruments owe their great superiority, as therapeutic agents, over other galvanic arrangements, for the general purposes which are aimed at in the use of electricity. However powerful their opera- tion, or however long continued, though they may produce insup- portable pain, and the most energetic muscular contraction, they never cause disorganizing inflammation; and, though a little ery- thematic redness of the skin may be produced, with erection of the papillse, the effect quickly subsides upon the cessation of the action. It is obvious that, the more rapid the succession of the inter- missions, the more rapid will also be the succession of the muscular contractions produced by them; and thus a method is offered of CHAP. I.J DIFFUSIBLE STIMULANTS.—ELECTRICITY. 525 controlling the effect, to a considerable degree, by diminishing or increasing the number of intermissions. The contractions, how- ever, are severally more powerful, when at long than short intervals; but, by their very frequent repetition, the muscle may be kept in an apparent state of steady contraction, similar to that produced under the influence of the will. There is a sort of vibratory movement in the fibres; but, to the touch, the muscle feels as though steadily contracting. An influence analogous to the healthful stimulus is thus obtained, which has a tonic effect on the muscle, and promotes its nutrition. Hence its application in cases of relaxation from debility, and in atrophy of the muscles. In relation to sensation, on the contrary, the more rapid the succession of intermissions, the greater is the effect. Hence, when it is important to awaken sensibility, as in cutaneous paralysis, the instrument should be made to act rapidly. On the contrary, a rapid movement is contraindicated in disease of the brain, upon which the pain may react injuriously; in cases of great natural susceptibility; and in operating on delicate organs, as the tympanum of the ear, different parts of the face, and the testicle. But this is not all the merit of these machines. By varying their mode of application, different physiological effects are obtained, each susceptible of beneficial therapeutic use. Thus, the current of the two wires, the larger and smaller, or, as M. Duchenne desig- nates them, the currents of the first and second order, differ materially in their effects. The machine with the double wire ope- rates much more powerfully on the face and eyeballs in producing luminous phenomena than that with only one wire; and the effect, according to M. Duchenne, is much greater from the electro-mag- netic than the volta-electric apparatus. Even with a feeble action of the former, considerable reaction is produced upon the retina; while the latter operates in this way only when somewhat intensely excited, and when the excitors are applied to the emerging points of the fifth pair, or to the globe of the eye itself. The current from the first order (larger wire) of the electro-magnetic instru- ment produces no stronger an impression than the volta-electric. But the luminous phenomena, excited by these machines, even by the second current of the electro-magnetic, are mtich feebler than those which result from simple galvanism. Moreover, the current of the first wire appears to have a special influence over muscular contractility, that of the second over cuta- neous sensibility; that is, though both currents act on both proper- 526 GENERAL STIMULANTS.. [PART II. ties, yet one produces a greater relative effect on the one, the other on the other. (Electrisation Localisee, pp. 15,16.) Cutaneous insensi- bility will often yield promptly to the current of the second order (small wire), when that of the first has no effect whatever; but, in very susceptible persons, it will be advisable to have recourse to that of the first or larger wire, because less disturbing to the sen- sibility. 3. Methods of Application. In describing the instruments for the development of static and galvanic electricity, and the effects of these two modes of electrical excitement, I have probably said as much as may be necessary in relation to their method of application. But the following obser- vations upon the application of induced electricity, derived almost exclusively from the work of M. Duchenne, appear to be necessary, to place the reader on a level with the state to which therapeutical electrization has been brought by that indefatigable investigator. 1. To the 3Iuscles.—Faradisation of the 3Iuscles (Duchenne).—To affect the muscles, we may operate either through the nervous plexuses and trunks, or directly on the muscles themselves. In the former case, we necessarily influence at the same time several associated muscles; in the latter, we may limit the action to a single muscle. The two excitors, or terminations of the directing conductors, should be placed near to each other, at distances varying from one to four inches. If the skin is well moistened, the electric influence penetrates readily through it to the parts beneath. When it is required to operate on the larger muscles, as those of the trunk for example, the cylinder with the moist sponge (Fig. 1, page 518) should be used. For small muscles, as those of the face or intercostals, or for deep-seated muscles, the conical excitors (Fig. 2, page 518), covered with thoroughly moistened leather, as the finger of a glove, are to be preferred. The latter also are preferable when it is desirable to excite the muscles through a nerve. The moist skin is a better conductor than the wet sponge; and, when a powerful effect is demanded, the conical excitors may be sometimes advan- tageously used even for large muscles, being in this case moved from point to point. To apply the instrument efficiently, the practitioner must of course have made himself acquainted with the precise situation of the muscles, and course of the nerves supplying them. Their depth below the skin must also be well understood. CHAP. I.J DIFFUSIBLE STIMULANTS.—ELECTRICITY. 527 The influence is never to be directed to the tendons. To act on a muscle duly, its whole surface must be covered; and consequently, if this is large, the excitors must be moved from point to point successively until the purpose has been accomplished. The muscle is known to be contracting by its firmness or hardness under the fingers; and it often happens that one part of a single muscle will be relaxed, while another contracts. The thicker the muscle, the more intense must be the current applied. In the face, it is difficult to avoid affecting the nerves so abundantly distributed over it. One of these is known to be touched when the contraction extends to several muscles simultaneously. Should this happen, the excitors should be moved a very short distance from the point, until the effect is no longer produced. When a muscle, on account of its depth, cannot be reached directly by the electric influence, it may be excited by means of its supplying nerve. The excitement of a nerve, or of a muscle, always produces in the healthy state both a sensation and con- traction. But the susceptibility of different nerves and muscles is very different in degree; and a force which will affect one but slightly, will on another act with great energy. Again, while one part is unusually excitable in relation to contractility, another is more so in relation to sensibility. It is against the latter that the operator must be particularly on his guard, prepared to withhold his hand, or diminish the force of the instrument, when the in- fluence becomes excessive. Sometimes the sensibility to pain is so great as to preclude this method of electrization. It is apt to be particularly strong in the muscles of the face, supplied by the fifth pair. The excitor should never be placed over the points corre- sponding with the suborbitar or mental nerve; and the excitation of the frontal nerves produces severe pain, which radiates through the head. The muscles of the eyelids, of the alae nasi, and of the upper and lower lips, are peculiarly susceptible. Of the muscles of the neck, the platysma myoides, the upper half of the sterno- mastoid, and the external edge of the upper half of the trapezius, are much more excitable than the remainder. The great pectoral and the muscles of the subspinal fossa are rather sensitive; the deltoid and the muscles of the arms somewhat less, the anterior being much more so than the posterior. The long dorsal and the sacro-lumbar are but slightly sensitive. The gluteal and fascia lata muscles are very much so, compared with those on the outer and posterior parts of the thigh; those of the internal crural region 528 GENERAL STIMULANTS. [PART II. more so than those of the external. The posterior muscles of the- leg are but slightly sensitive compared with the anterior and external. At the moment of contact, even when the surface is moist, severe pain is sometimes felt in the skin, which soon ceases. In such cases, in order to obviate the effect, the excitors should be brought into contact before application, so as to restore the equilibrium, and then gradually separated to the necessary distance. 2. To the Skin. If static electricity is employed for exciting the skin, it is necessary that it should be of feeble intensity, as it would otherwise penetrate the deeper tissues. The dynamic form is pre- ferable ; care being taken to have the surface of the excitors quite dry, so as to confine the influence to the skin. But the electricity of induction, the faradism of M. Duchenne, is here specially ad- vantageous, when mere excitation without organic disturbance of the surface is wanted; as it never, like galvanism, produces severe inflammation or cauterization. If, however, a powerful revulsive effect is desired, for the relief of chronic internal affections, gal- vanism is preferable. An excitor containing the moist sponge having been applied to one point of the surface, the other excitor, quite dry, is to be held by the operator, and, after the skin has been thoroughly dried by rubbing over it lycopodium or other absorbent powder, is to be passed rapidly over the part. Or cylindrical or olive-shaped dry excitors may be moved from point to point over the skin. .Some- times advantage may accrue from using the wire brush (Fig. 3, page 518) as an excitor, which may be moved over, or struck lightlv on the surface. M. Duchenne calls this latter process fustigation. The wires may also, in certain cases, be kept in contact with the skin; but this cannot be long borne, in consequence of the violent pain produced. The latter mode of electrization he calls electric moxa, as having, I presume, the powerful irritant and revulsive influence of that agent, without its organic results. It is applicable only when there is great cutaneous insensibility, or it is desired to promote the dispersion of white swellings, and other chronic tumours or tumefactions. The application of the electrified hand of the operator, under the influence of an intense current, excites lively sensation in the face, but is insufficient for other parts of the body. The rounded me- tallic excitors act powerfully on the face, even with a slight inten- sity of current, and sufficiently on the skin of the trunk and other parts of the body, except that of the hands and the soles of the CHAP. I.] DIFFUSIBLE STIMULANTS.—ELECTRICITY. 529 feet. For the last-mentioned parts the wire-brush must be used, which has three times the power of the blunt excitors. The inner and middle parts, however, of the soles of the feet have more sus- ceptibility. No single therapeutic agency is so efficacious in exciting cuta- neous sensibility as "faradisation." It maybe graduated to any required degree of impression, from a slight tingling to the most violent pain; the excitement in its higher grades is not exceeded by that of a burn, yet no disorganization takes place, not even so much as vesication; it may be carried rapidly over the whole surface of the body; and the pain subsides instantly, and almost completely, when the operation ceases. To Internal Organs. Most of these may be reached either directly by the excitors, or through the nerves which supply them. In affections of the rectum, one of the metallic olive-shaped ex- citors, upon a stem insulated by a covering of caoutchouc, may be introduced into the bowel, while the other is carried from point to point about the anus. If the sphincters are debilitated or para- lyzed, the excitor may be brought into apposition with them; if the muscular coat of the rectum, it should be passed successively over the whole inner surface of the bowel. Constipation, incon- tinence of the feces, and prolapsus of the rectum may often be advantageously treated in this way. In the same manner, the hypogastric plexus posterior to the rectum may be excited. The bladder and rectum are but slightly sensitive to pain from the electric impression. The latter, therefore, may be resorted to in operating on the former, an excitor being introduced into both; but care must always be taken, in using instruments for the purpose, that the stem should be completely isolated. The vesical excitor may be carried over the whole surface of the bladder. Should the rectum be too irritable for the purpose, the two excitors may be introduced through a double caoutchouc canula into the bladder; the instrument being so contrived that the excitors should not be allowed to meet. The bladder, however, should be quite emptied of urine, as this fluid would otherwise serve to connect the poles. The uterus may also be operated on by a somewhat similarly con- trived double instrument. This orgau also has but little sensitive- ness unless in pregnancy. The pharynx may be entered by an olive-shaped excitor, properly supported, which may be passed along the posterior part, while the other pole is applied to the nape of the neck. It is necessary to vol. i.—34 530 GENERAL STIMULANTS. [PART II. avoid the lateral portions of the pharynx, for fear of injuriously exciting the pneumogastric, glosso-pharyngeal, and accessory nerve of Willis, which are in this vicinity. In complaints of the larynx, as aphonia, one of the excitors may be passed down the pharynx below the posterior part of the larynx, while the other is applied, moistened, to the external parts answer- ing to the cryco-thyroid muscle. The inner excitor is then to be brought forward against the larynx, and passed upwards and downwards. The stomach, liver, lungs, and heart cannot be acted on directly, but may be reached through the pneumogastric nerve. By making the application to the lower portion of the oesophagus, which may be done by the introduction of a suitable instrument, isolated by a caoutchouc covering, except at its extremity, and placing the other excitor at the pit of the stomach, the influence may be directed to the stomach and liver. If the upper part of the nerve is acted on by applying the pharyngeal excitor to the upper and lateral part of the pharynx, and the second to the nape of the neck, all the viscera mentioned will be put under the electric influence. But these ope- rations require much caution, as the vital organs concerned might be unduly and dangerously affected; and M. Duchenne relates a case in which a patient, under the second of the operations just mentioned, fainted, and, upon recovery, stated that he had expe- rienced a feeling of suffocation, and indescribable precordial sensa- tions. On a repetition of the operation, with intermissions of a second, the patient did not faint, but had the same precordial sen- sation each time. To the Special Senses. For the sight, galvanism is preferable to electricity by induction, as it is more powerfully stimulant to the organ of vision. If either of the inductive machines be used, the electro-magnetic with a double wire should be preferred, as the more energetic of the two. The application may be made carefully to the ball, and around the orbit. In operating on the ear, the external meatus should be half filled with warm water, and a metallic wire from one of the poles should be introduced into the liquid, while the other excitor is applied to the nape of the neck; or the second excitor, protected by caout- chouc, except at the end, may be introduced through the nostrils, so as to come into contact with the Eustachian tube. As the tym- panum, however, is very sensitive, great caution must be observed. When the electric influence is wanted in the organ of smell, a CHAP. I.] DIFFUSIBLE STIMULANTS.—ELECTRICITY. 531 small sound, protected as usual except at the extremity, may be passed over the Schneiderian membrane; when in that of taste, the same instrument may be passed over the sides of the tongue and the palate; the second excitor, in both cases, being applied to the back of the neck. To the 3Iale Genitals. The testicle being very sensitive, must be operated on with caution; two excitors being placed near each other upon the scrotum. For operating on the vesiculse seminales, one excitor may be introduced into the rectum, and the second into the bladder, if there be no contraindication; otherwise the latter may be applied on the external surface. In insensibility of these organs generally, the influence should be directed along the whole course of the urethra, as well as to the different parts ex- ternally. •—♦— Notwithstanding the localization effected by these methods, a secondary influence will sometimes be extended to the nervous centres, against which it is necessary that the operator should be on his guard. The pain itself produced in the part, necessarily affects the cerebral centres; and, when care is taken to limit the current by keeping the poles near together, this is the chief, if not exclusive source of general disturbance that may be apprehended. In cases of paralysis of sensation, as well as motion, none of this effect is experienced. The muscle may contract; but, however long the operation may be continued, the patient is sensible of no inconvenience. Even reflex action from the spinal centres is ex- cited by this localized contraction only in certain pathological conditions. But when there is no loss of sensibility, much care is necessary. Certain individuals are, from idiosyncrasy, so exceed- ingly susceptible, that a slight influence, even insufficient to cause local sensation, occasions faintness, giddiness, dimness of vision, nausea, vomiting, and general feelings of torpor or numbness. These persons are unfit subjects for the use of the remedy. Acupuncture. In 1825, M. Sarlandriere proposed the direct ap- plication of the electric influence to deep-seated parts by means of acupuncture; and, seconded as the measure was by the recom- mendation of Magendie, it acquired for a time great reputation, and was extensively resorted to. It consisted in introducing very sharp needles through the skin into the part or organ which it was desired to excite, particularly the muscles, and passing the current 532 GENERAL STIMULANTS. [PART II. through them, so that in proceeding from point to point of the needles it must necessarily traverse the part. But the results have not corresponded with the first sanguine expectations, and the mea- sure is at present seldom resorted to. Nor is it now necessary in medical practice; as the methods of M. Duchenne accomplish the same end more effectually and less disagreeably. The objections urged by M. Duchenne against it are, 1. that the electrization of the muscle cannot be isolated from that of the skin; 2. that the cutaneous excitement being confined to the course of the needle, surfaces of considerable extent could not be stimulated; 3. that the contractions caused by it are irregular and cannot be foreseen; 4. that to excite the whole of a muscle, especially a large one, so many needles must be introduced that few patients would be found willing to bear the pain; and 5. that if it be desired to excite the muscle by passing the needle through the nerve, the operation is almost always im- practicable. Nevertheless, acupuncture may sometimes be usefully employed by surgeons for the discussion of tumours, and for promot- ing the coagulation of the blood in aneurisms. Platinum, or gold needles, should be used preferably to steel; as the latter are apt to become oxidized, and thus to irritate the parts. When a galvanic battery is used, the parts penetrated by the needle are apt to become inflamed, and a caustic effect is not unfrequently produced. —•— Great importance has been attached to the transmission of the electric current along the nerve, and in one direction rather than another, in imitation of the course of nervous influence. But much of what has been said on these points has been purely theoretical. M. Duchenne has come to the following conclusions. 1. In man, whatever may be the direction of the currents, or the degree of vitality of the nerves they traverse, the same results are always produced, when the conductors are applied to any portion of the course of the nerves; namely, muscular contractions and sensations. 2. A current prolonged for a considerable time along a healthy nerve, whether it be continuous or interrupted with rather short intermissions, weakens neither the contractions, the sensations, nor the voluntary movements, and produces no reflex phenomenon above the point excited. 3. A current long protracted in a nerve considerably debilitated, notably lessens its excitability, but with- out influencing the voluntary motions. 4. Changes in the direc- tion of the current exercise no appreciable influence over the mus- cular contractility or sensibility in man. 5. Electrization of the ter- CHAP. I.] DIFFUSIBLE STIMULANTS.—ELECTRICITY. 533 minal nerves of a limb, produces sensations only in the points ex- cited. 6. The currents which pass from the nervous extremities to the nervous centres, act principally on the sensibility of the limb, and produce, above the point excited, contractions which are irre- gular, and little proportionate to the intensity of the sensations. 7. Finally, the mode of electrization, by reflex action, has little efficacy in the treatment of palsy, and sometimes causes persistent neural- gia in the excited limb. (Duchenne, pp. 99, 100.) Should there be cerebral lesion existing at the time, it might do serious mischief. (Ibid., page 97.) A fact worthy of recollection is, that electric exci- tation of the surface is more effective in bringing on reflex muscu- lar contraction, than excitation of the muscles themselves. (Ibid., p. 33.) 4. Therapeutic Applications. Under the impression that nervous power is nothing more than a form of electricity, which some physiologists were at one time disposed to believe, it was imagined that the latter agent might be made extremely useful in disease, by supplying the deficiency, or correcting the redundancy of the former. Theoretical notions, founded on this basis, have always had, and continue to have more or less influence upon therapeutics. It has been supposed that nervous action in excess might be controlled by the use of negative, and when deficient might be replaced by that of positive electri- city. It has been considered important, through the direction of the electrical current, to imitate the natural presumed nervous cur- rents ; for one purpose to send the influence in one direction, for another in another direction; to procure in certain cases its trans- mission by one set of nerves rather than another; in short, to make use of electricity as if it were really the true nervous fluid, and wield it, as that instrument is wielded under the. powers of life, for the maintenance of all the functions in their due action and subordi- nation. It is true that this supposition of the identity of the two agents has been quite abandoned, under the irresistible contradic- tion of experiment;* but there still remains the undoubted and extraordinary analogy between them, to sustain the conjecture that * This was demonstrated by the experiments of Matteucci and others ; but an observation of M. Duchenne shows, in a striking point of view, the distinction of the two actions, the nervous, namely, and electric. According to that author, the muscles may be wholly insensible to electrical influence, and yet capable of acting under the influence of the will. (Electrisation Localisfe, &c, p. 402.) 534 GENERAL STIMULANTS. [PART II. they might operate under similar laws upon the system, and that consequently electricity might, in many instances, be substituted for the nervous influence, if brought to bear on the system in a similar manner. I fear, however, that it will be necessary to aban- don this view of the powers and uses of electricity. With the facts at present known in relation to its effects on the system, it is best to consider it simply as a universal excitant, capable of stimulating any function or organ upon which, it can be brought to bear directly, into increased activity, and having this special advantage over every other remedial agent, that, by its peculiar nature, it is capable of being directed to, and in a great degree limited in, any part which it may be desirable to operate upon exclusively. It must be borne in mind that it is not by its accumulation that it is capable of fulfilling any therapeutic purpose, but only by movement; and hence it cannot be brought to exert a direct simultaneous influence upon the whole system; for it is scarcely possible so to direct its current, that it should pass at the same time through all parts of the body. It is, therefore, though a universal stimulant, necessarily more or less local in its thera- peutic action at any one time. With its universal stimulant power, it exercises a special exci- tant influence upon the properties of sensation and muscular con- traction ; and upon this influence its most important remedial ap- plications are based. Through, the quick and powerful impression it makes upon the nervous centres, commonly designated as the shock, it is capable, if not carried too far, of arousing the whole system, and thus ful- filling another important indication. By this same shock, in its • more forcible application, it over- whelms, and for a time depresses or suspends function; and by a continued excitant influence, it exhausts excitability, and thus may induce secondary depression. It may consequently be made use of occasionally as ai sedative agent. In the depressing influence of the shock, it has, if properly managed, this great advantage, that, as it acts mainly on the nervous system, the reaction which follows is also mainly nervous, and, therefore, not disposed to lead to fever or inflammation. Again, it may, in certain forms, be made to produce inflamma- tion, and thus act revulsively. The influences hitherto mentioned have been vital. But it also CHAP. I.J DIFFUSIBLE STIMULANTS.—ELECTRICITY. 535 produces chemical effects, of which we may sometimes avail our- selves therapeutically. From what has been just stated, the following practical indica- tions for the use of electricity may be deduced: 1. to excite any particular function or organ which may be inactive or torpid, and which may stand in need of stimulation; 2. especially to stimulate parts in which sensation or the normal power of motion may be defective or wanting, as in paralytic conditions of the muscular power or general sensibility, or of the special senses; 3. to awaken the system generally from a state of torpor, as in asphyxia, syncope, and the poisonous effects of the narcotics; 4. to benumb deranged sensation, or excessive muscular contraction, as in neuralgia, some forms of rheumatism, and tetanus; 5. to operate revulsively by inflaming or irritating the skin, as in various inter- nal and subcutaneous affections, including chronic inflammations, rheumatism, &c.; 6. to alter morbid nutrition by stimulating the disintegrating process, and thus promoting the absorption of indo- lent tumours; and 7. through its chemical agency to effect various objects, as the coagulation of the blood in aneurisms, the solution of stone in the bladder, and the extraction of poisonous metals from the system, for all which purposes it has been recommended and employed. It is, I believe,- in some one of the above methods, or some combination of them, that it operates as a remedial agent. But to render it practically useful, we must be more precise, and consider severally the various diseases in which it may be used; pointing out in each the particular circumstances which may indi- cate or contraindicate it, and the particular modes of application most appropriate. 1. Paralytic Affections. It is only by stimulating the paralyzed part, or the nervous centre or nervous trunk supplying it, that electricity operates in the cure of palsy. It is obvious, therefore, that it is wholly inap- plicable to cases in which the affection depends upon high vascu- lar congestion, inflammation, or other organic disease of the nerv- ous centres. It is not less obvious that it can be of no use, when similar disease in the connecting nerves prevents the transmission of influence from the centres, even though these may be in a healthy state. Under these circumstances, so far from being ser- viceable, it may do serious harm, not only when applied directly to the diseased centres or nerves, but even when limited to the para- 536 GENERAL STIMULANTS. [PART II. lyzed part; for any excitement in this part reacts upon the nervous centres, and of course upon the nerves which convey impressions to them. But, when all excitement in the nervous centres or trunks has subsided, when the organic injury has been repaired, and the continuance of the palsy is owing simply to debility in the centres, or the habit of inertia, or defective nutrition in the paralyzed part, the electric influence is strongly indicated, and often does great service. The same remark is applicable to cases of palsy from wounds, or other mechanical injuries of the nervous centres or trunks. It is vain to stimulate the palsied part until the wound has healed, or the injury been repaired. But after this event, it not unfrequently » happens that the palsy persists, and sometimes seems as if it would persist indefinitely, unless the sluggish centre be stimulated, or the paralyzed part restored, by suitable excitation, to its proper organic condition and due sensibility. Perhaps, under these circumstances, no one agent is so efficient as electricity, because no one can be brought to bear so accurately upon the seat of the disease. In all cases of palsy arising from simple debility or depression of the centres, and all those of local origin, not dependent on irre- parable loss of parts, or other organic injury, much good may be hoped for from electricity. In relation to the precise circumstances under which, in the cases above mentioned as indicating this agent, it may be used with the greatest benefit, to the precise modes, moreover, in which it may be most effectually employed, and the probable results in each case, nothing has appeared which, so far as I am able to judge, approaches in value the recent contributions of M. Duchenne to this branch of therapeutics. In the following remarks on the use of the remedy in palsy, the reader will please to ascribe to that author most of the credit of what he may find in them that is meritorious. In the first place, it may be stated, as a general rule, that appli- cation directly to the palsied part is much more efficacious than when made through the medium of the nerve supplying the part. In palsy, the sensibility and power of motion may both be lost, or either, without the other. In reference to the condition of the muscles, palsies may be classified according to the mode in which the part affected is influ- enced by the electric current; and, by attention to these differences great assistance is gained, not only in diagnosis, but in the proper application of the remedy. There are two classes of the affection; CHAP. I.J DIFFUSIBLE STIMULANTS.—ELECTRICITY. 537 one in which the muscle does not contract, or contracts but slightly and inefficiently, under the electric stimulus, and the other in which it responds readily to the stimulus, and contracts whenever it is ap- plied. In one case the electro-contractility is lost or impaired, in the other it remains untouched. To the former class belong palsies depending on lesions, traumatic or otherwise, of the spinal marrow or nervous trunks proceeding from, it, and the palsy of lead; to the latter all \X\e purely cerebral palsies, whether proceeding from hemorrhage, inflammation, or other lesion, the palsies denominated rheumatic and hysterical, and- those dependent on atrophy or fatty defeneration of the muscle itself, which exhibits this property so long as any of the muscular fibre is left. The electro-sensibility, or susceptibility to painful impression from electricity, is somewhat differently modified. Generally speaking, a loss or diminution of electro-contractility is accompanied with the same condition of electro-sensibility; but with integrity of the electro-contractility, the sensibility may be normal, increased, diminished, or quite lost. Having made these prelimi- nary observations, we will proceed to the consideration of the spe- cial palsies. The reader will remember that it is the electricity of induction, the form, namely, developed by the magneto-galvanic or magneto-electric machines, that is employed, unless the fact is otherwise specially stated. We may sometimes use M. Duchenne's term of faradisation, to signify this mode of applying electricity. 1. Palsy from Cerebral Hemorrhage. This generally assumes the form of hemiplegia; but it may also be paraplegic or local. The reader will bear in mind the observations above made, in relation to the circumstances under which electricity becomes applicable in this affection. No attempt should be made to employ this agent, until there is reason to think that the effused blood has been ab- sorbed, and a cyst or cicatrix only remains, without inflammatory action. It will seldom be proper to commence with the use of it until six or seven months after the commencement of the dis- ease. If employed too early, there will be great danger of pro- ducing hazardous congestion or inflammation of the brain, through the reaction upon it of the local disturbance. To obviate this as far as possible, the excitors should be placed as near each other as may consist with the object of sending the current into the muscle, so as to confine the disturbance within the narrowest limits. If, in cases of cerebral hemorrhage, after from five to eight months, the palsy persists without any contraction of the muscles, a cure may be expected with considerable certainty under faradisation; if there 538 GENERAL STIMULANTS. [part n. be permanent contraction, little hope of a cure need be indulged; as this condition indicates a persistent state of cerebral inflammation or softening, which is not likely to cease. If there be only tempo- rary, irregular, or involuntary contractions, the prognosis is less favourable than with none, but not altogether unfavourable.; as this condition may be owing to an unhealthy excitability of the spinal centres, consequent on a diminution of cerebral poWer. Nor must the mere stiffening of a muscle, arising from its shortening by posi- tion, be confounded with tonic spasm or rigidity. M. Duchenne effected radical* cures in one-twentieth only of the cases, and ame- lioration in about one-quarter. The probability, I think, is that the electricity does not operate altogether locally, in these cases, in restoring voluntary contractility; but that the excitement produced in the muscle, also reacts usefully as a stimulant upon the cerebral centres. It may sometimes be very important, in deciding as to the proper period for commencing with the electric treatment, to know cer- tainly whether the affection is really cerebral. The complete in- tegrity of the electro-muscular contractility in the paralyzed muscle, which characterizes the cerebral cases, might be sufficient sometimes to determine the question. When palsy of the face and tongue only is left after the absorp- tion of the effused blood, it will in general readily yield to this remedy; but it should be employed, at first, with much caution, for fear of involving the brain, from its vicinity. Indeed it would be a good rule, in reference to cerebral palsy in general, to commence cautiously, with short sittings of not more than five minutes, and not repeated oftener than every second or third day, until the state of the brain shall have been sufficiently tested. The intermissions, too, should be distant, as exciting less disturbance of sensation, which is most to be apprehended; while the contraction produced is energetic. The influence should be directed to every paralyzed muscle; and those most deeply affected should be longest and most strongly excited. 2. Palsy of the Insane. This form of palsy is scarcely a proper subject, under any circumstances, for the application of electricity, which is contraindicated by the existing and increasing cerebral lesion. It may, however, sometimes be important not to mistake for it some other form of palsy which may be benefited by this agent. The fact that this variety is always attended with unim- paired electro-muscular contractility may sometimes serve to dis- CHAP. I.J DIFFUSIBLE STIMULANTS.—ELECTRICITY. 539 tinguish it from cases of general palsy, of another origin, in which this property may be wanting, and which may be amenable in some degree to the remedy. 3. Spinal Palsy. This has most frequently the form of paraplegia. When dependent on active congestion, inflammation, or even pres- sure from moderate hemorrhage or effusion, it often, I believe, ends favourably with the removal of the disease in the spinal column; and, in such cases, there is no indication whatever for electricity, which could be productive only of mischief. When the palsy, having originated in an injury or wound of the spine, persists after time has been allowed for the repair of the injury, the remedy may be used with hope of benefit. But as this case falls under the cate- gory of traumatic paralysis, of which I shall treat separately, it is unnecessary to say more of it at present. When the palsy continues in consequence of previous hemorrhage, the same prognosis and indications exist as in cerebral hemorrhage. But, unhappily, most cases of obstinate spinal paraplegia depend on spontaneous organic lesion of the medulla, generally of inflanfmatory origin, and little is to be expected from any remedy. Electricity should be used only when the palsy has survived all traces of spinal inflammation, under which circumstances it is indicated, and will no doubt often do good. I presume that most of the cases of paraplegia, not hys- terical, which end in recovery under the use of electricity and nux vomica, are of this character. In spinal paralysis, according to M. Duchenne, there is a complete absence of electro-muscular con- tractility and sensibility. I should say that there might be good reason to refer the disease to the spine when this condition is pre- sented; but it does not necessarily follow, because sensation and voluntary motion are lost in the lower extremities, in consequence of disease in the spinal marrow, that therefore reflex action should cease; for the lesion may be seated only in the conducting fibres by which the brain communicates with the limbs, and the spinal centres themselves may be untouched. Such, I believe, are the many cases of. paraplegia which M. Duchenne is indisposed to con- sider spinal, because wanting in what he deems to be the character- istic relation to electric influence, and which are benefited by fara- disation. 4. Traumatic Palsy. This is one of the forms of palsy in which electricity exercises the most extraordinary powers. It is applicable, of course, only after the wound or injury of the nerve has healed, or been repaired; but, after this event, there is occasionally left 540 GENERAL STIMULANTS. [PART II. behind a very paralytic condition, which shows no disposition to recovery, and may go on indefinitely, unless relieved. Scarcely any length of time offers an obstacle, in these cases, to the bene- ficial effects of electricity, unless the injury has been such as in its nature to be irremediable, or the muscle has undergone complete degeneration from want of use. Cases have been cured after a duration of four years. The application should be made every other day, and eight, or ten minutes at a time. The muscles are often much atrophied, and, as before stated, electro-muscular con- tractility and sensibility have been lost. The first step towards recovery is usually the excitation of painful sensation, with heat in the part. After this follows an obvious improvement in the nutrition of the muscle; the power of voluntary movement next returns; and all this may occur before the electro-muscular con- tractility has been restored. At length, however, the muscle con- tracts under the electric excitement, and the cure is completed. If electric contractility should not have been wholly abolished, it is unnecessary to delay the use of the remedy; but otherwise it would be best to wait for the complete repair of the injury, even so long as from four to ten months. Each muscle should be treated according to its condition. The more it is atrophied, and the less is its contractility, the more intense should be the current, and the more rapid the intermissions. The duration of each sit- ting should be ten or fifteen minutes at furthest; and rarely more than one minute should be given to each muscle. The operation should also pass rapidly from muscle to muscle, returning several times to each, in order to prevent too great fatigue to any one. Cures may be effected in the majority of cases. The mean duration of treatment is two or three months; but sometimes years are re- quired before a complete cure can be effected. 5. Rheumatic Palsy. This name has been given to a variety of palsy which comes on after exposure to cold. It is sometimes pre- ceded by pain, which disappears, leaving the palsy behind; some- times is wholly unattended with pain. It may occur in any part of the body, but is most common in the forearm and shoulder. Sometimes it affects the face through the seventh pair of nerves, and sometimes also probably appears in the form of paraplegia; in which case I have no doubt the seat of the rheumatic disease is in the spine. It is often a serious affection; the muscles becoming atrophied, and sometimes contracted so as to produce a good deal of deformity. It is distinguished from lead-palsy by the unimpaired CHAP. I.] DIFFUSIBLE STIMULANTS.—ELECTRICITY. 541 electro-muscular contractility and sensibility. In the face, it may sometimes be difficult to determine between it and cerebral palsy; but, independently of the facts that, in the latter case, there are generally obvious head symptoms, and palsy elsewhere, there is one diagnostic character worthy of attention. In hemiplegia we seldom meet with palsy of the orbicular muscle of the eyelid, and the inference is probable that, when cerebral palsy is confined to the face, this phenomenon will be wanting. When it occurs, there- fore, in facial paralysis, the affection may be considered as probably seated in the seventh pair. Correct diagnosis is here very im- portant; as, if the affection be cerebral, electricity is contrainclicated for a long time after the attack; whereas,, if it be mere rheumatic palsy of the seventh pair, the remedy may be applied speedily. Rheumatic palsy may almost always be cured by faradisation. The natural tonic contractility is often restored, thereby removing de- formity, before the muscles come under the control of the will. The muscles sometimes assume their proper symmetry three or four weeks before a single voluntary movement has been made by them. In the affection of the seventh pair, which is not unfre- quently attended with an unsightly distortion of the features, it is important to examine each muscle carefully, and give it the due share of electrical excitation. 6. Hysterical Palsy. When palsy attacks hysterical women, and can be referred to no precise origin, it is considered usually as entitled to this designation. It is characterized by retaining the electro-muscular contractility, but is generally attended with dimi- nished sensibility of the muscle. It will generally yield to elec- tricity; though, in some rare instances, it resists this, as all other remedies. Under such circumstances, however, it is probably something more than merely hysterical. The faradisation should be applied to every organ affected, and the application continued for some time after recovery. In consequence of the great nervous excitability of the patient, it is best to commence very lightly spending the first sitting in doing little more than accustoming the patient to the manipulations; and gradually increasing as she is found to tolerate the remedy. The diminished sensibility of the muscles renders rapid intermissions of the current necessary; but watchfulness must be observed, lest a little too much local disturb- ance should bring on an attack of hysteria. The remedy should be directed as well to the nervous trunk as to the parts affected. 542 GENERAL STIMULANTS. [PART II. Sometimes it may be sufficient to stimulate the cutaneous sensi- bility; but this is more painful, and will not often be submitted to. 7. Lead Palsy. If the muscles retain but a small portion of their electric contractility, it may be considered certain that the disease will recover easily and rapidly; and, even with a complete loss of that property, a favourable result may be expected, though it will be longer postponed. When, with the loss of the contract- ility, there is at the same time a great diminution of sensibility, with atrophy conjoined, the cure is still more difficult and pro- tracted. But the remedy will almost always succeed in the end. From thirty to one hundred sittings may be required, at the rate of three weekly; but, by operating at shorter intervals, the length of time required may be diminished. An intense current with rapid intermissions should be used. It is desirable to excite painful sensations; and as these are attended sometimes with considerable constitutional disturbance, it is impossible in many instances to have quickly repeated sittings. Hence the length of time often required for the cure. 8. Progressive Fatty Muscular Atrophy. Under this name M. Duchenne refers to a disease long known as a variety of general palsy, but which has only recently become well understood. It consists essentially in a gradually progressive atrophy of the muscles, with fatty degeneration of the fibres; and the paralytic phenomena are ascribable to the organic change.in the muscle. The credit of first ascertaining its true nature appears to be due to M. Cruveilhier, who demonstrated the existence of fatty degeneration of the affected tissue. It is distinguished from all other forms of palsy, by the irregular and apparently capricious method in which the muscles are struck with the disease; so that in the vicinity of a round plump muscle, is a cavity consequent upon the atrophy of another, thus giving a quite characteristic aspect to the complaint. The only other pathological lesion found, is a wasting or atrophy of the anterior roots of the corresponding spinal nerves, which has been noticed in one case. The spinal marrow is quite sound; and it is uncertain whether the nervous atrophy noticed was a result or cause of the affection. A singular fact in relation to the disease is that the muscles retain their electric contractility, or contract under electric excitement, as long as any of the fibres remairyj^estroyed. I^t was generally considered quite incurable; but M. Duchenne has monstrated that it may at least be arrested in its course by means faradisation; and has even rendered it probable that the muscle CHAP. I.J DIFFUSIBLE STIMULANTS.—ELECTRICITY. 543 may recover its normal structure, if it has not been so far destroyed, before the commencement of treatment, as to give no sign of con- traction when electrically excited. At least muscles which have been apparently wasted away almost to nothing recover their health- ful size, and their power of action. It is said that the atrophy pre- cedes the fatty degeneration; and it may be supposed that the shrink- ing is only in consequence of the absorption of the inter-fibrous matter; but M. Duchenne thinks that new fibres are created; and, if so, there is no reason why the muscle might not grow after par- tial destruction from fatty degeneration, as well as from any other cause. The treatment of the affection generally requires an appa- ratus of great force and rapid intermissions; and a feeble instru- ment may fail altogether. Each application, however, should not continue, longer than eight or ten minutes, for fear of exhausting the muscle, and thus hastening its destruction. The sensibility of the muscles, which is at first blunted, in general rapidly increases, and it is necessary gradually to diminish the energy of the treat- ment; but it should be sustained at the highest point possible. A similar affection is sometimes met with in infancy, and may be treated in the same way. 9. Paralysis of the Bladder. — Dysury. — Incontinence. Difficulty in evacuating the bladder sometimes proceeds from palsy or debi- lity of the abdominal muscles; the urine being forcibly expelled if a catheter is introduced. In such case9, the affection will generally yield promptly to faradisation of the abdominal muscles. In pro- per palsy of the muscular coat of the bladder, the electricity may be applied in the manner already described (see page 529), either by excitors introduced into the rectum and bladder, or into the bladder alone, or one. into the bladder, and the other moistened and moved over the hypogastric region externally. Sometimes there is loss of sensibility in the mucous coat of the bladder; so that the urine accumulates because the patient is unconscious of its presence. All that is requisite for its evacuation is the exercise of the will. Here it becomes advisable to make the application directly to the inter- nal coat. In incontinence depending on paralysis of the sphincter or neck of the bladder, one excitor should be introduced into the rectum, and moved over the parts corresponding with the levator ani, while the metallic extremity of the other is brought, through the urethra^ into apposition with the neck of the bladder. 10. Impotence may sometimes be usefully treated with electricity " 544 GENERAL STIMULANTS. [PART II. in this manner, applied to the organs of generation externally, and to the vesiculae seminales through the rectum or urethra. (See page 531.) 11. Paralysis of the Rectum, and of the Sphincter Ani. Palsy of the rectum, which is indicated sometimes by an obstinate constipa- tion, may often be relieved by faradising the rectum directly, in the manner before described. (See page 529.) Prolapsus ani, which is generally, when considerable, connected with relaxation of the sphincters of the anus, and in incontinence of the feces dependent on the same cause, one excitor may be in- troduced into the anus, and the other, in the form of a wet sponge, applied externally to the peringeum. The operation may be con- tinued eight or ten minutes. Obstinate cases of prolapsus in chil- dren have been promptly cured by this treatment. 12. Palsy of the Larynx.—Aphonia. When not dependent on organic lesion, or symptomatic of some other disease, this will sometimes yield to local faradisation applied to the muscles from without, and the skin also, or by operating through the pharynx. (See page 530.) The loss of the strength and character of the voice, often incurred by those who speak much in public, may be relieved by the same measure. Other modes of applying the remedy, as by successive discharges through the organ from a powerful bat- tery, by a galvanic current introduced by means of acupuncture, and by the simple apparatus of a small zinc and silver plate (see page 505), one on one side, the other on the other of the larynx, have also proved successful. But in these cases electricity, like all other measures, not unfrequently.'fails without any assignable cause. 13. Cutaneous Anaesthesia, or Loss of Sensibility in the Skin, The loss of sensibility in paralytic muscles is generally remedied at the same time with loss of motion. But sometimes the two condi- tions exist separately; and insensibility of the skin is not a very uncommon affection. In this isolated state, when not dependent on organic lesion of the nerves, it is generally an hysterical affec- tion, and yields readily to the electrical influence. When it affects the face, the best method of applying the remedy is by the hand which generally proves sufficient for the cure. If not the blunt excitors may be applied, and these will often answer for other parts of the body. But sometimes a more energetic impression is re- quired for the surface generally, which may be obtained by means of "fustigation" with the brush of wires. (See page 518.) The ex- CHAP. I.J DIFFUSIBLE STIMULANTS.—ELECTRICITY. 545 citors should generally be carried from one point to another of the surface, until the whole affected part has been electrified. Some- times, however, the insensibility is so great that it is necessary to leave the bunch of wires for some time in contact, until sensation is produced. First a tingling is felt, then a burning sensation, and this soon increases so that it can be borne no longer. As the skin becomes more sensitive, it is necessary to return to the blunt excit- ors again. In a few instances the return of sensibility, in a small space, is followed, without further application, by its extension over the whole part affected; but much more frequently it is necessary that every part should be subjected to the contact of the instru- ments. Sometimes the affection returns after having yielded, but may be cured by repetitions of the application. It is in the hands and soles of the feet, that the inconvenience of this paralytic con- dition is greatest, and the cure of it most important. 14. Amaurosis. Electricity should never be employed in this affection, if there be any reason to suppose that it depends on active congestion, inflammation, or other organic disease in the nervous centre of vision, the nerve itself, or its expansion on the retina. In purely functional cases, it may sometimes be used with benefit; but galvanism is here more effective than the induced electricity. In doubtful cases, it may be applied over the face and about the orbit in the first place, in order to excite the eye through the rami- fications of the fifth pair, which have a peculiar influence over vision when galvanically excited; and, if this measure is unsuccess- ful, the application may be made to the ball of the eye, in order directly to excite the optic nerve; one pole being placed in the orbit, and the other at the back of the neck. Acupuncture of tha parts about the eye has been brought to the aid of galvanism; and many cures of incomplete, and some of complete amaurosis have been reported, supposed to have been obtained in this way. (See Channing, 3fedical Application of Electricity, Boston, 1852, p. 87.) The electro-magnetic instrument with two wires may also be used for this purpose, though less effective than the battery. 15. Deafness. In nervous deafness, faradisation of the chorda tympani has been followed by happy results. Great care must be exercised in conducting this operation. While the patient lies on his side, the meatus auditorius should be half filled with water; a wire connected with one of the poles should then be introduced so as to touch neither the tympanum nor the walls of the passage; and the wet sponge excitor, connected with the other pole, should then be vol. i.—35 546 GENERAL STIMULANTS. [PART II. applied to the nape of the neck. The slightest power of the in- strument should be first exerted; not greater than may be sufficient to cause the least possible sensation when the excitors are applied to the end of the tongue; and then increased as may be found necessary. A slight buzzing sound is first produced by this opera- tion in the ear when healthful, followed by tingling, and then, with the increase of the force of the current, by severe pain: the tingling, with a sense of numbness, extending to the side and anterior part of the tongue. There is also a peculiar taste produced. M. Duchenne has seen this process cure, in a short time, cases of deafness which had long resisted energetic measures, under the most competent practitioners. It is not impossible that the same measure might be useful in deafness of organic origin, provided all acuteness of symp- toms has passed. The functional disorders of hearing which are so common, and so frequently alluded to by writers under the name of tinnitus aurium, often yield with the utmost facility to the remedy. It is asserted that galvanism has proved useful by promoting the absorption of pus and coagulable lymph in the cavity of the tym- panum, and in exciting the secretion of wax when deficient. 16. Smell and Taste. In paralytic conditions of these functions, as well as in palsy of the muscles of the tongue, the application of electricity may be made in the manner stated in page 530. Stammering, which may possibly sometimes be connected with debility of the muscles of the tongue, and other parts concerned in articulation, is said to have been benefited by a galvanic current directed from the tongue to the surface of the throat. 2. General and Local Relaxation, Debility, or Torpor. Under this head may be enumerated a considerable number of affections in which electricity has been found more or less useful. In asphyxia and syncope it may be resorted to in reference to the shock upon the system, and, in the former, to promote contraction of the diaphragm. In asphyxia, or a state approaching it, arising from, narcotic poisoning, especially that from opium, it has been em- ployed, with striking success, in several cases, among which may be mentioned one recorded by Dr. Page, of Valparaiso, and a second by Dr. James Russel, of London. Electro-magnetism was used in both these cases, the direction being, in the one case, from one side to the other through the heart; in the other, from the back of the neck to the sternum, by which respiration was restored. In asphyxia from drowning, a current of galvanism has been passed into the diaphragm, by cutting down to the muscle below the seventh rib CHAP. I.] DIFFUSIBLE STIMULANTS.—ELECTRICITY 547 with the apparent effect of saving life. Acupuncture would pro- bably have answered the same purpose. In these cases of asphyxia and syncope, it is probable that the mere shock upon the nervous centres, occasioned by pain, has great influence in rousing the patient; and, for the production of this effect, nothing is more powerful, prompt, and safe than the electro-magnetic current with rapid intermissions. Artificial respiration, when desirable, may be most conveniently produced, according to M. Duchenne, by calling the diaphragm into action, through a vigorous impression on the phrenic nerve, where it passes the anterior scalenus muscle. This nerve, after the union of its three roots, descends from without inwardly before the ante- rior surface of the scalenus. It is at this point that it is necessary to make the requisite application. Some difficulty is thrown in the way by the sterno-mastoid and platysma-myoid muscles, which cover the scalenus. But by depressing the skin from without inwards, with two fingers placed along the outer border of the clavicular fasciculus of the sterno-mastoid, then separating the fingers, and maintaining the pressure, access may be obtained to the anterior surface of the scalenus, without the interposition of the other mus- cles. One of the excitors is to be placed between the fingers, in such a manner as to cross the direction of the phrenic nerve. While an assistant holds the instrument in this position, the second excitor is to be similarly applied on the opposite side. Then the operator takes hold of both by their isolated handles, and the machine is set in motion. Any of the inductive machines will answer the pur- pose, if properly graduated, and of very rapid intermissions. The excitors should end in a small metallic cone, which should be co- vered with moist leather. The instant that the current is passed, the lower ribs expand, the abdominal walls rise, and air rushes with sound into the lungs. After a second or two, the current is broken, the walls of the chest subside, and expiration takes place. To complete the expiration, an assistant presses upon the chest and abdomen. In another second, the operation is resumed; and this artificial respiration, perfectly imitating the natural, may be kept up as long as may be necessary. (Electrisation Localisee, p. 485-6.) In poisoning from opium and other narcotics, even when threat- ening symptoms of asphyxia have not yet appeared, the painful excitation of the electro-magnetic machine is useful, independently of its influence on respiration, by stimulating the nervous centres, and sustaining life until the action of the poison has passed. A 548 GENERAL STIMULANTS. [PART II. case of this kind has been reported by Dr. Bullock, of Wilmington, Delaware. (See Am. Journ. of 3Ied. Sci., N. S., xxviii. 575.) In general muscular relaxation, the excitant influence of electricity may perhaps sometimes be usefully employed, by rapidly faradising the different muscles successively. In debility of various functions it has been used with supposed, and no doubt often with real benefit. In dyspepsia, a current of galvanism may be passed from the nape of the neck to the epigastrium, or immediately through the stomach, from before backward. Torpid, liver may be treated in the same way, the current being sent in various directions through the organ, so as to traverse the whole of it as far as possible. Constipation dependent on inertia of the bowels has often been treated advantageously with electricity. Allusion has already been made, under palsy of the rectum, to the mode of treating it when arising from that cause. In other cases, the current may be made to pass from the fundament, or from an excitor introduced into the rectum, to the pit of the stomach, or to various points over the surface of the abdomen; or it may be directed through the bowels from before backward, or from side to side. Amenorrhoea has been treated by electricity with great success. Dr. Golding Bird states that he has never known it to fail in ex- citing menstruation, when the uterus was capable of performing that function. (Lond. 3Ied. Gaz., June, 1847.) After proper attention to the general health, a dozen shocks of the Leyden jar were passed through the organ, from the sacrum to the pubes, and the measure was repeated daily, if necessary. Flooding after delivery is said to have been effectually controlled by galvanism, which produces contraction of the uterus. Dr. Rad- ford, who has employed the remedy for this purpose, states that it may be so applied as to excite not only tonic, but also intermittent contraction, and suggests it as a means of hastening tedious labours. He used a coil machine, applying one pole to the os uteri, and the other to the walls of the abdomen over the fundus. The conductor introduced into the vagina must be covered with a non-conducting material, except at its extremity. (Prov. Med. Journ., Dec, 1844.) In a cool, dry, inactive state of the skin, especially when connected with interior disease, much benefit may be expected from electric stimulation of the surface, which is accomplished, in the mildest method, by withdrawing sparks from the body in the electrical CHAP. I.] DIFFUSIBLE STIMULANTS.—ELECTRICITY. 549 bath; in the severest, through the agency of the electro-magnetic machine, and M. Duchenne's wire excitor; and, in intermediate grades, by the different arrangements at command. Indeed, elec- tricity, in its various forms and modes of application, affords to a practitioner, suitably provided with apparatus, a powerful method of revulsion to the surface, of which he may avail himself in a great number of diseased conditions. Indolent ulcers may be stimulated into a healing condition by making their surfaces the recipient of the galvanic current, either through the moist sponge excitor, or their own wet dressings con- nected with one of the poles, or by covering thernwith a plate of silver or copper forming one of the constituents of a galvanic arrangement, of which a zinc plate, applied to another portion of the surface, and connected with it by a wire, may form another. 3. Neuralgic and Rheumatic Affections. Neuralgia. Electricity has been found curative in many cases of this affection, operating, it would seem, sometimes directly by the benumbing influence of its excessive power, sometimes revulsively. Excessive cutaneous sensibility, which is a frequent accompaniment of hysteria, yields in general readily to faradisation. The treat- ment is applicable only to purely functional cases, and not to those dependent on lesions of the nerves or their centres. In the appli- cation of the remedy, the skin should be kept perfectly dry. Some- times fustigation may be used; in other cases, the blunt excitors, carried from point to point over the sensitive part, will be sufficient. The instrument should work with rapid intermissions, and with an intensity as great as the patient can well bear; and the operation may be continued from two to five minutes. A feeling of numb- ness follows the first pain, with an agreeable sense of relief. Some- times a single sitting is sufficient; but more frequently the com- plaint returns after some hours, though with diminished intensity; and several applications are required before the cure is effected. In many cases, however, only temporary relief is obtained. A similar excessive sensibility of the muscles sometimes occurs, which may either be conjoined with the cutaneous affection, or may coexist with insensibility of the skin. Though usually more re- sistant than the pure cutaneous affection, it often yields promptly to a similar excitation of the surface. In neuralgia of the face, tongue, &c, galvanism and electro-mag- netism have both been used with occasional success; the former 550 GENERAL STIMULANTS. [PART II. being sometimes aided by acupuncture; but the general result has not been very encouraging. Sciatica is an extremely obstinate form of disease, sometimes apparently purely neuralgic,'sometimes rheumatic, and. m otter cases attended with inflammation of the neurilema. When purely functional, it will sometimes yield to faridisation, after vain at- tempts to cure it by other means. Occasionally it will give way, for a time, to a sudden and violent pain excited by fustigation, or the contact of the wires, in any part of the surface. The measure, however, is more effectual when put in operation in the vicinity of the part. The skin must be thoroughly dried, so as to prevent the current from penetrating to the nerve, in which case the pain is aggravated. The relief at first procured is temporary; but, by repeating the fustigation upon each return, or at relatively short intervals, for six or eight times, the disease will often yield entirely. The most obstinate cases in the hospitals have recovered under the remedy. Electro-puncture is asserted also to have been used with advantage; but the cutaneous excitation is preferable. Angina pectoris, in one striking instance under the care of M. Duchenne, yielded speedily to electro-cutaneous excitation applied to the mammary region. At the moment of the application of the two metallic excitors, which proceeded from a powerful machine graduated to the maximum, and working with rapid intermissions, the patient uttered a loud cry, so as to render it necessary to inter- rupt the operation; but the pain of the angina, which had been excessive, ceased at once. By repeating the operation at each return, the disease appeared to yield entirely. In other neuralgic cases, whether external or in the viscera, the remedy has operated with equal success. It should be recol- lected that it is the cutaneous excitement that is produced here; the current being prevented from penetrating beneath the skin by drying it thoroughly with some absorbent powder. Rheumatism. In the neuralgic form, this complaint will often yield with great facility to the electric influence; and it is probable that many of the cases treated successfully under the names of neuralgia, sciatica, angina pectoris, &c, have been either of this character, or gouty. But ordinary muscular subacute rheumatism, such as lumbago, pleurodynia, torticollis, &c, will also frequently yield to the remedy as to a charm. Sometimes a single faridisation of the skin is sufficient to effect a cure; but more frequently the pain returns, and five or six applications may be necessary for the purpose. CHAP. I.] DIFFUSIBLE STIMULANTS.—ELECTRICITY. 551 It should not be abandoned until the last vestige of pain has been removed. Rheumatic arthralgia will also often yield happily to the remedy. To acute inflammatory rheumatism it is wholly inapplicable. In chronic rheumatism of the joints, galvanism, with the aid of acu- puncture, has sometimes proved efficient; but electro-magnetism would probably be safer, as less likely to excite inflammation, with an equal degree of power. Rheumatic contraction of the muscles, which not unfrequently affects the face, neck, shoulder, and parts of the chest, and which has a very disagreeable distorting effect, will generally yield to this remedy ap- plied to the skin. M. Duchenne also cures the affection by bringing the antagonistic muscles into play through the electric current, and thus establishing an equilibrium between'them. 4. Spasmodic Affections. Many of these complaints have been treated by electricity, with variable success, as hysteria, epilepsy, chorea, &c, and Matteucci even ventured to recommend it in tetanus, on the ground that a continu- ance of the electric current exhausts after a time the excitability of the muscles; but experience has not yet pronounced in its favour. In spasmodic asthma great relief is said to have been sometimes ob- tained by passing a current of galvanism from the nape of the neck to the pit of the stomach. Hiccough has been treated effectually, it is said, in the same way. 5. Indolent Swellings. Various tumefactions, hypertrophic, rheumatic, and scrofulous, the result of simple chronic inflammation, or left behind after sprains or other injuries, have from time to time been treated by electricity in its different forms, and with more or less success. The remedy probably operates as a simple excitant, hastening suppuration when the tendency is to that result, promoting the absorption of exuded fibrin and other secretions or depositions, and stimulating the dis- integrating process, so as to favour resolution. 6. Therapeutic Application of Chemical Influence. Electricity has been employed for three distinct purposes, in reference to its chemical reagency: 1. for the cure of aneurisms, through its coagulating influence upon the blood; 2. for the solu- tion of calculi in the bladder; and 3. for the abstraction of metallic substances from the system. 552 GENERAL STIMULANTS. [PART II. 1. Cure of Aneurisms. It has been experimentally proved that a current of galvanism, sent through the blood in the vessels, has the effect of coagulating it. By some, this effect is ascribed to a chemi- cal, by others, to a vital influence. It was supposed that, directed through the blood of an aneurismal tumour, it might have the same effect, and that it might thus be employed with some hope of success in the treatment of these tumours. The experiment has been tried, and some cases of apparent cure, with others of failure, have been reported. The needles for this purpose should be made of gold or platinum; because, if of steel, they might undergo chemical change, and thus become irritant in their course. They should be introduced so that their points may enter the blood, and there should be no contact between them. A battery of ten or fifteen pairs may be used, and the operation continued fifteen or twenty minutes, or longer. One of the risks incurred is of irritating the sides of the opening into the tumour, so as to form an eschar, which, on separating, may give exit to the blood. To avoid this, it has been proposed to coat the needles with shellac, except at the points; but this does not seem to have answered. The same measure has been employed for the obliteration of vari- cose veins, with apparent success, in several instances. 2. Solution of Calculi in the Bladder. The idea of destroying cal- culi in the bladder by means of the decomposing power of galvanism having been suggested, MM. Prevost and Dumas performed some experiments on a phosphatic calculus out of the body, by which they succeeded in partially dissolving and utterly breaking up the stone through this influence. They afterwards proved, by intro- ducing a calculus into the bladder of a dog, and, by means of two insulated conductors passed through the urethra, bringing to bear upon it a powerful battery, that the operation might be performed with safety, and with some chance of success within the body. But I am not aware that any useful results have been obtained by the process; the prominent objection to it being the insoluble cha- racter of the urinary calculi, which prevents a vigorous decomposing influence from being exerted upon them. 3.- Elimination of Metallic Substances from the System. Upon this subject, some interesting communications have been made to the journals, imparting most important results, should they be con- firmed by time and further observation. A memoir was presented to the Academy of Sciences of Paris, at its sitting of Jan. 29, 1855, by MM. Verges and A. Poeyr in which it is affirmed that metallic CHAP. I.J DIFFUSIBLE STIMULANTS.—ELECTRICITY. 553 substances, which have long been retained in the system, may be withdrawn through the decomposing agency of galvanism. The individual to be acted on is placed up to his neck in an isolated metallic bathing tub, and seated upon a wooden bench, with his legs extended horizontally. The liquid in the tub is water, acidu- lated slightly with either nitric or muriatic acid for the extraction of mercury, silver, and gold, or sulphuric acid for that of lead. The bathing-tub is then connected with the negative pole of a galvanic battery, and a conductor attached to the positive pole is placed in the hand of the patient, sometimes in one hand, sometimes the other. To protect the hand against the calorific influence of the current, the wire is terminated by a large handle of iron, sur- rounded by linen cloth. Through the action of the current, which now circulates through the body, and passes out in all directions from the surface, the metallic substances contained within it are decomposed, and the metal deposited in visible patches upon the metallic surface of the tub. The discovery of this power of gal- vanism was stated to have been made accidentally in New York, in April, 1852, by M. Vergnes, who, being engaged in the business of galvanic silvering and gilding, and having thus become affected with ulcers on the back of his hands, which refused to yield to ordinary measures, was cured by the introduction of his hands into an electro-chemical bath, positively excited. A metallic plate, in connexion with the negative pole, became covered in fifteen minutes with a coating of silver and gold, extracted from the flesh. A few repetitions of the bath were sufficient to effect a cure. (Arch. Gen., Mars, 1855, p. 371.) In another account of the same commu- nication, extracted by the London Medical Times and Gazette from La Presse, it is stated that the memoir was presented to the Academy through M. Dumas, that M. .Poey was a resident of Havana, and that experiments were made before the Faculty of Medicine, of that city, which succeeded perfectly. An energetic battery of thirty pairs of plates was used. (3Ied. Examiner, N. S., xi. 288.) But much further investigation is requisite, before this therapeutic power of galvanism can be admitted. There are individuals who have been so unfortunate as to have become discoloured over their surface by the internal use of nitrate of silver. A restoration of the healthy colour, in one of these persons, would afford irrefragible proof of the efficiency of the measure. 554 GENERAL STIMULANTS. [PART II. CLASS X. ARTERIAL STIMULANTS. These are diffusible stimulants operating especially on the cir- culatory function, with little comparative influence on the nervous system. They have sometimes been called Incitants or Simple Stimu- lants ; but it has seemed to me that the name here given best ex- presses their peculiar character. Of course, they in some degree affect the nervous system; for one great general function can scarcely be considerably excited without more or less involving the others; but their primary and prominent action is upon the heart and arteries. The obvious effects produced by the arterial stimulants, as a class, are a sensation of warmth or heat in the stomach, increased frequency and force of pulse, and augmented temperature of the surface. They, in general, also act as powerful irritants to the skin when directly applied to it, and indeed to any sensitive part with which they may come into contact. Each one, however, has characteristic properties, distinct from that of simple diffusible stimulation. They may be employed in all cases calling for stimulation, when the actions of the heart are depressed, and are frequently em- ployed both externally and internally, with the same object. They are specially applicable, and preferably to the other classes of dif- fusible stimulants, in those cases enumerated in the general obser- vations made upon diffusible stimulation, in which reaction must follow the state of prostration. In the collapse attendant upon severe injuries, and that which occurs at the commencement of febrile diseases, they are peculiarly indicated; because they have no special influence on the brain, and are not likely, therefore, as alcohol and some other cerebral stimulants, to affect that organ injuriously, when reaction takes place. They are, in general, contraindicated by gastric inflammation, because brought into immediate contact with the inflamed part and acting upon it with their whole stimulant power. A great number of medicinal substances have the property of CHAP. I.] ARTERIAL STIMULANTS.—CAYENNE PEPPER. 555 stimulating the circulation. Not to mention the nervous and cere- bral stimulants, which, in accordance with their very definition, have this power, and, in some instances, in a very high degree, there are many others distributed among the various classes. But all of these have other properties which serve to place them else- where, and for which they are chiefly employed as medicines; and, though their action upon the heart and arteries may sometimes be incidentally useful, they are seldom or never employed with an exclusive view to this effect. The aromatics approach nearest in their properties to this class; but they are much more powerful as local than as general stimulants; and their application, as internal remedies, is almost restricted to affections of the alimentary canal. Mustard, copaiba, guaiac, mezereon, cantharides, savine, and many others, more or less excite the circulation; but each one of them belongs to some other class, as the emetics, diuretics, diaphoretics, emmenagogues, or alteratives; and they are almost never given as arterial stimulants simply. The medicines strictly belonging to this class are very few, and might, perhaps, be still further limited; for carbonate of ammonia, which I attach to it, has, in addition to its influence over the heart and arteries, an action upon the nervous system, which would almost entitle it to a place among the nervous stimulants. I. CAYENNE PEPPER CAPSICUM. U.S., Lond., Ed., Dub. Syn. Red Pepper. Origin. Cayenne pepper is the fruit of Capsicum annuum, an annual plant from one to three feet high, inhabiting intertropical America, and supposed also by some to be a native of the East Indies. It is cultivated in most civilized countries, and abundantly in the United States. Other species contribute to the Cayenne pep- per of commerce. The fruit as grown in Cayenne, in South America, from which the medicine derived its common name, is said to be the product of Capsicum frutescens, and perhaps also of C. baccatum. Much of the powdered Cayenne pepper used in this country is brought from the W. Indies. Under the name of Liberia pepper, considerable quantities of a small fruit, about an inch in length, are imported from the coast of Africa. It is probably identical with that known in England as Guinea pepper, which Dr. Pereira ascer- tained to be the product of C. frutescens. 556 GENERAL STIMULANTS. [PART II. Properties. This fruit is a light shining berry, of various size and shape, and usually of a red or orange-red colour. The variety most employed in medicine is of a conical form, about as long as the fino-er, rounded at the base, and somewhat curved towards the smaller end. When cut open, it is seen to have two or three cells, containing flat whitish seeds, and a very loose medulla. When dried, it shrinks, becomes wrinkled, and assumes a darker colour. As employed in medicine, capsicum is in the form of a powder, which is bright-red when fresh, but gradually fades, and in time loses almost all its colour. That imported is usually lighter co- loured than our own, being brownish-yellow rather than red. It has a slight, peculiar, somewhat aromatic odour, and a bitterish, extremely pungent, burning, almost fiery taste, remaining long upon the tongue. It imparts its virtues to water, but more freely and largely to alcohol. Active Principle. The virtues of capsicum probably reside in a peculiar resinoid principle called capsicin, which is obtained by sub- mitting the alcoholic extract to the action of ether, and allowing the ethereal solution to evaporate. As thus procured, however, it is not pure; and the active principle cannot be said to have been entirely isolated. Capsicin is of the consistence of a thick oil or ' soft resin, of a reddish or yellowish-brown colour, of an almost in- supportably hot and pungent taste, slightly soluble in water, and freely so in alcohol, ether, and oil Of turpentine. It does not, like the volatile oils, rise with the vapour of boiling water; but, when strongly heated, it gives forth fumes which are excessively pungent to the nostrils. Effects on the System. Cayenne pepper produces a sensation of heat in the stomach, diffuses a general glow over the system, and somewhat excites the pulse. In ordinary doses, it has no observ- able effect whatever on the brain, or general nervous system. Lo- cally it is powerfully stimulating, more so proportionably than in its operation upon the circulation, and in this respect approaches the aromatics. On the skin it acts as a rubefacient. When taken into the stomach in excessive doses, it is capable of producing gastro-intestinal inflammation, with violent burning pain, vomiting, and purging; and is said to have caused vertigo and a sort of intoxi- cation, but on insufficient authority. Any cerebral symptoms it produces are probably secondary and sympathetic. Used too largely and too long as a condiment, it may give rise to chronic irri- tation or secondary debility of stomach, and by an over-stimulation CHAP. I.] ARTERIAL STIMULANTS.—CAYENNE PEPPER. 557 of the blood-making functions, may favour the development of gout. Therapeutic Application. The medicine may be used for the general purposes of the arterial stimulants, though less excitant to the circulation than others of the class. It has been employed as a safe stimulant in the cold stage of pernicious fever, and occasion- ally, as an adjuvant to other stimulants, in low typhoid fevers, when the stomach has been torpid, and the patient troubled with flatu- lence. In the low and malignant forms of scarlet fever, it has been much and advantageously employed; and it may be considered as among the best stimulants in that affection. I have myself given it frequently, and been satisfied of its beneficial effects. It is used both internally, and as a gargle. In the latter mode of application, I know nothing better adapted to that condition of the fauces, in which the mucous membrane has assumed a dark red colour, and has begun to slough, or appears to be on the point of doing so. But it has also seemed to me useful in almost all varieties of the sore-throat of scarlatina, in which, so far from irritating, it often soothes; at least patients have frequently assured me that, though it burned their mouth in its passage, it had quite a contrary effect upon the fauces, which it greatly relieved. In the early stage of scarlet fever, there is sometimes great back- wardness in the appearance of the eruption. A few purplish points may serve to indicate the nature of the case, and the vain struggle of the system to throw out the irritation upon the surface. Along with this condition there may be coma, or a disposition to it, with an appearance of general prostration. In such cases, Cayenne pepper may be freely used, both internally, in connexion with other stimulants, and outwardly as a rubefacient. It has been used, as a pervading stimulant of the capillaries, in old cases of palsy; and has recently been recommended highly in uterine hemorrhage, in doses of from five to ten grains, repeated every ten minutes until the hemorrhage ceases. (Brock, Assoc. 3Ied. Journ., June, 1854,-p. 582.) As a local stimulant, it has been much employed in atonic states of the stomach, usually in connexion with other medicines, to the action of which it is supposed to render that organ more sensible. The same influence is also extended to the bowels. It has been thought to be specially useful, in this way, in drunkards, whose stomachs have lost their excitability under the influence of strong- drink. It has been given, with this object, along with sulphate of / / 558 GENERAL STIMULANTS. [PART II. quinia in intermittents, with the simple bitters in dyspepsia, and with the cathartics in flatulence and constipation. It has also been specially recommended in the dyspepsia of gouty persons, and in convalescence from delirium tremens. Taken in the dose of a tea- spoonful, at the very commencement of sea-sickness, it is said some- times to set aside that affection. Topically, it is sometimes employed as a gargle at the commence- ment of ordinary angina, as a direct application in relaxation and elongation of the uvula, and externally as an active rubefacient. Administration. The dose of the powder is from five to ten grains, to be repeated, in acute cases, every hour or two, in chronic cases, three or four times a day. The powder may also be used locally as a cataplasm, or as an application to the fauces. In young children, who cannot gargle, I have found much advantage, when the use of capsicum in this way was indicated, as in the gangrenous condition of the fauces in scarlet fever or malignant sore throat, from mixing the powder with water into a sort of semifluid paste, and diffusing this over the fauces, several times a day, by means of a camel's-hair brush, or some similar implement. Should the child swallow a portion, it will be all the better. In the same way, it may be ap- plied to'the elongated uvula. The medicine is sometimes used also in the form of infusion (Infusum Capsici, U. S), which is made in the proportion of two drachms to eight fluidounces of boiling water, and given in the dose of half a fluidounce. In the same form, it may be employed as a gargle; but, for ordinary cases of sore throat, it should be diluted with from four to eight parts of water. The formula for the infusion of Dr. Stephens, which has been much used in scarlet fever, both internally and as a gargle, directs that two tablespoonfuls of the powder, and a teaspoonful of com- mon salt, should be macerated for an hour in a pint of liquid con- sisting of equal parts of boiling-hot water and vinegar. This is to be strained, and given in the dose of a tablespoonful every half hour. The officinal Tincture (Tinctura Capsici, U. S) may be used in- ternally in the dose of one or two fluidrachms; as a gargle, mixed with water or rose-water in the proportion of half a fluidounce to eight fluidounces; and externally, hot and undiluted, as a rubefa- cient. It may also be applied of full strength, by means of a camel's-hair pencil, to the relaxed uvula. CHAP. I.J ARTERIAL STIMULANTS.—OIL OF TURPENTINE. 559 II. OIL OF TURPENTINE. OLEUM TEREBINTHIN^E. U.S., Lond, Ed., Dub. Origin. As used in this country, oil of turpentine is obtained exclusively from our common or white turpentine, by distillation. Properties. It is a limpid, colourless liquid, of a strong, peculiar odour, and a warm, pungent, bitterish, and very characteristic taste. This odour and taste have been assumed as a standard of compari- son ; and, when similar properties are observed in other bodies, they are said to be terebinthinate. The oil is lighter than water, volatilizable, highly inflammable, very slightly soluble in water, scarcely soluble, when quite pure, in cold officinal alcohol, and readily dissolved by ether. On exposure to the air, it absorbs oxygen, and becomes yellowish and thicker, in consequence of the formation of resinous matter, which is held in solution in the oil. In time, it is in this way rendered very impure. But, as the resin formed is readily soluble in alcohol, the oil may be purified by agi- tation with that fluid, which dissolves the impurity, and leaves the oil fit for use. When quite pure, it is composed of hydrogen and carbon exclusively; but, as found in the shops, it almost always contains oxygen absorbed from the air. Effects on the System. The first effect of the oil of turpentine, when given to a healthy person in moderate doses, is usually a feel- ing of warmth in the stomach, which is followed by a glow over the system, and, after a short time, by increased frequency of the pulse. There is also generally an increased secretion of urine, which has a violet odour; and, after the oil has been taken for some time, a tere- binthinate smell is perceptible in the breath, and the exhalations from the skin. The oil is said, moreover, to be diaphoretic. This effect I have not noticed as a common event; though, in certain conditions of low fever in which it is given, I have often observed a soft and natural state of the skin following a dry and hot con- dition; but this change I have ascribed rather to the effect of the medicine in relieving the disease, and removing a source of irri- tation to the surface, than to its direct action on the perspiratory function. The kidneys and urinary passages are the parts in which the operation of the oil, after entering the circulation, is most ob- vious. Though, as stated above, the urinary secretion is usually increased under the stimulation of the medicine, yet, after some days, irritation is often produced, amounting even to strangury, and 560 GENERAL STIMULANTS. [PART II. attended occasionally with bloody urine; and the secretion is now diminished, instead of being augmented. With these phenomena, there is an entire absence of any evidence of special action on the brain or nervous system generally. From larger quantities, if within the limits of two fluidrachms, no other observable effects ordinarily result than perhaps some in- crease of the phenomena mentioned, and a disposition to disturb the bowels, which is sometimes also evinced even by the common medicinal doses. If the quantity be increased beyond half a fluidounce, up to one, two, or three fluidounces, a greater degree of general excitement is produced, in which the brain now participates; feelings of fulness of the head, and slight vertigo, being experienced, and sometimes, it is said, drowsiness, or a confusion of mind bordering upon in- toxication. A condition resembling trance is said to have been experienced in one instance. In the doses mentioned, the oil not unfrequently occasions nausea, and sometimes vomiting; and in a short time, usually within an hour or two, purges actively; after which the cerebral symptoms subside. These symptoms are pro- bably the result of a sympathetic impression upon the brain, ex- tended from the irritated; stomach, as may be inferred from their quick occurrence, and their rapid disappearance upon the discharge of the oil by the bowels. Another evidence, to the same effect, is that the large doses of the oil are less apt to produce irritation of the urinary passages than the smaller doses frequently repeated; showing that an equal amount of absorption has not taken place. The severer head symptoms are most apt to occur when the medi- cine does not, as sometimes happens, operate on the bowels. In this case, too, the exhalations from the skin and lungs are highly terebinthinate, and the urine has the violet odour strongly. Like most other stimulants, the oil sometimes appears to act as an emmenagogue. It can scarcely be considered poisonous; as not less than four fluidounces are asserted to have been taken without serious conse- quences. On the lower animals, however, it would seem to act deleteriously; for two drachms, given to a dog, are said to have proved fatal in three minutes, with symptoms of tetanus, and o-reat prostration. (Pereira, Mat. 3Ied., 3d ed., p. 1193.) The oil is undoubtedly absorbed. Tiedemann and Gmelin de- tected it in the chyle of'animals to whom it had been given. The odour of the urine, and that exhaled from the lungs and skin are CHAP. I.J ARTERIAL STIMULANTS.—OIL OF TURPENTINE. 561 of themselves sufficient proof. It may be absorbed into the system when inhaled in the form of vapour. I have had under my care a young man, attacked with strangury and bloody urine, from being confined on board of a vessel loaded with turpentine, during a voyage from North Carolina to New York; and he informed me that another of the crew was affected in the same manner. When applied to the skin, the oil acts usually as a powerful rubefacient. Therapeutic Application. From the variety and importance of its therapeutic effects, oil of turpentine deserves to rank among the most valuable medicines. In regard to some of these effects, the anthelmintic, namely, the rubefacient, and those exerted on the urinary organs, it will be considered elsewhere. In this place, it is to be treated of mainly as a stimulant, either generally to the sys- tem, or locally to the alimentary mucous membrane. Cold Stage of Fevers. In consequence of the absence of any direct effect on the brain, at least in ordinary stimulant doses, the oil may be given in all instances of depression or collapse, occurring in the cold stage of febrile diseases, when internal stimulation is required. In some cases of this kind, I have known it to be very useful; and it may be given with great freedom. Low Fevers generally. It has also been considerably used as a stimulant in low states of fever, especially when the existence of disorder of the brain may be supposed to contraindicate the alco- holic liquors, and other cerebral stimulants. In typhus and typhoid fevers it has long been employed with this view; and I found it in use upon entering into the practice of medicine, nearly forty years ago. But it was given only as a stimulant, and, though very successful in some instances, appeared in others to display little remedial power. I claim to have discovered the principle upon which its special success in these cases depended, or at least the precise circumstances under which it proved successful; so that its employment may now be regulated with considerable confidence of gaining the results aimed at. As a mere stimulant, it may be employed in most instances of low fever, but must take rank with others of the class, and indeed below several of them. In regard to the special object which I now have in view, it can be replaced, so far as I know, with equal benefit, by no other medicine. The advanced stage of the fever named specifically typhoid fever, but for which I have ventured to propose the name of enteric fever, affords the condition here referred to. I may, perhaps, be excused VOL. I.—36 562 GENERAL STIMULANTS. [PART II. if I relate the circumstances which led me to this discovery; as I shall thus be able to produce a stronger impression on the reader than by a mere abstract statement of results. In the year 1823, I had under my care a case of fever of the kind then known as nervous fever, or slow remittent, or typhus mitior, by which titles it was variably and somewhat indefinitely called, in the advanced stage of which, violent peritoneal inflammation came on, ending speedily in death. On examination, I found a number of ulcerated surfaces in the mucous membrane of the ileum, in one of which, near the caecum, a large perforation existed, through which a por- tion of the contents of the bowels had passed into the peritoneal cavity. In this case there had been tympanitic abdomen, and the tongue, after having parted with a portion of the fur in the centre, leaving a smooth moist red surface, had suddenly ceased to advance in the cleaning process, and become quite dry before the occurrence of the perforation. Not long previously to this, I had witnessed a fatal case in the practice of a friend, which, after an abortive attempt to clear the tongue in a similar manner, with a similar dryness afterwards, had become aggravated, and ended fatally. Comparing these cases, I was induced to think that the peculiar condition of the tongue referred to, with the tympanitic abdomen, might be the result of the ulceration of the ileum, and that, if I could find a medicine which would correct this ulcerative condition, I might possibly in future save my patients under similar circumstances. Not long afterwards another case presented itself, having the same distinctive characters. Terebinthinate remedies having been found useful in ulcerative affections of the bowels, it occurred to me that the oil of turpentine might possibly answer my purpose in this instance. I gave it accordingly. In twenty-four hours, the tongue showed a disposition again to become moist, a little white fur began to appear on the part before denuded, there was an amelioration of the other symptoms, and from that time the march towards health was uninterrupted under the continued use of the remedy, thouo-h I had in the beginning almost despaired of my patient. Other cases occurred afterwards, of the same character, and with the same results; and from that time to the present, though I have seen great numbers in my private practice, in consultation and in the Pennsylvania Hospital, I have lost only two, presenting the phenomena mentioned. Of these two, one exhibited, on examina- tion after death, such an amount of disease in the ileum as to have rendered a fatal issue unavoidable; and in the other, a small ulcer CnAP. I.] ARTERIAL STIMULANTS.—OIL OF TURPENTINE. 563 ated opening was found at the bottom of an offset of the bowel, or cul-de sac, about an inch and a half in depth, into which as it was filled with mucus, the oil had been unable to penetrate, so as to come into contact with the surface of the ulcer; while several large ulcerated patches in the ileum were rapidly cicatrizing, show- ing the probably beneficial' influence of the remedy on them. A brief account of the use of the oil in this condition of febrile dis- ease, and of the circumstances which led to it, was published in the North American Medical and Surgical Journal for April, 1826 (page 272). AVhen the admirable work of Louis on typhoid fever ap- peared, I at once recognized, in his description, the disease which had exhibited the phenomena above mentioned. The ulcerative condition, referred to, I had previously considered as liable to occur in any protracted fever. I now learned that it was the characteristic lesion of a special disease. My therapeutic views, therefore, were immediately transferred to the typhoid fever, which Louis had ena- bled us accurately to diagnosticate, and, having tried the remedy in this affection, found my best hopes fulfilled. Ever since that time, I have been in the habit, in my lectures in the University of Penn- sylvania, of strenuously recommending the oil of turpentine in the treatment of enteric or typhoid fever, and have done the same in my work on the Practice of Medicine, always restricting its use to the period of probable softening and ulceration in the diseased glandular patches, and expressing my belief that it was no specific in that dis- ease, but might be confidently relied on as having a favourable in- fluence over this peculiar morbid affection of the bowel, and vastly diminishing the danger from that source. Abundant testimony has been given to me, by practitioners from various parts of the Union, of very favourable changes having taken place in the mortality of the disease, after they had adopted the practice here recommended. It will be best, probably, after this brief history, that I should state distinctly, the condition under which, in enteric fever, the oil may be beneficially employed, and the principles upon which I believe it to act. Enteric or Typhoid Fever. Though the oil may be of some use as a mere stimulant in this disease, it is, in that respect, of but compa- ratively little value, and cannot be depended on to the exclusion of wine whey, carbonate of ammonia, and nutritious aliment, in low conditions of the fever. But the oil will accomplish what these cannot. It acts most happily in stimulating the diseased patches of Foyer's glands, and the isolated glands of the same kind, whereby the 564 GENERAL STIMULANTS. [PART II. softened and disorganized matter is more readily thrown off, and the ulcerated surfaces disposed to heal, when they might otherwise be unable to do so. The remedy, therefore, is to be given at the period during which the discharge of the softened matter is going on, and ulcers are forming, or in existence. This is usually, I believe, about the middle, or towards the close of the second week. Before this time I count upon no material service from the oil. It is now that the tongue becomes dry; and the occurrence of this dry state of the tongue in a decided degree, is the signal for commencing with the use of the remedy. I give it usually in doses of ten drops every two hours, but sometimes increase to fifteen or twenty drops. At the end of twenty-four, or at the furthest of forty-eight hours, there may very generally be seen a return of moisture with a white fur on the surface of the tongue at the sides, for its whole length, leaving the surface in the middle still dry and often cracked. With this amendment, there is often also a diminution of the tympanites, a cooler and moister skin, and a less frequent pulse. The same change goes on till the whole tongue becomes moist, and covered usually with a whitish fur, which then gradually disappears, commencing from the tips and edges. Sometimes, even when there has been no dryness of the tongue in the case, I have found the oil to act favourably in ameliorating the symptoms; and frequently, when the disease has appeared to linger in its advanced stages, and, though not severe, to show a perverse disposition to hang on to the patient, I have seen it almost immediately enter into convalescence under the use of the remedy. Again, when the case is marked in its progress by the cleaning of the tongue by flakes or in patches, leaving a red and smooth surface, as if deprived of the outer layer of the epithelium and papillae, and when the surface of the tongue, whether completely or only partially cleared, instead of remaining moist, as it does in favourable cases, becomes very dry, with an aggravation of the general symptoms, I take it for granted that there has been a corresponding unfavourable change in the intestinal ulceration, indicating the use of the oil. It is precisely under these circumstances that, previously to my original use of the oil, I had seen a majority of the cases that came under my notice prove fatal; and, since the use of it, only two. I do not claim for the oil any specific power over typhoid fever. It will not prevent death from intercurrent pneumonia, or meningitis or various other sources of mischief; but I do think, as the result, too, of great experience in the disease, that so far as the mere affection of the CHAP. I.] ARTERIAL STIMULANTS.—OIL OF TURPENTINE. 565 intestinal glands and its direct consequences are concerned, it will vastly diminish the chances of a fatal issue. The reason why, in the special condition of the tongue last described, the favourable effects of the remedy may be almost certainly calculated on, is that, at the commencement of the cleaning process, the proper idiopathic disease has about run its course, and would almost certainly end well, but for an unfavourable change in the condition of the ulcer- ated surfaces; and whatever, therefore, will favour the healing of these, will in all probability secure a favourable termination. I have been more particular in this account of the use of oil of tur- pentine in enteric fever, because I have great confidence in the effi- ciency of the remedy myself, and wish to prevail on others to use it by showing the grounds of this confidence, and pointing out the precise circumstances under which, according to my experience, it should be employed. Scarlet Fever. In the advanced stage of this complaint, a trouble- some diarrhoea not unfrequently supervenes, which is sometimes, I believe, sustained by ulcers in the small intestines. It is not un- common for this condition to be attended by a dry tongue, as in enteric or typhoid fever. Under these circumstances, I have pre- scribed the oil of turpentine with apparent benefit. Dysentery and Diarrhoea. Whenever, in the course of these com- plaints, whether acute or chronic, the tongue exhibits a smooth surface, as if deprived of its papillary structure, and at the same time becomes perfectly dry, I always unhesitatingly employ the oil of turpentine, believing that this aridity indicates a deficiency of the vital forces, which calls for the stimulating property of the oil, while the probable existence of ulcers in the bowels requires its alterative action. In chronic dysentery, particularly, I have repeatedly seen the happiest changes effected by the remedy, under the precise circumstances mentioned, and would strongly urge upon the reader a trial of it. One instance occurs to me, in which the patient had been very long ill, and was reduced to the lowest condition compatible with life. No one who saw the case had any hope of a cure. But the same favourable change took place, under the use of the oil, as in the analogous condition in enteric fever, and the patient recovered. I seldom fail, in such cases, in restoring moisture, and an otherwise favourable condi- tion to the tongue, even though the disease may prove ultimately fatal. The oil should be combined with a little laudanum in these cases. 566 GENERAL STIMULANTS. [PART II. Gastritis and Yellow Fever. In the last stage of inflammation of the gastric mucous membrane, when the skin has become damp with cool sweats, hiccough has set in, and the patient vomits dark matter; in short, when symptoms of threatened gangrene appear, the oil of turpentine with laudanum sometimes offers a last chance for safety. It acts as a stimulant and alterative to the diseased surface, while it somewhat stimulates the system. I have seen at least one apparently desperate case recover from such a condition under the use of it. Now this condition is very frequently pre- sented in the second stage of yellow fever, anticipatory or attendant on black vomit. The oil has been highly recommended under these circumstances, being commenced with after the subsidence of the primary fever. Some have even employed it throughout the disease; but in the early stage, when the gastritis is yet active, the use of a powerful local stimulant like this would not correspond with my views of sound therapeutics. Puerperal Fever. Dr. Brenan, of Dublin, has spoken in the strongest terms of the usefulness of this remedy in puerperal fever. He gave it in doses of one or two tablespoonfuls every three or four hours, and at the same time covered the abdomen with flannels saturated with the oil. There is no doubt that benefit may accrue from the external use of the remedy in the way mentioned; and, in the malignant forms of the disease, when the blood is impaired, and the inflammation partakes of the same depraved character, it is not impossible that the powerful revulsion towards the inner from the outer surface of the bowels may have proved useful. The recommendation of Dr. Brenan has not been without the support of other highly respectable practitioners; but the remedy has not been adopted by the profession generally; and it certainly appears to be contraindicated in all cases of genuine vigorous inflammation, in which it might be proper to employ the lancet. I cannot, however, speak of it from experience. Chronic Rheumatism and Gout. Oil of turpentine has consider- able reputation in these affections, more especially the former in which it is said to have sometimes proved very efficacious. It has been more particularly recommended in this disease, in the forms of lumbago and sciatica. The oil is undoubtedly a penetrating remedy, reaching the minutest capillaries, and apparently acting on them with considerable energy. It may thus prove alterative in some of those obstinate rheumatic cases, which have taken so deep a hold of the tissues as to be capable of being unseated by nothing CHAP. I.] ARTERIAL STIMULANTS.—OIL OF TURPENTINE. 567 which cannot be brought to bear with considerable force im- mediately upon the molecules of the tissue affected. I have no faith whatever in the diaphoretic action of the oil, to which some have been disposed to ascribe, in part at least, its efficiency in rheumatism. The medicine has not only been used internally, but has also been applied in the form of a bath of the vapour, at a tem- perature of from 140° Fahr. to 160°, which is said to be well borne. In this case it is probable that the diaphoretic effect of the heat may add to the efficiency of the oil. (Arch. Gen., 4e sdr., xxviii. 80.) Nervous Diseases. Cures are stated to have been effected by the oil of turpentine in neuralgia, chorea, epilepsy, and tetanus; and it is probable that, largely employed, it may sometimes cure these affec- tions, when purely functional, by its strong influence upon the capillaries, and its revulsive action towards the alimentary canal; but I cannot recommend it on the ground of my own experience. Hemorrhages. Oil of turpentine is among our best haemostatics. Some have supposed that it operates in the hemorrhages by an astringent property. But I have not been able to discover that it has this property in the slightest degree. On the contrary, its tendency is to expand the capillaries of the part with which it is brought into contact. But we do not know the precise condition of the minute vessels in hemorrhage; and it may well be, that the stimulant and alterative influence of the oil upon them may check the hemorrhagic tendency without diminishing their volume. The conditions which I have considered as prerequisite to the use of the oil, are the want of general febrile excitement, and of active congestion in the part affected. Under these circumstances, it may be tried in any of the hemorrhages; but that in which, according to my own observation, it has proved most efficient, is the haemop- tysis of consumptive patients, or of persons supposed to be con- sumptively inclined. In this affection it has proved in my hands more effectual than any other remedy, or combination of remedies. I was first induced to employ it, from having noticed its great efficiency in a medical student more than twenty years ago, who had employed it in his own case, in a very severe attack. This student is now Dr. James L. Pierce of Philadelphia. Since that time I have used it very successfully, and sometimes when all other remedies had been without effect. Should evidences of active con- o-estion be present, they should be removed by cups or leeches before the use of the oil; at least this is the method which I have generally followed. 56S GENERAL STIMULANTS. [PART II. Ghronic Bronchitis. This affection, when attended with copious expectoration, is said to have been advantageously treated with the oil; as have other excessive mucous discharges. Affections of the Stomach and Bowels. In gouty spasm of the stomach, fiatulent colic, excessive fiatulence without spasm, and a tympanitic state of the abdomen, the oil is often beneficial through its direct stimulant influence. In tympanites, given both by the mouth, and in the form of enema, it is one of the most effectual remedies. It may be employed also in hiccough, and has been recommended, in combination with ether, as one of the best reme- dies in biliary calculi. But experience has not proved its effi- ciency in the latter affection; and it is difficult to imagine in what way it could prove serviceable, unless possibly sometimes by re- laxing the spasm attending the passage of these calculi through the ducts. The external use of the oil will be treated of under the rube- facients ; its employment in affections of the urinary passages under that of diuretics; and its application as a vermifuge, under the anthelmintics. Administration. The dose of the oil for the purposes of a gene- ral stimulant is from five to twenty drops, repeated every half hour, hour, or two hours, in acute cases, and three or four times a day in chronic. But the dose may be much increased if thought advisable. Should it occasion strangury or bloody urine, it should be sus- pended. It may be administered dropped on sugar, or in the form of emulsion, made by suspending it in water by means of gum arabic and loaf sugar; each tablespoonful of the emulsion contain- ing a dose of the oil. Laudanum may often be usefully added, either when the oil is disposed to purge, or when there is an indication for the checking of diarrhoea at the time of its administration. Of its use in the form of enema, it will be treated of under the head of the cathartics. It has been recommended in the form of bath, for its constitu- tional impression, by Dr. T. Smith of Cheltenham, England, who employs in each bath from five to ten fluidounces of the oil, a fluid- ounce of the oil of rosemary, and two pounds of carbonate of soda. Its external use in the form of a vapour bath in chronic rheu- matism has already been noticed. Skoda recommends the inhalation of its vapour in gano-rene of the lungs. CHAP. I.] ARTERIAL STIMULANTS.—CARBONATE OF AMMONIA. 569 III. CARBONATE OF AMMONIA. —AMMONIA CARBONAS. U.S.,Ed. — Ammonia Sesquicarbonas. Dub., Lond. Preparation. Carbonate of ammonia is prepared by subliming a mixture of carbonate of lime and muriate of ammonia. The muriatic acid and lime, reacting upon each other, produce chloride of calcium and water; and the water thus formed unites with the carbonic acid and ammonia to generate the compound under con- sideration, which rises in vapour, and is condensed in a proper recipient. During the process a portion of ammonia is liberated. The cake formed by the condensation of the vapour is broken into lumps, which should be kept in a well-stopped bottle. Composition. This is not a neutral carbonate, as its officinal name implies, but either a sesquicarbonate, consisting of three equiva- lents of carbonic acid, two of ammonia, and two of water, or, as some chemists prefer to consider it, a compound of one equivalent of the proper carbonate of ammonia and one of the bicarbonate. When purified by a second sublimation, it is said to lose a portion of carbonic acid, and to become the 4-5 carbonate of ammonia, thus acquiring more stimulating properties. Properties. The salt, as kept in the shops, is usually in whitish lumps, more or less rectangular, hard, fibrous, translucent, of a cha- racteristic very pungent odour, and an acrid, alkaline, yet some- what cooling taste, with a burning sensation in the throat, which renders it difficult of administration to persons of very sensitive fauces. It is very soluble in cold water, and freely dissolved by proof spirit; but is scarcely soluble in pure alcohol. By heat it is wholly volatilized. Exposed to the air, it gradually parts with the proper carbonate of ammonia, and is ultimately converted into the bicarbonate, becoming at the same time quite white, opaque, and disposed to crumble. I have noticed that, after long exposure, the resulting substance deliquesces, and ultimately assumes the liquid form. The lumps should always be translucent when held up to the light; otherwise they have undergone more or less completely the change just referred to, which is a deterioration, as the bicarbonate is much less stimulating than the officinal salt. A loss of odour, and of the property of changing to brown the yellow colour of turmeric paper held over it, are also signs of deterioration. Incompatibles. A solution of carbonate of ammonia is decom- posed by most acids; by potassa, soda, and their carbonates; by 570 GENERAL STIMULANTS. [PART II. lime-water and magnesia; by alum and corrosive sublimate; by the soluble salts of lime, lead, zinc, and iron, excepting the tartrate of iron and potassa and the analogous ferruginous compounds; and by most salts with excess of acid, as the bitartrate and bisulphate of potassa. Effects on the System. Carbonate of ammonia is irritant in its local action, and an energetic stimulant to the system. Taken in- ternally it occasions a sense of heat in the stomach, increases the fre- quency and force of the pulse, and produces a general glow through the system. Though sometimes causing a sensation of fulness in the head, it has no conspicuous influence over the special cerebral functions; and there are few substances so actively stimulant to the circulation, with so little obvious effect on the brain. It ap- pears to excite more or less the general organic nervous system, and might even rank with the nervous stimulants; but its influ- ence on the circulatory system is so much more decided, and its best therapeutic uses so closely dependent on this action, that I have concluded to rank it in the present class, with this explana- tion as a caution to the learner. As a diffusible stimulant, it is remarkably characterized by the brevity of its action. With its general stimulant influence on the circulation and or- ganic nervous system, it has a tendency to increase the secretions. It often produces more or less diaphoresis, sometimes operates as a diuretic, and appears to act on the pulmonary organs, if not as an expectorant, certainly as a special stimulant of the respiratory function. In over-doses it irritates the stomach, and, if not discharged by vomiting, which generally happens when it is given very largely, may produce dangerous inflammation of the mucous membrane, with severe burning pain. It is probably only in this way that it is capable of acting as an acute poison in the human subject; but Huxham relates a case in which its long-continued use was fol- lowed by a cachectic state of system and depraved state of the blood, as indicated by hemorrhage from the nose, gums, and intes- tines, pustular eruptions on the surface, dropping out of the teeth, and a general wasting of the body, with hectic symptoms. The patient ultimately died from the effects of the poison. These pro- bably depended mainly upon a constantly sustained excess of alka- linity of the blood. Two drachms and a half given to a dc* were found by Orfila to produce gastric inflammation with tetanic spasms. The obvious antidote, should an over-dose be taken, would be one CHAP. I.] ARTERIAL STIMULANTS.—CARBONATE OF AMMONIA. 571 of the mild vegetable acids, as the acetic in the form of vinegar, the citric in that of lemon or lime-juice, or the tartaric. Therapeutic Application. In an impure form this salt has long been used in medicine, under the names of sal volatile, salt of harts- horn, &c. It may often be very usefully employed. In conse- quence of the energy and, at the same time, brevity of its stimu- lant action, it is admirably adapted to all those cases of sudden depression or collapse, which, if the patient survive, must be followed by febrile reaction, if not acute inflammation. The want of any special influence on the brain adapts it peculiarly to those in which the, reaction will be likely to be attended with inflammation or great vascular excitement of that organ. Instances of the kind are not unfrequently presented in the cold stage of febrile diseases, the collapse of concussion of the brain, and the prostration of any sudden shock. Under these circumstances, it is an admirable ad- juvant of the hot bath. In all fevers, assuming in their progress a low form, requiring sti- mulation, this is one of the first of the diffusible stimulants which may be had recourse to. In typhus and enteric fevers, in the various exanthemata assuming . a typhoid condition, especially scarlatina, smallpox, and malignant erysipelas, and even in the phlegmasia when attended with the same state of system, it may often be used very advantageously, associated with other stimulants, especially with wine-whey, and the preparations of Peruvian bark. -Its tendency to produce softness or moisture of the skin adds to its usefulness; and sometimes, when the breath and exhalations from the patients have a sour smell, as they are apt to have in low fevers, its pro- perty of neutralizing acid, may be considered a peculiar recom- mendation. In the malignant pustule, carbuncle, glanders, metastatic abscess, and all cases of purulent infection of the blood, and other affections of a similar kind, accompanied with a depressed condition of the system, it may be used, conjointly with other stimulants, with hope of benefit. There are few conditions in which it acts more happily than in the advanced stages of the different pectoral inflammations, when the occurrence of suppuration with a tendency to prostration calls for the use of stimulants. I have frequently seen it of the greatest possible service in pneumonia under these circumstances, when the great oppression of breathing, the cool skin, the feeble pulse, and the sweats at night, have indicated the probable approach if not occurrence of the third stage of the disease, and the absolute neces- 572 GENERAL STIMULANTS. [PART II. sity of supporting treatment. I do not think it is going too far to say that I have repeatedly, in this condition, known it to be the main agent of safety to the patient. It probably operates, under such circumstances, not only by a general stimulation of the circu- latory and nervous systems, but also by a special excitation of the ultimate tissue of the lungs, concerned in the respiratory function. In a somewhat less degree, it often proves serviceable in protracted acute bronchitis, with a suppurative condition of the mucous mem- brane. In chrome bronchitis also, and in phthisis, when the lungs are loaded with pus, and too feeble to discharge it effectually, the carbonate of ammonia yields much relief by stimulating the ex- pulsive power. It has been recommended both in chronic and acute rheumatism. There is a condition of the latter affection in which it may be very appropriately employed. This condition consists in an asthenic state of system, probably dependent on impoverished blood, in which, though there may be considerable inflammation, it is apt to be movable, changing its seat from place to place, and a good deal of nervous irritation mingles with it, along with a frequent but feeble pulse, a tendency to paleness, and, perhaps, coolness of the surface, and sweats during sleep. This is altogether different from the typhoid state of system, with depraved blood, and yields more happily and speedily to a well directed stimulation. Perhaps the use of the medicine may be ascribed in part to its alkalinity, which is indicated sometimes in these cases by an excess of acid in the system. In chronic rheumatism the medicine is usually given in connexion with guaiacum, in the form of the ammoniated tincture of that gum resin; and probably acts by stimulating, in a manner similar to that of the oil of turpentine, the ultimate structure of the inflamed tissue into a new action, which may supersede the old. The medicine has been recommended in scrofula; but it exercises no special influence over the diathesis, and only proves beneficial sometimes in states of depression attendant on this disease, as in a similar state in any other. As an antispasmodic in the nervous affections it has received high commendation. Hysteria and epilepsy are the particular complaints in which it has been most praised. In the former affection it will no doubt often prove beneficial, partly, in all probability, by a direct stimulation of the nervpus centres, but much more, I believe, by obviating the flatulence, spasmodic pains, and other disordered sensations in the stomach and bowels which so often attend and CHAP. I.] ARTERIAL STIMULANTS.—CARBONATE OF AMMONIA. 573 aggravate the disorder. In epilepsy, when entirely functional, it may sometimes prove beneficial. Dr. Pereira thought he had de- rived much advantage from it both in epilepsy and hysteria, given in doses of fifteen or twenty grains three times a day, and continued steadily for two or three weeks. Dr. Barlow recommends carbonate of ammonia in diabetes, in con- junction with a diet of animal food and the cruciferae, exercise, the warm bath, and opiates; but experience has not proved it to pos- sess any special influence over that complaint. (Brit, and For. Med. Rev., Oct. 1841.) Cazenave has found it useful in scaly affections of the skin; but a much more effectual remedy, in these affections, is arsenic in some one of its medicinal forms; and it is scarcely advisable to postpone the cure by using substitutes which exercise a comparatively feeble, and at best uncertain influence over the disease. Carbonate of ammonia has been much commended for the pos- session of certain antidotal virtues. In the depressed state of system resulting from sedative poisons, such as tobacco, digitalis, and hydro- cyanic acid, it is obviously indicated as a rapid and active stimulant; but, in regard to hydrocyanic acid, it has been supposed to have special powers as an antidote. Whether it can be of any service chemically by neutralizing the poison, is a matter of some doubt; but it should at least be employed as one of the most efficient agents, if not the most efficient, in counteracting its effects. Either in this form, or that of solution or spirit of ammonia, the volatile alkali has obtained great credit, as an antidote to the bites of poisonous animals. Numerous cases are on record in which, ap- plied locally and taken internally, it has been supposed to prevent the poisonous effects of the bites of serpents. But as these bites often produce no fatal effects if left alone,-it is extremely difficult to decide upon the amount of credit which the supposed antidote may really merit. The reputation of the medicine was mainly based on the apparent success of the eau de luce, a liquid contain- ing ammonia as its chief ingredient, which was given by Bernard de Jussieu to a servant bitten by a viper. But Fontana proved that the bite of the viper rarely causes death, and that its effects are in no degree diminished by the use of ammonia; and the same observation was extended to the bites of venomous insects. Trous- seau and Pidoux state that they have never seen the external or internal use of ammonia modify, in the least degree, the symptoms of poisoning by the bites of venomous animals. (Traite de Therap., 574 GENERAL STIMULANTS. [PART II. 4e ed., i. 336.) I have never had the opportunity of trying the remedy in any serious case of the kind. Another antidotal application of ammonia has been to the relief of the intoxicating effects of alcoholic drinks. Over absolute drunk- enness it has no control whatever; but in slight disorder from this cause, either the carbonate of ammonia, or the alkali itself in aqueous or spirituous solution, occasionally gives relief. The local effects of carbonate of ammonia on the stomach and bowels are often advantageous. In excess of acid with a languid state of the stomach, such as not unfrequently exists in dyspepsia, in sick headache with the same complication, and in the spasmodic pain or other uneasiness of flatulence and atonic gout, it maybe prescribed alone, or in connexion with tonics and purgatives; but thaaromatic spirit is usually preferred, under these circumstances, to the car- bonate in its ordinary form. The main contraindication to the use of carbonate of ammonia, in cases which may seem to call for it, is the existence of inflam- mation of the stomach. Administration. The dose of the medicine is from two or three to twenty grains, repeated every half hour, hour, or two hours. From five to ten grains every hour or two is the ordinary dose in low fevers. Thirty grains or more will generally vomit. The medicine maybe given in pill or solution; but the latter is the bet- ter form; because, should the pill come in contact with the coats of the stomach, it would be more apt to excite irritation. But the acri- mony of the salt should be covered by mixing it, in solution, with gum arabic and loaf sugar, and the taste corrected by using one of the aromatic waters as the vehicle. The carbonate of ammonia, broken into minute fragments, and mingled with the volatile oil of bergamot, lavender, or other aro- matic, is put into small bottles, and used as smelling salts. The ammoniacal odour, which is rendered agreeable by that of the vola- tile oils, is pungent and exciting; and the preparation is frequently used by delicate persons to obviate unpleasant nervousness, and to relieve faintness. Indeed, the application of ammoniacal vapour to the nostrils is one of the most efficient of the milder methods of preventing or remedying syncope. For this purpose, either the car- bonate may be used, or one of the liquid preparations of ammonia to be mentioned directly. They are simply held to the nostrils so that the patient, if still breathing, may inhale the vapour with the air; and even without inhalation, a portion of the vapour will enter CHAP. I.J ARTERIAL STIMULANTS.— CARBONATE OF AMMONIA. 575 the nostrils on the principle of the diffusion of gaseous bodies; but caution is necessary, especially when the patient is insensible, that the vapour should not be too concentrated, nor too copiously ap- plied; as there is risk of producing severe inflammation of the nos- trils, of the larynx, and even of the bronchial tubes, when it is carried into the lungs with the inhaled air. The salt is sometimes used externally, mixed with olive oil, as a mild rubefacient liniment. This may be made, as described by the London College, by mixing a fluidounce of a saturated solution of the salt with three fluidounces of olive oil. An imperfect soap is formed; but the union of the carbonate with the oil is less perfect than when the solution of ammonia is used, and the preparation consequently less elegant than the officinal liniment of ammonia. There are several other ammoniacal preparations which are more or less used internally for their stimulant effects. 1. SOLUTION OF AMMONIA.—Liquor Ammonia. U.S., Lond., Dub. — Ammonle Aqua. Ed.— Water of Ammonia. This is water impregnated with gaseous ammonia. As it is much more used as an external irritant than as a stimulant internally, it will be more particularly treated of among the rubefacients. Its effects upon the system are essentially the same as those of the carbonate above described, and it may be used for the same purposes; but, as it would be more likely, if given in excess, to irritate or inflame the stomach, the salt is generally preferred. As a stimulant anta- cid, it is sometimes used in heartburn, and in sick headache depend- ent on acidity of stomach; and it has had considerable reputation as an antidote to the poison of serpents, being applied for this pur- pose to the bite, as well as taken internally. There is some reason, however, to doubt its efficiency; and, though it may be employed, it should never be relied on to the exclusion of more efficient mea- sures. When taken by accident undiluted, or insufficiently diluted, it produces severe inflammation of the mucous membrane of the mouth, fauces, and stomach, aud may even vesicate or act cor- rosively. The antidotes are the vegetable acids. Much more cau- tion is requisite in applying this to the nostrils, in order to revive fainting persons, or to rouse from positive syncope, than the car- bonate,'in consequence of the causticity of the vapour. Several in- stances of severe inflammation of the air-passages are on record from this cause, some of which proved fatal. In one of the instances, the vapour of the ammonia was inhaled as an antidote to hydro- 576 GENERAL STIMULANTS. [PART II. cyanic acid. The dose is from ten to thirty drops, which should be given in one or two fluidounces of water. 2. SPIRIT OF AMMONIA. — Spiritus Ammonia. U.S., Ed. This is a solution of gaseous ammonia in officinal alcohol, and differs, therefore, from the last mentioned preparation only in the menstruum. It has about the same proportion of ammonia as the watery solution, and consequently about the same strength. It may be used for the same purposes, and requires the same caution. The dose is from ten to thirty minims in one or two fluidounces of water. 3. AROMATIC SPIRIT OF AMMONIA. — Spiritus Ammonle Aromaticus. U. S., Lond., Ed., Dub. It is unfortunate that preparations differing somewhat in nature, and very much in strength, are directed by the different Pharma- copoeias under this name. The following remarks are applicable to the preparation of the United States and London Pharmaco- poeias. The aromatic spirit of ammonia is made by submitting to dis- tillation muriate of ammonia, carbonate of potassa, cinnamon, cloves, and lemon-peel with a mixture of equal measures of alcohol and water. Carbonate of ammonia is formed by the double decom- position of the salts, and comes over with the vapour of alcohol, water, and the volatile oils of the aromatics. But, as the process is stopped before nearly all the liquor has distilled over, much of the water is left behind. No ammonia is lost, as in the process for preparing the officinal carbonate of ammonia by sublimation. Consequently, it is the proper carbonate and not the sesquicar- bonate that is formed; and the preparation consists of the solution of carbonate of ammonia (one eq. of acid and one of base) and the volatile oils of cinnamon, cloves, and lemon-peel in strong spirit. It has an agreeable pungent odour, and the peculiar taste of ammonia pleasantly qualified by that of the aromatic oils. Upon the system its effects are the same as those of the officinal car- bonate of ammonia, and it may be employed for the same purposes. The use of it, however, is generally confined to cases in which its influence as a stomachic stimulant, or slight excitant of the nervous system is wanted. Hence, it is given to obviate nausea and vomit- ing in debilitated states of the stomach, to relieve fiatulence and flatulent pains, and to correct gastric acidity, and the heartburn and sick headache, which frequently attend it. Languor, faintness, and CHAP. I.] ARTERIAL STIMULANTS.—PHOSPHORUS. 577 the slight nervous disorder incident to hysteria are often relieved by it; and it is occasionally used to remove the lighter symptoms of intoxication caused by alcoholic drinks. It is a good addition to saline cathartics in weak conditions of the stomach. The dose of it is from half a fluidrachm to two fluidrachms, in a wineglassful of water. The Edinburgh and Dublin preparations are made by simply dis- solving aromatic volatile oils in the spirit of ammonia, consisting of a solution of caustic ammonia in alcohol. They are much stronger than our own officinal aromatic spirit, and, from the caustic state of the ammonia in them, more apt to irritate even in equivalent doses. Their dose is from ten to thirty drops. IV. PHOSPHORUS. Lond. Preparation. This is obtained by first decomposing the phosphate of lime, contained in calcined bones, by means of dilute sulphuric acid, and afterwards decomposing the excess of phosphoric acid in the super-phosphate thus procured, by heating the latter with charcoal, which takes the oxygen of the acid, and escapes as carbonic acid, while the phosphorus distils over, and is received under water, where it hardens. Properties. As usually kept in the shops, phosphorus is in cylin- drical sticks, of a light-yellowish colour, translucent, tasteless, of an odour like that of garlic, quite insoluble in water, very slightly soluble in alcohol, of which a fluidounce dissolves only about a grain,* and considerably more soluble in ether, chloroform, and the fixed and volatile oils. In the absence of air, it melts, and is vola- tilized by heat. It is extremely inflammable, taking fire at 100° Fahr., or with slight friction at ordinary temperatures, and sometimes when held between the fingers without friction. Exposed to the air at ordinary temperatures, it undergoes a slow combustion, emitting white fumes, which shine like flame in the dark. Hence, it must be kept under water; but, even thus protected, it appears to unite with the absorbed oxygen of the water, as it is asserted to impart active properties to the liquid. Phosphoric acid results * M. Labarraque supposed that it might dissolve a grain and a half to the ounce (Diet, de Mat. Med., Merat et De Lens, v. 277); and Dr. Boling, of Montgomery, Alabama, found that an ounce would dissolve a grain, or possibly a little more. (X. Orleans Med. and Surg. Journ., x. 736.) VOL. I.—37 578 GENERAL STIMULANTS. [PART II. from its rapid, phosphorous acid from its slower combustion. To the latter it no doubt owes its alliaceous smell. Effects on the System. Phosphorus is generally admitted to be irritant to the stomach, and powerfully stimulant to the system, especially to the circulation. It is said also to stimulate the nerv- ous centres, strongly to excite the sexual appetite, and to promote the secretions, especially those of the skin and kidneys. In its stimulant action it is highly diffusible, operating promptly and but for a short time, so that to sustain its effects, the dose must be frequently repeated. When given in moderate medicinal doses, it is said to occasion a feeling of warmth in the stomach, to increase the frequency and fulness of the pulse and the heat of the skin, to invigorate the mental functions and muscular power, to stimulate the sexual organs even to priapism in the male, and to act more or less ener- getically as a sudorific and diuretic. It is asserted that the urine sometimes becomes phosphorescent, and that a garlic odour may be perceived in the breath. Given more largely, it often causes burning pain in the stomach, vomiting, purging, and great epigastric tenderness; and, in its highest degree of action upon that organ, gives rise to severe in- flammation, and sometimes even to gangrene and perforation. Upon the system at large the poisonous action is said to be accom- panied, after great excitement, by convulsions and insensibility before death. The probability, however, is that, in most fatal cases, the result has been attributable to intense inflammation or disor- ganization of the mucous membrane of the stomach. The quantity capable of causing death is exceedingly variable. Lobelstein Lobel asserts that he has seen poisoning produced in a maniac twenty- five minutes after the administration of one-eighth of a grain in substance (3Ierat et De Lens, v. 281); Dr. Christison mentions an instance of fatal result from one grain and a half; while Dr. Pereira once administered sixteen grains to Chabert, famous as the { fire king, without any injurious consequences. (Pereira, 31at. Med., 3d ed. p. 332.) A slow poisoning results from long exposure to the fumes of phosphorus, as in the manufacture of lucifer matches. The operation of the poison is said to be first experienced, occa- sionally at least, in toothache and caries of the teeth • but necrosis of the jaws is the ultimate and characteristic effect. This has been ascribed by some to the direct action of the fumes upon the bone CHAP. I.] ARTERIAL STIMULANTS.—PHOSPHORUS. 579 through the teeth; but it is scarcely possible that an acrid sub stance should act so powerfully from without, and yet exhibit no effect on the soft parts; and phosphoric acid, which has been con- jectured to be the agent, does not act similarly upon those exposed to the air of factories impregnated with it. Besides, the disease of the jaws is not the only effect. Sallowness of the complexion, bloated face, a dull expression of the eye, and gastric derangement have also been noticed; and a case is on record in which copious inhalation of the vapour produced various functional derangement, ending in failure of the sexual' functions, paralysis, and death in three years. (Arch. Gen., Feb. 1853, p. 219.) The probability is that the fumes of the phosphorus, consisting either of phosporous or hypophosphorous acid, enter the circulation through the lungs, and act specifically on the jaws, as mercury does on the gums. The fumes of phosphorus are said to be locally irritant to the mucous membranes of the eye and the air-passages, and to have produced serious inflammation in the latter. When phosphorus is burned in contact with the skin, it sometimes leaves a peculiarly troublesome and obstinate ulceration behind it, as I have expe- rienced in my own person. This has been ascribed to the irritant properties of the phosphoric acid remaining in the wound. Mode of Operation. Phosphorus itself, unchanged, is probably quite inert. Its entire insolubility, the perfect impunity with which it can be handled, and its want of taste when quite clean, are evidences to this effect. Its whole influence probably depends on changes which it undergoes in the stomach, or in the blood after absorption. In relation to its direct influence on the gastric mucous membrane, it may be supposed to produce its simple ex- citant effect through some one of the acids resulting from its oxidation, and, when it is taken very much divided in solution, the probability is that it is mainly the phosphorous acid which is pro- duced, and which acts. This is of course conjectural; for we do not know the precise effects of that acid when given in substance. It may be that the heat evolved by the slow oxidation of the phosphorus may have some effect in producing the excitation of the mucous membrane. But, in relation to its violent and poison- ous action on the stomach, to the high inflammation, corrosion, and gangrene which have sometimes resulted, I am among those who ascribe them to the active combustion of the phosphorus. This takes fire at 100°, and the heat of the stomach probably is equal to that degree or above it. Atmospheric air is often contained in 580 GENERAL STIMULANTS. [PART II. the organ. These then are the two requisites for combustion; and it is probable, whenever phosphorus is swallowed in the solid state, and comes into contact with the air, that it takes fire. Thus we can explain why it is that, when serious accidents have occurred, it has generally been from phosphorus taken undissolved. Hence too the great uncertainty in its poisonous effects. It may be readily understood that a grain, or even a small fraction of a grain, taking fire in contact with the surface of the stomach, may produce fatal disorganization; while sixteen grains may be swallowed with im- punity, if shielded from the air, or if no air is present. The effects on the system are almost certainly the result of ab- sorption. That in one form or another the phosphorus enters the circulation, is proved by the alliaceous odour of the breath, and, as has been asserted, of the blood. It is probably in the state partly of phosphorous, and partly of phosphoric acid, that it is taken up. The odour of the breath would seem to indicate the former, the excess of phosphates in the urine the latter. It is not impossible that the phosphorus itself, in the state of solution, is also absorbed; and the fact must be admitted, if it is true that the urine sometimes becomes phosphorescent under its use. If phosphorus should have been taken in dangerous quantities, it should be immediately evacuated by an emetic, with copious draughts of mucilaginous drinks to envelop the poison, and keep it as much as possible from the action of air in the stomach; mag- nesia being at the same time given to neutralize any acid which may have resulted from its oxidation. Should symptoms of inflam- mation or corrosion remain after the evacuation of the poison, they must be combated by the ordinary methods, such as leeches fol- lowed by emollient cataplasms to the epigastrium, mucilaginous drinks, and opiate enemata; while one of the alkaline bicarbonates may still be exhibited to neutralize any acid that might remain. It has occurred to me that, should a piece of solid phosphorus be swallowed, the free use of carbonic acid water, with bicarbonate of soda in solution, might be useful until the poison could be evacu- ated. The carbonic acid evolved from the liquid by the heat of the stomach would fill its cavity with a gas, which not only does not support combustion, but, mingled largely with atmospheric air, sup- presses the supporting power of it also; while the alkaline bicar- bonate would neutralize any free acid present, and still further increase the atmosphere of the acid gas. It has been recommended CHAP. I.] ARTERIAL STIMULANTS.—PHOSPHORUS. 581 to wash the burns produced by inflamed phosphorus on the surface with an alkaline solution, in order to remove the phosphoric acid. Therapeutic Application. The use of phosphorus as a medicine takes date from the middle of the last century. Though now little employed, in consequence of its frequently violent effects, it has at different times and by different persons been used in a great num- ber of diseases; and, properly guarded, is probably capable of useful therapeutic application. Nervous diseases, acute and chronic, as epi- lepsy, palsy, catalepsy, hypochondriasis, functional apoplexy, tetanus, periodical headache, venereal exhaustion, and amaurosis; intermittent fevers; various other febrile diseases of a low or malignant form; retro- cedent eruptions; hemorrhages; different forms of gout and rheumatism; cholera, diarrhoea, and colica pictonum; chlorosis and amenorrhoea; sterility and impotence; and even the phlegmasise, as typhoid pneu- monia, catarrhal croup, chronic pleurisy, and bronchitis, have been enumerated by authors among the diseases in which phosphorus has been employed and recommended. A sound discretion, however, would select, from this list, the affec- tions in which its known powers might justify its use. The collapse which takes place in the early stage of certain fevers; great prostration occurring in the course of febrile diseases generally; the alarming depression sometimes attendant upon the retrocession of scarlatina, erysipelas, &c.; in short, all low states of the system requiring prompt and powerful stimulation, and in which ordinary stimulants fail; these afford the conditions under which the practitioner would be justified in having recourse to this energetic remedy. In cases, too, of morbid depression of the generative powers, whether in the male or female, it would appear to be indicated, through one of the best established of its physiological properties. It may, moreover, be tried in old and very obstinate rheumatic and paralytic cases, when no discoverable organic lesion renders any amelioration altogether improbable. Administration. With proper caution in its use, no serious dan- ger need be apprehended. In the first place, it should never be given in the solid or undissolved form, not even in a state of' me- chanical division, however minute. It should always be exhibited in solution; and, happily, its different menstrua take up so small a portion of it, that it is brought into contact with the stomach in an extremely diluted state, and the combustion of its particles, should this take place, could do little or no injury. In the second place, it should not be administered when the stomach is quite empty, unless 582 GENERAL STIMULANTS. [PART II. accompanied with copious nutritive or enveloping material, which would secure the mucous surface against its concentrated effect. Very different opinions have been advanced as to the suitable dose. A mean between the extremes would give one grain during the day, in divided doses, frequently repeated. The only suitable preparations are solutions in ether, chloroform, olive or almond oil, or some analogous menstruum. Ether and olive oil each dissolves about four grains to the fluidounce. Objections to the former men- struum are the length of maceration necessary, which renders ex- temporaneous preparation difficult, and the great liability to the loss of the ether, and the consequent precipitation of the phos- phorus, when the solution is kept. The solution in oil is pre- ferable, as it is made more speedily, and keeps better. It is pre- pared, according to the Prussian Pharmacopoeia, in which it is designated as Oleum Phosphoratum, or Phosphorated Oil, by putting twelve grains of phosphorus, minutely divided, into a fluidounce of almond oil, melting the phosphorus by means of a water-bath, and then agitating until solution seems to have been effected. As the oil really dissolves but four grains, the undissolved portion should be separated by decantation or filtration. This oil should be phos- phorescent when exposed to the air. The dose of it is from five to ten drops, which may be repeated, in cases of urgency, every half hour; in ordinary cases of debility, every hour or two through the day. It should be given in an emulsion with one of the aromatic waters, so made that a tablespoonful should contain a dose of the phosphorus. Dr. R. M. Glover proposes chloroform as a solvent. This dissolves one-fourth of its weight of phosphorus, and has the advantage that the solution is not inflammable. (London Lancet, Jan. 8, 1853, p. 34.) The preparation should be made extempora- neously, in consequence of the great volatility of chloroform. One minim of a saturated solution, mixed with fifteen minims of ether and half a fluidounce of wine, might be given, in acute cases, every two or three hours. Dr. Glover also proposes a solution of phos- phorus in cod-liver oil, containing half a grain to the ounce, for use in scrofula. (See U. S. Dispensatory.) CHAP. I.J NERVOUS STIMULANTS, OR ANTISPASMODICS. 583 CLASS XX. NERVOUS STIMULANTS. Syn. Antispasmodics. This class of medicines is characterized by the property of stimu- lating the nervous system generally, without specially acting on the brain. Most of them are also more or less stimulant to the cir- culation, increasing the frequency of pulse and heat of skin, and often exciting the secretory functions; but these properties are incidental, and not essential to them as a class; and some, as coffee and tea, are nearly or quite destitute of them. Their peculiarity is simply that they stimulate the nervous centres generally and equably, without concentrating their force upon any one or a few of these centres; and the possession of this property would of itself be sufficient to entitle any medicine to a place in the class. It is this universality of their action that distinguishes them from the following class, or that of cerebral stimulants. As one of the nervous stimulants may superadd to its own characteristic property that of the arterial stimulants, so may it also possess additionally the peculiar influence of the cerebral stimulants, only that its own action would^ in that case be swallowed up or overwhelmed in this more powerful influence; and such really appears to be the case with some of the nervous stimulants. Thus, while assafetida, valerian, coffee, tea, &c, can scarcely be made to evince, in any quantity, or by any mode of administration, a peculiar tendency to operate on the cerebral centres beyond others, some medi- cines, much used and very efficient as nervous stimulants, if given more freely than is necessary for the exertion of their influence in this way, not only operate on the brain specially, but do so with great energy; as is the case with ether, camphor, and opium, which, in small doses, produce all the effects of the present class. The only difference between these two sets of nervous stimulants is, that, while both, in certain doses, stimulate equably the general nervous svstem, the former cannot be made to operate specially on the brain, and the latter can be made so to act by simply increasing the dose; 584 GENERAL STIMULANTS. [PART II. that is, in small doses they appear to operate diffusively and equably, and in larger, besides this general impression, superadd a special one upon the brain, which quite covers, if it does not supersede the first. In order to avoid unnecessary repetition, I shall treat of these latter remedies exclusively with the cerebral stimulants; as their most important therapeutic uses would attach them to that class; and it will be easy to point out their applications as nervous stimulants, when they are considered individually. Ether, camphor, and opium, therefore, will be found among the medicines of the next class. The medicines here denominated nervous stimulants are generally called antispasmodics in therapeutic treatises, in consequence of the property of relaxing spasm, which they certainly possess, under fa- vourable circumstances, in a very high degree. But spasm depends on so many causes, and is associated, as an effect, with so many dif- ferent pathological conditions, that the number of remedies appli- cable to its relief would scarcely fall short of the whole therapeutic catalogue. Dependent often upon inflammation, it may be treated advantageously by all the means which prove useful in the latter affection; that is, by most of the evacuants, revulsives, sedatives, and alteratives; in other instances, having its origin in debility, it will yield to astringents, tonics, and stimulants; and, in a third set of cases, being excited or sustained by various diseases in the dif- ferent organs and functions, it must be encountered by measures calculated to restore the affected organ or function to health. Again, this class of medicines is by no means confined, in its therapeutic agency, to spasmodic diseases. It is equally effectual in numerous other nervous disorders, to which more particular reference will be made directly. The nervous stimulants are but a very small section of the great host of antispasmodics, while they are themselves much more than mere antispasmodics. The name, therefore, being, in one sense, much too comprehensive, and, in another, scarcely in a less degree too restricted, should be abandoned, with other titles of a similar therapeutic origin, as the antiphlogistics, antiscorbutics, anti- syphilitics, &c, which it has been found impossible to retain in any well-considered pharmacological classification. I have proposed a name for the class which simply expresses one of their most pro- minent properties, and the one for which they are most used in medicine. CHAP. I.J NERVOUS STIMULANTS, OR ANTISPASMODICS. 585 1. Effects on the System. It has been already stated that most of these medicines stimu- late the circulation, and consequently increase the temperature of the surface. Indeed, this effect is often more obvious in health than their influence over the nervous system. The latter is so diffusive that the balance of the functions is little disturbed; and, no one being prominently affected, there is no striking departure from their healthy condition. Yet some influence upon the nervous functions may almost always be observed. A feeling of cheerfulness, a gentle exhilaration of the spirits, greater vividness of the fancy and energy of intellect, a disposition and capacity for increased muscular action, and some excitement of the organic functions, which are more or less under the influence of the nerv- ous centres, and particularly the function of secretion, may gene- rally be noticed. In great excess, some of them produce disor- dered sensations in the head, as feelings of fulness, vertigo, and headache; but very rarely do any of them, not belonging also to cerebral stimulants, occasion delirium, intoxication, or stupor. But in disease their effects are very obvious; the most violent apparent disorder of the nervous functions, yielding sometimes promptly to their influence. They are for the most part highly diffusible, acting quickly, and soon ceasing to act. They differ, however, much in this respect; and some of them continue to operate for a considerable time. Most of them are either volatile, or contain a volatile principle, which is often highly odorous, and generally disagreeably so to those unaccustomed to it, though it is often rendered tolerable and even agreeable by habit. Many persons acquire a strong relish for the smell and taste of assafetida and garlic. It has been thought by some that the nervous stimulants pro- duce their remedial effects exclusively, or nearly so, through the organ of smell. I have never been of that opinion. They will often operate powerfully when taken in the form of pill so as to conceal their smell and taste, and not unfrequently will produce the most prompt and powerful effects when given by enema. In some instances they do probably act by an impression made on the nostrils, which is conveyed through the communicating nerves to the nervous centres; but, in general, there can be no doubt that it is through the alimentary canal that they affect the system. In relation to some of the more odorous, as musk, assafetida, and garlic, the odour which they impart to the exhalation from the 586 GENERAL STIMULANTS. [PART II. lungs and skin, is an incontestable proof of their absorption; and the strong probability is, in reference to all of them, that the active principle enters the circulation, and is carried with the blood to the parts upon which it is to operate. When their volatile principle is inhaled into the lungs, it finds a ready entrance into the circulation; and some of the class, when applied externally, are absorbed with considerable facility; as is certainly the case with garlic, and probably with assafetida. 2. Therapeutic Application. The special application of this class of medicines is to the relief of nervous disorder. They are used in all affections of this kind, whether the result of over-excitement, or of depression of the nervous centres, provided only they are purely functional; that is, unconnected with active congestion or inflammation, or any other organic disease in those centres. This may at first sight seem singular; that the same remedy should prove useful in morbid excess and morbid deficiency of action; but the apparent anomaly is not insusceptible of explanation. The characteristic effect of these medicines is to stimulate the nervous centres. It will, therefore, be readily conceded that they may prove serviceable in disease, consisting in a depressed state of the nervous functions. But how can they, by their stimulating power, relieve a disease, consisting essentially in an already mor- bidly excited condition of the parts upon which they act ? To answer this question, we must admit, as a starting point, that there is only a limited amount of nervous excitability in the sys- tem; in other words, that, taking the whole nervous system toge- ther, it is insusceptible of unlimited exaltation, and that there is a point beyond which its actions cannot be elevated. Again, it must be admitted that the nervous energy is transferable, like the blood, from one part to another; that an over-excitement in one or more parts will call it off from others; and that in health there is a general tendency to an equilibrium of distribution. By supposing the existence of a nervous fluid, this reasoning might, perhaps, be rendered somewhat more intelligible; but I avoid this advantage, as the existence of such a fluid has not been proved; and the argu- ment is equally cogent without it. Admitting the above proposi- tions, which I believe are nothing more than statements of facts susceptible of satisfactory demonstration, we have only further to recollect, that the nervous stimulants are characterized by the uni- CHAP. I.J NERVOUS STIMULANTS, OR ANTISPASMODICS. 587 versality and equability of their action on the nervous centres. Suppose now that one of the cerebral centres is irritated into dis- eased action, which exhibits itself in spasms of the muscle directly connected with and dependent on that centre. A nervous stimu- lant is administered. It of course excites all the centres, operating on the one diseased in the same degree as on the others. Each becomes the seat of an attractive effort, calling to itself as much of the nervous power as may correspond with the degree of excitation applied. All, therefore, draw with a united force upon the surplus in that one centre, in which there is supposed to be a morbid accumu- lation. To this united force it can oppose only its own attractive force, under the irritation to which it is exposed. If, therefore, the combined excitation applied to the nervous centres generally, is not less than that existing in the one diseased, under the morbid irrita- tion, united to the excitation of the remedy, which it shares equally with the others, it must part with its surplus, and be reduced to the general level, or near it. If the causes of irritation shall have ceased, and the disordered centre be continuing to act morbidly simply from having begun to do so, the equilibrium can be en- tirely restored, and the disease cured. If not, the equilibrium is but partial or temporary; and the disease, though relieved, will be liable to return. The nervous stimulants, therefore, though they may afford much relief, even during the continuance of the cause, cannot be expected to effect a cure until this shall have ceased to act. In former times, these stimulants were said to prove useful by equalizing excitement. This term conveys succinctly the idea which I have endeavoured to demonstrate in the above paragraph. Our predecessors could not but notice the effect, though I am not aware that they have attempted a precise explanation. Their notions of the influence of the nervous centres were less definite, probably, than those now prevailing. Functional nervous disease may be, in the first place, idiopathic or self-existent, and alone; or, secondly, it may be idiopathic, and associated with other diseases; or, thirdly, it may depend upon other diseases; and each of these conditions has a bearing upon the therapeutic application of this class of medicines. 1. It appears to me beyond dispute that the nervous centres may become originally the special seat of functional disease, as well as any other part of the body; the cause operating on them directly through the same avenues by which they receive impres- 588 GENERAL STIMULANTS. [PART II. sions in health; and the disease may exist without any complica- tion whatever, other than such as may be induced in the functions under the control of the centre affected. It is to affections of this kind that the nervous stimulants are peculiarly applicable. Such are, in many instances, the morbid phenomena denominated hyste- rical. There is no other disease than that directly produced by causes external or internal, operating strongly upon the healthy centres, or moderately upon centres abnormally excitable. Even during the continuance of the cause, the nervous stimulants will often, by sustaining an equable tension of the nervous force, keep the disorder at bay; but, for a permanent cure, measures must be taken to obviate the cause, when the nervous centres are not in fault, or to give these a healthful power of resistance when unduly excitable. When the cause has been removed, and the disorder continues, as it often does through a sort of law of continuity in the actions of the system, the nervous stimulants will often remove it like a charm. Thus a female has been thrown into violent hys- terical disorder by some exterior influence, slight or severe, as the case may be, which, however, no longer acts; but the disorder continues with little abatement for hours, perhaps for days. In such cases, one of the nervous stimulants, a few doses of assafetida for example, perhaps even a single dose, may put a speedy end to the phenomena. 2. Sometimes the affection, originating as above, may coexist with other diseases originating in different causes. Inflammation of one of the important organs may complicate the hysterical phe- nomena, and demand a close scrutiny. The danger is that, in the turbulence of the nervous phenomena, the more serious disease may be overlooked. It will be the duty of the practitioner to in- vestigate the case carefully, and, having made the diagnosis, to employ the nervous stimulants altogether in subservience to the measures required by the more dangerous affection. To go on stimulating with assafetida, ether, camphor, &c, in such a case, under the impression that it is merely nervous, might prove very detri- mental, perhaps fatal. Yet, with due attention to the coexisting disease, the nervous stimulants may often be used safely in con- junction with other remedies, and even beneficially to the more serious complaint, by preventing the injurious reaction of the nervous disorder upon it. 3. More frequent than either of the preceding categories is that in which the nervous disorder merely complicates some other CHAP. I.J NERVOUS STIMULANTS, OR ANTISPASMODICS. 589 pathological condition, which has called it into existence and sus- tains it. In such cases, much injury has been done by overlooking the real disease, and addressing remedies to the more obvious and apparently violent nervous phenomena. It has been too common to treat them by the nervous stimulants chiefly or exclusively, and to persevere long with such treatment to the unspeakable injury of the patient. The practitioner should be always on his guard against this easy mistake, and never rest satisfied, in the treatment of nervous diseases which may be at all obstinate, until he has traced them satisfactorily to their cause. Judicious measures now em- ployed will often put an end to an affection, which may have been torturing the patient, and embarrassing the practitioner, for months, perhaps for years. We have not space here to specify the several morbid conditions which may thus give rise to nervous disorder. The consideration of them belongs to treatises on the practice of medicine. My object here, in noticing them, has been to complete a view of the circumstances which should regulate the use of the nervous stimulants. I would merely call attention to the stomach and bowels, the liver, the urinary organs, and in women the uterus, as the frequent seats of disease exhibiting itself in various nervous disorders; and to an anemic state of the blood, as one of the most prominent and efficient causes of the same affections. This impo- verished state of the blood may act doubly. It directly weakens the nervous centres through the want of material for their support; while the insufficiently supplied functions of the system generally, by their unceasing calls upon the nervous centres of circulation and respiration to supply them with more and better blood, main- tain in these centres a high degree of irritation, leading to diver- sified nervous disorder. Now the indications, in all such cases, is to address remedies especially to the original disease, and to employ the nervous stimulants simply as adjuvants, in order to suppress any occasional excess of nervous derangement, and to prevent its injurious reaction upon the organs or the system. In the use of this class of remedies, the practitioner should also bear in mind the general rule in relation to all stimulants; that the system becomes habituated to them by constant use, and thus, after a time, almost ceases to feel their influence, unless exhibited in constantly increasing quantity. They should, therefore, seldom be employed continuously for any great length of time. Hence, in persistent, and especially incurable organic diseases, the nervous stimulants are of doubtful utility, and should be used rather to 590 GENERAL STIMULANTS. [PART II. correct occasional disorder, than to sustain a permanent impres- sion. This class of medicines is contraindicated in inflammatory and febrile diseases, when the state of the system is sthenic, and the blood rich and abundant. Simple fever, or even inflammation, does not always forbid their use; on the contrary, when the blood is impaired in those cases, and a tendency to a low condition is observable, or even in the mere absence of the opposite condition, they may often be used advantageously in relieving attendant nervous disorder. They are especially contraindicated, when high congestive irritation, positive inflammation, or organic disease, such as hemorrhage, tumours, &c, occupies the nervous centres themselves. To the severest nervous diseases, or those which are deeply radicated in the cerebral or spinal centres, the nervous stimulants, as such, are inapplicable. Apoplexy, epilepsy, insanity, palsy, tetanus, profound coma, and even convulsions, other than those of a comparatively light character, are beyond their control. They may occasionally be used as adjuvants in such affections, when not contraindicated; but should not be relied on. Before closing these general observations, it will be proper to give a brief view of the different nervous affections, or rather forms of nervous disease, in which this class of medicines is employed. Preliminarily, I would call the attention of the reader to the admitted fact, that depression and over-excitement or irritation of the nervous centres are attended, to a considerable extent, with the same phenomena. How this may happen I have endeavoured to explain in my treatise on the Practice of Medicine. The circum- stance is practically of little importance as concerns the use of the present class of medicines; for they are applicable, as already ex- plained, to both these opposite conditions, except, in reference to irritation, when it is attended with active congestion or inflamma- tion in the centre itself, or its immediate vicinity; but the view which the practitioner may take of the pathological condition, whether one of exaltation or depression, will very much influence the coincident treatment. The nervous conditions or affections requiring the use of the nervous stimulants may be arranged under the following heads. 1. 3Iorbid Excitability of the Nervous Centres. This is a morbid condition, not a deranged action. The patient may possess it, yet, in the absence of any excitant agency, may appear perfectly well! CHAP. I.J NERVOUS STIMULANTS, OR ANTISPASMODICS. 591 The condition, however, is on the brink of disease, into which the slightest impulse may precipitate the system. It is often the result of a luxurious and easy life, with sedentary habits, and a feeble restraint over the various propensities, moral, sensual, or physical, which belong to our nature. Some, by their original constitution, inherited or accidental, have a tendency to it. Such persons are said to have a nervous temperament. Women, by their very nature, are more subject to it than men; because, having a great additional function to perform, beyond what belongs to the other sex, for the preservation of the species, they require more impres- sible nervous centres, so that all parts of the double existence may be brought into a due relation, by a ready perception of their mutual wants. On the same principle, to a certain extent, children are more excitable than adults. The rapid growth of their systems requires a quick impressibility of their nervous centres, in order to preserve a proper balance of the functions. Hence, in all these classes, nervous diseases -are more common than in others. It is true, that the nervous stimulants have little effect in correcting this morbid excitability; but they may be occasionally used ad- vantageously to guard against positive disorder under circum- stances of necessary exposure. The cure of the condition must depend upon a removal of its causes, and the employment of measures calculated to invigorate without exciting the system. 2. Spasmodic Affections. These are extremely numerous, and, whenever dependent on mere depression or excitement, without active congestion of the nervous centres, may be treated advantage- ously with the nervous stimulants. These medicines are equally efficient, whether the spasm occupies the voluntary muscles, the involuntary, or those partaking of the character of both. Of the first, or that seated in the voluntary muscles, we have examples in subsulius tendinum, cramps or painful spasms of par- ticular muscles, and clonic spasms or convulsions, sometimes confined to the muscles of one or a few parts of the body, and sometimes more or less general. In the first and last of these kinds of spasm, the nervous stimulants are more efficient than in the intermediate. This generally depends on an amount of irritation either in the nervous centres or other part, which is in most cases beyond the reach of these medicines. For example, the spasms of tetanus, the external cramps of cholera, and even ordinary cramps in the limbs, are little influenced by the nervous stimulants, given in 592 GENERAL STIMULANTS. [PART II. their proper capacity. Such of them as have narcotic properties are often serviceable, when carried to the point of narcotism. Among the spasmodic affections of the involuntary muscles are cramps of the stomach and bowels, gall-ducts, ureters, and bladder, spasm of the bronchial tubes, as in asthma, of the oesophagus, and, in women, of the uterus and vagina. There are none of these, when dependent on mere functional disorder of the nervous centres, whether spinal or cerebral, which may not be benefited by the nervous stimulants. But they are often produced by local causes, and associated with inflammatory conditions, which contra- indicate the medicines of this class. Of spasm in the mixed voluntary and involuntary muscles we have examples in the diaphragm, as in hiccough, which generally yields to the nervous stimulants, and in painful spasm or cramp, which may often be benefited by them, but often also requires more powerful remedies; in the muscles of respiration generally, as in hooping-cough, which is much alleviated, but seldom or never cured by them; and in the muscles of the glottis, as in laryngysmus stridulus and catarrhal croup, the former of which is often benefited by them, the latter seldom. 3. Irregular Movements of the Voluntary 3Iuscles, not Spasmodic. Of this kind are general restlessness, jactitation, aimless muscular mo- tions, whimsical gesticulations, imitative or suggestive movements but half voluntary, hysterical laughter, sobbings, facial distortions, hurried respi- ration, violent coughing, &c, all of which are often happily controlled by these remedies. 4. Disordered Sensation. This is extremely frequent, and of a character more or less amenable to nervous stimulation. Exam- ples of general disorder of this kind are presented in malaise or uneasiness, fidgetiness, weariness, lassitude, and soreness; and of local disorders an infinite variety, as tingling, itching, prickling, &c, in the skin and other parts; neuralgic pains, which may occur almost any- where; headache, giddiness, dizziness, weight, tension, fulness, &c, of the head; buzzing, roaring, hissing, whizzing, &c, in the ears; sparkling, flashing, perverted colouring, double vision, muscse volitantes, &c, in the eyes; false odours and perverted tastes; feelings of want of breath, weight, tightness, oppression, suffocation, &c, in the chest; constrictive globus hystericus in the throat; and, in the stomach, bowels, and other abdominal and pelvic viscera, numerous and diversified' feel- ings of uneasiness, which are too vague to be described, or to have been named. CHAP. I.] NERVOUS STIMULANTS, OR ANTISPASMODICS. 593 5. Diminution or Loss of 3Iuscuhr Power or Sensation. Dimness of vision, hardness of hearing, loss of articulation, aphonia or more or less complete loss of voice, paralysis of one or more of the voluntary muscles, incontinence of urine and feces, constipation, and tympanites from suspended peristaltic movement, are examples of nervous dis- order, which, though frequently dependent on affections quite be- yond the influence of the nervous stimulants, are sometimes purely functional, and yield more or less to their influence. 6. Mental Disorder. Under this head may be placed depression or false elation of sjnrils, hysterical fancies and emotional pjerversions, brief delusions, hypochondriasis, hysterical insanity, and the delirium, of cere- bral exhaustion, as in low typhoid fevers, and proper delirium tremens. Obstinate wakefulness, untimely drowsiness, lethargy, disturbed sleep, nightmare, uneasy or whimsical dreaming, somnambulism, and long- continued hysterical insensibility, may be placed in the same category. 7. Derangements of the Organic Functions. These embrace every conceivable disorder of every function, whether increase, diminu- tion, or perversion, provided only that it do not result from inflam- mation or organic disease; for all these functions are more or less under the control of the nervous centres. I shall not pretend to enumerate them; but a brief notice' of a few of them may serve to give the student some idea of their nature. In relation to the lungs, there is dyspnoea and asphyxia; to the heart, palpitations and faint- ness, or positive syncope; to the stomach, nausea, vomiting, eructations, flatulence, loss of appetite, morbid craving, and desire for strange arti- cles of food or. medicine; to the bowels, borborygmi, diarrhoea, and constipation; to the kidneys, excessive limpid diuresis; and to all other secretory organs, more or less perversion of their office. Of the recognized diseases in which the morbid phenomena above noticed occur most frequently, and in greatest diversity, and in which they most readily yield, at least temporarily, to the nervous stimulants, hysteria undoubtedly stands at the head. Probably nervous rheumatism and gout stand next in order; and the greater number of the phenomena above mentioned are often nothing more than results of disordered function, arising from influences which, ordinarily producing the inflammatory symptoms of those diseases, cause only nervous disorder when they act upon feeble, anemic, or nervous individuals. I have noticed, however, that the functional disorder of these affections, though occasionally much benefited by this class of remedies, does not yield to them so readily as the ana- logous affections in hysteria. Chorea, pertussis, spasmodic asthma, vol. I.—38 594 GENERAL STIMULANTS. [PART II. nervous cough, hypochondriasis, and delirium tremens are other special diseases in which the nervous stimulants are often indicated, but are generally alone insufficient to effect a cure. Epilepsy and neu- ralgia are sometimes benefited by them, but very seldom cured. There are, indeed, few diseases which are not occasionally attended, in certain stages of their progress, or in certain associated condi- tions of the system, with one or more of the symptoms enumerated, and in which the nervous stimulants are not sometimes indicated. There are various remedial influences which act upon the nerv- ous centres in a manner somewhat analogous to the nervous stimulants, and which, not being properly medicines, must be con- sidered in this place. They may be included under the heads of the emotional and the sensational. 1. EMOTIONAL INFLUENCES. The excitant emotions may often be usefully brought into play, in depressed or disordered states of the nervous functions. Hope, confidence, joy, love, ambition, and other analogous states of mind, exercise, within due bounds, a most happy influence, overflowing, as it were from their own special centres, over the whole cerebral and spinal regions, and throughout the sensitive system, diffusing a sort of physical exhilaration, which is admirably adapted to equalize excitement, and raise up the morbidly depressed nervous functions to their healthy level. Their effects are, indeed, closely analogous, in several respects, to that of the purer nervous stimu- lants. They not only excite the nervous centres, but, through them, increase the frequency of the pulse, diffuse a glow over the frame, and not unfrequently increase the various secretions, including even the menstrual. These are ordinary effects of the class of medicines we are now considering. Another coincidence is the wakefulness which they often occasion in a state of health, while they sometimes produce sleep by quieting the nervous dis- order, which prevents it in disease. Like these medicines, also, in excess, they may give rise to vertigo, headache, mental confusion, tremors, &c; but very seldom, like the narcotics, cause positive intoxication, delirium, or stupor, by their own immediate action. The methods of bringing their influence to bear upon a patient in any particular case, and the precise circumstances under which they should be resorted to, must be left to the sagacity and judg- ment of the practitioner. But every one should bear in mind CHAP. I.J NERVOUS STIMULANTS.—EMOTIONAL INFLUENCES. 595 their great efficiency, and be prepared to avail himself of it when the occasion may offer, ne should also bear in mind one im- portant rule; to proportion, namely, the degree of the influence wanted to the requisitions of the case, and take care that injury is not done by excess. He must be as cautious not to overdose his patient, in the use of these remedial means, as in that of medicines. Hysteria, hypochondriasis, and insanity, are affections upon which the m,edicina mentis may often be brought usefully to bear. The in- fluence of hope and confidence in favouring the action of other medicines is well known. How often do neuralgic pain and even spasm seem to yield to means wholly inert, as to the metallic trac- tors, or the globules of the homceopathist, when the hopes of the patient are strongly excited, or his full confidence gained in the efficacy of the measures used! How often do we see epileptic con- vulsions postponed for months, perhaps, in pure functional cases, set aside completely, under the use of remedies from which the patient confidently expected relief, though long experience may have satis- factorily proved their utter worthlessness. Intermittent fever, and other periodical diseases, are often interrupted by a conviction inspired into the patient, by whatever means, that he will miss the approach- ing or any particular paroxysm. It is well known that successful love has often arrested approaching insanity, if it has not proved remedial even after the disease has been established. But it is unnecessary to multiply instances. I have no doubt that the vari- ous excitements of travel, its anticipations, novelties, surprises, diversified incidents, varieties of scene, and multiplied enjoyment of social pleasures and the beauties of nature and art, contribute, in many cases of nervous disorder, more powerfully to the cure, than any medicine or combination of medicines which could be applied. Under the same head may also be placed the effects of surprise, or other startling impression upon the mind, in overcoming neuralgic pains, and morbid mental or physico-nervous associations. One of the most efficient methods of checking mild singultus is to startle the patient by a sudden exclamation, or by a declaration calculated to produce quick and strong emotion. The hysterical female, or hypo- chondriac male, will be roused out of apparent stupor in the case of the former, or some morbid conceit in that of the latter, by skil- fully contrived plans of powerfully impressing their feelings or imagination. Nervous headache is often relieved by a sudden and strong diversion of the attention, however effected. 596 GENERAL STIMULANTS. [PART II. 2. SENSATIONAL INFLUENCES. These may often be so employed as to become powerful means in the cure of various functional disorder. They operate cither by a direct excitation of depressed nervous centres, or by revul- sively relieving those which are in a state of irritation. There are two sets of them, one acting through the special senses, the other through the general sensibility. a. Through the Special Senses. A sudden impression on the retina, as from a flash of sunlight in a dark place, or of lightning in the night, may sometimes rouse a torpid brain, when only functionally affected. Similar impressions on the sense of smell will often check asphyxia; and the disagreeable odour of fetid substances is one of the means by which they relieve nervous disorder. A sudden sharp sound may arrest a threatened attack of syncope; and blowing in the ear is one of the remedies recommended for laryngismus stridulus. It is probable that music operates reme- dially, in part, by a moderately stimulant influence on the auditory centres; although something higher than sensation is here also concerned; for sounds arranged melodiously, or in harmony, have associations with our mental constitution, which often powerfully excite emotion, and thus produce nervous stimulation by an addi- tional influence. In calming morbid nervous irregularity or excite- ment, music is well known to have had extraordinary influence from the times of the Hebrews, when the harp of David composed the mental distemperature of the Jewish monarch. I was once witness to a striking case of this kind. It was in a stage-coach full of passengers, among whom were two or three women who could sing. A young man was suddenly seized with symptoms of insanity. After having attempted to escape by jumping out of the window of the vehicle, he was seized by the passengers, and com- pelled to remain. The idea took possession of his mind that he was in the power of robbers, who intended to kill him. He began to scream violently and incessantly; and no assurances, or anything else that could be done, seemed to pacify him. At length our female companions suggested the effects of music. The suggestion was approved, and they began to sing in concert; entertaining us with song after song with the greatest zeal and good nature. The poor maniac gradually began to show the influence of the music. His cries became less violent, and by degrees subsided into complete calmness, and before the strains ceased he was fast asleep. The CHAP. I.J NERVOUS STIMULANTS.—SENSATIONAL INFLUENCES. 597 music probably acted as a stimulant, calming the perturbation, by bringing all the nervous centres to the same level of excitement, after which they fell into a state of exhaustion consequent on the previous exaltation, and sleep ensued. There is no doubt that an excessively disagreeable taste may operate similarly in rousing the nervous centres of respiration and circu- lation. A strong pressure on the upper lip will sometimes enable one to control an otherwise irresistible tendency to sneeze; and a smart slap on the back may surprise nervous spasm of the glottis into relaxation. b. Through the General?Sensibility. Smart pain produced by any cause will often relieve, nervous disease. Not unfrequently a rest- less patient may be made to sleep by a pair of blisters to his ex- tremities. I knew a gentleman who was never free from morbid hypochondriacal sensations except when he had a blister drawing upon his epigastrium. The pain produced by a sinapism over the stomach is probably quite as efficient as the revulsive effect of the inflammation, and even more so, in relieving spasm of that organ. But pain may be carried so far as to overwhelm instead of rousing the nervous centres, as we see constantly in violent spasms of the stomach, bowels, ureters, &c. As a remedial measure, therefore, it must be used with discretion. To this category belong the shock produced on the nervous centres by cold and by electricity, each of which merits a brief notice. Cold as a Nervous Stimulant. Cold operates, in this capacity, solely through the sensation produced by its contact with the sur- face. Though a depressing agent in its direct action upon the part with which it comes in contact, it yet communicates to the nervous centres an impression, denominated the sensation or sense of cold, which is really excitant. This excitant impression may often be taken advantage of therapeutically to arouse the nervous system generally, or some great function, as the circulatory or respiratory, the nervous centres of which may be prostrated. Cold is applied in various methods, and in various degrees of intensity for this purpose. 1. One of the mildest is by simply sprinkling cold water on the face, or dashing it with a slight degree of force by means of the finger. This often answers an excellent purpose in obviating syncope or asphyxia, and will suffice to arouse a patient from slight attacks of this kind. 2. A stronger method, is to dash it upon the head, back of the neck, and shoulders, out of a small vessel. This plan 598 GENERAL STIMULANTS. [PART-II. may be resorted to in cases of stupefaction from narcotic poisoning, as by opium for example, in which it will sometimes temporarily excite the susceptibility of the brain, and enable it to feel the im- pression of emetic medicines upon the stomach. Vomiting may thus be induced, which the medicine unaided might be incompe- tent to effect. In asphyxia from hydrocyanic acid, it is one of the most efficient means of bringing about a return of respiration. One of the first effects of cold, suddenly applied to the surface, is to induce an involuntary inspiratory effort, through its excitant influence on the nervous centre of respiration. This inspiration is what is needed for the recommencement of the vital movements. Air is inhaled, the blood is changed, the pulmonary capillaries before torpid carry onward the arterialized fluid, this reaches the heart, and the central organ of circulation, thus reanimated, sends the life-giving current everywhere through the body. If the poison has ceased to act, this simple measure may be sufficient; if not, it at least gives the opportunity for the employment of others more efficient. So also in the asphyxia from chloroform, and other poisons operating in a similar manner. Spasmodic closure of the glottis in hysteria, epilepsy, and laryngismus stridulus may be relieved in the same way; the excitant impression on the nervous centre which causes the effort at inspiration, operating so as to relax the spasm which would impede the entrance of air. 3. A third and still more energetic method of applying cold for the purposes of a nervous stimulant, is by means of the cold shower bath. This may be employed, in cases of mental torpor, to rouse the energies of the brain; but care must always be taken that there is sufficient energy in the system to ensure reaction against the immediately depressing influence of the cold on the surface. 4. A fourth method, more energetic as a nervous stimulant than either of the others, is cold affusion, or the pouring of cold water, in considerable quantities, from pails, or other vessels, held two or three feet above the body. This was recommended by Dr. Currie of Liverpool in fevers, with the view of cutting them short; an object which is effected in some cases of typhus, and possibly in remittents, but never in typhoid or enteric fever. The operation of the remedy is partly by cooling the heat of the surface; but it is mainly by the powerful shock upon the nervous centres, breaking the morbid associations upon which the disease depends, and intro- ducing a new series of actions which may subside into health. But the measure does not always succjjJ, and is somewhat hazard- CHAP. I.] NERVOUS STIMULANTS.—SENSATIONAL INFLUENCES. 599 ous where it does not; and in general there are other and milder means which are in the end probably more effectual. But there is a condition of great danger, in which cold affusion has been em- ployed with much asserted success; and in which, should other measures fail, the practitioner would be justified in having re- course to it. I allude to the condition of collapse sometimes oc- curring at the commencement of malignant febrile diseases, and often characterizing the onset of pernicious or congestive fever. The patient in this condition, though really cold both without and within, as shown by the state of the breath, not unfrequently complains of burning heat. The sensation of the cold affusion is said to be agreeable to him at first; and, the moment at which he begins to feel an unpleasant sense of chilliness, is the time to cease with the application of cold, and to .apply the measures re- quisite for favouring reaction; as wiping him dry, wrapping him up in blankets, &c. The powerful stimulus of the cold to the nervous centres is, under these circumstances, the great agent of restoration. Other affections in which cold affusion has been used are the collapse of cholera, asphyxia from carbonic acid, and puerperal convulsions. In the use of affusion, the patient should be stripped naked, and may either have the water poured upon him from above while sitting over a tub; or, what is more convenient, he may be placed horizontally, and the affusion be made from a pitcher from one end of the body to the other. 5. The most energetic method of applying cold as a nervous stimulant is by immersing a patient in the cold bath. Generally speaking, this is too powerful for the object aimed at, which can be sufficiently accomplished by one of the other plans. Nevertheless, I have known it to be resorted to in one case of apparently almost fatal prostration in the pernicious paroxysm, with the supposed effect of producing reaction, and sav- ing the life of the patient. The temperature of the water for these purposes may be from 33° to 60° F., but must vary with the method of application. When merely sprinkled upon the face, it can scarcely be too cold. When dashed moderately on the head or shoulders, or used in the form of a shower bath, it may be at the mean between the two extremes mentioned. When poured from a height over the whole body, or used in the form of bath, it may be between the mean and the highest temperature. The period of application should always be very short. It is the shock that is wanted, not the depressing influence of the cold. If it be continued too long, 600 GENERAL STIMULANTS. [PART II. the depressing effect will reach even the nervous centres them- selves, and a result exactly the reverse of that desired will be obtained. An instant is often enough; and the application should seldom be protracted more than two or three minutes. Electricity in Relation to its Sensational Effect. In the precise sense in which the remedy is here considered, electricity acts merely by exciting sensation. In regard to its influences in general, it is a universal stimulant, and has been treated of, along with heat, under the general head of stimulation. The various methods of apply- ing it have there been considered. Here we have only to do with the influence of its shock, in other words, with the sensation it excites when applied so as to make a painful impression upon the nervous centres, which painful impression is the source of the remedial influence. For this purpose, it may be applied in two modes, either by the discharge of a Ley den jar, or by rapid inter- missions of the current by means of the different coil machines. The latter is the more effective method, as the impression is sus- tained, and can be graduated exactly to the requisitions of the case. The therapeutic effect aimed at by thus exciting sensation, is to rouse the functions from torpor by the diffusive stimulation which such an impression produces, when not overwhelmingly violent. It is not in the prostration from long continued disease, or that which often attends the progress and close of febrile and inflammatory affec- tions, that the remedy is indicated. There is here not force enough to sustain the excitement after it has been produced; and a con- tinuance of the measure would only further exhaust the excita- bility. The cases in which electricity is applicable, upon this principle, are those in which the system has been suddenly pros- trated into more or less complete insensibility through impressions on the nervous centres, and in which the excitability remains un- exhausted. Such are attacks of syncope or asphyxia, especially after the cause has ceased to act. The cases of poisoning by opium, before referred to (see page 546), in which the electro-magnetic machine aroused sensation in the advanced stage, when the direct symptoms of the poison had been followed by great prostration, and in which life appeared to be saved in consequence, are exam- ples of this kind. The apparently comatose condition of hysteria is another condition which indicates the use of the remedy. It would probably, moreover, serve an excellent purpose in some cases of malingering. O O" CHAP. I.] NERVOUS STIMULANTS.—MUSK. 601 I. MUSK. MOSCHUS. U.S., Lond., Ed., Dub. Origin. Musk is the product of an animal bearing some resem- blance to the deer, usually less than three feet high, with elevated haunches, long and narrow ears, a short tail, and tusks projecting downwards from the upper jaws. It is of various colours, but the most common is a deep iron-gray. The musk is contained in an oval sac, situated between the umbilicus and prepuce, and opening outwards by a small orifice. The animal inhabits the mountainous regions of Central Asia, lying between Siberia in the north and the Himalaya Mountains on the south, and comprehending Chinese Tartary and Thibet. It is solitary and timid, preferring the highest and most inaccessible places among the mountains, and seeking its food at night. The natives catch it in snares, or kill it by means of cross-bows set in its paths. Sometimes they also shoot it with guns, or with the bow and arrow. After its death, the bag is cut off and dried. The musk of commerce is brought from two sources; from Si- beria, through Russia, and from China, by the port of Canton. The Chinese variety is the best, and, so far as I know, is the only one imported into this country. The great value of musk leads to its frequent adulteration, and it seldom reaches our shops quite pure. The Chinese open the sacs, remove their contents, which they mix with dried bullocks' blood and other impurities, and then reintroduce a portion of the mixture into the sac, and close the opening more or less carefully. Another portion they inclose in artificial sacs, made from the skin or scro- tum of the animal; and it is these latter which are most frequently- brought to the United States, according to my own observation. After importation, the contents of the bags are removed, and, as we are informed, undergo another adulteration, in the process of granu- lation, by which it is prepared for the shops. Sensible and Chemical Properties. The true musk sac is oval, between two and three inches long, bare on the side at which it was attached, covered on the other with coarse hairs, which are arranged concentrically about a small opening. The sacs com- monly imported are of about the same size, but are full and rounded as if stuffed, have a piece of membrane on one side, and a portion of hairy skin on the other, and show clearly where the two pieces have been clumsily sewed together. 602 GENERAL STIMULANTS. [PAKT II. As usually kept in the shops, the musk is in irregular grains, soft and unctuous to the touch, of a brown or reddish-brown colour, and frequently mingled with the short hairs of the sac, which ap- pear to have been added to increase the weight. The smell is strong, extremely diffusive and permanent, to most persons very disagree- able in its greatest intensity, but usually considered agreeable when slight, and much esteemed in perfumery. So diffusive and so per- manent is it, that a small portion of musk will scent the whole atmosphere of a chamber for many days, without losing any por- tion of its weight; and the slightest contact with it will give an odour to the person or clothing, which remains for a considerable time. In some very nervous personSj the smell produces giddiness and faintness; and it has been known to throw hysterical women into convulsions. The taste is bitter, somewhat acrid, and disagree- able. Musk is inflammable. It imparts its virtues partially to water and alcohol; but neither fluid has been found to act satisfactorily as a menstruum in pharmacy. The active principle has not been isolated. Though musk contains a considerable proportion of matter volatilizable by heat, yet it cannot be deprived of its odour by distillation with water. Musk will keep for a long time unimpaired in a well-closed glass bottle, in a dry place. It should always have its own strong cha- racteristic odour and taste, a colour neither very pale nor blackish, and an unctuous feel, without grittiness. Effects on the System. In medicinal doses, musk produces a feeling of warmth in the stomach, followed by slight cerebral excitement, some increase in the frequency and fulness of the pulse, and a warm softness of the skin, which continue for a short time, and then sub- side without leaving any unpleasant effect behind. Taken more largely, it is said to disturb the stomach, and to occasion a feeling of weight, giddiness, and pain in the head, with considerable excite- ment of the circulation, and a tendency to sleep. I have, however, never noticed this last effect. In very large doses, we are told bv Jorg, that it causes trembling of the limbs, and sometimes convul- sions. It is, then, a moderate stimulant to the circulation, and a powerful stimulant of the nervous system, though possessed of little narcotic power. Trousseau and Pidoux have found it somewhat excitant to the genital organs. (Trait, de Therap., 4e ed., ii. 218.) It is said also to have sometimes proved diaphoretic and diuretic; which, indeed, may be said of all the stimulants. Its odorous principle, which is probably also the source of its CHAP. I.J NERVOUS STIMULANTS.—MUSK. 603 medicinal activity, is certainly absorbed; as it was noticed by Tie- demann and Gmelin in the blood, and is often strongly perceptible in the urine, perspiration, and pulmonary exhalation. Therapeutic Application. Musk was unknown to the ancients, and is said to have been introduced into Europe by the Arabians. It may be used for the general purposes of the nervous stimulants already detailed; and probably exercises their peculiar influence in a higher degree than any other of the class. It would appear to be specially applicable to cases in which severe spasm, or great nervous disturbance, is associated with a prostrate circulation. Low Fevers. It was formerly much used in low fevers, with sub- sultus tendinum, nervous tremors, and hiccough; and, so far as these nervous phenomena were concerned, it was no doubt useful; but its stimulant powers are inadequate to the demands of such cases, and it is now little employed. Adynamic Pneumonia. M. Recamier has recommended musk in a certain condition which occasionally supervenes upon pneumonia, and is characterized by the occurrence of delirium, with a general failure of the vital forces, and dangerous prostration. MM. Trous- seau and Pidoux have tried it, in similar cases, with favourable results, and are disposed to prize it highly under these circum- stances. (Ibid., p. 223.) The condition alluded to is not that de- bility which attends typhous pneumonia, and may be supposed to depend on a depraved state of the blood. Neither is it that which comes on after the occurrence of the suppurative stage of the dis- ease. It is one in which the nervous power appears to fail at once,, and the general powers of the system to give way with it, as hap- pens in sudden attacks ©f the- pernicious state in our remittent miasmatic fevers. The last-mentioned writers have found it to occur in pneumonia of the upper lobe of the lung, which seems to be a preferable seat of the disease in adynamic cases. In the con- dition of pneumonia referred to, a few successive doses have been sufficient to raise the patient out of this adynamic state, and to remove the delirium, after which the disease has followed a regular march towards health. Pernicious Fever. It has been stated that the condition of pneu- monia just mentioned was analogous to the pernicious paroxysms which sometimes supervene on miasmatic fever, in which the pro- minent symptoms depend on vast prostration or disorder of the nervous power. From the experience of the highly authoritative practitioners above mentioned in these pneumonic cases, I would 604 GENERAL STIMULANTS. [PART II. suggest the use of musk in the stage of collapse of our miasmatic pernicious or congestive fevers, in which the pathological state cer- tainly affords a fair indication for its use. Though less stimulant to the circulation than some of the medicines employed in this affection, it is very powerful in its influence on the nervous centres, which are probably specially in fault. It might be used in con- junction with the other remedies, and certainly, I think, could do no harm. Gouty Spasms in the Stomach. Dr. Cullen speaks in very strong terms, from his own experience, in favour of musk in gout attack- ing the stomach; and there can be no doubt of its efficiency in spasmodic cases of this kind, whether retrocedent or original. If the spasm is accompanied with coldness of the skin and depressed pulse, and resist ordinary measures, recourse should always be had to musk, which should be given freely. Cullen recommends it in other cases of retrocedent gout; and, whenever the affection is spasmodic, or'purely nervous, and the same depressed condition of the circulation exists, it may be employed with propriety; but it is contraindicated in the internal inflammatory attacks of that disease, and might do serious injury. Painful Spasms of the Involuntary or Sem{voluntary 3Iuscles. In all cases of painful spasm of the muscles of organic life, as of the oesophagus, stomach, bowels, bladder, ureter, and gall-ducts, or of those conjointly of animal and organic life, as of the diaphragm, if attended with collapse of the circulation, and especially when other measures fail, musk may be used as one of the most powerful anti- spasmodics at command. But, as in the case of gout in the sto- mach, it must be given freely. Infantile Convulsions from Intestinal Spasm. The late Dr. Joseph Parrish employed musk in this affection with great success; and, following his practice, I have found it extremely useful in similar cases of a very threatening character. A proper diagnosis, how- ever, is all-important. In many of the convulsive affections of children, with strong determination to the brain, it would be not only useless, but injurious. In the cases referred to, the convulsions are frequently preceded by a sudden stiffening of the body, as if the child were in great pain, and sometimes by a quick piercin^ scream- and, if the abdomen be examined, it will generally be found more or less tympanitic. These convulsions are also strongly character- ized by a sudden return of intelligence after they have ceased, in- stead of the protracted coma which is apt to follow those in which CHAP. I.J NERVOUS STIMULANTS.—MUSK. 605 the brain is actively congested. The effect depends on a sudden impression made on the cerebral centres by the painful spasm of the bowels; and, under the disturbance of these centres, before time has been allowed for the occurrence of vascular irritation, the convulsive movements take place. The convulsions often return frequently, from hour to hour, or even at shorter intervals, and the life of .the child is in imminent danger. The musk may be given, in these cases, by enema; two or three grains being administered to children a year old, and repeated every two hours, if necessary. Hiccough. Within my experience, there is no remedy or combi- nation of remedies so efficacious in hiccough as musk; and, were its only recommendation the almost certain command which it has over this affection, it would be a highly valuable medicine. Ordi- nary hiccough is quite trivial; but sometimes, whether as an appa- rently original affection, or as an attendant on other diseases, it is extremely obstinate and troublesome, racking the patient, prevent- ing sleep, and wearing out the strength by its constant agitation. I have known it to continue in this way for a week, resisting all ordinary measures, and reducing the patient almost to despair. So far as my observation has gone, and it has been somewhat exten- sive, musk has never failed to put an end to the affection, and in general very promptly. The only instance in which it did not effect an entire cure was an intermittent attack of the spasms, occurring in paroxysms at regular intervals. Musk always con- trolled the paroxysms, but they returned at the stated period, and were finally arrested by quinia. In another case, of an ex- tremely obstinate character, I had used the remedy for twenty- four hours without effect; when, on examining the musk, I found it very feeble. Another parcel was sent for from a different quar- ter, and promptly arrested the affection. It was used in the ordi- nary dose. Various Nervous Diseases. Musk has been commended in hys- teria, chorea, epilepsy, tetanus, eclampsia, mania, and even hydro- phobia, and has been employed also in asthma, hooping-cough, palpitations, cholera, and colic. It may no doubt be useful in most of these affections, under circumstances calling for the nervous stimulants; but it is probably in no case more efficacious than some other articles of the class, might under many circumstances prove injurious if not used with great discrimination, and has been abandoned generally by the profession after a fair trial. I need not say that it is altogether useless in hydrophobia. Its enormously 606 GENERAL STIMULANTS. [E'ART II. high price when pure, and the great uncertainty as to the degree of its purity as it is kept in the shops, are also strong objections to its use, and have no doubt very much contributed to the neglect into which it has fallen. I would, however, urge its use upon the profession, in the affections in which it has been recommended above; namely, in obstinate hiccough, and the convulsions of infants from intestinal spasm, from my own experience; in painful spasms of the involuntary muscles ivith collapse of the system, especially when gouty, upon the authority of Cullen, and general experience; in the peculiar condition of pneumonia referred to, on the authority of M. Recamier and of MM. Trousseau and Pidoux; and in the collapse of the first stage of pernicious fever, upon the ground of reason and analogy. Administration. Musk is given in substance; all liquid prepara- tions of it having been geuerally abandoned. The dose is from five to thirty grains; but the least quantity which should be given to an adult, as the drug is ordinarily found in the shops, is ten grains; and this should always be increased, if found to produce no observable effect on the system. Should the dose occasion a feeling of weight, vertigo, or pain in the head, it ought to be some- what diminished. It may be given in pill, or emulsion ; in the latter form, being suspended in peppermint water or diluted cinna- mon water, by means of gum arabic and sugar. Great care should be taken that no particle should be spilled when it is exhibited; as it will long scent the apartment disagreeably, and to some perhaps injuriously. II. CASTOR. CASTOREUM. U.S., Lond., Ed., Dub. Origin. Castor is a product of the #beaver, Castor Fiber of natu- ralists. In this animal, in both sexes, there are two pairs of folli- cles or small sacs, situated between the anus and external genitals, of which the lower and larger contains the castor. After death this is removed and dried, the pair being still connected by a slender cord, which is their excretory duct. Two varieties of castor are recognized in the books, one collected in Russia, the other in the northwestern parts of this Continent distinguished as the Russian, and American or Canadian castor. The latter alone is used in this country. CHAP. I.J NERVOUS STIMULANTS.—CASTOR. 607 Properties. The two sacs composing the pair, are of unequal size, the larger being usually two inches or more in length. They are pear-shaped, but much flattened and wrinkled, brown or black- ish externally, and internally divided by a whitish membrane into cells, which contain the castor. This is softish when fresh, but hardens with time, and then, though somewhat unctuous to the touch, is brittle, and exhibits when broken a resinous lustre. Its colour is brown or reddish-brown; its odour strong, fetid, and pe- culiar; and its taste bitter, acrid, and disagreeable. It yields its virtues to alcohol or ether, but not to water. Upon distillation it yields a little volatile oil, having its characteristic odour and taste, and upon which possibly its virtues may depend; but this point has not been decided. Castor deteriorates by time, but very slowly if kept in a cool, dry place. Exposed to heat and moisture, it speedily undergoes decomposition. Effects on the System. From the small doses in which castor is usually given as a medicine, no observable effect is experienced unless occasionally unpleasant eructations. Mr. Alexander states, in his experimental essays, that he took two drachms of it, at various doses, without any other effect than this. Jorg and his pupils experienced only slight uneasiness of the stomach, with dis- agreeable eructations. Thouvenel, however, found it, in the quan- tity of about half an ounce, to increase the frequency of pulse and heat of skin, and to produce other excitant effects. If a stimu- lant, therefore, to the circulation, it is a very mild one; but it must not be inferred that it is inert as a medicine; ,for the influence of the class of medicines now under consideration upon the nervous system is, in no degree, measured by that which they may exercise upon the heart and arteries; nor is their remedial power in nervous diseases to be measured by their apparent effect in health; so that the efficiency of castor as a medicine must be decided solely upon the ground of experience. This would seem to have determined in its favour, if medical testimony is to be admitted as having any authority; yet the medicine is certainly not very powerful. Therapeutic Application. Castor was employed by the ancient Greeks, and has ever since held its place in the Materia Medica catalogues. It was anciently used chiefly in hysteria and amenor- rhoea. By modern physicians it has been given in most of the nervous diseases, already enumerated, as affording indications for 608 GENERAL STIMULANTS. [PART II. the nervous stimulants. At present it is probably most used to relieve the disordered nervous phenomena of low fevers, and in the different phases of hysteria, especially when associated with suppression or retention of the menses. Trousseau and Pidoux speak in decided terms of its utility in amenorrhoea, attended with painful tympanites, and in hysterical colic, with paleness, cold sweats, and sudden prostration. In the North of Europe it is said to be used for promoting labour, and the expulsion of the placenta. I can say nothing of it from experience, having very seldom used it. The dose of ten or twenty grains, usually mentioned in the books, is probably too small, and may be at least doubled. It may be given in pill or emulsion. A Tincture of Castor (Tinctura Castorei, U.S.) is prepared with undiluted officinal alcohol, and given in doses varying from thirty minims to two fluidrachms, which might be doubled, should the quantity of alcohol not be contraindicated. An Ammoniaied Tincture is directed by the Edinburgh College (Tinctura Castorei Ammoniata, Ed), which is made with assa- fetida, castor, and the spirit of ammonia of that College, itself a very active stimulant. This is no doubt an energetic antispasmodic and stimulant; but owes its powers much less to the castor than the other ingredients. It may be used in spasm of the stomach, .and other nervous affections demanding active stimulation. The dose is from thirty minims to two fluidrachms. III. ASSAFETIDA. ASSAF(ETIDA. U.S., Lond., Ed., Dub. Origin. Assafetida is a concrete juice, derived from the root of Narthex Assafoetida, an umbelliferous herb, from six to nine feet high, growing in the interior mountainous regions of Persia, and neighbouring countries. It is obtained by twisting the leaves from the root, dio-oino- the earth from about it, then slicing off the top of the root transversely, and scraping the juice from the surface as it exudes; the leaves being employed to shelter the wounded root from the sun. When the exudation ceases, another slice is removed; and thus till the root is exhausted. CHAP. I.] NERVOUS STIMULANTS.—ASSAFETIDA. 609 The juice thus collected is allowed to concrete in the sun, and is then taken to Bushire, whence it is carried in vessels to Bombay, and from that port is distributed over the world. Properties. Assafetida is in irregular lumps or masses, often soft- ish in the interior as first imported, but gradually becoming hard and brittle. The colour is brownish externally, but, upon the freshly broken surface, is whitish or variegated, quickly becoming red on exposure to the air, and ultimately changing to brown. The lumps are sometimes homogeneous or nearly so; but usually consist of smaller portions aggregated, or of whitish tears embedded in a darker paste. The odour is strong and extremely fetid, so as to have acquired for the drug the name of stercus diaboli. Yet it sometimes becomes tolerable by habit; and it is not requisite to go so far as the East Indies to find individuals who are even fond of it. The taste is bitter and subacrrd. In some parts of Hindostan, the inhabitants use it habitually as a luxury; and the streets of Surat are said to be sometimes redolent of the drug. Both the smell and taste are diminished by drying, and by age; and, in the recent condition of the juice, the former is said to be intensely offensive. Assafetida softens by heat, but cannot be quite melted. It is very inflammable. In chemical constitution it is a gum-resin, consisting of gum, resin, and volatile oil. The odour is owing to the oil, the medical virtues to that and the resin conjointly, and the gum is inert. When rubbed with water, the gum-resin forms a white milky emulsion; the resin and oil being suspended by the intervention of the gum. This emulsion often assumes a pinkish hue on exposure. Alcohol dissolves all the active matter, forming a transparent tinc- ture, which becomes turbid on the addition of water, in conse- quence of the separation of the resin. Effects on the System. Assafetida stimulates the stomach and the circulatory system moderately, and the general nervous system powerfully, is somewhat expectorant and often laxative, and is believed by some to have emmenagogue and anthelmintic proper- ties. In moderate medicinal doses, it produces a feeling of warmth in the stomach, somewhat increases the frequency of the pulse and the heat of skin, often more or less exhilarates the spirits, and is said also to excite the genital organs, and sometimes to bring on the menstrual flow in women. When rather freely taken, it occa- sionally produces slight vertigo or headache, but never intoxication or stupor. It not unfrequently operates as a cathartic, but not so VOL. i.—39 610 GENERAL STIMULANTS. [PART II. uniformly as to deserve to rank in that class of medicines. In large doses it disturbs the stomach, and may even excite nausea and vomiting; but these are rare effects when that organ is quite sound. That it should cause offensive eructations is a necessary result of its fetid odour and carminative properties. The volatile oil of assafetida is certainly absorbed. A sufficient proof of this is the fetid odour of all the secretions under its use, of the breath, the perspiration, the urine, and, as has been asserted, of the discharges from ulcerated surfaces. As the oil is probably the main active principle, the drug no doubt produces its consti- tutional impression through the circulation; though it is highly probable that the offensive odour may sometimes also act favour- ably on the cerebral centres, through the sense of smell. Therapeutic Applications. Assafetida is a highly important me- dicine, and there is reason to apprehend that it may be too much neglected in consequence of its extreme offensiveness. The pro- bability is that it was employed by the ancient Greek physicians; though some doubt has been entertained upon that point. It was certainly known to the Arabians, and appears to have been intro- duced by them into modern Europe, through the school of Saler- num. It may be employed in almost all cases of nervous disease calling for medicines of this class, and, upon the whole, may be regarded as the most useful of them. Less powerful than musk in over- coming obstinate hiccough, in relaxing those painful spasms of the involuntary muscles which have a deeper source than mere hys- teria, and in rousing up the nervous centres from profound torpor or prostration, it is superior to it in hysteria, and in certain other nervous affections which will be noticed immediately, and probably quite equal in general efficiency. In hysteria, in almost all its forms, assafetida is a most valuable remedy. Even the convulsions of this disease will often yield to it, or undergo favourable modification under its use. In such cases, as it is often impossible for the patient to swallow, it should be exhibited by enema. In the same form, also, it may be employed in general hysterical insensibility simulating coma, and in dysphagia arising from hysterical spasm of the glottis. In the allied disease of hypochondriasis in males, it is among the remedies which afford most relief to the various nervous disorders, though it may be inadequate to the cure. In all convulsive affections, purely functional, that is, unconnected CHAP. I.J NERVOUS STIMULANTS.—ASSAFETIDA. 611 with active congestion, inflammation, or other form of organic disease, it may be used with reasonable hope of benefit. The particular form, besides the hysterical, in which most good may be expected from it is that of infantile convulsions, arising from spasm in the intestinal tube. It should be given, in cases of this kind, by enema during the convulsion, and by the mouth, at regular periods, every hour, two, or three hours, in the interval. Epilepsy is quite beyond its unaided powers; though the medicine may sometimes relieve it, and, in connexion with other medicines, may even contribute to its cure when purely functional. In chorea it is occasionally adequate to the cure, if employed in association with cathartics; the patient being kept steadily under the use of the assafetida, while a purgative is given every second or third day. Hooping-cough is one of the complaints in which assafetida is most useful. After the subsidence of the initial catarrhal symp- toms, and when those of a spasmodic character have become fully established, it should be given regularly, every two or three hours, until the violence of the paroxysms has begun to abate. The child receives so much relief from the medicine, that, after having become accustomed to its taste, he will often call for it, even by cries, if too young to speak. This I have seen repeatedly. Nervous coughs sometimes occur, which, after obstinately resisting measures addressed to them as catarrhal, will yield at once to a few doses of assafetida. They are most apt to occur in women, though I have seen them when there was no reason to suppose them hysterical, and have found them to yield as promptly as if they had been merely a phase of that disease. In some of these cases, the cough may be a form of nervous gout or rheumatism. I would urge upon the inexperienced practitioner to be on the watch for these cases. When he encounters a severe and harassing cough, which can be traced to no special source, and which, he is satisfied, cannot depend on inflammation of any part of the air-passages, let him try the assafetida, and I feel quite sure that he will often find it successful. The nervous element may even complicate ordinary coughs, and give them an unusual obstinacy; which will yield by combining the use of assafetida with the other measures indicated. The medicine may be employed in the paroxysms of spasmodic asthma; but cannot be relied on in that affection. In complicated cases however, in which the dyspnoea is associated with chronic catarrh, the system being feeble, and the circulation and skin re- 612 GENERAL STIMULANTS. [PART II. laxed, it may be of much service by its combined expectorant and antispasmodic powers. Laryngismus stridulus, or pure spasm of the glottis occurring in infants, is said to have been beneficially treated with it, but I have not used it in that complaint. I would particularly call attention to a certain condition in the advanced stage of pectoral inflammation in infants and young children, whether bronchial or parenchymatous, in which assafetida is an ad- mirable remedy. In patients of this age, the nervous system is very apt to suffer, whatever may be the nature of the case, if in any degree severe. Even in their inflammations, the nervous centres seem to become exhausted before the disease has run its course, and alarming symptoms from this cause not unfrequently complicate the case. In the pectoral inflammations, this condition may be rea- dily, and, I believe, often has been fatally overlooked. This is probably one of the reasons of the great mortality of infantile bronchitis and pneumonia. The nervous exhaustion shows itself by symptoms which may be readily mistaken for an aggravation of the original affection. The respiration is much hurried, the alae nasi visibly expand and contract, the child is sometimes anxious and restless when not stupid, and the pulse is very frequent and feeble. Under such circumstances, if the patient is at a somewhat advanced period of the disease, and, upon application of the hand, it should be found that -the ears, tip of the nose, cheek, or fingers feel cold, or even cool, it may be taken for granted that the system, and especially the nervous centres of respiration, need support; and this support assafetida, freely used, and repeated every hour or two, will often yield, to the vast relief of the patient. I am quite con- fident that I have seen lives saved, mainly by this remedy, in the condition referred to. While useful as an expectorant, it operates, I believe, chiefly by stimulating the exhausted nervous centres. My attention was first called to such cases by my preceptor, Dr. Jos. Parrish, and I have since had frequent occasion to thank him for the valuable practical lesson. In low states of fever, assafetida is sometimes useful in obviating nervous symptoms, such as subsultus, general tremors, restlessness, hic- cough, &c; but it is not more efficacious than other much less dis- agreeable remedies, and is, therefore, little used. In the tympanites, however, of these complaints, given as an injection, it is a valuable remedy, second only to the oil of turpentine in efficiency. In constipation with flatulence in old people or hysterical women CHAP. I.] NERVOUS STIMULANTS.—ASSAFETIDA. 613 and in the colicky affections of the latter class, assafetida may often be advantageously combined with laxatives, such as aloes and rhu- barb. If amenorrhoea be superadded, myrrh may be combined with the other ingredients; and if ansemia, one of the preparations of iron. The laxative properties of the gum-resin often add to its advan- tages as a nervous stimulant; but sometimes it is necessary to coun- teract them with a little laudanum. Of the special uses of this gum-resin as a stimulating expectorant there will be occasion to treat hereafter. Assafetida is contraindicated in acute inflammation, and in fever with hot skin and a full, strong pulse; and especially so when the nervous centres themselves are the seat of high vascular irritation, inflammation, or organic disease, even though convulsions, spasm, or other nervous disorder should appear to indicate the use of this class of medicines. Administration. The dose of assafetida is from five to twenty grains. More, however, might sometimes be given with safety and probable advantage. It should generally be administered in pill or emulsion; the former being preferable whenever the latter form is not specially called for, in consequence of the opportunity it affords of concealing the taste and smell. The emulsion, however, is always preferable when a prompt effect is desirable; and this is most frequently the case. It may be made by simply rubbing the gum-resin thoroughly with water, and straining. The emulsion is directed, in the U.S. Pharmacopoeia, under the name of Assafetida 3Iixture (Mistura Assafcstid^;). It is the milk of assafetida or lac assafcetidse of the older pharmacy. A fluidounce contains fifteen grains, and one or two tablespoonfuls may be given for a dose. As an enema, assafetida is administered in the form of emulsion; and from half a drachm to two drachms may be used in half a pint of water. The Tincture of Assafetida (Tinctura Assafostid^, U. S), may be given in cases where a prompt effect is required, and there is no objection to the alcohol. Officinal or undiluted alcohol is used in its preparation. The medium dose is a fluidrachm. It should be diluted with water, which becomes milky by the separation of the resin. Pills of Aloes and Assafetida (Pilule Aloes et Assafcetid^:, U. S) are officinal. They contain equal quantities of aloes and assafetida mixed with soap, and are given in torpid bowels with 614 GENERAL STIMULANTS. [PART II. flatulence and debility of the alimentary canal. From two to five of the pills, each containing four grains, may be given for a dose. A Plaster of Assafetida (Emplastrum Assafostid.e, U. S) is also officinal. It is used as an application to the chest, or between the shoulders, in hooping-cough, and over the abdomen in the flatulent colics of hysteria. Several other gum-resins, having properties analogous to those of assafetida, though much inferior, have been more or less in use from the times of the ancient Greeks and Romans. At present, however, they are much less employed than formerly. A very brief notice of them will be sufficient; as there is not one of them which might not very well be dispensed with, in reference merely to its powers as a nervous stimulant. The medicines alluded to are sagapenum, galbanum, and ammoniac. 1. SAGAPENUM. Lond. This is the concrete juice of an unknown Persian plant, supposed to be umbelliferous. It is imported from the Levant. As brought to us, it is either in irregular masses of agglutinated tears, trans- lucent, and of a wax-like consistence, or in soft adhesive masses, in which no tears are visible. It has a brownish-yellow, reddish- yellow, or olive colour, paler within than without, and becoming darker by time. The odour is alliaceous, but weaker and less dis- agreeable than that of assafetida; the taste, bitterish, somewhat acrid, and nauseous. It becomes softer and tenacious by heat, and is inflammable. Water and alcohol dissolve it partially, diluted alcohol completely. It consists essentially of volatile oil, resin, and gum, of which the two former are probably the active constituents. The odour depends upon the oil. This gum-resin produces effects on the system similar to those of assafetida, but is too feeble to be depended on as a substitute, in which capacity it might otherwise be used, in consequence of its less offensive odour. It is occasionally employed as an adjuvant to cathartics, in flatulent states of the stomach and bowels. The dose is from ten to thirty grains, which may be given in pill or emulsion. 2. GALBANUM. U.S. Galbanum is the concrete juice of an uncertain plant, probably a species of Ferula, growing in Persia, on the borders of the Caspian. It is said sometimes to be procured by incision, sometimes to exude spontaneously, and harden in the form of tears. In this latter state CHAP. I.J NERVOUS STIMULANTS.—GALBANUM. 615 it is sometimes, though rarely, imported; the tears being about as large as a pea, round, shining, translucent, and of a yellowish or brownish-yellow colour. More frequently it is in masses composed of whitish, reddish, or yellowish tears, simply agglutinated together, or imbedded in a darker, yellowish-brown, or greenish substance. It has the consistence of wax, but softens with heat, and at the temperature of the surface becomes adhesive. At 212° Fahr. it melts so that it can be strained, and is thus freed from impurities. Its odour is peculiar and disagreeable; its taste, bitterish, warm, and acrid. Water dissolves it partially; alcohol, the oil and resin; diluted alcohol, the whole of it, excepting impurities. It consists of gum, resin, and volatile oil, of which the two latter are active. Its medical properties are similar to those of sagapenum, though generally considered feebler. With a slightly stimulant influence over the circulation and nervous system, it has been supposed to unite expectorant and emmenagogue powers; and hence has been given in hysteria and other nervous disorders, enfeebled digestion, flatulence, chronic bronchial affections, chlorosis, ame- norrhoea, chronic rheumatism, &c. It was formerly very much employed, and entered into a large number of preparations for in- ternal and external use. But it has been almost wholly superseded by assafetida, and is little used at present. The dose is from ten to twenty grains, given in pill or emulsion. Compound Galbanum Pills (Pilul,e Galbani Composite, U.S.), composed of galbanum, myrrh, and assafetida, are officinal. They are used as a nervous stimulant and emmenagogue, in hysteria and amenorrhoea, in the dose of from ten to twenty grains. Dr. Arnold has strongly recommended the local use of a tincture of galbanum in various diseases of the eye, such as scrofulous ophthalmia, ocular debility from prolonged reading, spasmodic motions of the eyelids, oedema of the eyelids, weakness of the lachrymal canal, &c. He moistens the surface of a compress with the tincture, and applies it immediately over the eye for an hour; then removes it for several hours, and again applies it; and thus successively till the object is accomplished. A burning heat is first felt, which gradually lessens, and ceases within an hour, when the compress becomes dry. The tincture may be made by dissolv- ing an ounce in a pint of diluted alcohol (Merat et De Lens, Diet. de Mat. Med., i. 685). The Compound Galbanum Plaster (Emplastrum Galbani Com- POSITUM, U.S.), which consists of galbanum, Burgundy pitch, tur- 616 GENERAL STIMULANTS. [pART II. pentine, and lead plaster, is a good discutient application in chronic scrofulous swellings, inflammatory indurations, and chronic rheu- matic and gouty disease of the joints; care being taken that signs of acute inflammation should always be absent. 3. AMMONIAC—Ammoniacum. U.S., Lond., Ed., Dub. This gum-resin will be hereafter treated of as a stimulant expec- torant, when its origin, properties, composition, and physiological effects will be detailed. In the present place it is sufficient to state that, along with other properties, it is supposed to possess those of a nervous stimulant, in a degree somewhat less than the two pre- ceding gum-resins. In this capacity, it has been supposed to be useful in obstinate colicky affections of the bowels with constipa- tion, and in asthma complicated with chronic bronchitis; being aided in the former of these affections by its laxative, and in the latter by its expectorant' properties. The dose of it is from ten to thirty grains, given in the form of pill or emulsion. Ammoniac is used externally, as a local stimulant, in the form of Plaster (Emplastrum Ammoniaci, U. S). This often produces a papulous eruption, and sometimes considerable inflammation of the skin. It is used chiefly to promote resolution of scrofulous tumours, and other chronic swellings of the joints. Combined with mercury, as it is in the Plaster of Ammoniac with Mercury (Emplastrum Ammoniaci cum Hydrargyro), it acquires increased discutient powers; and in this form is applied additionally to vene- real nodes and tumefactions, and over the region of the liver in chronic hepatitis. This plaster sometimes affects the gums. ■♦» IV. VALERIAN. VALERIANA. U. S, Lond, Ed., Dub. Origin. This is the root of Valeriana officinalis, a European herbaceous perennial, from two to four feet high, with branches terminating in clusters of small sweet-scented flowers. The plant is now cultivated in this country for medicinal purposes. The root is collected preferably in the autumn after the decay of the leaves, or early in the spring before they appear. Properties. The root consists of a small tuberculated head, send- ing forth numerous long cylindrical fibres or radicals, and bears no inconsiderable resemblance to Virginia snakeroot. The colour of CHAP. I.] NERVOUS STIMULANTS.—VALERIAN. 617 the radicals is externally yellowish or brownish, internally white; that of the powder yellowish-gray. The odour, which in the fresh root is slight, is, in the dried, strong, somewhat aromatic, and highly peculiar. To some it is agreeable, to others the reverse. Cats are said to be extremely fond of it, and under its influence to experience a kind of intoxication. The taste is at first sweetish, afterwards bitterish, somewhat acrid, and disagreeable. Active Principles. The active principles are a peculiar volatile oil, and probably an extractive matter of a sweetish and slightly bitter taste called valerianin. Upon the former depend the stimu- lant properties of the root; the latter niay be slightly tonic. The oil of valerian, being one of the officinal preparations of the root, will be noticed more particularly below. Effects on the System. Different opinions are held as to the sti- mulant influence of valerian on the circulation; some believing it to have such an influence, others denying it altogether. I am among those who consider it as in general very moderately stimu- lant, though its effects in this respect are somewhat uncertain. Upon the stomach it also produces a slightly excitant impression, which, when it is largely taken, often amounts to irritation. Upon the nervous system, however, its action is more decided. This is shown, in the ordinary medicinal doses, rather by its influence in composing nervous disorder, than by any decided disturbance of the nervous functions in health, unless, perhaps, in certain very susceptible persons. But in very large doses, it produces, even in robust individuals, some degree of headache, vertigo, and disturb- ance of sight and hearing; and in others of a more nervous tem- perament, may superadd to these effects more or less mental excite- ment, visual illusion, general agitation, and even involuntary muscular movement. It never, however, causes positive delirium or coma; and is probably incapable, in any quantity, of acting as a poison. It sometimes disturbs the bowels. Therapeutic Application. We have no proof that valerian was employed by the ancients. Much more efficacy has been ascribed to it by many writers than it is now generally believed to possess. I have never, myself, seen from it anything more than very mode- rate remedial influences. It was brought into notice by Fabius Columna, a Neapolitan of high birth, who, labouring himself under epilepsy, and searching eagerly in the field of botany for a remedy, thought he had found it in valerian. Many reports have since then been made of its efficiency in that disease; but the credit of 618 GENERAL STIMULANTS. [PART II. curing epilepsy is one which it must share with numerous other substances, not a few of which are much more inert than itself. In this disease the mental condition of the patient has great influence; and anything which strongly excites his confidence or his hopes, may, for a time, and occasionally does, for a considerable time, suspend the recurrence of the paroxysms. If, in the mean time, the cause which sustained the disease should have ceased, a perma- nent cure might seem to have been effected by what is in itself wholly useless. Nevertheless, it would not be proper to deny all efficiency to valerian in epilepsy. In some purely functional cases, before the disease had become firmly seated in the habits, if not in the structure of the brain, it may possibly have set it aside; and it may still be exhibited, with some hope of benefit, as an adjuvant of more powerful remedies; but no curative effect can be expected from it, unless freely given and long persevered with; and reliance should never be placed upon its exclusive use. To the cure of fixed epilepsy it is quite inadequate. The morbid conditions to which valerian is most appropriate are the milder form of hysteria and hypochondriasis, in which the in- dication is to obviate depression of spirits, or to control the slighter nervous irregularities, which, in countless diversity, are spring- ing up in the course of the former disease. Even under such circumstances, it is probably more used as an adjuvant to other remedies intended to make a permanent and curative impression, than exclusively for its own effects. Thus, in a case of chlorosis, while the disease is pursuing a regular march towards health, under the use of the chalybeates and a good diet, valerian may sometimes be employed advantageously to quiet palpitations, re- lieve unpleasant cerebral sensations, or general uneasiness, and obviate irregular muscular movements of various kinds. . Not unfrequently, dyspepsia is accompanied with much nervous discomposure, especially in women, and in those, too, who have shown no tendency to hysteria. Valerian may often be usefully associated, in such cases, with the bitter tonics, laxatives, &c, which may be employed to meet more important indications. The same may be said of its use in other diseases of depression or debility, in which nervous disorder is a mere attendant phenomenon, having no important signification, but nevertheless often very annoying to the patient. Its application to the relief of wakefulness, restless- ness, general uneasiness, muscular tremors, &c, complicating low febrile diseases, would come into this category; though the same CHAP. I.] ' NERVOUS STIMULANTS.—VALERIAN. 619 ends may generally be better attained by the use of Hoffmann's anodyne, sweet spirit of nitre, camphor water, &c, than by valerian. In the treatment of hemicrania, it has enjoyed some reputation in connexion with Peruvian bark or sulphate of quinia. I have repeatedly, in former times, seen this very troublesome affection yield, in two or three days, to an ounce or two of bark taken daily, in divided doses, in a pint or two of infusion of valerian. The first effect was generally somewhat to augment the pain; but it ceased at the end of the time specified. On making similar at- tempts more recently, with sulphate of quinia and oil of valerian, I have not been in an equal degree successful. It is not impossible that the oppression of stomach, produced by the bark in powder, may have had something to do with the result. M. Rayer has found valerian efficacious in a case of excessive thirst, in a boy, attended with copious discharge of light-coloured, limpid, inodorous, and tasteless urine. The quantity of liquid drank and discharged was enormous. The affection was looked on as nervous, and yielded in about a month to the powder of valerian, employed under this view of its nature. Administration. Valerian is most effectively given in the form of powder, which should be preferred when a strong impression is desired. The dose is from thirty to ninety grains three or four times a day, and may be increased, if thought desirable, so that an ounce may be taken in twenty-four hours; the quantity being of course diminished if unpleasant cerebral phenomena should occur. The Infusion (Infusum Valerianae, U.S.), is officinal, and is di- rected to be made in the proportion of half an ounce to a pint of boiling water. The medicine is said to be less apt to irritate the bowels in this form, than in that of powder. The dose is two fluid- ounces.. There is also an officinal Tincture (Tinctura Valeriana, U. S), which has the virtues of the medicine, but unfortunately also the stimulant properties of alcohol, which, except under rare circum- stances, should forbid its use. The danger of its abuse, when care- lessly prescribed for slight nervous affections, is too obvious to re- quire that more should be said to put the young practitioner on his guard. The dose of it is one or two fluidrachms. The Ammoniated Tincture (TlNCTURA VALERIANAE AMMONIATA, U. S) is a much more effective preparation, being made with aromatic spirit of ammonia instead of diluted alcohol. I would particularly caution the reader not to confound this tincture with 620 GENERAL STIMULANTS. [PART II. that of the Edinburgh Pharmacopoeia, of the same title, which is probably three times as strong with ammonia. The dose of the U. S. tincture is from one to two fluidrachms, which should be largely diluted. It is especially indicated in cases of hysteric spasm of the stomach, or troublesome flatulence having the same origin. The Fluid Extract of Valerian (Extractum Valeriana Fluidum, U.S.), which is peculiar to the U. S. Pharmacopoeia, is an elegant preparation, concentrating the virtues of the medicine in a small bulk, convenient for administration. The dose is from one to three fluidrachms. The Volatile Oil (Oleum Valerianae, U. S), which is supposed to have all the virtues of valerian as a nervous stimulant, is now much used as a substitute. It is obtained from the root by distil- lation with water. As first procured, it is of a pale-green colour, with a pungent odour of valerian, and a somewhat aromatic taste. By exposure, however, it becomes yellow and viscid, in consequence of the absorption of oxygen. Much importance has recently been attached to the fact, that this oil contains, associated with it, a pecu- liar volatile acid denominated valerianic acid, which may be sepa- rated by a chemical process. This acid is a colourless volatile liquid, having a very offensive odour, recalling that of valerian yet quite different, and a sour disagreeable taste. It forms salts with the acids, and carries its odour in some degree with it in the com- bination. It has been supposed to be one of the active principles of valerian, if not the most active; but, when it is considered that, if it exist at all in valerian uncombined, it cannot be in any con- siderable proportion, this idea must be abandoned. It is the result of the oxidation of one of the two oils which conjointly constitute the oil of valerian, and may be much increased by the reagency of an alkali, which disposes to its formation, and then combines with it. The dose of the oil is from four to six drops. Various salts of valerianic acid have been introduced into medi- cine, under the notion that this acid was the active principle of valerian, and would carry its peculiar virtues with it into the com- binations it might form with salifiable bases. Hence the valerianates of iron, of zinc, and of quinia, which have been added to the list of medicinal preparations. Experience has not shown that they pos- sess any peculiar advantages over the other salts of those bases re- spectively, while their repulsive odour.and comparative cost are real objections. CHAP. I.J NERVOUS STIMULANTS.—GARLIC. 621 V. GARLIC. ALLIUM. U.S., Ed. Origin. Garlic consists of the bulbs of Allium sativum, or com- mon garden garlic, a native of Europe, but cultivated in most civil- ized countries. The bulbs, when taken from the ground, are dried, usually with portions of the stems remaining, by which they are tied into bundles, and thus brought into market. Properties. The bulb of garlic consists of five or six smaller bulbs, commonly called cloves, each invested with a distinct coat, and the whole compactly arranged around the stem at its base, and inclosed in a white membranous covering, consisting of several thin, delicate layers. The substance of the minor bulbs, deprived of their coat, is whitish, moist, and fleshy, and contains a juice, which, on the addition of a little water, may be separated by ex- pression. When these little bulbs become dry, as they do when very long kept, the medicine is wholly useless. The odour of garlic is strong, penetrating, disagreeable, and cha- racteristic; so much so that it serves as a standard of comparison for other odours, which, when thought to resemble it, are said to be alliaceous. The taste is bitter and acrid. These properties, as well as the medical virtues of garlic, are yielded to water, vinegar, or alcohol; but are impaired or destroyed by boiling. They de- pend on a peculiar volatile oil, which pervades the whole plant; but is especially abundant in the bulb. This is easily separated by distillation with water, leaving the residue quite inert. The oil, when pure, is a combination of carbon, hydrogen, and sulphur, constituting, according to Wertheim, the sulphuret of a compound radical denominated allyle, which consists of carbon and hydrogen (C6H5). After exposure to the air it contains oxygen. Effects on the System. Garlic is a local and general stimulant, operating directly upon the part to which it may be applied, and, through the absorption of its active principle, upon the circulatory and nervous systems, and the various secretions. Its influence upon the nervous centres, though very decided, and quite sufficient to allow it to rank in the present class of medicines, has not, I think, been so prominently noticed by pharmacological writers as it deserves to be. It agrees, too, with the nervous stimulants in having no tendency to disturb the special cerebral functions. 622 GENERAL STIMULANTS. [PART II. Moderate doses warm the stomach, excite the appetite, and facili- tate digestion. In a short time the frequency of the pulse and general warmth are somewhat increased; and the patient feels an agreeable excitement, which, though little noticed, contributes, I have no doubt, to the favour in which it is held as a condiment, notwithstanding its originally very repulsive odour and taste, by vast numbers of people, indeed by whole nations in some parts of the world. Through its influence on the secretions, it acts as an expectorant, sometimes as a diuretic or diaphoretic, according as it is directed by circumstances preferably to the kidneys or the skin, and also as an emmenagogue. It is said occasionally to prove anthelmintic. Too largely taken, it produces uneasiness of sto- mach, sometimes even nausea and vomiting, occasionally purges, and is capable of exciting a febrile state of system, with headache, quickened pulse, heat of skin, &c. Applied to the skin it acts as a rubefacient, and will sometimes vesicate. All these effects it owes to the volatile oil, which is absorbed with great facility, and rapidly pervades the whole system. Its absorption is proved by the odour it imparts to the breath, perspi- ration, urine, and even the secretions from the surface of ulcers. In the lower animals, it affects the milk and the flesh with its pecu- liar properties of smell and taste. The absorption takes place not only from the stomach, but readily also from the rectum, and even from the skin. Garlic poultices applied to the soles of the feet will sometimes communicate their odour to the breath. The oil, there- fore, though quickly entering the circulation, has a tendency to leave it rapidly, and, as it passes out through the different emunc- tories, stimulates them into an increase of their several functions. In its whole medicinal character, garlic bears a considerable resemblance to assafetida, though perhaps somewhat more stimu- lant locally and to the circulation, and somewhat less so to the nervous system. Therapeutic Application. Garlic has been used as a condiment and medicine from times immemorial. Some of its most beneficial applications are grounded upon its properties as a nervous stimu- lant ; and these are to be particularly noticed here. Its uses as a stimulating expectorant and diuretic will be referred to, under the heads of those classes respectively. As a stimulant to the stomach it is useful in debility of that organ, enabling food of difficult solubility, to be digested more rea- dily, and more comfortably to the patient. It is also an excellent CHAP. I.J NERVOUS STIMULANTS.—GARLIC. 623 carminative, producing the expulsion of flatus, and relieving spas- modic pains which its presence is apt to occasion, whether in the stomach or bowels. But as the expelled air is impregnated with the oil, the eructations are apt to be offensive, if not to the patient, at least to others in his vicinity. One of the most useful effects of the medicine is to relieve the various disturbances of the nervous system which are so apt to attend the febrile diseases of children, such as restlessness, wake- fulness, vague general uneasiness, twitchings of the muscles, startings, and convulsions. For this purpose it is almost always used exter- nally, being applied in the form of poultices to the feet, and as a lo- tion to the spine, made either by infusing the bruised bulbs for a short time in hot brandy, or by incorporating the expressed juice with oil or lard. The reader will observe that it is used here not merely as a revulsive agent, in which capacity it is inferior to mustard and other rubefacients, but in reference to the absorption of the oil, and its operation upon the nervous centres. It often most happily quiets the disturbance, and promotes sleep by removing the state of the nervous system which prevented it. In the advanced stage of the inflammatory diseases of children, and especially the pectoral, there is often a prostrated condition of the nervous centres, which very injuriously complicates the case. I have already, under the head of assafetida, called attention to this condition, and pointed out how it may be recognized, especially as attendant upon advanced bronchial and pulmonary inflammations. Garlic is scarcely inferior as a remedy to assafetida in some of these cases. I have used it often, and am quite sure with much benefit. It i3 not merely as an expectorant that it operates. It stimulates the nervous centres, and enables them to supply the necessary sup- port to the functions of respiration and circulation, which are failing for the want of it. The remedy is especially useful, when, with this debility of function, there is also spasmodic complication, as in the affections referred to occurring in the advanced stages of hoop- ing-cough, or in asthmatic children. I have usually employed it, in these cases, internally, in the form of syrup. In almost all the spasmodic and convulsive complaints of children, whether affecting the alimentary canal, the chest, or the external muscles, or occurring as original affections, or as attendants on other diseases, garlic may be used externally, in the form of lotion or poultice; the application being made along the spine in convul- sions, and both there and over the organ affected in internal spasms. 624 GENERAL STIMULANTS. [PART II. The only contraindication would be high vascular congestion or inflammation in the nervous centres. In mild cases of hysteria, especially when affecting the stomach and bowels, as in spasmodic pains, flatulent discharges, borborygmi, &c, garlic is often useful, though not unfrequently objectionable in consequence of the odour imparted to the breath. In all hys- terical affections, it may be freely employed externally. The medicine was formerly used in intermittent fever; but has been abandoned since the discovery of Peruvian bark. As a topical application to the ear, it has been used advantage- ously in atonic deafness. For this purpose, a small piece of raw cotton may be impregnated with the juice, and introduced into the external meatus. If it irritate too much, the juice should be diluted. Applied in the shape of a large cataplasm to the hypogastrium, it has been recommended in retention of urine from debility of the muscular coat of the bladder, and incontinence from weakness of the sphincter. As an anthelmintic it has enjoyed some credit, being used by the mouth, and, in the instance of ascarides, by the rectum. As a resolvent in indolent tumours, and a stimulant in chronic palsy and rheumatism, it has been applied locally in the form of lotion or poultice. Administration. The dose of garlic, in substance, is from half a drachm to one or two drachms for an adult. It may be given in the shape of pills, or bruised and mixed with syrup or other vehicle as an electuary, or in the state of the unprepared clove or small bulb, either whole, or cut into pieces of convenient size for swal- lowing. But neither of these forms is adapted to children. The most convenient preparation for internal use in the case of children is the syrup. This may be made extemporaneously by bruising the cloves, adding a little water, so as to enable the juice to flow out, then expressing and mixing the liquid obtained with twice its weight of sugar. There is an officinal Syrup (Syrupus Allii, U. S), which is prepared by first forming an infusion with vinegar, and afterwards incorporating this with sugar. The dose of either preparation for a child a year or two old is a fluid- drachm, which may be repeated every hour or two, in acute cases. For external use, cataplasms are made by thoroughly bruising the garlic, and incorporating it with the bread and milk poultice, or mixing it up with flaxseed meal or other adhesive powder, and hot water. CHAP. I.J NERVOUS STIMULANTS.—COFFEE AND TEA. 625 Lotion may be made by bruising the garlic, and heating it with proof spirit, which may then be applied by means of flannels wet with it, or by gentle friction. A liniment may be prepared by incorporating the expressed juice with olive oil or lard. A boiling heat should not be applied in the preparation of garlic, as it has the effect of driving off the oil. Other species of Allium have effects analogous to those of A. sativum. The native garlic of our fields might probably be sub- stituted without disadvantage. The onion (A. Cepa) and the leek (A. Porrum) have similar properties, but are much weaker. Never- theless, a syrup made from expressed onion juice and sugar will be found very useful in some of the pectoral affections, in which garlic has been recommended above. VI. COFFEE AND TEA. I consider these two substances together, because their effects are of a closely similar character, and, where any difference exists, it can be readily indicated without producing confusion. Of their origin and physical properties it is necessary to say lit- tle, as they are generally well known. It will be sufficient to state, in relation to coffee, that i^ is the seed of the Caffea Arabica, a native of Arabia and Africa, and largely cultivated in various tropical countries of the old and new continents; and, in relation to tea, that it is the' prepared leaves of at least two species of Thea, T. viridis, and T. Bohea, both natives of China, the former of which probably produces green, and the latter black tea. As regards the composition of these two products, there is one principle which they both possess, and upon which it is highly probable that the effects they produce in common upon the system depend. This has been called caffein as found in coffee, and thein as in tea; but the name generally recognized at present is the former, from whatever source the principle may be derived. So far as we are at present concerned with caffein, it is sufficient to state that it is a highly nitrogenized body, with feeble basic proper- ties, crystalhzable, of a slightly bitter and disagreeable taste, and soluble in water, alcohol, and ether. A remarkable fact in connex- ion with this principle is, that it has been found in three vegetable products, namely, coffee, tea, and Paraguay tea, all quite distinct in VOL. I.—40 626 GENERAL STIMULANTS. [PART II. their botanical affinities, inhabiting widely distant regions of coun- try, and yet each one of them employed by the natives of the seve- ral regions they inhabit, and for the same purposes, without any previous intercourse. Providence seems to have distributed them over the world for the enjoyment at least, if not for the profit of the human family; and a sort of instinct to have led to their dis- covery and use. Caffein is thought to exist in coffee partly free, and partly combined with a peculiar acid. Besides this principle, which is common to coffee and tea, there is in the former, according to Pfaff, a variety of tannin which he calls caffeo-tannic acid; and, after it has been roasted for use, two new substances appear to have been generated, one a bitter principle, and the other an empyreumatic oil to which it owes its peculiar flavour in this state. It is probably to the combined influence of the caffein, the tannin, and the two newly developed empyreumatic pro- ducts, that we must ascribe the effects of coffee on the system. Tea owes its active properties to the caffein, which is in some- what smaller proportion than in coffee, jointly with a considerable quantity of tannic acid of the variety found in galls, a peculiar bitter principle, and a volatile oil to which it owes its characteristic aroma. Though the two varieties of tea, the green and black, differ very considerably in their taste, they agree very closely in chemical composition, and in their effects on the system; the latter being somewhat weaker than the former. For a more particular account of the origin, preparation, and sensible and chemical properties of coffee and tea, the reader is re- ferred to the Appendix of the U. S. Dispensatory. I have called attention only to those points which have some immediate bearing upon their physiological and therapeutic effects. Effects on the System. I shall first treat of the effects of roasted coffee, and afterwards allude to the slight differences which exist befween them and the effects of tea. Unroasted coffee, being almost never used, will not be considered. In moderate quantities, coffee stimulates the stomach gently, and the nervous system decidedly, without much exciting the circula- tion, or producing any narcotic impression on the brain. These are the properties which characterize the nervous stimulants, and to this class, therefore, it properly belongs. It will be found to belong to it equally by its therapeutic effects. Upon those who use it habitually, its characteristic influence is not fully evinced; as it has either lost its power in great measure by repetition, or the CHAP. I.J NERVOUS STIMULANTS.—COFFEE AND TEA. 627 secondary are so mingled with the primary effects, that the latter are not readily distinguishable. The following are the phenomena of its operation in a system not yet rendered insensible to it by habit. The first effect of a moderate quantity is usually a warming cor- dial impression on the stomach, which is followed after a short time by an agreeable feeling of comfort or satisfaction, and an ob- vious exaltation of the imagination and intellectual faculties. The disposition to cheerful conversation, or to other exercise Of the mental powers, is awakened along with this increase in their vigour. Every one accustomed to witness social coffee or tea-drinking, must have noticed the increased vivacity, the more rapid interchange of thought, the general buzz which spreads through the company after partaking of the beverage. The student finds himself capaci- tated for a clearer understanding, and more prompt appropriation of the subjects of his study; the writer, for a more vigorous exer- cise of his mental powers, a quicker and happier arrangement of his thoughts or fancies, and a much greater facility of expression. In my own person, I every day experience something of this effect from black tea. For hours after dinner, even a moderate and entirely temperate dinner, I am often unable to perform, at all to my own satisfaction, any intellectual task which may have devolved upon me. An immediate change is produced by the tea, and, after the closing meal of the day, I find myself possessed of my intel- lectual capabilities, whatever they may be, to their full extent. Along with this nervous excitement, there is a strong tendency to wakefulness produced; and, under the influence of the beverage, if taken rather late in the evening, one's labours may often be pro- longed far into the night, without any sense of fatigue or disposi- tion to sleep. One or two strong cups of coffee at bedtime not un- frequently prevent sleep for the whole night; and persons who wish to watch prepare themselves often in this way. During all, this time there is little acceleration of the pulse; and that which may be noticed is probably rather owing to the reaction of the ex- cited nervous centres upon the heart, than the result of a direct in- fluence upon the circulation. The state of exaltation subsides after many hours into a corresponding depression; and the self-indul- gence is paid for the next day by feelings of gastric uneasiness, languor, and general malaise, which gradually wear off, or disap- pear under a repetition of the stimulant. It will be readily under- stood, therefore, that the habit of coffee-drinking is not on the 628 GENERAL STIMULANTS. [PART II. whole healthful, unless carefully guarded as to extent, or counter- acted by active physical exercise. I shall refer, directly, to the evils which are apt to result from the abuse of this luxury. When coffee is taken in excess, it causes a feeling of oppression or anxiety in the epigastrium, with over-excitement of the nervous system, indicated frequently by vertigo, headache, palpitation, muscular tremors, and other symptoms of irritation of the nervous centres. But, even in the largest quantities, it never produces, so far as I have ever witnessed, intoxication or stupor, or any other of those peculiar effects on the brain, which characterize the cere- bral stimulants or stimulating narcotics in full action. The habitual use of coffee in excess is very apt to occasion a train of very disagreeable and annoying symptoms, which can only be got rid of by abandoning the habit. The constantly repeated over-excitement, followed by the as constant depression of the nervous functions, gives rise at length to persistent irregularity; and the exhaustion of the excitability of the nervous centres by the strain to which they are subjected, ends in a deficiency of power, and a consequent insubordination of all the functions placed under their regulating influence. These effects are espe- cially displayed in persons of susceptible nervous temperament, and those of sedentary habits. Some individuals appear to be almost insusceptible to influence of any kind from the ordinary use of coffee; and its effects, whether direct or indirect, may be greatly controlled by habits of steady and vigorous muscular exer- cise. Indigestion, habitual constipation, and torpor of the liver, are among the effects of its abuse exhibited in the digestive func- tion; nervous headache, sick headache, vertigo, various disorders of sight and hearing, neuralgic pains and an infinite diversity of disordered sensation, palpitations, muscular tremors, hysterical symptoms in women, hypochondriacal in men, are some of the consequences of the same abuse in the nervous system. As the blood-vessels are little excited directly by the stimulant, the vas- cular system is apt to suffer less than the nervous; and it is unusual to encounter, from the abuse of coffee, any of those in- flammations, as of the stomach, liver, brain, &c, which are so apt to follow the use of the cerebral, or even the arterial stimulants in excess. Hence it happens that, unless the nervous disorder has been so long continued as to have at last brought about organic change, all that is necessary, in order to escape from the evils, is to abandon the use of coffee. CHAP. I.J NERVOUS STIMULANTS.—COFFEE AND TEA. 629 As illustrative of the above statements I will observe that, per- sonally, being of a somewhat nervous temperament, I am unable to use coffee steadily without much suffering; and the same peculiar- ity belongs to most of my immediate family. For years I was troubled with frequently recurring nervous headache, which at times incapacitated me for the performance of any active duty. Scarcely a day passed without some uneasiness or deranged sensa- tions in the head; such as roaring, buzzing, and singing in the ears, sounds as of pounding, or bell-ringing in the distance, swimming or vertiginous feelings, muscse volitantes, &c. &c; and I never walked in the streets without the fear of a sudden attack of these symptoms, which, when they came, took away all mental energy. It occurred to me that a single cup of coffee which I took daily in the morning, and to which I had reduced myself from the necessity of escaping the dyspeptic sufferings which a more free use of it had occasioned, might be the cause of these distressing phenomena. I abandoned the habitual use of it, substituting black tea for coffee; and from two weeks after that time up to the pre- sent, a period of many years, I have been almost entirely free from the symptoms referred to. I was once called to a female patient labouring under great gastric uneasiness, troublesome palpitations, distressing nervous disorder of various kinds, and extreme emaciation. I requested to see her tongne. It was covered with small black points, which she told me proceeded from some burnt coffee she had been chew- ing. I wished to know if she was in the habit of using coffee freely. " Yes, doctor," she replied, " I drink it at breakfast, dinner, and supper, and chew the grains between whiles." I requested her to leave off the use of it entirely. She did so, and quickly recovered her health. I have no doubt that a vast deal of disease in our country, especially among the women, who in general drink coffee habitually, and use too little exercise, originates in this cause; and I have often been able to afford relief, in long standing cases of distress, by the simple measure recommended in the above case. I have dilated more largely on this point than may be deemed exactly in accordance with the general scope of this work; but I feel desirous of impressing my views upon the profession, feeling confident that, if adopted, they will lead to beneficial results. 3Iethod of Operating. The immediate effects of coffee on the sto* mach result, I presume, from its direct contact with the tissue. Those upon the nervous system are probably produced by some one or \ 630 GENERAL STIMULANTS. [PART II. more of its ingredients being absorbed, unaltered or modified, into the circulation. I do not know that any positive proof has been adduced upon this point. Certainly caffein does not escape with the urine; and the odour of coffee is not sensible in the breath or perspiration. Some interesting experiments have been recently made, which are supposed to prove that coffee and tea diminish the rapidity of the physiological change of structure in nutrition. It has been found that certain miners, and other labourers, are enabled, by the use of coffee, to do as much work, without loss of flesh or strength, upon a much smaller amount of food, as when they drink water alone; and the experiments of Drs. F. W. Bocker and Julius Lehmann show, that the quantity of urea and other results of the rnetamorphosis of the tissues, lost through the emunctories, is much diminished by the use of these beverages. (See Brit, and For. 3Ied. Chirurg. Rev., Oct. 1854, Am. ed. p. 313.) These are important results; but I would attach a different ex- planation to them. It is difficult to conceive how stimulant medicines, which are acknowledged to increase the activity of the functions, particularly those of digestion and of the nervous sys- tem generally, can diminish the amount of organic change which takes place in the exercise of the functions. It is much more probable that these substances act by enabling the digestive organs, and others concerned in the conversion of the food into blood, to effect this conversion more thoroughly, and thus, not only to j enable the system to do with less food, because the little which is used is thoroughly appropriated, but to diminish also the amount of excretion; because the food being converted more thoroughly into blood, is less wasted by those imperfect attempts at assimila- tion which only effect the change partially, and cause the remainder of the food to be thrown off in the form of urea. A proof of the correctness of this view is afforded by experiments of Dr. Becker, < which show that not only is the urea thrown off by urine dimi- nished, but the amount of feculent matter discharged from the bowels is remarkably diminished also. (Ibid.) Now it is much easier to conceive how a more thorough consumption of the food shall produce this diminution of feculent discharge, than that the same thing shall be effected by a reduction in the activity of the metamorphosis of the tissue in the nutritive process. Besides it is the nitrogenous articles of food only to which the remark applies; and these are the very articles which alone can furnish urea by their imperfect conversion into blood or solid tissue. I believe, therefore, that this important result is really owing to the stimulant CHAP. I.J NERVOUS STIMULANTS.—COFFEE AND TEA. 631 influence of the medicines upon the processes of digestion and assimilation, by which the nitrogenous food is more thoroughly converted into blood and consumed in nutrition, and consequently less of it escapes from the bowels undigested, and less from the kidneys, in the form of urea, in consequence of imperfect assimila- tion. It is stated by Dr. Lehmann that, in persons following an active occupation, the use of an ounce of roasted coffee in infusion daily, reduces the daily waste one-fourth, and consequently dimi- nishes, in the same proportion, the quantity of nitrogenous food necessary to health. (Ed. Month. Journ. of Med., Jan. 1855, p. 9.) It is not at all improbable, that the highly nitrogenous caffein is itself decomposed, and made to contribute to the nourishment of the body; so that in this way also the necessary proportion of food is diminished. In relation to the different actions of the several constituents of roasted coffee, Dr. Lehmann thinks he has proved that the empy- reumatic oil is that which most powerfully contributes to the results just stated, while it operates as a laxative, diaphoretic, and diuretic, invigorates the intellect, and, in excessive doses, produces irregular mental action, restlessness, and insomnolency. Caffein he found, in excess, to occasion rigors, acute pulse, urinary disorder, head- ache, and delirium. (Ibid., p. 314.) Tea differs in its effects from coffee mainly in degree. It is less stimulant to the nervous system, less apt to oppress the stomach, probably quite as efficient as a tonic to the digestive organs, and more astringent in consequence of the amount of tannic acid it contains. Certain it is that tea, especially black tea, may be drank habitually with impunity by persons who cannot use coffee without suffering, and that it sits more lightly on the stomach. In febrile diseases, a cup of tea is often not only tolerated, but agreeable to the patient, and refreshing in its effects; while coffee, however much it may be relished in health, is usually repulsive to the patient in a fever, and not well accepted by the stomach or the system. Therapeutic Application. Coffee and tea came into use in Western Europe about the middle of the seventeenth century. Unfortu- nately, their habitual use as articles of diet limits very much their therapeutic application. The system is so much accustomed to them, that their remedial influence can scarcely be felt, in ordinary doses. There can be no doubt that, under other circumstances, they would be very serviceable in dyspepsia, the very disease of which, through their abuse, they are among the most frequent causes. 632 GENERAL STIMULANTS. [PART II. Occasionally used, they would serve as agreeable tonics in these cases, in which they would also be recommended by their cheering influence upon the spirits, ordinarily so much depressed in that complaint. If, instead of using them at the morning meal, when the stomach and system are most excitable, we should restrict their employment to the close of dinner, as is done with coffee in France, they might prove serviceable by facilitating the digestion of the food, and rendering it less oppressive to the stomach, while their injurious influence on the nervous centres would be less felt. Thus, too, to those who do not habitually abuse them, they would be found an admirable restorative in the exhaustion of excessive labour, mental or physical, and an excellent correction of mental disquietude arising from morbid states of the system, or the vicis- situdes of life. In attacks of nervous headache, or of sick headache, they often afford great relief to patients not insensible by habit to their effects; and, even in those who have brought on habitual headache and nervous disorder by their abuse, they will often control temporarily the paroxysm of those affections if given very freely; just as ardent spirit will relieve, for a time, the horrors which have origin- ated in their continued excess. Their influence in producing wakefulness may sometimes be taken advantage of in lethargic and soporose conditions of system with good effect. They have, with this view, been recommended in the stupor of low fevers; and a cup of tea occasionally given may prove useful in that condition; but coffee is usually too heavy upon the stomach, and might be injurious by disturbing that organ. In narcotic poisoning, these medicines are obviously indicated. The stupor from this cause may depend either upon a direct seda- tive influence on the nervous centres, as from chloroform, or upon a congestion, as from opium, alcohol, belladonna, &c. In either case, coffee, as the stronger of the two medicines, in its stimulant powers, may be usefully employed. In both cases, it relieves by its general diffusive stimulation of the nervous centres, causing a more equable distribution of the nervous force, thus supplvino- the deficiency in the one instance, and unloading the overwhelmed centres in the other. Experience has proved it to possess consi- derable efficacy in obviating the stupefying effect from poisonous doses of opium. Though it should never be relied on exclu- sively in cases of this kind, it may be used conjointly with other methods; and, after the evacuation of the poison, is anions the best means not only of preventing stupor, but also generally of CHAP. I.] NERVOUS STIMULANTS.—COFFEE AND TEA. 633 supporting the system in its tendency to collapse. It must, how- ever, be given strong and freely to produce much effect. In the same way it proves useful in dissipating slight effects from alcoholic liquors; and the habitual use of it, at the close of dinner, is some- times advantageous in other methods than by promoting the diges- tion of the food. In the paroxysm of spasmodic asthma, strong coffee often affords considerable relief. It should be given quite saturated, and in the dose of a cupful every twenty or thirty minutes. In hooping-cough, too, it has been highly recommended, given at the close of each meal. It is only in children unaccustomed to its use that it could be expected to be beneficial; and in these it may at least be tried with the hope of advantage. I have heard of a case of ordinary catarrhal or spasmodic croup, in which it relaxed the spasm, and seemed to be the cause of cure. In attacks of nervous dyspnoea and palpitation of the heart, coffee is said to have proved highly useful; and, though it might be deemed inadequate to the cure of so serious an affection as angina pectoris, it might be employed along with other measures, given as above recommended in spasmodic asthma. Coffee has been found effectual in many cases of intermittent fever. Its strong influence upon the nervous centres, through which each paroxysm of an intermittent disease probably makes its approach, might be expected to endow it with a certain amount of antiperiodic power. In some parts of Greece, it is said by Dr. Pouqueville to be very successfully used in connexion with lemon- juice. At least an ounce of the powder must be employed, in the form of decoction or infusion, between the paroxysms. Other complaints in which it has been recommended are cholera infantum, diarrhoea, calculous affections, and amenorrhoea. It has also been used to cover the taste of sulphate of magnesia, castor oil, sulphate of quinia, &c, which may be administered in it as a vehicle; but it is said not to be effectual for this purpose, unless the mixture is heated for a time to the boiling point. Administration. Coffee may be used in medicine in the form of powder, decoction, or infusion. Of the powder, a drachm or two may be taken for a dose; but it is very seldom used in this way. The decoction may be made by boiling an ounce of the coarse pow- der in a pint of water for a short time, and then clarifying by the white of an egg. The infusion is best prepared by displacement. A cupful of either may be given for a dose, and repeated, if ne- cessary. 634 GENERAL STIMULANTS. [PART II. Caffein, in the form of citrate, has been recommended as a remedy or preventive of sick headache, in the dose of a grain every hour, before or during the paroxysm. Caffein itself, in doses varying from two to ten grains, was found by Lehmann to produce vehe- ment excitement of the nervous and circulatory systems, with pal- pitations, oppression of chest, headache, perversion of hearing and sight, sleeplessness, erections, and delirium. Tea is always given in infusion. It is probably preferable to coffee, especially the green variety, when given very strong, as a preventive or cure of sick headache. As a refreshing drink in febrile diseases it is also preferable, being much more agreeable to the patient and acceptable to the stomach. In diarrhoea, too, it might be expected to prove more effectual than coffee, through its astringency. In consequence of the tannic acid it contains, it might be used as an antidote to tartar emetic; and I have often employed it, on the same account, as a gargle in mercurial sore mouth. There are two other substances which merit a brief notice here, the one from its former reputation, the other from its indigenous origin, though neither of them is in general use. 1. RECTIFIED OIL OF AMBER.—Oleum Succini Rectificatum. U.S. This is obtained from amber by subjecting it, mixed with sand, to dry distillation. A sour liquid comes over, on the surface of which a very dark-coloured oil floats, which is removed, and puri- fied by redistillation with water. The rectified oil thus obtained is of a light yellowish-brown or amber colour, a strong, peculiar,disagreeable odour, and a hot acrid taste. It is insoluble in water, but is dissolved by alcohol and the fixed oils. Exposed to the air, it absorbs oxygen, and gradually darkens and thickens, until at last it becomes black and solid. It consists, when pure, of carbon and hydrogen, but contains oxygen as found in the shops. 3Ied/cal Properties and Uses. Oil of amber is locally and gene- rally stimulant, exciting both the circulation and the nervous sys- tem, and sometimes promoting the secretions. It has been employed in most of the diseases to which this class of medicines are consi- dered applicable; as tetanus, epilepsy, hysteria, hooping-cough, and the convulsive affections of children. It has also been given in amenorrhoea. The dose is from five to fifteen drops, which may be CHAP. I.] NERVOUS STIMULANTS.—DRACONTIUM. 635 most agreeably given in emulsion, made with gum arabic, sugar, and one of the aromatic waters. The oil has been used locally, as an antispasmodic liniment, rubbed on the skin along the whole length of the spine, in hooping-cough, and infantile convulsions. It has also been employed in chronic rheumatism and palsy, as a rubefacient. In the convulsions of children, connected with intestinal spasm, the late Dr. Joseph Par- rish was in the habit of using a liniment composed of equal partg of this oil and laudanum, mixed with three or four parts of olive oil and brandy. It was rubbed freely along the spine. 2. DRACONTIUM. U.S. This is the root of Symphcarpus foetidus, or common skunk cab- bage, an indigenous plant, with broad cabbage-like leaves, and a very fetid odour, growing in low meadowy or swampy places, throughout the northern and middle sections of the United States. The root should be collected twice a year, if possible, early in the spring and late in the autumn, should be carefully dried without heat, and then kept in closely stopped bottles. It should not be kept in powder. Properties. There are two parts of the root, the body and the radicals or rootlets, which are separated when collected. The body, as kept in the shops, is either whole or in slices. In the former state it is two or three inches long, by an inch thick, dark-brown and rough externally, and white and starchy within; in the latter, it is in circular pieces, which are transverse sections of the root. The radicals are of various lengths, about as thick as a hen's quill, flattened and wrinkled, white within, and invested by a light brownish-yellow epidermis. The root has a peculiar extremely fetid odour, which is strongest in the recent state, is retained, however, in drying, but gradually lessens, and at length disappears. The taste is acrid, and in like manner is injured by time. A boiling heat deprives the root both of smell and taste. These sensible properties are connected with one or more highly fugitive principles, which it has been found im- possible to isolate, probably because they are destroyed in the pro- cess. Dr.Bigelow found that water distilled from the root was but feebly impregnated with the odorous principle, but was somewhat acrid, if the process were carefully conducted. It lost its acrimony, however, on standing a short time. (Med, Bot., ii. 46.) The root is said to yield its virtues to water and alcohol. It should not be kept longer than a year for use. Jfedical Uses. Dracontium is locally irritant, and, in its effect on 636 GENERAL STIMULANTS. [PART II. the system, stimulant both to the circulation and nervous centres; and it is thought also by some to be expectorant. The Rev. Dr. Cutler, of Massachusetts, introduced it to the notice of the profession as a remedy or palliative in the paroxysms of spasmodic asthma, in which he had found benefit from it in his own person. Many prac- titioners have confirmed the statements of Dr. Cutler. Dr. Bigelow has seen a number of instances in which it proved useful in the catarrhal affections of old people; and Dr. Eberle gives similar testi- mony, from his own experience, in chronic cough "attended with a cold phlegmatic habit of body." (3Iat. 3Ied. and Therap., 4th ed., ii. 154.) It is probably useful in these catarrhal affections mainly by its stimulant influence on the nervous centres of respiration. Dr. Thatcher, in his Dispensatory, states that it has been found useful in hysteria, hooping-cough, spasmodic pains, chronic rheumatism, and dropsy. Dr. Heintzelman has used it, "with unequivocal benefit," in hooping-cough, in the spasmodic stage, finding it, when not suc- cessful in completely eradicating the disease, almost always to miti- gate the severity of the symptoms. (N. J. Med. Reporter, iv. 310.) He has also used it advantageously in phthisis. There can be little doubt that it is a very efficacious nervous stimulant, when used in sufficient doses, and before its virtues have been impaired by time. As kept in the shops, it is often nearly or quite inert; and its great disadvantage is that, in the uncertainty as to its strength, it is im- possible properly to graduate the dose unless it be quite recent. The practitioner in the country can always command it of full strength; for it is almost everywhere abundant in the low grounds. The dose of the recently dried root in powder, to begin with, is from ten to twenty grains, three or four times a day. Dr. Bigelow found thirty grains of it to occasion vomiting, vertigo, headache, and dimness of vision. But it has been given in larger doses with entire impunity; and the probability is that different individuals are affected by it with different degrees of facility. The dose above recommended, if it produce no obvious effect, should be gradually increased till it does so, in order to determine the degree of its activity. It may be given also in strong cold infusion, in tincture, or syrup. The infusion should be made by percolation with cold water, in the proportion of an ounce of the recently dried root to the pint, and given in the commencing dose of half a fluidounce to an adult. An infusion, prepared in the same way, but of four times the strength, may be formed into a syrup with twice its weight of sugar, and given in half the dose. The dose of a saturated tincture is stated at one or two fluidrachms. CHAP. I.J CEREBRAL STIMULANTS. 637 CLASS XXX. CEREBRAL STIMULANTS. Syn. Stimulant Narcotics. These are medicines which, to a stimulant influence over the circulation and nervous system generally, add a peculiar power over the special functions of the brain, as evinced, in their higher grades of action, by delirium and stupor. From their stupefying property, they have been called narcotics, derived from the Greek verb j'apxfw, which signifies to be or become torpid, dull, or stupid. But I do not think that the possession of this property is a suffi- cient basis for the formation of a class; for it belongs to medicines quite different and even opposite in their modes of operation, and therapeutic character. Thus, both opium and digitalis are capa- ble of producing stupor; but the former is directly stimulant, and the latter directly sedative; and so opposite are they in their effects upon the system, that the former is one of the best means of control- ling the excessive action of the latter. Besides, certain medicines, as alcohol and ether, are generally excluded from the narcotics, though they act upon the brain with an energy scarcely inferior to that of any acknowledged substance of the class, and are both powerfully stupefying agents. I have thought it best, therefore, to abandon the old class of narcotics, and to arrange the medicines composing it according to their more important affinities; placing in separate categories the stimulating and the sedative, and merely retaining the word narcotic to express a quality, as we employ the terms anodyne, soporific, &c. The only properties in which all the medicines of this class agree are those stated in the definition. In all other respects they differ among themselves, and some of them very greatly. In the first place, they differ very much in the degree of their general stimu- lant power. In this respect, alcohol and ether may be placed at one end of the scale, and henbane at the other; the two former medicines being among the most powerful stimulants in our pos- session, the latter having no more of this property than barely sufficient to justify its position in the class. Secondly, they differ 638 GENERAL STIMULANTS. [PART II. in the degree in which they relatively affect different organs or functions. Thus, if we compare alcohol and opium, we shall find that the former has a greater proportional influence in stimulating the heart and arteries, the latter in stupefying the brain. Thirdly, they differ in the manner in which they affect precisely the part or organ upon which they operate. The symptoms of cerebral dis- turbance produced by alcohol are unlike those resulting from the use of opium; and both differ materially in this respect from bel- ladonna. Fourthly, there is, for the most part, in each one of them, a characteristic mode of affecting some function apart from their general action as cerebral stimulants. Thus, opium produces con- stipation of the bowels, hyoscyamus often acts as a laxative, and belladonna occasions a characteristic dryness and irritation of the fauces. In some measure, this difference of action may be accounted for by supposing, that the influence of the several articles of the class is directed more especially to some one portion of the brain rather than to another, though all parts may be more or less affected. Thus, alcohol, from its peculiar influence on the voluntary move- ments, and the powerful stimulation it exercises upon the sexual propensities, may be supposed to operate more especially on the cerebellum; opium, from its great stupefying power, to act on the cerebral lobes with peculiar energy; belladonna, from its property of impairing vision, to have a more immediate influence on the optic thalami or corpora striata. But too little is yet known of the precise functions of different portions of the encephalon, or of the phenomena by which influences upon them respectively could be recognized, to justify any very decided opinion upon the affinity which the several cerebral stimulants may have for particular parts of that structure. Though differing so much among themselves, there are affinities between certain articles of the class, which might serve to arrange them in subdivisions, having, to a considerable extent, a common therapeutic basis. They might thus be arranged in groups, of which one would contain alcohol and ether, another opium, extract of hemp, lactucarium, and hyoscyamus, and a third belladonna and stramonium; the other individuals of the class remaining isolated. By considering them successively according to these relations, we may sufficiently, for practical purposes, fix in the recollection of the student the resemblances referred to. Before proceeding to a general account of the mode of operation, CHAP. I.] CEREBRAL STIMULANTS. 639 and therapeutic properties of the class, it will serve to prepare the way, if we dwell for a short time on certain peculiarities in cerebral pathology, which, if not understood, will inevitably lead into great confusion. It is a well established fact, that opposite morbid conditions of the brain, or parts of it, express themselves by similar phenomena; and the law probably holds true of the nerv- ous centres universally. Pain and other morbid sensations, spasrn and other forms of irregular muscular action, delirium partial or complete, mild or severe, chronic or acute, and every grade of stu- por, from slight drowsiness to the deepest coma, may all arise, and frequently do arise, from the two opposite affections of irritation and depression of the cerebral centres. For proofs of this, and for an explanation, which, in the opinion of the author, may serve to reconcile the apparent contradiction, readers are referred to the article on functional diseases of the brain in his work on the Prac- tice of Medicine. It would occupy more space than could be spared to repeat them here. But the application of this fact to the sub- ject now before us is of great practical importance. From a cer- tain similarity in their obvious effects, medicines essentially differ- ent in character, have been associated together in the minds of writers and practitioners, and been considered as nearly identical in nature, so that they might be interchangeably employed under the same circumstances, without disadvantage. Now, as opposite morbid causes, acting on the same cerebral centres, may produce the same morbid phenomena; as, for example, insufficiency and excess of blood in the brain may either of them produce delirium, coma, and convulsions; it follows necessarily that medicines, which in excess are always morbid causes, may also, though really oppo- site in character, give rise to closely resembling, if not identical symptoms. Thus, of the medicines usually ranked together as narcotic, because they produce the common effect of stupor, some operate as direct stimulants, others as direct sedatives to the nerv- ous centres; and it will be readily understood that, if such medi- cines are used remedially, under the impression that they are identical in character, the most serious consequences might ensue. Thus, opium is stimulant to the nervous centres, aconite is sedative; but both in overdoses are capable of producing coma. In a case of active congestion of the brain, in which the latter may be use- ful the former could do only injury; and vice versa. To administer them, therefore, indiscriminately, because of their common stupe- fying effect would be a grievous error. But a case more in point, 640 GENERAL STIMULANTS. [PART II. because there is reason to think that attention has not yet been sufficiently called to it, is that of ether and chloroform. Both of these are powerful anaesthetic agents; and, under the impression that their mode of action is essentially identical, they have been used and recommended in similar cases, with little discrimination. The one is, in fact, one of the most powerful cerebral stimulants known, the other is among the most powerful cerebral sedatives; is it, therefore, surprising that, used indiscriminately, one of them at least should have occasioned so fearful an amount of mortality ? The importance of guarding against such a therapeutic error is, it appears to me, an irrefragable argument in favour of the division I have made of the narcotic medicines into classes, founded not on phenomena which are readily misinterpreted, but on their real physiological influence on the brain, and the general system. Effects on the System. The first effect of a cerebral stimulant, given in doses calculated to bring its characteristic influence into operation, is more or less to excite the stomach. In a short time, its influence extends to the general system, showing itself usually, in the beginning, by a moderate increase in the activity of the sen- sorial functions, and in the movements of the heart. But very quickly more obvious cerebral phenomena are exhibited; while the circulation may or may not be proportionably excited. The sen- sorial functions are now perverted. Abnormal sensations are felt in the head, such as fulness, pressure, confusion, swimming, giddiness, singing in the ears, perhaps pain; the mind wanders more or less; the voluntary movements are apt to become irregular; and intoxi- cation or delirium may supervene. Next succeeds a gradual diminu- tion of the sensorial functions. Heaviness and languor, or a feeling of general and pleasing calmness, soon deepens into drowsiness, and this at length into stupor, which more or less closely resembles natural sleep, according to the character of the narcotic used. All these are the direct effects of the medicine. The stupor con- tinues for a length of time varying from one or two to twelve hours or more, according to the particular article used, gradu- ally descending from its greatest intensity, till the patient at length becomes fully awake, when the direct operation of the medicine is passed. But now a condition of depression takes place, more or less corresponding with the previous excitement, and the strength of the direct impression. This is characterized by feelings of lan- guor and dejection, often with more or less general or local uneasi- ness, especially headache, by a pale, cool, and relaxed state of the CHAP. I.J CEREBRAL STIMULANTS. 641 surface, and feebleness of the pulse, and by a depressed state of the gastric functions, as indicated by want of appetite, nausea, and per- haps vomiting. These symptoms may be so slight as to be scarcely noticed, or they may be severe and extremely uncomfortable to the patient, but from appropriate doses are seldom serious. After a few hours they gradually pass away, under healthy vital influences, and the previous state of system returns with little or no appreci- able change. From larger doses of the medicine, the primary excitant impres- sion is stronger but shorter, the succeeding period of stupefaction deeper and more lasting, and the secondary depression greater, more protracted, and more serious. In very large quantities these medicines become poisonous. The symptoms of excitement and exhilaration, though sometimes in- tense, are very brief, and the subsequent stupor profound and alarming. Instead of being confined mainly to the cerebral cen- tres, the influence of the poison extends to the centre of respiration in the medulla oblongata, which may be overwhelmed by the force of the poison, and death may result from this cause. Or the direct effects of the narcotic may pass over without fatal consequences, and the patient may lapse into the secondary condition, and perish from the universal prostration of his functions. • If the dose of the poison has not been quite sufficient to destroy life, he rises slowly and with difficulty from the profound depression, and may not for several days recover his previous state of health, perhaps even for a much longer time, if any organic lesion shall have taken place. The course of the symptoms has been given above; but they require explanation. First, it may be proper to observe that the description is applicable only as a general rule. Special phenomena are sometimes exhibited by the individual narcotics, which it will be most convenient to treat of along with their other properties and effects. The first impression on the stomach is due to the direct contact of the medicine, which operates both on the nervous and vascular tissue of the organ, exciting it to an increase of function, which is followed by the same stupor, locally, if we may so express our- selves, as that experienced by the general system. It is not impos- sible that the original gastric excitation may be sympathetically propagated to the cerebral centres, giving rise to the first pheno- mena of general stimulation, and afterwards increasing the direct influence of the medicine when it reaches the brain through absorp- VOL. I.—41 042 GENERAL STIMULANTS. [PART II. tion; but we have no positive evidence to this effect; nor indeed have we, in relation to some of the narcotics, any demonstrative proof that they are absorbed at all. But, as some of them are known to be so, the inference is quite allowable that they are all taken into the circulation, or at least their active principles; and it is most probable that their constitutional effects are chiefly, if not exclusively, produced in this way. The impression of the medicine on the cerebral centres is pro- bably throughout, so long as its direct influence remains, of a stimulating character. That it is so at first, is rendered obvious by the symptoms. Some have ascribed the stupefaction which ensues to a sedative operation. I cannot agree with them. I cannot con- ceive that a medicine, in its direct influence on an organ, shall pass so speedily from a stimulant to a sedative action. A true sedative condition will result, but that is after the medicine has ceased to act directly. It is not difficult to explain the occurrence of intoxica- tion and stupor upon the principle of continued stimulation. I have demonstrated elsewhere that, in the continuous operation of an excitant directly upon any organ, the first effect is an increase, the next a derangement, and the last a depression or suspension of its function. These results probably follow the gradually increasing amount of blood drawn into the organ by the irritation, at first in quantities merely sufficient for the support of the increased function, afterwards sufficient to derange it, though still increased, and lastly congesting it to a point at which its function is embarrassed and im- paired, or quite overwhelmed. Applying this general rule to the operation of the cerebral stimulants, we have first the simple excita- tion, as shown by the obvious phenomena; next, the perverted ex- citation, exhibited in the mental confusion, or intoxication; and thirdly, the overwhelming congestion, as evinced by the drowsiness and stupor. But when the immediate operation of the medicine has ceased, either in consequence of its decomposition or elimination, the stimulated organ is left to its own powers. Its excitability having been exhausted by the previous over-action, it is insuscep- tible to the ordinary healthful influences of the blood and other vital agents, and consequently acts feebly, or for a time ceases to act. Hence the prostration which follows the cessation of the direct ope- ration of the medicine. The exhausted organ, however, if not fatally depressed, recovers its excitability by rest, and, being again able to feel and respond to its healthy stimuli, returns to its normal state of action. When poisonous quantities have been taken, death occurs CHAP. I.] CEREBRAL STIMULANTS. 643 in one of two ways. Either a nervous centre essential to life, as the respiratory centre in the medulla oblongata, is so far overwhelmed by the active congestion as to be unable longer to perform its office, in which case the function of respiration ceases as a necessary con- sequence: or the general depression following the enormous pre- ceding excitement of the cerebral centres generally, and of the whole system, is too great for reaction, and the patient dies com- pletely prostrated. In the former case, which is by far the most common, the respiration ceasing, the blood is no longer oxygenated in the lungs; the capillaries consequently refuse to carry it forward; the heart, failing to receive a supply necessary to the support of its function, now in its turn ceases to act; and death takes place finally because the blood no longer circulates. In proof that the above is the true explanation of the operation of the cerebral stimulants, dissection after death always shows congestion of the brain, when the patient has not died of pure prostration after the poison has ceased to act. Death, then, from the cerebral stimulants is usually an example of asphyxia. The heart, as in the same affection from other causes, continues to beat for a short time after respiration has ceased, some- times in a greater or less degree for five minutes, thus affording the opportunity for the employment of recuperative measures, even after apparent death. Brodie first proved, by experiments on the lower animals, that, after apparent death from a narcotic poison, life might be saved by artificial respiration. The blood being thus sup- plied with oxygen, begins again to move onward; and the heart, which has not yet quite ceased to beat, receiving a due supply, resumes its normal action, and the phenomena of life return. All that is necessary now is to continue the artificial respiration, until the nervous centres shall be in a condition to resume their function, and to support the strength of the patient against the secondary prostration. In several instances these measures have been suc- cessful in the preservation of human life. The cerebral stimulants are capable of producing their character- istic constitutional effects, to whatever part of the body they may be applied; a fact which strongly corroborates the idea of their operation through absorption. Of the ordinary avenues by which they are introduced into the system, with a view to remedial effect, they operate most speedily through the lungs, next through the stomach, and after this through the rectum, or the skin deprived of 644 GENERAL STIMULANTS. [PART II. the epidermis; and the duration of their effect is usually inversely proportionate to the rapidity with which it is induced. The local effects of the cerebral stimulants upon the surface of application are analogous to their general effects, probably through their direct action upon the vessels and nerves of the part. They first excite the actions of the part, then diminish its sensibility, and lastly leave it, upon their removal, in a somewhat depressed con- dition; unless, indeed, their first stimulant impression shall have been sufficient to induce a positive inflammation, which will com- plicate the result. This class of medicines, more rapidly than perhaps any other, lose their effect upon repetition. Each successive stimulant im- pression serves, in some degree, to lessen the excitability of the or- gans acted on; and, if time is not allowed for the system to recover its normal state before a renewal of the impression, this diminution of the excitability must be constantly and steadily continued. To produce a given effect, the dose of the medicine must be increased pari passu with this diminution of the excitability; and there are no fixed limits within which this augmentation is restrained. As the medicines have no corrosive effect, and therefore do not directly destroy the organization of the parts on which they act, the quan- tity which an individual may attain the ability to support, with present impunity, is enormous. In Dr. Chapman's Therapeutics the case of a woman is mentioned, affected with cancer of the uterus, who took three, pints of laudanum, besides a considerable quantity of opium daily, enough probably to kill from fifty to one hundred healthy individuals. (2d ed., ii. 236.) But the protracted use of the cerebral stimulants in excess is often attended with the most deplorable consequences in the end. As before explained, under the head of the Tonics, there are two great evils flowing from this abuse; the one a gradual wearing out of the excitability of the system, and a consequent gradual depression of its functions and powers, and the other, the production finally in some one or more of the organs upon which the stimulant specially acts, of a low chronic inflammation, the result of the incessantly repeated irritation. This complication of general debility with local disease almost necessarily destroys life in the end if it be not previously cut short by the occurrence of some accidental affection, which the exhausted frame is unable to support. More will be said on this point when the particular cerebral stimulants are treated of, which are most liable to be thus abused. CHAP. I.J CEREBRAL STIMULANTS. 645 When the system has become habituated to one of these stimulants in great excess, its sudden withdrawal is sometimes followed by the most alarming prostration; and this is a fact which it is highly important to bear in mind, in the treatment of the diseases of indi- viduals who are the victims of such self-indulgence. Even in their inflammatory affections, when depletion may be necessary to save life, though the habitual stimulant may be lessened, it should not be altogether withheld. AVhen called to a patient suffering under the effects of the abuse here referred to, the only remedy is the total abandonment of the evil habit. But this should, if possible, be effected gradually. Should the patient be under his own control, and unable or unwil- ling to persist in such a course of gradual'reduction, the best sub- stitute is to throw aside the particular stimulant abused at once and completely, and to support the strength by other stimulants of analogous powers, but less injurious in their effects, and possessing less attractions for the patient; then gradually to diminish the amount of this support, and ultimately withdraw it altogether. Therapeutic Application. The therapeutics of this class of medi- cines will be most conveniently treated of under the several indi- vidual articles; as there is so much specialty in their uses, that few general observations would be applicable to the whole, or even the greater number. There are, however, a few considerations which it may be proper to present in this place, to spare inconvenient explanations and useless repetition hereafter. General Stimulation. Among the cerebral stimulants are medi- cines which are most powerful and most relied on under circum- stances calling for the most vigorous support to the depressed or exhausted system. In consequence of the universality of their stimulant power, and especially of their influence over the functions of the brain, the due maintenance of which is essential to life, they are better adapted than any other class of medicines to diseases of debility, in which these functions may participate in the general prostration. The only circumstance which contraindicates their use, and which might preferably direct the attention to other stimulants, is the existence at the moment, or the probable occur- rence at the period of reaction, of active congestion or inflamma- tion of the brain. Relief of Pain, Spasm, d'c. Besides general stimulation, they are much employed for the relief of pain, the relaxation of spasm, and the composure of nervous irritation generally. All these effects they 646 GENERAL STIMULANTS. [part II. produce by rendering the nervous centres insensible to impressions of an irritant character, and incapable of radiating influence from themselves. It must be remembered, however, that in thus operat- ing, they stimulate the centres instead of depressing them. Their influence comes under the general law already referred to in these preliminary remarks, namely, that irritation of an organ, in its highest grade, diminishes or depresses the function of that organ, probably by overloading it with blood. When the sensorial centres are thus stimulated, the impression sent to them from the suffering part is no longer felt, and pain of course ceases. Or, if the pain originated in disordered function of the centre itself, the feeling is equally abolished; because the function itself is temporarily sup- pressed. The same explanation applies to spasm and other forms of nervous derangement. If they originate in external irritation transmitted to the sensorium, they are relieved when the sensorium can no longer feel the irritation; if in disorder of the sensorium itself, they cease temporarily with the cessation of its function. But it frequently happens that pain, spasm, and other nervous dis- order originate in a depressed condition of the nervous centre; perhaps in a deficiency of its supply of good blood. The centre, under these circumstances, becomes a negative point towards which nervous force may be supposed to flow from the periphery cor- responding with it, which suffers from the loss, and exhibits that suffering in one of the modes alluded to. The cerebral stimulants meet the indication here precisely. They sustain the depressed centre by a direct excitation, and by supplying it with good blood, when this is to be had, and even when it may happen to be want- ing; for they often serve, by their stimulant influence on the blood- producing functions, to improve its character, and increase its quantity. But of course the cerebral stimulants are altogether unsuited for the relief of disordered nervous phenomena, when dependent on active congestion or inflammation of the brain itself. No one but a homceopathist would think proper to prescribe alcohol or opium in acute cerebritis or apoplexy; and the homceo- pathist himself, in doing so, escapes the crime of manslaughter only by the absolute nothingness of the dose. Production of Sleep. This is another purpose which some of the cerebral stimulants are, beyond all other medicines, calculated to fulfil. They produce the effect, in all probability, simply by so con- gesting the sensorial centres as temporarily to suspend their sensi- bility to impressions, and their power of action. Sleep necessarily CHAP. I.] CEREBRAL STIMULANTS.—ALCOHOL. 647 ensues, and is more or less profound, according as the centres are more or less deeply affected. It will be remembered that the con- gestion is, in these cases, merely the result of a stimulation of the centres inviting the blood into them, and may occupy, therefore, only the minute portions of cerebral matter of which the proper centres may possibly consist; differing altogether from the universal conges- tion caused by forces driving the blood into the brain, or by obstruc- tions preventing its return. Sleep may equally be produced by influences on these same centres, depressing them below the point of impressibility or of action, as is probably the case with chloro- form. This, too, is probably the source of sleep in health; the centres ceasing for a time to act, under the loss of excitability, exhausted for a time by their activity in the waking state. But several of the cerebral stimulants produce the therapeutic effects referred to in the last two paragraphs, in the manner of the nervous stimulants or antispasmodics, and in doses too small to give rise to their characteristic effects upon the brain. Pain, spasm, &c, are thus relieved by them, not by rendering the nervous centres insensible to impression, but probably by equalizing the excitement, the disturbance in the balance of which has occa- sioned the disorder. In producing sleep, their effect thus given is wholly different from their ordinary and characteristic operation. It is only when rest is prevented by nervous disturbance, that they are capable of acting in these small doses. The patient sleeps because the disorder which interrupted his rest has been relieved, not from the direct impression of the medicine on his nervous centres. A little paregoric, two or three grains of camphor in solution, or half a teaspoonful of Hoffmann's anodyne; doses which would have scarcely an observable effect in health, will often have this composing influence in disease. Different names have been conferred upon articles of this class, expressive of certain effects produced by them; as narcotics be- cause they stupefy, anodynes because they relieve pain, ansesthetics from producing insensibility in general, and soporifics or hypnotics from causing sleep. I. ALCOHOL. I propose first to give a general account of alcohol, its effects, and medical uses, and afterwards to treat of the forms in which it is used, and of what may be peculiar to each. 648 GENERAL STIMULANTS. [PART II. Alcohol is the product of a chemical process denominated vinous fermentation, by which, at a temperature between 60° and 90° Fahr., and with the aid of a nitrogenous material called yeast or ferment, sugar, either contained in certain vegetable juices or infusions, or dissolved in water, is converted into alcohol and carbonic acid, the latter of which escapes with effervescence. The liquids thus pre- pared, containing the newly-formed alcohol, are called fermented liquors. Many of them are employed in medicine, especially wines and malt liquors. AVhen these are submitted to distillation, the alcohol comes over mixed with a considerable proportion of water, and a small proportion of other volatilizable matter contained in the liquid employed. The liquids thus distilled are called ardent spirits, of which there are numerous forms, varying with the character of the fermented liquor from which they are prepared. Among them are brandy, rum, gin, and whiskey, all of which are occasionally used in medicine. By subjecting the ardent spirits to another distillation, or, as the process has been called, to rectification, the alcohol comes over with much less water, and a smaller amount of other impurity, and now constitutes rectified spirit, or, as it is named in the U. S. Pharmacopoeia, simply alcohol. It must be noticed, however, that this is not pure chemical alcohol, but still contains water, and has the sp. gr. 0.835. It is the strongest alcoholic liquid recognized in our officinal code; and there is no occasion for a stronger, for medical or pharmaceutical purposes. As a chemical agent, however, it is sometimes necessary to have purer alcohol, which can be procured by further distillation; and, if quicklime be added to the liquid before it is distilled, all the water is retained, and alcohol comes over quite free from that liquid. This is called pure, absolute, or anhydrous alcohol. Of pure alcohol it is only necessary to say, that it is a colourless, volatile, inflammable liquid, of the sp. gr. 0.794 at 60° Fahr., of an agreeable pungent odour, and a burning taste, capable of combining in all proportions with water and ether, and composed of 4 equi- valents of carbon, 6 of hydrogen, and 2 of oxygen. The latest views, and the one now generally received, of its precise chemical constitution, is that it is a hydrated oxide of a compound radical called ethyl; in other words, consists of 1 equivalent of ethyl (C4H5) and 1 of oxygen, combined with 1 eq. of water. 1. Effects on the System. The following observations have reference to alcoholic beverages in general, and not to any one distinct form; but the effects de- CHAP. I.J CEREBRAL STIMULANTS.—ALCOHOL. G49 scribed are to be understood as exclusively those of the alcoholic ingredient. When any particular fermented or distilled liquor has peculiar properties, independently of the alcohol it may contain, these will be mentioned when the liquor itself is treated of. Alcohol appears to be a universal stimulant. It excites the part to which it is applied, the circulatory and nervous systems, the digestive, nutritive, and reproductive functions, and, under favour- able circumstances, the various secretions; but its most powerful and characteristic effects are those produced upon the brain. Local Effects. AVhen applied, sufficiently concentrated, to the skin or mucous membranes, its immediate effect is to induce pale- ness, with more or less pain, according to the sensitiveness of the part; after which, the blood-vessels expand, heat and redness are produced, and sometimes inflammation. If the application be con- tinued for some time, the tissue shrinks, and becomes wrinkled and hardened, in consequence, as some suppose, of the affinity of the alcohol for moisture, which it is thought to abstract from the part, or of its property of coagulating albumen and fibrin, which are thus solidified in the tissue. It certainly has been proved by Orfila, when thrown in considerable quantity into the veins of the lower animals, to coagulate the blood; and, when injected into the cellular tissue, to produce the same effect in the neighbouring blood-vessels. But, in the former instance, it is brought into direct contact with the blood, so as to exercise all its chemical influence upon the albu- men and fibrin of that fluid; and, in the cellular tissue, it easily penetrates the extremely tenuous walls of the capillaries, and is in like manner enabled to act, in a concentrated state, directly upon the blood. Its influence in these cases is chemical; and, in general, death in the one case, and local death in the other are the conse- quences. But in its condensing or solidifying action upon the skin, we have no proof of any chemical agency. It probably simply increases the vital contractility of the tissues, in the same manner as the astringents. The surface is thus rendered more capable of resisting injury, which would scarcely happen if its organi- zation were impaired. It is a common mode of preventing bed- sores, to wash frequently the parts liable to pressure with brandy, or other form of ardent spirit. General Effects. When taken into the stomach, alcoholic drinks produce a feeling of warmth in the epigastrium, which is soon fol- lowed by increased frequency and force of the pulse, heat and flushing of the face, brilliancy of the eyes, and a characteristic 650 GENERAL STIMULANTS. [PART II. sensation in the head; a sort of slight swimming or giddiness, which serves as a warning to the prudent not to allow the effects of the stimulant to proceed farther. The spirits are at the same time ex- hilarated ; there is a more rapid flow of thought and fancy; and increased energy is given to any emotion or passion that may pre- dominate. There is, too, in general, a greater disposition to give expression to the thoughts and feelings of the moment; the re- straints of modesty or timidity are removed; the tone of voice becomes louder and more energetic; and the limits have been ap- proached, which cannot be transgressed without hazard. Beyond this point, if the drinking be continued, the control over the judg- ment is lost, and latent feelings are betrayed, or new ones arise, which are by no means always creditable. Persons, however, are very differently affected. Some are cheerful and good natured, others disposed to a fondling friendliness of manner, others, again, positive, domineering, or disputatious; and expressions are often used, or offence taken, in the excitement of the moment, which not unfrequently lead to the most sad results. The thoughts can now no longer be commanded. The ideas become confused, fancies are changed into realities, and various delusions are apt to occur, which often lead to corresponding acts. It is in this state, that the absurd follies, or cTeplorable violences are perpetrated, with which the annals of drinking teem. The species of delirium entitled intoxication has now come on. In common English, the individual is drunk. Not unfrequently the senses are perverted at this stage; and double vision is one of its well-known characteristics. With all this cerebral disturbance, there is continued vascular excitement, the secretion of urine is generally much augmented, and the sexual propensities often powerfully stimulated, especially in the earlier stage. At the commencement of intoxication, the control of the will over the muscles begins to be impaired; and, after a time, it is quite lost. Each muscle may contract regularly; but the associated action necessary for the attainment of any particular object cannot be commanded. Hence the staggering of drunkards, their zigzag movements, the frequent tumbles, and often vain efforts to regain their feet. At length, the disordered functions gradually subside into insensibility; first, heaviness and vacancy of expression come on, then drowsiness, and, lastly, deep sleep or a sort of coma, from which, however, the patient may generally be roused more or less completely. If he cannot be roused, he is vulgarly said to be dead drunk. The pulse subsides along with the nervous excitement, CHAP. I.] CEREBRAL STIMULANTS.—ALCOHOL. 651 but, though slow, remains often full, and of a certain strength, such as characterizes compression of the brain. The sleep or in- sensibility continues for several hours, perhaps from six to ten on the average; and, during this period, the pulse gradually declines in strength, the skin relaxes, and not unfrequently copious perspi- ration takes place. The awaking is attended with headache, gene- ral uneasiness, and feelings of languor and depression; the pulse is feeble, and the skin cool and relaxed; and want of appetite, often nausea and vomiting, clamminess of the mouth, and a furred tongue evince depression of the digestive organs following their great excitement. This condition passes off gradually; and, under the influence of cool water, fresh air and exercise, and the usual appliances of health, the system recovers its tone; and, in the course of a day or two, no traces of the debauch may remain, except, perhaps, the feeling of degradation. Now and then, instead of the series of phenomena above pre- sented, nausea and vomiting come on at some period in the pro- gress of the debauch, and the further development of the symptoms is prevented. The patient goes to bed, and sleeps off the effects of the stimulant. If the drinker have the prudence to cease before other cerebral disturbance is produced than the slight swimming of head alluded to, the excitement of system will gradually subside, perhaps with a copious diuresis, and there will be little observable depression afterwards. Should he, however, repeat the potation every day, he will, after a time, begin to find that, as the period approaches for recurring to the stimulant, there are feelings of uneasiness and of a want to be supplied, which are the inevitable penalty of over- indulgence ; and there is always some danger, under these circum- stances, of the formation of a very pernicious habit. Every day, more and more will be required to relieve the uneasiness, and pro- duce feelings of exhilaration ; and, if the temptation to increase the quantity is yielded to, the power of resistance gradually diminishes, and confirmed intemperance ensues. The only preventive of this course of deterioration, when once entered upon, is to break off the use of the drink altogether, or to fix positive limits for the quantity daily used, which shall not be exceeded; and this quantity should not be large enough to produce sensible exhilaration. The former plan is much the safer. The moderate use of these drinks, when a certain limit is never exceeded, and this falls short of obvious cerebral excitement, may 652 GENERAL STIMULANTS. [PART II. be continued by many persons for a life-time without serious in- jury. The system accommodates itself to the stimulus, which •enters into the regular means of life, and no observable difference will be noticed between such an individual and another of the same natural constitution who is abstemious, except that the former, when from any cause diseased, has probably somewhat diminished powers of resistance, and stands more in need of artificial support. But, if carried to the borders of intemperance or beyond them, the stimulant soon makes itself felt, in an individual before health}'', by an increased vigour or at least activity, of the digestive, assimi- lative, and nutritive functions. More and perhaps richer blood is made out of the same quantity of food, and the system passes into a plethoric condition, as shown by the fuller and stronger pulse, and the general redness of the surface, especially of the face. At the same time, the increased fulness of habit, and weight of body, proves that the nutrition has been promoted equally with the other processes; and in fact all the functions of the organic life are in a higher state of activity. This condition of things may continue long, in a constitution originally well-balanced, without serious in- jury; and the individual may think himself in a high state of health. He is, however, on the brink of disease, and the slightest accident may precipitate him into it. If a considerable excess is maintained, the countenance, instead of the ruddy hue and fulness of health, assumes a deeper tint and a bloated appearance; and the signs of an excessive indulgence become obvious even to the most unobservant. Poisoning by Alcohol. Every serious injury to the health, result- ing either from a temporary debauch, or from the habit of drinking alcoholic liquids to excess, I consider as falling strictly under this head. First I shall treat of the acute, and secondly of the chronic poisoning. Acute alcoholic poisoning is that in which life is endangered by large quantities of the stimulant taken at once, or in successive portions at short intervals, so that the conjoint effect is felt at the same time. Sometimes, in such cases, death is almost instantaneous. Orfila, in his Toxicology, mentions two instances of this kind. Two sol- diers drank, each, four litres (eight pints) of brandy. One died immediately, the other while they were bearing him to the hospital. It is probable that, in such cases, death results from an overwhelm- CHAP. I.J CEREBRAL STIMULANTS.—ALCOHOL. 653 ing impression on the stomach, affecting the brain sympathetically; and that the symptoms are those of great prostration from the first. But such instances are extremely rare. Generally there is a brief excitement, followed speedily by coma, from which, when the result is fatal, death usually takes place at a period varying from twelve to twenty-four hours. The symptoms vary considerably in different cases. In some, the coma is so profound that the patient can be made to show no signs of sensibility or intelligence; in others, he can be partially and temporarily roused. The pulse is usually slow and full, sometimes natural as to frequency, but to- wards the close extremely feeble, and at length imperceptible. The respiration is also slow. The face may be flushed, with a venous hue, or may be pale. The pupils, though occasionally con- tracted, are more commonly dilated. Complete immovability of the pupil is an unfavourable sign. Convulsions are rare. Death results from the suspension of the respiratory process, either through the direct alcoholic congestion, or the secondary prostra- tion of the nervous centres in the encephalon. When recovery takes place, as the affection was functional, the patient, upon the disappearance of the coma, returns to health, after a short period of secondary depression, with an aggravation of the symptoms already mentioned as characterizing the same stage in an ordinary debauch. Another mode of acute alcoholic poisoning is by the superven- tion of apoplexy. This generally occurs in persons predisposed to that affection. In such cases, even a comparatively moderate in- dulgence may produce this effect by determining blood to the brain. It is no very uncommon event for persons thus predisposed to be attacked at the table. But occasionally the result is to be ascribed purely to the alcohol. The quantity of blood thrown into the brain produces a general congestion of the organ, and some- times positive sanguineous effusion takes place. The patient may recover from either of these conditions ; but, in the latter, paralytic symptoms will be apt to remain. A third mode of poisoning is by the superinduction of inflamma- tion of the brain or its meninges. This condition is either left behind after the disappearance of the coma, or the symptoms of the two conditions are commingled. AVhenever, with more or less stupor, there are delirium, convulsions, tonic contraction of the flexor mus- cles, and local or partial palsy, the existence of the inflammatory complication may be considered as pretty certain. This condition of things, however, is more apt to accrue from a continued debauch 654 GENERAL STIMULANTS. [PART II. of several days, or weeks, than from one hard drinking spell, un- less there may have been a predisposition to the affection. It is a very dangerous condition, and many die of it; often sinking into a state resembling typhoid fever before death. Still another mode of poisoning is by acute inflammation of the stomach and bowels. Gastritis, in a greater or less degree, I fre- quently witness, in the Pennsylvania Hospital, among patients brought in while labouring under the effects of strong drink. But it is very seldom fatal. Instances, however, are on record, in which this seems to have been the immediate cause of death. The accidental deaths resulting, in the coma of drunkenness, from exposure to cold, from drowning, or from various kinds of violence, as when the body is run over by a locomotive on rail- roads, do not properly fall into this category; though they are use- ful warnings, and may be appropriately enumerated in the list of evils consequent upon this terrible vice. Chronic Poisoning. A great diversity of evils arise from the ha- bitual use of alcoholic drinks. I shall treat of them in the order of their successive occurrence. 1. The stimulant influence of alcohol renders the system at all times more liable to inflammatory attacks from ordinary causes, especially in the earlier stages of its habitual use, or in those per- sons who employ it in such a manner as not materially to impair the energies o£ their system. It has this effect, first, by inducing a plethoric state of the blood, which predisposes to inflammation, and, secondly, by stimulating the circulation, and thereby acting as an exciting cause when a predisposition already exists, or aiding other irritant influences. 2. Conjointly with the use of rich food and stimulating condi- ments, it contributes to the development of gout. In persons predisposed to this disease from inheritance, it hastens its appear- ance ; and, in those not predisposed, it is quite sufficient, in con- junction with the other agencies mentioned, to originate the diathesis. But, of those who abuse alcoholic liquors, only a com- paratively small number are attacked with gout. This demands explanation. The origination of the gouty diathesis requires the co-operation of causes which, without materially impairing the vital forces, shall produce and sustain an habitual state of ple- thora and excitement. In great excess, alcoholic drinks rapidly wear out the excitability of the system, and induce an indirect de- bility, which leads to various other disorders, but is incompatible with the generation of the gouty constitution. More moderately CHAP. I.] CEREBRAL STIMULANTS.—ALCOHOL. 655 used, however, and with rich food, they stimulate the blood-making functions, without so rapid an exhaustion of the excitability. A greater amount of food, therefore, is converted into blood than without the aid of the stimulant, and a state of plethora is pro- duced, which the continuance'of the same habits sustains. The abuse, consequently, of wines and malt liquors is more apt to cause gout than that of ardent spirits; and hence the prevalence of this disease among the rich and luxurious. But the amount of exercise taken has also much influence over the result of alcoholic stimula- tion. By vigorous exercise, the plethora induced by wine drinking and a rich diet is repressed, the excess of blood is consumed by the excess of the excited functions, and the equilibrium of health is preserved. Hence, a person of somewhat luxurious habits of eating and drinking may counteract their effects by proportionally vigorous exercise. It is from a conjunction of the moderately luxurious with sedentary habits that we are to look for the de- velopment of gout. Again, an excess in the use of alcohol which would soon indirectly wear out the powers of a sedentary man, if counterbalanced by violent bodily exertion, may tend to sustain the system at a point of elevation favourable to this disease. Hence, an individual may become intoxicated at his table every evening, and yet, if he spend all the morning in some active exercise, as on horseback in the chase, may ward off the prostrating influences of the poison, and escape with only the penalty of gout. It is not so much, therefore, the particular quality of the liquor drank, whether it be wine, or whether rum, which determines the occurrence of gout preferably to general debility, as it is the quantity of the stimulus used, and the other attendant circumstances. 3. Another evil arising from the abuse of alcohol is the direct production of inflammation in the organs upon which its stimulant agency is most strongly exerted. Sometimes this inflammation is acute; but much more frequentty it is chronic, and the necessary result of a long sustained irritation. The organs upon which alco- hol especially expends its force are the stomach, the brain, and, secondarily, the lungs and the liver. These, therefore, are most frequently affected; but the bowels, kidneys, heart, and arteries sometimes, participate in the disease. Evidence of this is exhibited not only by the symptoms during life, but by the appearances upon dissection. Every physician is familiar with the chronic gastritis of drunkards. Inflammation of the brain or its membranes is scarcely less common, though, in the acute state, often confounded 656 GENERAL STIMULANTS. [PART II. with delirium tremens, and, in the chronic, ma.sked by the disorder in the cerebral functions incident to habitual intoxication. Refer- ence is frequently made, in the records of insane asylums, to intem- perance as one of the causes of insanity. There are some persons who always have an attack of this disease, when they indulge in the use of alcoholic drinks. The duty is devolved upon the lungs, partly at least, to throw off, in the form of vapour, the portion of alcohol not expended in the nutritive process. Hence, bronchitis is a common disease of drunkards; and other pectoral inflamma- tions are not unfrequent. The liver is another of the emunctories through which the superfluous alcohol is thrown off, probably in the form of fatty matter. This organ, therefore, is kept constantly in a state of undue excitation, and, as a result, is not unfrequently inflamed. Disease of the liver is among the most common com- plaints of habitual drunkards; and though, as will be seen directly, it is not exclusively inflammation that occurs, yet it does take place in a considerable proportion of cases. Out of seventy-three cases of drunkards examined after death by Dr. F. Ogston, of Aberdeen, Scotland, the liver was found generally hypertrophied in nine, and partially in two cases; and, though this hypertrophy may probably have been in some instances the pure effect of a sustained over- excitement, yet much more probably there was in all an admixture at least of inflammation during life. It is not necessary to refer more particularly to the other organs mentioned. In all of them lesions are frequently found, which may be best explained by the supposition of the previous existence of chronic inflammation. 4. From the constant stimulation of the whole system, and espe- cially of the brain, the excitability is so far exhausted that, on the withdrawal of the stimulus, a condition of extreme prostration takes place, which frequently ends fatally, unless counteracted. The brain, left without its habitual support, exhibits its suffering in a peculiar kind of delirium, called delirium tremens or mania a potu, the charac- teristics of which are singular hallucinations, the fear of some present or impending evil, sleeplessness, and muscular tremors. This has been considered by some as inflammation of the brain. But, in its pure form, it has nothing to do with inflammation. It is the simple result of the withdrawal of the alcoholic stimulus, and is a condi- tion of real depression in the cerebral centres, showing itself by the irregularities referred to; and is relieved by restoring the stimulant impression by means of alcoholic drinks or opium. In the Penn- sylvania Hospital, I have had frequent opportunities of watching CHAP. I.J CEREBRAL STIMULANTS.—ALCOHOL. 657 the attack and removal of this affection. I have, in numerous in- stances, seen it coming on more or less completely when the wonted stimulus has been withheld, and have almost as constantly seen it yield to a renewal of the stimulus. It will be observed that I am now speaking of pure delirium tremens. But there are often mixed cases of a very different character. In these, some inflammatory and febrile attack has rendered the patient careless of the stimulant, or averse to it. The cerebral centres, left unsupported, fall into the abnormal state under consideration, and there is now a mixture of local inflammation with delirium tremens. Not unfrequently the inflammation is the direct result of the alcoholic stimulus. The patient, goaded by his insatiable thirst for the poison, gives himself up for a period to the most frantic indulgence, until he is at length brought up by an attack of inflammation of the brain or the sto- mach, the direct result of the excessive quantity of alcohol taken. Then the debauch ends, and, the drink being suspended, delirium tremens along with the meningitis or gastritis seizes on its victim. These attacks, unless promptly and efficiently treated, especially the meningeal cases, are very apt to terminate fatally, and not un- frequently do so even under judicious treatment; while the simple delirium tremens, which constitutes the vast majority of cases, is curable almost certainly, if the patient'be prevented from'sinking into a fatal prostration from the want of support. But it is not only upon the withdrawing of the wonted stimulus that the effects of depressed function are experienced. With the constant repetition of the excitement, there is as constant a dimi- nution of the excitability, so that the stimulated functions can be sustained only by a steady increase in the quantity of the stimulus, until the time at last comes when no quantity that can be taken is sufficient to support the working of the exhausted organs. It is surprising how much ardent spirit the system can be brought to bear. Two or three pints of raw spirit are consumed daily by some confirmed rum-drinkers. But, as just stated, even should no organic mischief happen in the mean time, the functions must at last fail. In relation to the stomach, dyspepsia; to the bowels, constipation; to the liver, insufficient secretion, are ordinary results. The circu- latory and respiratory functions are also enfeebled; the generative function is impaired; and even nutrition, at first over-stimulated, now fails, and the patient becomes either emaciated, or pale and bloated. The .cerebral functions also suffer greatly. The intellect is enfeebled, the power of self-command is lost, and the predomi- vol. I.—42 658 GENERAL STIMULANTS. [PART II. nant propensities or passions, whatever they may happen to be, are scarcely resisted. The influence of the will over the muscles is greatly impaired, and the patient is subject to habitual tremors when not under the fullest action of the stimulus. These tremors sometimes deepen into positive paralysis, though there is reason to think that, by this time, the brain has become organically deranged. 5. The last stage of physical degradation is now reached. The failure of the functions both organic and nervous leads inevitably to degenerate organization. The blood is depraved, nutrition suffers, and different parts of the frame undergo various degrada- tion ; those being most affected the functions of which have been previously most stimulated, and consequently most exhausted. In many instances the vital forces have been so prostrated in parti- cular organs, that chemical influences predominate, and the tissue is converted more or less into oil. This is the fatty degeneration. In other instances the disorganization is less complete; and abnormal tissues bearing some resemblance to the fibrous, cartilaginous, or bony, take the place of the healthy structure. The brain, the stomach, the liver, the kidneys, and the heart and blood-vessels are peculiarly the seats of this organic degradation; and their great vital functions suffer accordingly. The most diversified forms of functional or organic disease are presented in different cases, most of them tending to a dropsical condition, in which the patient is at last apt to perish, if he has escaped the numerous dangers which have beset him almost from the beginning, and which cause vast numbers to be carried to a premature grave. The cirrhosed or fatty liver, the granulated kidney, the hypertrophied or dilated heart with its various valvular disease, the ossified blood-vessels, and the depraved blood, deficient in red corpuscles, but abounding in oil and carbon, are the most frequent causes of the dropsy. Dr. Magnus Huss, Professor of Clinical Medicine in Stockholm, has recently described a paralytic affection, which he denominates alcoholismus chronicus, and which he ascribes solely to the poisonous influence of alcohol. It is very common in Sweden, where intem- perance is said to prevail to a fearful extent. The affection shows itself first in tremors and unsteadiness of the voluntary muscles, usually commencing in the upper extremities, then extending to the lower, and at length involving the muscles of the trunk. The trembling is often violent, particularly on the occasion of any voluntary effort, and is greatest in the mornings before the patient has had recourse to his accustomed stimulus. Sensation after a CHAP. I.J CEREBRAL STIMULANTS.—ALCOHOL. 659 time begins to be affected; formication occurs here and there; and at last both sensation and the power of motion are lost over a greater or less extent of the body, the special senses being not unfrequently involved. Instead of this paralytic condition, the poisoning may assume the spasmodic or convulsive character, marked at first by twitchings, and afterwards various irregular muscular contractions, terminating in positive epileptic paroxysms. All these phenomena are readily explicable. The first failure of muscular power is probably the result of mere exhausted function in the brain; but the more serious subsequent results must be ascribed to the organic changes which have, in the mean time, been going on in the cerebral tissue. 6. Another and not the least evil of the abuse of alcoholic liquors, is the increased danger given by it to other diseases; partly through the impaired state of the constitution, which renders it less able to resist them; partly through the impossibility under which it places the physician, of using that energy in the treatment which the diseases may require; and, in some degree also, in con- sequence of the relative inertness of alcoholic remedies in the intemperate, in whom they are most needed. I have purposely avoided the consideration of the moral aspect of intemperance, which, even if we confine our views to this world, presents an amount of evil, far exceeding the physical, terrible as this must be acknowledged to be. Appearances on Dissection. When death has occurred suddenly from enormous quantities of the poison, no pathological appear- ance need be expected after death; the stomach and brain being at once overwhelmed by the violence of the shock. In the more protracted cases of acute poisoning, the signs of inflammatory congestion of the stomach are sometimes, though not always pre- sented; but there is usually congestion of the brain, with occasional effusion into the ventricles, which has the odour of alcohol, and in one instance is said to have been inflammable. In cases of habitual drunkards, dying either directly from the effects of the poison, from suicide, or other forms of violent death, and from accidental diseases, there is almost always some lesion discoverable, which may be fairly ascribed to the poison; some- times the direct consequence of constant irritation, as hypertrophy; sometimes of pure deficiency of action, as atrophy; ver}' frequently of inflammation, and still more frequently of various degeneration. 660 GENERAL STIMULANTS. [PART II. Out of 117 cases examined by Dr. Ogston, only one was without some discoverable lesion.* The lesions were most numerous in the brain and its appendages, and after this, successively, in the respira- tory organs, the liver, the circulatory organs, the kidneys, and the alimentary canal. That the smallest number should be found in the stomach and bowels is not what might have been anticipated; but the probability is that more of the lesions in this structure were to be ascribed to the alcohol exclusively than in the others, unless the brain be excepted. It will of course be understood that many of the morbid appearances would have been found in tempe- rate persons; but assuredly in greatly less proportion. In the brain the most frequent changes were thickening of the arachnoid, ef- fused serum, injection of the pia mater, and induration or softening of the cerebral substance; in the respiratory organs, pleural adhesion and partial emphysema; in the heart and its appendages, hypertro- phy and dilatation, obesity, valvular disease, pericardial adhesion or thickening, and atheromatous or osseous deposition or degene- ration in the large vessels; in the stomach extraordinary diminu- tion of size or atrophy, congestion, softening of the mucous mem- brane, and hypertrophy or thickening of the walls, which, however, was seen in three only out of the whole number of cases; in the liver fatty degeneration, hypertrophy, cirrhosis, and the nutmeg appearance; in the kidneys hypertrophy, congestion, and fatty degeneration. (Brit, and For. Med.-Chir. Rev., April and October, 1854.) Treatment of Alcoholic Poisoning. In the acute cases, the pro- minent indication, in the earlier stage, is to evacuate the stomach; for which purpose recourse may be had to emetics or the stomach pump. The latter is the most effectual method, though, in the absence of the necessary implements, the former should not be neglected. At the same time, cold water should be freely and steadily applied to the head, and sinapisms or other rubefacients, or hot pediluvia, to the lower extremities. Pouring cold water into the ear has been recommended, in order to rouse the patient from stupor; and, with the same view, in its first application, it may * Of the different organs, the brain and its appendages were affected in 108 of the oases, or 92.3 per cent.; the respiratory organs in 74, or in 63.24 per cent.; the liver in 66, or in 56.4 per cent.; the heart and its appendages, including the aorta and pulmonary artery, in 56, or in 47.86 per cent.; the kidneys in 51, or in 43.58 per cent. ; and the intestinal tube in 48, or in 41 per cent. (Brit, and For. Med.-Chirurg. Rev.. July, 1855, Am. ed. p. 145.) CHAP. I.] CEREBRAL STIMULANTS.—ALCOHOL. 661 be poured from a height on the head or shoulders. Bleeding, either general or local, or both, should be used when the pulse is full and strong, and organic mischief in the brain is apprehended. Should respiration be suspended or nearly so, it should be sup- ported artificially, until nature may be able to maintain the func- tion, or undoubted death shall have taken place. In the stage of prostration, after the direct action of the stimulant has ceased, and nothing remains but the depression consequent on the previous excitement, the strength should be supported by external and internal stimulation. When the patient cannot swallow, the stimu- lant should be injected into the stomach or rectum. Carbonate of ammonia, or aromatic spirit of ammonia may be used, so far diluted as not to injure the mucous membrane; and even brandy may be resorted to, especially in the form of milk punch by the stomach. It is not now the presence of the alcohol that is endangering life. It is the prostration ; and that may be very properly counteracted by a smaller amount of the stimulus, so as to cause the system to subside gradually from its previous state of exaltation. This treat- ment, however, should not be employed until the skin becomes cool, the pulse feeble, and the danger from prostration obvious. In chronic poisoning, the only remedy is abstinence. It is rarely that the affection has proceeded so far, that a cure may not be effected, or the state of the system very much ameliorated, by this measure. Unless some essentially fatal disorganization has taken place, as in cirrhosis of the liver, the system may be gradually led back to health by a reversal of the process which has brought it into the diseased state. A sudden withdrawal of the stimulus, without the substitution of something of a similar cha- racter, is dangerous. Death frequently results from this cause. Delirium tremens is an almost constant consequence, when the habitual excess has been great and long continued. The great difficulty lies in the want of co-operation upon the part of the patient. The same infirmity of will that led to the evil, is in the way of its removal. I have often, however, had patients under my care in the Pennsylvania Hospital, who have been willing to submit to the requisite restraints, and invariably they have been dismissed without evil consequences, and cured for the present of the evil habit. The simple measure is to allow them at first some- what less than their ordinary amount of stimulus, preferring the milder kinds when they will answer, as wines and the malt liquors, aud daily to diminish the quantity, always endeavouring to sustain 662 GENERAL STIMULANTS. [PART II. them above the point of sleeplessness or delirium. Opium often comes in very happily as an adjuvant, to obviate nervous disorder and produce sleep; but this also must be withheld, as the system is found capable of doing without it. Sometimes there is an ad- vantage in partially substituting for the pure stimulus one of the bitter tinctures, especially that of hops; and recourse may be had to the nervous stimulants, as assafetida, valerian, and Hoffmann's anodyne, when nervous irregularities may seem to call for them. When the health has been materially impaired by the long con- tinuance of the habit, it is necessary, as the original stimulus is withdrawn, to address remedies to the system in order to correct the diseased functions, or repair the diseased organs; such as the bitter tonics and aromatics for dyspepsia, rhubarb and aloes for constipation, the chalybeates to improve the blood, and nitro- muriatic acid or the blue pill to obviate hepatic disease. When the patient cannot or will not summon resolution enough for a steady perseverance in the above plan, it is better for him to break off at once, and take the risk of the evil consequences, than to incur certain destruction from perseverance in the vicious habit. Under proper medical superintendence, even should delirium occur, the case may almost always be conducted to a safe issue. Of the management of delirium tremens, I do not propose to treat in this place, as I have already fully considered the subject in my work on the Practice of Medicine. I would simply observe that, on the whole, I prefer the opiate plan of treatment, giving only so much alcoholic drink as may be sufficient to obviate pros- tration, and gradually withdrawing both. There is one important practical point, however, to which I would especially invite the attention of the student. He is not to consider cases of meningeal inflammation or acute gastritis, when brought on by intemperance, and then mingled with delirium tremens, as cases purely of the latter disease. In these cases, he must deplete for the inflammation, while he supports the actions of the nervous centres by alcoholic stimulation, which, in these per- sons, when given in less than the habitual amount, acts as a, real sedative. The same rule holds in regard to inflammatory affec- tions, which may come on accidentally in the intemperate, and, in consequence of the suspended use of the stimulant, become com- plicated with their peculiar delirium. CHAP. I.] CEREBRAL STIMULANTS.—ALCOHOL. 663 2. Mode of Operating. The operation of alcohol as a stimulant is probably dynamic, that is, the result of its influence on the vital properties of the tissues, and independent of any chemical action exerted upon those tissues. At least, we have as yet no proof of chemical change produced in the organs which it stimulates; and all theories based upon such a change are, in the present state of our knowledge, conjectural. It is true that, in its more concentrated form, its affinity for water, and its disposition to coagulate albumen, may cause disorganization of the tissues, as any other chemical escha- rotic may do; but this is not its ordinary medicinal operation, to procure which it is always given much diluted. The theory that the excitement it occasions is a vital reaction against its chemical affinities, is, therefore, gratuitous. It may possibly be true; but we have no proof of it; and the safest conclusion is that, like any other stimulant, it produces its characteristic effects simply through its relation to the vital properties, which determines that, when it is brought into contact with the living tissues, these should take on an increase of action. Its first effects on the brain may possibly result, in part at least, from the sympathy of that organ with the stomach. Indeed, so close is this relation, that any strong impression in one is very apt to make itself sensible in the other. The fact stated by Orfila, that alcoholic liquors act with less energy when injected into the cellular tissue than when taken into the stomach, seems to favour this view. But, whether the cerebral effects have or have not their commencement in sympathy with the gastric impression, they are chiefly, throughout their course, attributable to the direct action of the alcohol circulating through the brain. That this principle is absorbed, when liquids containing it are swallowed, is beyond all doubt. Its rapid disappearance from the stomach, and its odour in the breath are sufficient proofs of the fact. But it has been found also in the urine, bile, liquors of the serous cavities, brain, liver, and the blood itself. It was especially abundant in the brain, in the ventricles of which it is asserted sometimes to have existed in an inflammable state. Dr. Ogston in one instance " found about four ounces of fluid in the ventricles, having all the physical qualities of alcohol" (Pereira's 3Iat. 3Ied., 3d ed. p. 1987); and, in another instance, while heating over a candle, three or four drachms of urine taken from the bladder of a man who was 664 GENERAL STIMULANTS. [PART II. drowned while intoxicated, he observed that its vapour was set on fire by the flame. (Brit, and For. 3Ied.-Chir. Rev.. July, 1855, Am. ed. p. 148.) Coming then into direct contact with the nervous centres, the alcohol stimulates them into excessive action, and thus gives rise to the phenomena of excitement which characterize the early stage of its operation. Every excitation of a part is attended with an increased flow of blood into it, and the active congestion increases with the excitation. By the continued operation of the alcohol, the congestion is continually increased in the cerebral cen- tres, which, after their brief exhilaration, become disturbed, and at length embarrassed or overwhelmed, all through the direct and continued irritation of the same agent. Hence the intoxication and ultimate stupor which follow the primary excitement. But at length, the alcohol ceasing to act, the cerebral centres become depressed in proportion to their previous elevation; and gene- ral prostration of the system results. The wearing out of the excitability, the ultimate general debility, and the consequent degradation of the organs, resulting from long continued intempe- rance, have been sufficiently noticed. The influence of the alcohol upon the brain has been ascribed to the altered and more highly carbonized state of the blood. Of this there is no proof whatever; nor, except in the single fact of stupor, is there any resemblance between the effects of this sub- stance and the condition of the blood referred to. From the expe- riments of Dr. Bocker it would seem that alcohol diminishes the amount of the solid and fluid excretions by the urine,/and the quantity of carbonic acid exhaled in respiration, without increas- ing the fecal discharges, the perspiration, or the loss of water by the lungs. Hence it has been inferred that it lessens the rapidity of the normal disintegration of the solids, and consequently di- minishes the general activity of the functions; for the measure of their activity is the quantity of effete matter thrown out of the system. Hence, too, the practical inference, that it enables the body to be sustained by a less amount of food. But these are con- clusions much too large for the basis on which they rest. We need many more, and much more variously repeated experiments, before they can be justified. No facts of observation seem more obvious than that alcohol stimulates the functions of the stomach and brain to increased activity; that it for a time invigorates di- gestion, promotes nutrition, increases the action of the kidneys or the skin, according as it is directed to one or to the other and CHAP. I.] CEREBRAL STIMULANTS.—ALCOHOL. 665 elevates the intellectual and emotional functions. How it can effect all these ends, without a more rapid disintegration and re- newal of the structure, is inconceivable to one who considers such disintegration as a necessary attendant of every vital action. That, when taken in excess, it will overwhelm and, in some measure, paralyze the functions after the first excitement is past, and that, in this way, it may on the whole diminish the amount of the ex- cretions; and that by the wearing influence of its long continued abuse, the functions come at last to be in great measure prostrated, is readily intelligible. But that, during its stimulant operation, it should not promote a more rapid change of the tissues which it stimulates, is quite incompatible with the present views of the con- nexion between the actions and the wear and tear of the system. But it is an undoubted fact that the habitual use of alcohol lessens the desire and apparent necessity for food; and it seems to be well proved, that a labourer can do a certain amount of work with less ordinary aliment, if freely supplied with beer or wine, than when water alone is allowed for drink. But this fact is explained, at least in the early stage of the action of alcohol, not by the diminished integral change in the tissues, but by the double fact, that it pro- motes the more perfect digestion of the food taken, and at the same time supplies food itself. If the usual amount of food is swallowed, alcohol favours its digestion and conversion into blood, and hence produces a plethoric state. This reacts on the stomach, diminish- ing the desire for food; and hence less is taken. But, as stated, alcohol is itself in all probability assimilated. What else becomes of it ? Assuredly, but a very small portion of that taken into the body leaves it unchanged. It is certainly decomposed in the sys- tem. If, as some suppose, it were merely oxidized into water and carbonic acid, there would be a vast increase of the excretions of these products by the lungs, which, from the experiments of Dr. Boker and some others, would seem not to be the case. It is pro- bably converted into some one or more of the proximate consti- tuents of the body; and I am among those who believe that it may, through the agency of the vital forces, and in the presence of organized nitrogenous matter, be converted into any one or all of those constituents, excepting only the mineral. The one, however, which most obviously results, is oil; and this is often generated with great rapidity. It is not only visible in the increase of the adipose tissue, and in the promotion of obesity in certain indivi- duals, but it exists also in abnormal proportion in the blood; and 666 GENERAL STIMULANTS. [PART II. the oleaginous change is probably the first step of the conversion of alcohol into materials fit for organization. And why should not alco- hol be capable of digestion? It is generally admitted that many of the organic acids are so, as vinegar, citric acid, &c. Now, by a very easy change, alcohol itself is convertible into acetic acid. The inference seems to me inevitable, that it also is capable of being digested and assimilated. It is food, therefore, as well as a stimu- lant ; and this view certainly best explains the plethoric condition, and increased weight and fulness of the body, often so strikingly observable under its use, while the amount of other kinds of food taken is diminished. But this fact in no degree justifies its abuse. The various evils to which its excess gives rise are neither lessened in themselves, nor do they constitute a less unanswerable argument against the abuse of alcohol, from the fact that it may contribute to the nourishment of the body. In opposing an enemy, it is use- less if not dangerous to shut our eyes against his good qualities, and bad policy to put ourselves into a position in which we cannot avail ourselves of them. 3. Therapeutic Application. The first great question in the therapeutics of alcohol is how far its habitual use is favourable or unfavourable to health. In the greater number of cases, judging from the experience of the world since the beginning of history, it is of little consequence to the health of the individual, whether he drink it or not, provided he do not exceed the limits of temperance, and especially if he con- fine himself to the pure fermented liquors. But there are two classes of individuals to whom this remark does not apply. In one of these classes, the possession of a peculiarly sanguine or nerv- ous temperament, renders them strongly susceptible to injury from substances calculated, in the one instance, to favour the over- production of blood, and, in the other, to stimulate the unduly excita- ble nervous centres. In these persons, the habitual use of alcoholic drinks, which have in a high degree both the properties mentioned, is hazardous to health, and should, therefore, be avoided. It en- dangers inflammation, hemorrhage, and serious cerebral disease. In the second of the classes referred to, the contrary of this proposi- tion is .true. Nature, while planting in so large a proportion of the human family a disposition to scrofulous or tuberculous com- plaints, seems to have provided, in the fermented liquors, what, if properly used, may be considered as in some degree a counteracting CHAP. I.] CEREBRAL STIMULANTS.—ALCOHOL. 667 agent. Physicians have often noticed that drunkards seldom die of phthisis. In this respect, my own observation coincides with that of others. During my tour of hospital duty in the winter, I meet with great numbers, both of drunkards and of tuberculous individuals; but it is very seldom that the two classes coincide. This is a singular fact, and not exactly what might have been anti- cipated ; for the tuberculous constitution belongs to the same cachectic category with that which gives a tendency to fatty dege- neration, cirrhosis of the liver, granular disease of the kidney, &c, and is not unfrequently associated with it. A priori, it would have been imagined that the exhausted state of general health, charac- terizing the advanced stages of intemperance, would favour tuber- culous deposition; and the discovery of the opposite truth has been something like a surprise to the profession. This result of observation has been singularly confirmed by recent pathologico- anatomical investigations.' Out of 117 cases of confirmed drunk- ards, whose bodies were examined after death by Dr. Ogston, there were only two who exhibited any evidence of tuberculous disease of the lungs. In one of these there were some latent tubercles, and in the other a single tuberculous cavity in the right lung; and in neither was this affection the cause of death. (Brit, and For. 3Ied.- Chir. Rev., April and October, 1854.) In the same number of tem- perate persons, of different sexes and ages, examined after death from other causes, the same result would certainly not have been obtained. How alcoholism acts adversely to the development of tubercle may be conjectured, but is not certainly known. In its earlier stages, it may be supposed to sustain a grade of elevation in the vital functions, and richness of the blood, above that at which there is a tendency to the deposition of tuberculous matter. But this is certainly not the case in the latter stages, during which, so long as the stimulus continues to be used, there appears to be the same exemption. Perhaps, as many suppose, it is the more highly carbonated state of the blood in the inebriate that protects him against tuberculosis. Possibly, the large proportion of oil contained in it may have some preservative tendency, similar* to that exercised by cod-liver oil. It would be a perverse reason that would deduce from the fact here stated an argument in favour of intemperance. Assuredly, of the two, even admitting that the security afforded is complete, which it is very far from being, death from pulmonary consumption is infinitely preferable to death from drunkenness, or even to the life of a drunkard. But a just infer- 668 GENERAL STIMULANTS. [PART II. ence is, that they who may be predisposed to phthisis or scrofula, or may be labouring under the disease, may, with propriety, and probably with advantage, employ the fermented liquors habitually, though always in moderation. By adhering to the rule, never, under any circumstances of ordinary health, to use any one of the forms of ardent spirit, but to adhere exclusively to the fermented liquors, they may avoid the danger of intemperance, and yet obtain all the immunity which alcohol can confer. In giving the above general rules in relation to the habitual use of alcoholic liquors, it will be perceived that I confine myself wholly to the medical aspect of the question. How far an individual may feel himself bound to forego a harmless gratification, or to sacrifice, in some instances, a positive good, for the sake of an example to others of weaker will, or of a constitution more susceptible to in- jury from alcoholic drinks than himself, is a moral question upon which there is no occasion to express an opinion in this place. One point, however, I would urge, with whatever weight of authority a life of observation may have given me, and with all the strength of expression I possess, that, whenever an individual discovers in him- self the least tendency to excess in these drinks, or the least defi- ciency of power to restrain himself withiu due limits when slightly under their influence, he should promptly abandon them altoge- ther, and permit no sophistry of inclination to overcome his reso- lution of entire abstinence for the future. In low febrile diseases the alcoholic liquors are a most valuable resource, and, indeed, often indispensable. At least, I have very frequently met with conditions in these fevers, in which I should have quite despaired of a cure without their aid. They are not so well adapted to the prostration or collapse which sometimes occurs in the cold stage, at the commencement of the fever, as to the debility coming on in its course. The continuance of their stimulant influence into the stage of reaction, and their special tendency to the head, might possibly, under the former circum- stances, injuriously increase the fever and cerebral disturbance; and they should, therefore, be employed only when the arterial stimu- lants may prove inadequate to the end in view. But to the latter condition, the debility, namely, which so often supervenes in febrile diseases, and not unfrequently constitutes their greatest danger, they are adapted, beyond all other medicines, by the universality as well as energy of their stimulant property. Operating specially upon the brain, they rouse it from the torpor by which it is apt to be CHAP. I.] CEREBRAL STIMULANTS.—ALCOHOL. 669 overwhelmed in the advanced stage of fevers of the typhoid cha- racter, and prove much more efficient in sustaining life than the arterial or nervous stimulants. They are indicated when the pulse is feeble, and the skin cool, and particularly when, with these evi- dences of debility, are associated the dark tongue, the sordes about the teeth, and the stupor or low delirium of the typhous state, indi- cating a depraved condition of the blood. Even when the skin is hot, if the other symptoms appear to call for their use, they should be tried. I believe they not only stimulate in these cases, but prove useful also by directly contributing, through their nutritive proper- ties, to the improvement of the blood. Unless the prostration is sudden and alarming, the mildest form of these stimulants should be first employed, and recourse be had to the stronger only as the increasing debility may seem to require them. Thus, it is usually advisable to begin with wine-whey, then, if necessary, to advance to pure wine, and ultimately to brandy. Should the skin become hotter and dryer, the pulse more frequent, and the patient more restless and delirious under the stimulant, it should be diminished or discontinued; but, should the contrary condition occur, should the skin become soft or moist, the pulse slower, fuller, and stronger, and the patient more comfortable and less disposed to delirium, it may be taken for granted that the remedy is operating favourably, and should be continued. It is in typhus, and enteric or typhoid fever, that the alcoholic remedies generally prove most useful; but most other febrile affections sometimes assume the same low character, and require the same treatment. The alcoholic liquids may often be advantageously used in scarlatina, smallpox, and erysipelatous fever, and occasionally in bilious remittent and yellow fevers, when they present typhoid symptoms. Even the existence of inflamma- tion, under these circumstances, does uot positively contraindicate them. Active alcoholic stimulation is often necessary in typhoid or typhous pneumonia. In the advanced stage of inflammation, when copious suppuration has taken place, and the patient is sinking under it, the alcoholic stimulants are often called for, to aid in supporting the strength until the exhausting influences shall have ceased, or, when the case is hopeless, to render the patient more comfortable, and protract his life. Such a condition is presented in the suppurative stage of pneu- monia, abscess of the lungs and kidneys, purulent phlebitis, lumbar and psoas abscess, sup>puration of the large joints, extensive caries of the bones, and numerous ulcers upon the surface. To this category may be added 670 GENERAL STIMULANTS. [PART II. various constitutional affections attended with suppurative or ulcer- ative conditions, as erysipelas affecting the cellular tissue, confluent smallpox after the maturation of the pustules, all scrofulous affections including phthisis, syphilis in the ulcerative stage, and several of the cutaneous affections, particularly rupia and ecthyma. Precisely the same indication is offered by gangrene, whether re- sulting from inflammation, from purely depressing agencies, or from a vitiated state of the blood. The system requires support against the directly depressing influence of the gangrene, and of the processes requisite for the separation of the slough, and also to enable it to repair the injury done. It is unnecessary to enumerate all the affections in which this condition may occur. In severe in- ternal inflammations, there is occasionally an abrupt cessation of the pain, with symptoms of great prostration, which have been supposed to indicate the occurrence of mortification, and often per- haps truly, even though certain evidence may not be exhibited by putrefaction after death. Strangulation of the bowels, whether con- cealed as in invagination, or obvious, as in hernia, very often ends in mortification. Other examples of this affection we have in gan- grene of the lungs and of the mouth, that which attends malignant erysipelas, carbuncle, and the malignant pustule, and lastly that aris- ing from severe burns, injuries of the blood-vessels, arteritis, the poison of ergot, &c. In the above suppurative and gangrenous affections, and all others of a similar character, alcoholic stimulation is very frequently indicated, and sometimes strongly so. But it must be remembered that they are usually attended with more or less remaining inflam- matory or systemic excitement, which requires caution in the use of the stimulant; and, as a general rule, the fermented liquors will be preferable to the spirituous. Most frequently in these condi- tions, there is also an indication for the use of opium and sulphate of quinia, or other preparation of Peruvian bark. There is a state of system, essentially one of debility, in which the blood is poisoned by noxious matter absorbed into it, and which does not come exactly into either of the preceding divisions. To this belongs the condition denominated purulent infection, metastatic abscess, and pyogenic fever. It is a condition in which, probably, disintegrated pus, or other sanious secretion from vitiated sores, is absorbed into the blood, and depraves its character. Analogous to it is the state of system arising from dissecting wounds. Alcoholic stimulation is often indicated in this condition. CHAP. I.] CEREBRAL STIMULANTS.—ALCOHOL. 671 Considerable attention has recently been attracted to the asserted efficacy of this remedy in the state of system resulting from the bites of poisonous serpents; and cases have been recorded which go far to prove that it really possesses no inconsiderable curative powers.* The prostration of system which attends the operation of the poison would appear to indicate stimulation; and the ammoniacal preparations have long been in repute as antidotes. To produce the desired effect, the alcoholic remedy, it is said, must be given very freely; and, in most of the cases, it has been pushed to intoxica- tion. It seems, however, that the system, when strongly under the influence of the poison, resists its influence, as tetanus is known to do. In a case recorded by Dr. T. A. Atchison in the Southern Journ. of the 3Iedical and Physical Sciences for March 1853 (vol. i. p. 108), in which the patient, a young woman of seventeen, was found almost moribund two hours and a half after the bite of a rattlesnake, three pints of whiskey, given in doses of a glassful every hour, though it produced reaction, and apparently saved the life of the patient, occasioned not the slightest intoxication. During the same time, however, eighty grains of carbonate of ammonia were given, which has been supposed to have some power of obviating the inebriating effects of alcohol. A young medical friend of mine informed me that, while upon an excursion in Texas, he was bitten by a poisonous serpent, and had already begun to experience alarm- ing local as well as constitutional effects, when the progress of the poisoning seemed to be arrested by ardent spirit, given until it rendered him insensible. So many instances occur, in which spon- taneous cures of snake-bites take place after the exhibition of threatening symptoms, and so many others in which the effects of the bite are simply those of a shock produced by fright upon the nervous system, that it is very difficult to determine how much value can be attached to any remedy, which may be recommended on the ground of experience. In the St. Louis Med. and Surg. Journ. (xii. 26) is a communication from Dr. J. Gilman, in which, as the result of numerous experiments directly with the poison of different * For accounts of cases, see a paper read by Dr. Edward Hallowell, before the College of Physicians of Philadelphia, Dec. 1, 1852, in the Transactions of the Col- lege, N. S. i. 394 ; the New Jersey Medical Reporier for March, 1853 (vol. vi. p. 195), in which a case is recorded credited to the Southern Medical and Surgical Journal; the Southern Journal of the Medical and Physical Sciences for March, 1853 (vol. i. p. 108); and the Boston Medical amd Surg. Journ. for January, 1854 (vol. xlix. p. 506). 672 GENERAL STIMULANTS. [PART II. serpents upon plants and animals, he found that alcohol, "if brought in contact with the venom, is, to a certain extent, an antidote;" while the poison mixed with the solution of ammonia and various other agents " seemed to act with undiminished energy." In some nervous diseases, alcohol possesses considerable powers. In tetanus it has been given very freely, in the form of wine and ardent spirit, and is among the remedies upon which most reliance has been placed. The most suitable time for giving it is at the first appearance of the characteristic symptoms, and before the dis- ease has become fully established; and it should be so exhibited as to give obvious proofs of affecting the system. It has been much used also as a preventive, when serious apprehensions have been entertained of an attack. The disease, when fully formed, resists the influence of alcohol strongly; and it is very difficult to obtain its characteristic effects. In the trembling palsy, alcoholic stimula- tion is sometimes temporarily beneficial; and it may be used with great advantage in those cases of delirium from, exhaustion, which imitate delirium tremens. Of its employment in the latter affection enough has been said already. Finally, alcoholic liquors may be used in the debility arising from excessive secretion or hemorrhage, in that of convalescence, and in that which attends the advanced stages of most incurable diseases before the fatal issue. In the acute diseases of intemperate persons, it is generally necessary to have recourse to them, in order to sustain life, even when there might be otherwise no indication, or a positive contraindication ; care being taken to give them in as small a quan- tity as the circumstances of the case will admit, while efficient me- thods are employed to combat the disease, such as would be used in cases without this complication. In the use of these drinks, a preference should always be given to the weaker, whenever sufficient to answer the intended purpose; and, from the weakest up to the strongest, there should be a gradu- ation directly in proportion to the debility, and at the same time the insusceptibility of the system. Contraindications. In chronic debility, the alcoholic liquors should be employed with great reserve, from the fear of originating habits of intemperance. They are contraindicated in plethora, in fever and acute inflammation with a sthenic state of system, in acute gastric and cerebral inflammations under almost any circumstances ■ except in drunkards, and in cases of special vascular determination to the brain. CHAP. I.] CEREBRAL STIMULANTS.—WINES. 673 4. Forms in which Alcohol is used. a. Fermented Liquors. I. WINES.—Vina. The U. S. Pharmacopoeia recognizes only two kinds of wine; 1. White Wine (Vinum Album, U.S.), by which is meant the variety known in commerce as sherry wine, and 2. Red Wine (Vinum Ru- brum, U. S), which is specially defined to be port wine. The wines used in medicine are exclusively the fermented juice of the grape. The same name has been given to the fermented juice of various other fruits, as the currant, gooseberry, elderberry, &c; but these are not admitted into the Materia Medica, and should never be employed medicinally in the place of genuine wine, when the latter can be obtained. Wines have been differently classified, according to their quali- ties and origin. The most important distinction for the physician is into the light and the strong wines; the former including those which consist exclusively or nearly so of the fermented grape-juice; the latter, those to which brandy or other form of ardent spirit has been added, to increase their body, and enable them to keep better. Among the former are sauterne, claret, champagne, the Rhine and 3Ioselle wines, and burgundy; among the latter, madeira, teneriffe, sherry, and port. It will be noticed that the distinction between the two kinds is not only the difference in the quantity of alcohol they contain, but also in the circumstance that, in the one, this ingredient is in the state in which it was produced by the act of fermentation, in the other, is partly superadded, after having undergone the pro- cess of distillation. Another distinction is into the white and red wines, the former being prepared from colourless grapes, or the juice of the red, with- out the skins; the latter, from the red, with their skins remaining. The only important difference between them, medically considered, is that the red contain tannic acid, which gives them astringent pro- perties, and the white little or none. Of the wines above mentioned, sauterne, champagne, the hock or Rhine wines, and the Moselle wines, of the lighter varieties, and madeira, teneriffe, and sherry, of the stronger, generally rank among the white; and claret and bur- gundy, of the light, and port, of the stronger, among the red. Another distinction is into the still and sparkling, the latter being characterized by the property of effervescence, depending on the vol. I.—43 674 GENERAL STIMULANTS. [PART II. presence of carbonic acid. This excess is owing to the circumstance that they have been bottled before the entire completion of the fer- mentation, so that the carbonic acid subsequently generated is con- fined. Any wine may be made sparkling in this way; but, generally speaking, it is only the champagne and sparkling 3Ioselle that have this quality. An excellent sparkling wine is made at Cincinnati, Ohio, from the juice of the Catawba grape. Some wines are acidulous, others sweet, and others, again, have scarcely any perceptible sourness or sweetness to the taste, though almost all contain acid, and most of them more or less grape-sugar. The light wines are generally the most acidulous. Composition. Besides alcohol and water, wines in general contain small proportions of bitartrate of potassa, malic, tartaric, and carbonic acids, extractive, mucilaginous and colouring matters, cenanthic ether, and a volatile odorous principle; and many of them, grape-sugar and tannic acid. The proportion of absolute alcohol contained in them varies, according to Christison, from 6 to 17 per cent, by weight. The table of Brande gives proportions varying from about 10 to 26 per cent.; but it is alcohol of the sp.gr. 0.825, containing a con- siderable proportion of water, that is here referred to, and the ratio is by measure instead of weight; so that his numbers are necessarily higher. It is probable that the former statement approaches the truth most nearly. It is a point worthy of special notice, that the wines above mentioned as belonging to the lighter class contain, on an average, about half as much alcohol as those belonging to the stronger; and this remark holds true of the several varieties of the two classes. This fact is important in regulating the dose of the wines. Bitartrate of potassa is most abundant in new wines, and is gradu- ally deposited as they become older. Of the free acids, the malic is said to be most common, the tartaric being generally combined. Carbonic acid is probably in some degree present in all; but is most abundant, of course, in the sparkling. Acetic acid is sometimes present, but always probably as a product of the acetous fermenta- tion of the alcohol, and therefore to be regarded as an impurity. The odorous matter upon which each wine depends for its cha- racteristic aroma is probably a volatile oil peculiar to each- but it has not been separated. There is in most if not all wines a volatile oily matter, in extremely minute proportion, which serves to impart to wines, as a class, their peculiar flavour, and quite dis- CHAP. I ] CEREBRAL STIMULANTS.—WINES. 675 tinct from the characteristic aromatic principle of the several wines. This is the cenanthic ether, discovered by Liebig and Pelouze, and is said not to exceed one in forty thousand parts. It has been obtained separate, and has been found, in this state, to have a disagreeable, very strong, intoxicating odour, and an unpleasant taste. It has been supposed that it might contribute to the intoxicating effects of the wines; but the point has not been determined. Sugar is not a desirable ingredient in medicinal wines, and the sweeter varieties are therefore little employed. Tannic acid is present in the red wines, and tends to render them astringent; but its effect in this way is, in some of the lighter wines, more than counteracted by the bitartrate of potassa, and other saline matter, and by the free acids they contain. Both this principle and the colouring matter is gradually deposited with time; and port wine, so strongly astringent when fresh, becomes after many years almost as colourless and free from astringency as madeira. By long keeping, wine becomes softer to the taste, in consequence of the deposition of the bitartrate of potassa, to which they mainly owe their tartness, and of the tannic acid and colouring matter, when contained in them. When kept in casks, they gradually lose alcohol; but, according to a not uncommon opinion, their intoxicat- ing property is rather increased than diminished; a result which, if true, may possibly be ascribed to the production of cenanthic ether. Effects on the System. The effects of wine, as a mere alcoholic liquor, have been already sufficiently described; but there are cer- tain peculiarities in its operation which demand notice. These result either from other ingredients, or from the peculiar state in which alcohol exists in the fermented liquors. Probably both these causes have some influence. It was at one time supposed that alco- hol might not pre-exist in the fermented liquors, but result from the distillatory process. This, however, has been fully disproved; as Brande obtained it from wines without distilling them. There can, however, be little doubt that its influence on the system is modified by the state of association in which it exists in the fer- mented liquors. Wine is much less intoxicating, in proportion to the alcohol it contains, than ardent spirit; and the lighter wines much less, in the same relation, than the stronger, to which brandy has been added. Madeira has rather less than half the proportion of alcohol contained in brandy, and claret, according to Christi- son, about half as much as madeira; yet every one knows that 676 GENERAL STIMULANTS. [PART II. two glasses of madeira are less intoxicating than one of brandy; and two of claret less so than one of madeira. It would seem, therefore, that distillation unsettles some association of the alco- hol which has a strong influence in modifying its intoxicating power. Wine, moreover, operates more slowly as a cerebral stimu- lant than ardent spirit, and maintains its action longer; in other words, it is less diffusible and more tonic; and the same may be said of the lighter wines in relation to the stronger. The proba- bility is, that the proper alcohol of the fermented liquors is capable of a more ready digestion and assimilation than that which has been distilled; and that, therefore, while it stimulates the brain less, it has greater efficacy in increasing and enriching the blood, and in promoting nutrition. The practical application of this fact, sup- posing it to be a fact, will be seen directly. In relation to the several wines, the lighter kinds are more diuretic, and more disposed to be laxative than the stronger; and the astrin- gent wines more apt to produce costiveness than those not astrin- gent, unless the tannic acid is associated with enough saline matter to counteract its effects. Thus, port wine, which is highly astringent, and not very acidulous, not unfrequently disposes to constipation, while claret, though it also contains tannic acid, is yet rather laxa- tive than otherwise, probably through its bitartrate of potassa. Burgundy has been said also to be disposed to constipate in consequence of its astringency; but I have not found it so in prac- tice. The sparkling wines are thought to be much more rapidly and powerfully intoxicating than the still wines of the same strength; carbonic acid being supposed to favour their influence upon the brain. But I am inclined to think that this difference has been over-estimated. Nothing is more true than that persons drinking champagne are vastly more apt to become excited than by the still wines of much greater strength; but, with careful observation, I think it will be found that this results much more from the quan- tity taken, and the rapidity with which, from its agreeable flavour, it is usually taken, than from the mere difference in quality. Yet I do not altogether deny that the sparkling wines are rendered more rapidly intoxicating by their carbonic acid. They are at first also more acceptable to the stomach; but, in their secondary operation, are very apt to discompose it, and to occasion headache, nausea, and other unpleasant sensations. This may in part be owing to the saccharine matter which accompanies them, and has a CHAP. I.J CEREBRAL STIMULANTS.—WINES. 677 tendency to produce acidity of stomach; an objection to which sweet wines in general are liable. Wines used habitually in excess are much more apt to produce gout, and uric acid lithiasis, than either delirium tremens, or chronic disease of the liver. The reason probably is, that, by stimulating less, and favouring the blood-making processes, either directly or indirectly, more than ardent spirit, they are more apt to induce the plethoric condition of the blood which favours these affections. Their injurious influence is very much diminished by vigorous exercise; and the resolute wine-drinker, if he have any regard for his health, should sedulously avoid a sedentary life. Therapeutic Application. Wines may be employed for all the purposes for which alcoholic stimulation is demanded, and, as a general rule, are greatly preferable to ardent spirits. Almost the only exceptions to this rule are in the cases of the habitually in- temperate, and in those instances of great prostration, or extraor- dinary insensibility to the effects of alcohol, in which the system refuses to respond to the influence of wine. For some local pur- poses, also, the distilled liquors are preferable. But few practical observations, therefore, will be required; and these few will refer rather to the choice of particular wines than to their general use. When the habitual use of alcoholic drinks, in moderation, may be deemed advisable, as in those disposed to scrofula and phthisis, or labouring under these diseases without the complication of acute inflammation, the lighter wines should always be preferred to the stronger. Sauterne, claret, hock, or burgundy should be given preferably to madeira, sherry, or port. The object is here not cerebral stimulation, but a sustained tonic effect, the promotion of the digestive, assimilative, and nutritive functions, and perhaps more than all, that condition of the blood which experience has shown to be unfavourable to tuberculous formation. I am not now treating of the relative value of wines and malt liquors, but of the choice between the different kinds of wine. In relation to the state of the stomach, when that is disposed to be disordered, I think burgundy will generally be found to agree with it better than the clarets or hocks, though probably somewhat more stimu- lant to the brain. When, on the contrary, wine is required for a temporary pur- pose, and for its stimulant influence solely, the stronger wines' should generally be preferred. They answer the indication more effectively, and are less apt to produce acescency and otherwise to 678 GENERAL STIMULANTS. [part II. disorder the stomach. They are usually also better adapted to cases attended with dyspepsia. To fulfil the indications offered in the low or typhoid states of fever, and in general prostration from any cause, the stronger wines should be chosen. 3fadeira or sherry is, in general, preferable to the other stronger wines, and especially the latter, as being more free from acid. Whenever, however, there is a coincident indication for astringency, as when diarrhoea exists, or hemorrhage, especially from the bowels, port wine should be preferably employed. When the stomach, in cases requiring stimulation, is very irritable, and rejects the other wines, cham- pagne, or sparkling moselle, will sometimes answer an admirable purpose; but those varieties should be selected which are most free from saccharine matter, and in which the fermentation has been most nearly completed. The factitious champagnes might, under these circumstances, prove noxious, rather than remedial. When wines are required in cases presenting a joint indication for a sti- mulant and diuretic, as sometimes happens in dropsy, the lighter acidulous wines should be employed; and the same remark is appli- cable to enfeebled states of the system, with copious phosphatic deposition in the urine. Wine whey is an excellent preparation for use in all low fevers, in the debility which often attends the advanced stages of acute diseases, when the violence of the special disease is past, and in the same condition occurring at the close of incurable affections. Whenever stimulation is required in these cases, it is best, as a general rule, to begin with wine-whey, and advance to pure wine only after that preparation may prove inadequate to the demands of the case. It should be prepared by boiling a pint of milk, add- ing half a pint of wine while it is still boiling hot, and stirring until the mixture is complete. After coagulation, the whey should be strained off, and given generally without sweetening. Madeira or sherry should be employed in its preparation. The proportion of wine mentioned is requisite, in order to insure perfect coagula- tion. If desirable, the whey may afterwards be diluted with solu- lution of gum, or one of the amylaceous matters, or by rennet whey. It has the advantage over diluted wine of being more nutritious, and often more acceptable to the patient. The dose of wine-whey is, ordinarily, in low febrile cases, a wine- glassful every two hours; but it must be diminished or increased, both in frequency and amount, according to the effects desired, and those produced. The stronger wines may be given in doses vary- CHAP. I.] CEREBRAL STIMULANTS.—MALT LIQUOR. 679 ing from a tablespoonful to a wineglassful, at the same interval. In chronic or protracted cases, the dose should, in general, be less frequently repeated. When the lighter wines are used, the quan- tity must be regulated altogether by effects; but one strict rule should be'adhered to; namely, never to allow their influence to proceed so far as to disturb the sound operation of the brain. To become intoxicated, or even to approach intoxication, would be quite unjustifiable in patients using these wines habitually for their health. 2. MALT LIQUOR.—CEREVISIA. This is prepared, by means of the vinous fermentation, from an infusion of malt, which is made from barley, by exposing it to a moderately elevated temperature with moisture, so as to promote germination, and then drying the germinated grain by artificial heat. In the germination of barley, there is first generated a nitro- genous principle called diastase, through the agency of which the starch of the grain is converted into grape sugar. This is extracted by infusion, and along with it a matter which is capable of acting as a ferment. Hops are added to the infusion, and the liquid is exposed to a temperature favourable to vinous fermentation. The result is malt liquor, which differs according to the quantity and character of the malt employed. Three prominent varieties are recognized; namely, table beer, ale, and porter. In the drying of the malt, it is exposed to different temperatures from 100° Fahr. upward. When dried at the lowest temperature, it undergoes little change of colour, and is called pale malt; at a greater heat, but insufficient to decom- pose it, the colour is changed to amber brown ; and, at a high heat, it is roasted and charred, losing its characteristic properties to a considerable extent. In the preparation of ale, the pale malt is used; in that of beer, the brownish; and in that of porter, the same with the addition of some of the roasted malt to deepen its colour. Table beer, in which but a small proportion of malt is used, con- tains insufficient alcohol to preserve it, and is therefore apt to spoil in hot weather. It is unfit for medical use, and may be left out of consideration. Composition. Malt liquor, besides alcohol and water, contains sugar, gummy and extractive matters, and gluten, derived from the malt; a bitter principle and volatile oil, from the hops; and lactic and carbonic acids, the product of the chemical change in fermen- 680 GENERAL STIMULANTS. [PART II. tation. There are also various salts of little or no importance. The bitterness of the liquor is owing to the bitter principle of the hops, and its aroma in part to their volatile principle. Ale owes its light colour to the paleness of the malt. Accord- ing to the analysis of Brande, it contains on an average 6.87 per cent, by measure of alcohol of the sp. gr. 0.825, and of course has somewhat more than one-half the average strength of the light wines. Porter is very dark-coloured, in consequence of the burnt malt used along with dried malt in its preparation. For the same reason it is somewhat weaker when prepared from an equal amount of malt; for the portion burnt has lost its virtues. The alcoholic strength of London porter, as given in Brande's table, is 4.20 per cent., of brown stout 6.80 per cent. The carbonic acid in malt liquors is owing to the incompleteness of the fermentation when they are bottled. In consequence of having a smaller proportion of alcohol than the wines, they more readily become sour on exposure, and are often unfit for use. Effects on the System. So far as their alcohol is concerned, these liquors do not differ from the wines in their effects; and the re- marks made upon the modified influence of the alcohol as existing in the latter, are equally applicable to the former. But the malt liquors are richer in nutritive matters, leaving the alcohol out of consideration, than the wines, and have, in addition, the properties of the hops employed, which are actively tonic, and exercise a decided narcotic influence on the brain, producing a tendency to drowsiness. Hence ale and porter, while they are capable of sti- mulating to intoxication, are less enlivening and exhilarating than the wines, and more tonic and soporific. When perfectly sound, they usually agree well with the stomach; but in the dyspeptic, though the hops they contain act favourably on the digestion, they are not- unfrequently injurious by their acescent tendency. Therapeutic Application. The malt liquors may be used for the same general purposes as the wines; but they cannot compete with them in any case in which the stomach is in a delicate state; and are therefore generally unsuited to acute diseases. In the conva- lescence, however, from these affections, when the stomach is no longer diseased, they are often preferable to the wines as less stimulating and more tonic. For the same reason they are better suited to chronic cases in which the indication is for the habitual employment of supporting CHAP. I.] CEREBRAL STIMULANTS.—ARDENT SPIRITS. 681 measures, as in scrofulous or tuberculous affections. Persons dis- posed to these complaints, or labouring under them, may often ad- vantageously make use of ale or porter, to the amount of a pint or more in twenty-four hours. They are also an excellent substitute for the stronger alcoholic drinks, when it is desired gradually to correct habits of intoxica- tion ; the hops they contain acting usefully towards obviating the wakefulness and nervous disorder, so apt to ensue upon a material diminution of the stimulus. But it must be understood that the porter or ale also must be ultimately withdrawn. In the treatment of delirium tremens, it is often sufficient to allow the patient the free use of malt liquors in connexion with the opium used; or, if ardent spirit is employed, it should as soon as possible give way to these milder stimulants. b. Distilled Liquors. Under this head may be included all that is necessary to be said both of the ardent spirits, and the stronger preparation called in the U. S. Pharmacopoeia simply alcohol, and by the British Colleges rectified spirit. 1. ARDENT SPIRITS.— Proof Spirit. These are prepared by a simple distillation of the fermented liquors, and receive names according to the particular liquors from which they may be severally derived. Thus, the spirit distilled from wine is called brandy; that from a fermented solution of sugar, rum ; and that from the fermented infusion of malted grains, particularly rye, is called ivhiskey, or, if flavoured with oil of juni- per, gin. There is little difference between these, in relation to the effects of the alcohol; but one is sometimes preferred for its flavour, or in consequence of some peculiarity of effect from peculiar im- pregnation, as in the instance of gin, which is more diuretic than the others from its oil of juniper. Medically, therefore, it is of little importance that the different forms of ardent spirit are now fre- quently prepared artificially, by first obtaining rectified spirit, then freeing this from the fused oil by passing it through charcoal, and finally reducing it with water to the requisite strength, and giving the desired colour and flavour by suitable additions. Brandy (Spiritus Vini Gallici, U.S.) is recognized in the U.S. and London Pharmacopoeias as officinal. It varies somewhat with 682 GENERAL STIMULANTS. [PART II. the character of the wine from which it is procured. French bran- dies have the highest reputation, and of these the cogniac and armagnac. Brandy, according to Brande, contains 53.39 per cent. by measure of alcohol of 0.825. It has, therefore, somewhat more than twice the strength of madeira and sherry wines, four times that of the light wines, and from eight to twelve times that of ale and porter. Besides alcohol and water, it contains a little volatile oil, colouring matter, cenanthic and acetic ethers, and a minute pro- portion of tannic acid. Its colour is sometimes deepened by the addition of burnt sugar. Effects on the System. These have been already fully described in the general observations on alcohol. The consequences of their abuse are so fearful, that they should be banished altogether from customary use. Less apt than wines and malt liquors to cause gout, they much more frequently give rise to delirium tremens and meningeal inflammation, and, in their ultimate operation, if the many dangers by the way be escaped, to diseased liver, degenera- tion of various organs, and finally death with universal dropsy. Therapeutic Application. The distilled liquors should never be employed, when the fermented will answer equally well, in conse- quence of the terrific dangers of their abuse. But occasionally they are necessary to the salvation of life. It is sometimes, in low fevers, advisable to introduce stimulus into the stomach in as concentrated a state as the organ will bear, when considerable quantities both of it and of nourishment are required. Thus, it is better, in such in- stances, to give a tablespoonful of brandy with two of milk, than an equivalent quantity of wine and other liquid aliment. The sto- mach receives better, and subsequently manages better, the material in smaller bulk. Again, cases now and then occur, in which the prostration and insensibility are so great that wine is powerless. Brandy or some equivalent liquor is then our only resource. In the low diseases of drunkards, it is necessary to stimulate with ardent spirit; as wine will have little more effect than water. In delirium tremens, it is not unfrequently necessary to use it to prevent death from sheer prostration. There are certain diseases, too, in which there is an extraordinary insusceptibility to alcoholic liquids; and enormous quantities are requisite to act decidedly on the sys- tem. This is often the case in tetanus, and it is said to be so in the state of system resulting from the bites of venomous snakes. Some- times in prolonged syncope, and in asphyxia, it may be advisable to administer brandy, either by the mouth or the rectum. CHAP. I.J CEREBRAL STIMULANTS.—ARDENT SPIRITS. 633 In dyspeptic affections a little brandy often yields great relief to patients unaccustomed to its use. A teaspoonful or two will gene- rally relieve the peculiar and distressing epigastric uneasiness of that complaint, and, taken at meal times, will facilitate the solution and digestion of the food. The relief, indeed, is so great, that the patient often feels an irresistible inclination to repeat the remedy; and as, from time to time, by the gradual diminution of the excita- bility of the organ, it becomes necessary to increase the dose in order to obtain the same relief as at first, the patient is led on, almost without a suspicion on his own part, into confirmed habits of intemperance. Many a drunkard has probably owed a miserable death to the inconsiderate recommendation of a little brandy in dyspepsia. To obtain the same advantages with less danger, the bitter tinctures, as those of gentian, quassia, and columbo, may be prescribed, and so associated with other medicines, that the patient may not be able to trace his relief to the spirit. The aromatic spi- rit of ammonia, which is only alcohol holding a little carbonate of ammonia in solution, with aromatic oils, may also be substituted. In no case should the remedy be continued uninterruptedly and indefinitely. Brandy sometimes affords quick relief in gastrodynia, pure gastric spasm, and nervous colic. It is also sometimes useful in correcting the effects of limestone water, when no other drink can be obtained, and when this pro- duces nausea and diarrhoea, as it is very apt to do with persons un- accustomed to it. In travelling in limestone regions, I have often found advantage from adding a single teaspoonful or two to a tum- bler of the water. It covers the nauseous taste, and often corrects the purging tendency. Brandy is much and very usefully employed externally as a stimulant and rubefacient. In all low states of the system, with a cool surface, it may be employed in the way of friction, and as hot as the skin will tolerate. Under the same circumstances, it may be rendered more efficient by admixture with rubefacient medicines, as cayenne pepper, and, when the case is complicated by spasmodic or other nervous disorder, with garlic. It may be used also, in the form of hot fomentation, to relieve internal abdominal pains, when associated with a depressed state of system. For the prevention of bed-sores, and excoriations from other causes, it is often applied with benefit by lotion to the skin; and Dr. Christison recommends particularly a mixture of brandy and the white of egg, to be ap- 684 GENERAL STIMULANTS. [PART II. plied to the part by a brush ; the application to be repeated as each layer dries, until a coating of sufficient thickness is formed. Brandy maybe given diluted with water, or mixed with milk, in the form of milk punch. The latter is an excellent remedy when there is a conjoint indication, as often happens, for stimulation and nutrition. The successive introduction of the milk in small por- tions, with stimulus enough to promote its digestion, has a very happy effect. For use in low fevers, one part of brandy should be added to two or three of milk; and the preparation may be given in wineglassful doses. Under the name of Mistura Spiritus Yini Gallici, or Brandy 31ixture, the London College directs a preparation consisting of brandy and cinnamon water, each, four fluidounces, the yolks of two eggs, refined sugar half an ounce, and oil of cinnamon two minims, mixed together. Two or three tablespoonfuls may be used for a dose in low fevers, when brandy is indicated. 2. ALCOHOL. U. S.—Spiritus Rectificatus. Lond.—Recti- fied Spirit. By the term alcohol, as before stated, the U. S. Pharmacopoeia recognizes a spirit of the sp. gr. 0.835, prepared by distilling brandy or other form of ardent spirit. It is. never used internally; but externally it may be employed as an evaporating lotion, being applied on a single thickness of linen, so as to admit of free evapo- ration. By its chemical influence in the abstraction of water, it is thought to produce the shrinking of blood-vessels; and, when brought into contact with the blood, causes its coagulation. Hence it has been recommended for the suppression of hemorrhage by direct application to the bleeding vessels. But its chief value is as a chemical and pharmaceutical agent. From its solvent and pre- servative properties, it answers an excellent purpose for preparing tinctures of substances wholly insoluble in water. (See first part of this work, page 64.) Diluted Alcohol (Alcohol Dilutum, U.S.) is prepared by mixing equal measures of officinal alcohol and water. It is not quite so strong in alcohol as the proof spirit of the British Colleges, or as ordinary full proof brandy. It is used chiefly in the preparation of tinctures from substances containing active principles soluble both in water and alcohol. (See Ibid) CHAP. I.] CEREBRAL STIMULANTS.—ETHER. 685 II. ETHER. U.S., Lond. ETHER SULPHURICUS. Ed., Dub.—Sulphuric Ether. Ether is obtained by the distillation of a mixture of alcohol and sulphuric acid; but, as thus procured, it is impure, containing, besides the pure ether, sulphurous acid, ethereal oil, alcohol, and water. From these it is purified by redistillation from a strong solution of potassa. Ether consists of the same ingredients as alcohol less one equi- valent of hydrogen and one of oxygen, in other words, less one equivalent of water. This equivalent of water is abstracted by the sulphuric acid. Chemists differ as to the precise mode in which the end is attained; but the result is as stated. At the same time, a reaction takes place, by which a very small portion of the sul- phuric acid is converted into sulphurous acid, and of the alcohol into heavy oil of wine, or ethereal oil. Hence the presence of these impurities in the product of the first distillation. In the second distillation, the potassa neutralizes the sulphurous acid, and abstracts any water that may be present, the alcohol is retained by the water, and the ethereal oil is either decomposed or remains behind. The ether obtained, however, still contains a little alcohol, from which it is not necessary that it should be entirely freed for medical pur- poses. Properties. Ether is a colourless liquid, having, when quite pure, about the sp. gr. 0.712, but, as directed in our officinal code, 0.750, and by the British Colleges from 0.735 to 0.750. Its odour is strong, penetrating, and rather grateful; its taste, hot and pun- gent, yet somewhat cooling also. It is extremely volatile, rapidly escaping when exposed to the air, and producing cold during its vaporization. Its boiling point is extremely low, scarcely exceed- ing the heat of one of our hot summer days. It is also highly inflammable; and its vapour forms an explosive mixture with atmospheric air. Caution should, therefore, be observed, not to allow the too near approach of flame when it is used. The affinity between it and water is not strong. Nine parts by measure of water will dissolve one part of ether; and, conversely, ether will take up about the same proportion of water. If mixed in other proportions, the two liquids will separate, the ether floating on the surface. It unites in all proportions with alcohol. On exposure to the air, it undergoes gradual decomposition, producing acetic 686 GENERAL STIMULANTS. [PART II. acid and water. It should evaporate wholly on exposure, and should not become milky on being mixed with water. Composition. All agree that ether consists of 4 eqs. of carbon, 5 of hydrogen, and 1 of oxygen (C4HsO); but, as to the precise mode in which its constituents are combined, different views have been entertained. According to the one most generally received, it is simply the oxide of ethyl, consisting of 1 eq. of ethyl (C4HJ and 1 of oxygen. 1. Effects on the System. Ether is a universal and highly diffusible stimulant, closely resembling alcohol in its action, but much more speedy and less durable. When I say that is universal, I do not mean that it absolutely stimulates every function at the same time; but only that there is no function which it is not capable of stimulating. Its operation is very evanescent. Applied externally, and confined so that it cannot evaporate, it speedily produces burning pain with redness, and, if the application be continued, sometimes vesication. When taken, internally, it occasions much irritation in the mouth and fauces, with almost suffocating sensations, arising in part from its vaporization; so that many persons find great difficulty in swallowing it. It leaves a burning sensation in the oesophagus, and produces the same feeling in the stomach. By its rapid evaporation, it fills the stomach with its vapour, which is often thrown up by the forcible contractions excited. Its influence is very quickly diffused over the system, causing an increased frequency of pulse, and excitement of the nervous system, especially of the brain, attended with a sense of fulness of the head and feelings of exhilaration. They are fol- lowed by drowsiness, and after a short time not unfrequently with perspiration, after which the effects pass off with more or less depression. The effects of very large doses in man are not well understood, because, in consequence of the difficulty of swallowing it, the instances are very few in which there has been an oppor- tunity of observing its action when thus administered. It is said, however, when taken excessively, to produce intoxication, nausea, giddiness, and stupefaction. That, if swallowed in very lar°e quantities, it is capable of producing fatal narcotic effects, unless rejected from the stomach, is fairly inferrible from experiments which have been made upon the lower animals, and by its well known action when inhaled. Orfila states that a dog, in the stomach of which half an ounce of it was introduced, and the CHAP. I.J CEREBRAL STIMULANTS.—ETHER. 687 oesophagous then tied, was rendered comatose, and died in three hours, presenting marks of inflammation of the stomach after death; and from four to six drachms of it proved sufficient, in the experiments of Brodie, to plunge a horse into deep lethargy. (3Ierat et De Lens, iii. 166.) Inhalation. Though long known to be capable of acting power- fully by inhalation, it is only of late that its effects, when given in this way, have been carefully studied. More than thirty years ago, I remember well that it was quite a fashion among the boys in Philadelphia to inhale ether for its intoxicating effect, which re- sembled that produced by nitrous oxide. A teaspoonful or more was introduced into a large bladder, with a mouth-piece attached, through which the vapour was inhaled. One case of death with coma occurred, and several other cases of an alarming character, and the practice soon ceased. The first effect is ordinarily irrita- tion of throat with coughing, which soon subsides, and is followed by marks of general stimulation; the respiration being quickened and more audible, the pulse usually increased in frequency, and the face more or less flushed. An agreeable exhilaration, amounting to intoxication, is now generally felt, which is sometimes quiet; but in other cases is attended with various muscular movements, occa- sionally amounting to convulsions. In a period of from two to five minutes, sometimes, however, prolonged to ten or even fifteen, sleepiness is produced, the eyes are closed, the voluntary muscles become relaxed, and the patient falls back apparently quite unconscious. The mind, however, is not wholly inactive; for the individual often afterwards speaks of curious dreams or visions, which seem to him to have been of long duration, and which, though occasionally disagreeable or even fearful, are for the most part very much the reverse; and, altogether, the effects are so pleasing that a repetition of the process is frequently desired. But, with an increased influence of the vapour, a deep comatose sleep is induced, often attended with snoring, in which there is an entire loss of consciousness. When the period of stupefaction commences, the pulse becomes slower, the skin relaxed, and the face palish or of a venous hue, which, as the stupor increases, may deepen into a dark suffusion. If the agent is omitted as soon as the stupor appears, this state subsides as quickly as it was pro- duced; and, though there may sometimes remain a momentary confusion of mind, and slight languor of body for a short time, occasionally, perhaps a little headache or nausea, the subject of the 688 GENERAL STIMULANTS. [PART II. process soon returns to his previous condition, as if nothing had happened. In the period of excitement, it occasionally happens that the sexual function becomes the special seat of stimulation; and the delusions of the patient, or his dreams, may take a cor- responding direction, and, even after the perfect return of conscious- ness, may remain impressed on the mind with the vividness of reality. This is a very important medico-legal fact. Should the inhalation be persevered in, there is risk of a suspension of the function of the respiratory centre in the medulla oblongata, and of death from asphyxia. Some instances of this kind are on record; but they are extremely rare. With ordinary care, and in an ordi- nary state of system, death can scarcely result from this cause under the influence of ether. Indeed, I believe that the ethereal intoxication is much less dangerous, even than the alcoholic. But an undue perseverance in its use, in cases which resist the stupefy- ing influence of the ether, is sometimes followed by serious nervous disorders, and injurious if not dangerous sanguineous determina- tions, which may last for a considerable time, and should serve as a warning to the practitioner not to urge the measure, in all in- stances, and at all hazards, to entire stupefaction. There are two points, in connexion with the influence of ethereal inhalation, which, though strictly pathological, and, therefore, not belonging exactly to the physiological effects of ether, may be most conveniently considered in this place, in order that the whole series of facts in relation to the influence of the process may be presented in one view. I allude to the anaesthetic influence of etherization by the lungs, and that which it exercises in relaxing spasm. That ether is capable, when inhaled, of abolishing sensibility, is an obvious corollary to its stupefying power. The sense of touch as well as every other special sense, is, in the very nature of the case, suspended in coma. This, then, is no new discovery. But it was not so obvious that the general sensibility might be diminished, and even quite suspended, while consciousness, and, to a consider- able degree, the special senses, remained unaffected. This, however, is a most important fact in relation to etherization. Under the influence of this agent, pain is often abolished if existing and averted when it would otherwise have been produced, before the occurrence of any degree of stupor, or of any considerable anes- thesia of hearing, sight, &c. The woman in childbed ceases to suffer from her labour pains, though still conscious; the patient under the knife of the surgeon sometimes scarcely suffers, thou<>h CHAP. I.] CEREBRAL STIMULANTS.—ETHER. 689 he may follow every step of the operation; and the pain of violent spasm is subdued as by a charm, without the least degree of appa- rent stupefaction. An eminent medical gentleman once assured me that, while labouring under the most exquisite pain from spasm of the bladder, he had inhaled ether, with the effect of completely re- lieving the pain, though he retained his consciousness unimpaired, and even took pleasure in noting the return of each contraction of the bladder, of which he was distinctly sensible, though it was quite painless. The other point referred to was the efficacy of ether when in- haled in relaxing spasm. That it should have this power, in refer- ence to the voluntary muscles, so far as the cerebral centres are concerned, was almost inferrible from the property it evinces of re- laxing these muscles, when the system is brought completely under its influence. But the muscles of organic life usually remain un- affected, at least not materially affected, in the stupefaction, unless carried to the last degree short of absolute death. Respiration goes on; the peristaltic movements, so far as is known, are not impaired; the sphincters generally act as in health; and the uterine contractions during labour are undiminished in force, though no longer painful. But over the morbid contractions of these muscles, over their spas- modic conditions, for example, etherization has great control. It is capable not only of relieving the pain of these spasms, but, in a somewhat higher degree of its action, of relaxing the spasms them- selves. Though, as before stated, the spasm will sometimes continue after the pain has ceased, yet the two often cease together, and, when this is not the case, the muscular relaxation generally soon follows the anaesthetic effect. This only proves that the nervous centres of pain, and those of the involuntary movements, are not the same, and that the former usually come under the influence of the ano- dyne before the latter. The pains of tetanus, for instance, cease before the muscular spasms, but these also will often yield, tempo- rarily at least, to ether. In their tetanic movements, the muscles cease to be voluntary muscles; and are under the control of the spinal centres. From all this, it may be physiologically deduced that, in etherization, the nervous centres of organic life, those, namely, of the spinal marrow, and the sympathetic ganglia, either come last under the power of the stupefying agent, or, to speak more pre- cisely, are the least susceptible to its action. Another valuable therapeutic agency of ether by inhalation is the relaxation it often produces in the mucous tissues, with an in- VOL. I.—14 690 GENERAL STIMULANTS. [PART II. crease of the mucous discharge. This has been noticed in the mucous membrane of the generative organs of women in childbed, and in the bronchial tubes, and may possibly extend to the others; as it is probably rather through the organic nervous centres that it acts, than directly on the tissue affected. Judging from the effects above detailed, we may pretty certainly conclude that the cerebral centres of general sensation, and those of thought and emotion, are most susceptible to the influence of ethereal inhalation, that next in order are those of special sensation and the will, and that lower still in the scale of susceptibility are the centres of organic force, of which the respiratory centre in the medulla oblongata is the lowest. Perhaps there is no powerful remedy to which the system be- comes more speedily accustomed than this; so that, to sustain a given effect for a long time, it must be administered on successive occasions, in rapidly increasing quantities; and the amounts which have been given, in some cases, without material injury, are almost astounding, considering the powerful effect produced at first by a small quantity, and the rapidity with which the larger amount has been reached. Even while the ether, which may have caused all the characteristic phenomena, still remains in great measure in the system, it has quite lost its effects on the cerebral centres; for the breath continues to smell of it long after all the phenomena of its action have disappeared. The previous habit of using alcohol or opium also greatly lessens the susceptibility to the impression of ether, showing a close resemblance between these three cerebral stimulants in their mode of action. The only morbid appearances noticed after death from ether are those incident to asphyxia; namely, darkness of the blood, fulness of the right cavities of the heart, and congestion of the brain, lungs, &c. In poisoning from ethereal inhalation, the shock of cold water upon the face, head, or shoulders, and the introduction of pure air into the lungs by artificial respiration, are probably the most effi- cient measures. When the prostration is great, the ammoniacal stimulants may be resorted to by the mouth or rectum, and ex- ternal stimulation by rubefacients should not be neglected. 2. 3Iode of Operating. Ether probably operates as a stimulant by a direct influence on the vital susceptibilities of the tissue, without any chemical reac- tion. One proof of this is the vast amount which may be taken CHAP. I.] CEREBRAL STIMULANTS.—ETHER. 691 with impunity after the system has become accustomed to it, by a gradual increase of the dose. The case of a chemist is recorded, who took a pint of ether daily. (3Ierat and De Lens, iii. 166.) When large quantities have been introduced by inhalation, the observable effects often cease long before the evidence afforded by the breath that a portion still remains in the system. This could scarcely be, if the effect were chemical, whether on the solid tissues, or the blood. The higher carbonization of the blood has been supposed to have something to do with the effects of ether. This, however, is probably a mere respiratory result. That the first stimulant impression on the circulation, respiration, and cere- bral functions, may depend on the propagation of the local influence, through the nerves, to the nervous centres of those functions, is not impossible; and the rapidity with which the effect is produced might be advanced as an argument in favour of this view; but experi- ments have satisfactorily shown, that the round of the circulation is accomplished in time to permit the operation by this route within the actual period; so that the view referred to cannot by any means be considered as demonstrated. The probability is that most of the effects of ether are due to its absorption into the circulation, and direct action upon the nervous centres, the functions of which are first increased by the stimulation, then deranged, and afterwards diminished or temporarily suppressed, under the general law of irritation. I have already referred to the relative degree in which the centres are susceptible, deduced from the period at which they respectively come under its influence. .That ether is absorbed, is almost too obvious to require proof. The odour of the breath, which always smells strongly of ether, in whatever way adminis- tered, and sometimes continues to smell of it, when large quantities have been administered, for twenty-four hours or more after it was given, is a sufficient evidence; not to allude to the fact, that its odour has been noticed in the ventricles of the brain, when death has from any cause followed soon after its exhibition. The great difference in the effects of the medicine, as administered by the stomach and the lungs, is probably owing to its much slower ab- sorption from the former organ. Its powerful direct stimulant action, in the liquid state, upon the stomach, producing an active congestion of the blood-vessels, may be one reason of its relatively- slower absorption through this organ than the lungs, when com- pared with some other volatile medicines,such as hydrocyanic acid. 692 GENERAL STIMULANTS. [PART II. 3. Therapeutic Application. The use of ether as a medicine dates from an early period in - modern history. I shall treat of its employment first as adminis- tered by the stomach, secondly by inhalation, and lastly as an ex- ternal application. 1. Use by the Stomach. In the course of low fevers, especially of malignant typhus, in cases of delirium tremens, and in other diseases of debility, sudden sinking spells occasionally take place, approaching asphyxia in character, which require prompt and energetic stimu- lation of the nervous centres. In such cases, ether is strongly indicated, and may be given in connexion with carbonate of am- monia, or the aromatic spirit of ammonia, in order as speedily as possible to restore action, which may then be sustained, if neces- sary, by the more permanent stimulants and tonics. In the poison- ing by mushrooms it has been recommended, probably upon similar grounds. A similar condition sometimes occurs in angina pectoris, and de- mands instant interference to prevent death. Here also ether is highly valuable in connexion with other medicines. In the seem- ingly spasmodic pains of that affection, in which it would appear that sudden cramp had seized on some portion of the cardiac muscles, and during which the whole system is extremely prostrate, ether and laudanum are the internal remedies mainly to be relied on. Such a condition occasionally takes place in nervous gout, constitut- ing probably the most dangerous example of that disease. ^The prompt and powerful stimulation with which ether operates upon the nerves, adapts it admirably to those spasmodic affections, unattended with acute inflammation, which are characterized by o-reat depression of the circulation, coolness and dampness of the surface, and apparent general prostration. Hence its usefulness in violent spasms of the stomach, and of the bowels, attended with feeble pulse, cold skin, &c, in which it may often be advantageously combined with laudanum or other liquid preparation of opium, and given in teaspoonful doses. The same remark is applicable to spasms of the ureters and of the gall ducts, occasioned by the passage respectively of urinary or biliary calculi. In the latter affection it has been supposed to be peculiarly useful, when combined with the oil of turpentine. Upon the same grounds, too, it is indicated in the approaching collapse of cholera attended with internal and external cramps. Its powerful stimulation of the nervous centres, in these CHAP. I.] CEREBRAL STIMULANTS.—ETHER. 693 cases, may be supposed to rouse them from the torpor in which they appear to be thrown by the concentration of the nervous energy in the suffering organ, and thus to act revulsively in the relief of the spasm. In the paroxysm of spasmodic asthma it has sometimes been used beneficially, though less efficient in this disease than some other remedies. In small doses, ether acts purely as a nervous stimulant, and is „ much employed for the relief of various mild nervous affections. For this purpose it is usually prescribed in the form of compound spirit of ether, or Hoffmann's anodyne, under which this highly useful application of the remedy will be more particularly noticed. Ether has also been recommended in sea-sickness, in which a tea- spoonful of it may be given in a glass of sherry or Madeira wine. M. Bourdier has employed it with success for the expulsion of the tapeworm, giving it both by the stomach and rectum with an infu- sion of male fern, and following it in an hour by a dose of castor oil. Ether is contraindicated in all cases of sthenic febrile action and acute inflammation, especially of the stomach and brain. Administration. The dose of ether is from half a fluidrachm to two fluidrachms, which, if a given effect is to be sustained, should be repeated at intervals of half an hour, or at most one hour, as the effect rapidly passes off. It may be given in one or two wine- glassfuls of sweetened water, well mixed at the moment of adminis- tration, and taken cold. A useful method of dissolving it in water for exhibition, suggested originally, I believe, by the late Dr. Jo- seph Hartshorne of Philadelphia, is to rub it up with spermaceti, two grains being used to each fluidrachm, then to rub this mixture well with water, and to strain. As water will take up about one- ninth of its bulk of ether, the dose ought to be readily dissolved in a wineglassful of that fluid. In France, a syrup of ether is pre- pared by putting one part of the ether and sixteen of syrup in a flask, with a tubulure at the lower part on the side, fitted with a cork, through which passes a short tube, the outer extremity of which is closed with a small cork. The mixture is shaken occa- sionally for four or five days, and then allowed to stand. The syrup, at first turbid, afterwards becomes clear, with a portion of the ether floating on the top undissolved. It is drawn off through the tubulure when wanted for use, and a fluidounce may be given at a dose. (Trousseau and Pidoux, 4e ed. ii. 260.) 2. Use by Inhalation. Ether has long been used in this method. The late Dr. P. S. Physick was much in the habit of employing it 694 GENERAL STIMULANTS. [PART II. in pulmonary affections, and invented a small extemporaneous in- haler for the purpose. It is only as an anaesthetic agent, that any claim to discovery has recently been advanced in reference to its exhibition by the lungs. The way to this discovery had been gradually opened by attempts to effect the same object by other agents; but the proper credit of it must be divided between two American physicians, Drs. C. T. Jackson and W. T. G. Morton, of Boston, the former of whom appears to have conceived the idea of using ether for this purpose, but the latter first carried the concep- tion into practical effect. It was in October, 1846, that the atten- tion of the profession was called to this highly important disco- very. The process was originally applied by Dr. Morton to the relief of pain in dentistry. He made known his success to Dr. John C. Warren, who was the first to test its efficacy in an impor- tant surgical operation. Though first used to prevent pain in surgical operations, this mode of administering ether may be resorted to in a wide circle of spasmodic, convulsive, and neuralgic affections. Of the painful spasmodic diseases, it may be used advantageously in spasm of the stomach, bowels, bladder, ureters, gall-ducts, and diaphragm, in violent external cramps as those of cholera, and in tetanus. In the atrocious affection last named, it will generally afford more or less relief, and sometimes contributes to the cure. In the poisoning from strychnia it is also indicated. In infantile convulsions from spasm of the bowels, it should be resorted to if other measures fail. The measure has been recommended in chorea, pertussis, and the convulsive affections of hysteria; but, as it will seldom cure these complaints, but only afford temporary relief, there may be danger of inducing a bad habit of indulgence, without corresponding benefit. I have used it with apparent advantage in peculiarly vio- lent or obstinate hysterical convulsions, but, as a general rule, it would be more prudent to dispense with it. For the relaxation of spasm, it may also be employed in dysphagia from spasm of the oeso- phagus and in strangulated hernia. In the paroxysm of spasmodic asthma, when not complicated with acute bronchitis, it may be tried with good hope of benefit; and in the dyspnoea dependent on chronic bronchitis it is doubly useful, if carefully managed, both by relieving the distressing sensation, and favouring mucous secretion. In these cases the remedy should not be pushed to positive insensibility. Neuralgia, dysmenorrhoea, angina pectoris, and severe or obstinate CHAP. I.] CEREBRAL STIMULANTS.—ETHER. 695 nervous headaches, are complaints in which the remedy is indicated for its anaesthetic virtues. In delirium tremens it sometimes powerfully co-operates with opium in producing sleep, and may be tried in obstinate cases. It has been used also as an antiperiodic in intermittents, and there can scarcely be a doubt, that it would frequently interrupt the paroxysms if applied about the expected period of their approach. It is, however, only in exceptional cases that there can be any occasion for its use. I would recommend that it should be tried in otherwise desperate cases of the pernicious paroxysm of miasmatic fever, when not attended with comatose symptoms. As an Anaesthetic Agent in Surgery. There has been no little controversy about the propriety of using measures to prevent pain in surgery; but the mass of the profession, influenced in some degree, no doubt, by the powerful instincts of our nature, have come to the conclusion that such measures are not only admissible, but very often advisible. ■ The advocates for their use maintain, and, as appears to me, very reasonably, that not only is the suffer- ing of the patient mitigated if not entirely prevented, but that, in severe operations, the measure proves positively salutary, and con- duces to a favourable result by obviating the shock on the nervous system, which is sometimes fatal even during the operation. The objection on the score that nature intended that there should be pain in surgical operations, if it need an answer, is fully met by the simple counter statement, that nature has also presented us with a remedy for the pain. The notion that ether might act injuriously by depraving the blood, and retarding the healing process, has proved as groundless on trial, as it really was in theory. The opium which almost every surgeon formerly gave, left a much more pow- erful impression on the system than the brief action of ether could do; and yet no one supposed that it prevented the healing of wounds. Another objection to the use of ether has been the doubt, whether it really exercised the anaesthetic influence ascribed to it, as patients, by their agitation during the operation, seem to evince some degree of suffering. But when, as has often happened, they have retained sufficient consciousness of what was going on to give an authoritative statement in the case, they have almost uniformly declared that they felt no pain or very little; and the agitation was really ascribable to some dreamy delusion at the time, or merely to reflex action. The only real question, as it seems to me, is whe- ther ether can be given safely; for I doubt whether we have the 696 GENERAL STIMULANTS. [PART II. moral right to relieve pain, at any appreciable risk of life. Rea- soning from our knowledge of the effects of ether, I should say that a full dose of it, sufficient to bring on the state of anaesthesia, is less dangerous than a full soporific dose of opium, supposing in both cases the system to be in health. Etherization is certainly less dangerous than intoxication from alcoholic liquor, as the cir- culation is disturbed less, and the influence is much shorter in duration. Nor has experience contradicted the suggestions of rea- son. The instances are extremely rare, if in fact there are any on record, in which etherization, employed to prevent pain in opera- tions, has proved fatal when the measure was judiciously applied, and the case properly selected. The measure itself is certainly not accountable for the ignorance or carelessness of the person who employs it, and should not be rejected on this score, any more than opium or mercury, or even quinia, should be rejected for the mis- chief they have often done in reckless and unskilful hands. In- deed, considering the number of instances in which ether has been used, even by the most notoriously ignorant persons, it is somewhat surprising that we have heard so little of its mischievous effects. This assuredly cannot be said of chloroform, which our professional brethren in Europe cling to with so much pertinacity, notwithstand- ing that almost every journal comes to us burthened with some fatal case, and it is presumable that many happen which never find their way into the public records. Ether has also been much employed to mitigate or annul the pains of childbirth. Upon the propriety of this application of it, there has been even greater difference of opinion, or rather there has been greater opposition to the measure, than in reference to its use in surgery. Having no practical experience of my own in this branch of our profession, I feel altogether incompetent to give an opinion upon the subject, and allude to it here as a point in the history of etherization which cannot be wholly overlooked. Cautions. Ether should not be recklessly used. In cases of seriously diseased heart, active congestion or acute inflammation of the lungs, brain, or stomach, apoplectic or active hemorrhagic tendencies, or a generally plethoric condition, it should either be avoided altogether, or used only after a careful preparation of the system. It should be carried no further than is sufficient for bringing about the state of anaesthesia, and should be at once with- drawn, should a failing pulse indicate any danger of asphyxia. The utmost care should be taken that sufficient atmospheric air is CHAP. I.] CEREBRAL STIMULANTS.—ETHER. 697 inhaled. The want of this is probably the greatest danger of the process under unskilful management. The patient, by the very state of insensibility into which he is thrown, becomes incapable of giving warning through his feelings of suffocation; and hence the greater necessity for care on the part of the operator. The rule simply is that, while the vapour of ether is admitted into the lungs, it should be accompanied with free access of the atmospheric air. Various instruments have been invented to meet the requisitions of convenience and safety in inhalation; but probably nothing is better, on the whole, than a large piece of sponge, hollowed out on one side so as to admit the nose. This should be applied saturated with the ether, so that the vapour may enter with the air drawn by inspiration into the lungs. In this way a due supply of atmo- spheric air is insured; and the only disadvantage is, that more of the ether is lost by evaporation than when it is confined within an instrument. The patient should breathe preferably tlirough the nostrils. Bags containing ether should never be used. AVhen an instrument is used confining the ether, from one to two fluidounces may be employed; when a sponge, the quantity should be doubled. The operator should keep his fingers on the pulse, and, if he find it failing, should withdraw the ether. Should convulsions supervene, he must also suspend the process. 3. External Use. Ether is used externally for two purposes, for stimulation, and refrigeration. For the first, it is confined to the part to which it is applied; for the second, it is allowed freely to evaporate so as to lower the temperature. In neuralgic pains, nervous headache, and nervous earache, it may be applied near the part affected, by means of a compress satu- rated with it, and then covered by a piece of oiled silk, to prevent evaporation. Sometimes a little of it, applied to the forehead, and held there in the hollow of the hand, will prove rapidly service- able in nervous headache. It very quickly produces burning sen- sation and redness. In earache it is said sometimes to afford in- stantaneous relief, when dropped into the external meatus. Among the external uses of ether may be mentioned its application to the nostrils in cases of faintness, or even positive syncope, in which it will often do good by its pungency. With a view to local refrigeration, it may be used in any case where this effect is required upon the surface of the body; the cuticle being sound. It is employed, however, chiefly in headaches with exter- nal heat, and in superficial burns or scalds. It may be dropped 698 GENERAL STIMULANTS. [PART II. on the part, or applied on a single layer of thin muslin or linen. In strangulated hernia, it has been much commended; the object being, in this case, to produce contraction of the strangulated part, and thus enable it to pass back through the opening. It is applied most effectually by letting it fall upon the seat of the hernia in a slender stream. A considerable reduction of the temperature can be obtained in this way. There are two officinal preparations of ether which require no- tice, viz. the Spirit of Ether, and the Compound Sjnrit of Ether. 1. SPIRIT OF ETHER. — SPIRITUS ^ETHERIS SULPHURICI. Ed. This is simply a mixture of one part by measure of ether and two of officinal alcohol. The only advantage of the preparation is that it is readily miscible with water, and may, therefore, be taken more conveniently than pure ether. The dose of it is two or three fluidrachms. 2. COMPOUND SPIRIT OF ETHER. — SPIRITUS ^ETHERIS COMPOSITUS. U.S.— Compound Sjnrit of Sulphuric Ether.—Hoff- mann's Anodyne Liquor.—HoffmanrHs Anodyne. As directed in the Pharmacopoeias, this is made by mixing toge- ther half a pint of ether, a pint of alcohol, and three fluidounces of ethereal oil or heavy oil of wine. The ethereal oil or heavy oil of wine, is a yellowish liquid, heavier than water, of a penetrating peculiar odour, and a sharp bitterish taste, and boiling at 540° Fahr. It contains sulphuric acid, combined with certain products of the decomposition of alcohol acting as a base or bases, and is considered by Liebig as a double sulphate of ether, and etherole; the latter being another name for light oil of wine, which is a 4—4 carbo-hydrogen (C4H4). It is obtained by dis- tilling a mixture of alcohol and sulphuric acid, the latter being in much larger proportion than is used in the preparation of ether. A portion of it is usually produced in the process for procuring ether, especially towards the close, and hence contaminates that product as obtained by the first distillation. But, though precise rules are given for the preparation and use of the ethereal oil in the Pharmacopoeias, it is in fact seldom if ever made in this country; and the product sold as Hoffmanns ano- dyne, in our shops, is actually prepared by continuing the distilla- tion in the process for procuring ether, after it has been stopped in reference to the latter product. A mixture is thus obtained of CHAP. I.J CEREBRAL STIMULANTS.—SPIRIT OF ETHER. 699 ether, alcohol, and oil of wine, which is somewhat modified to make it suit the views of the manufacturers, and sold as Hoffmann's anodyne. It contains the ingredients of the officinal preparation, but much less of the ethereal oil. Compound spirit of ether has a peculiar odour, which it owes to the ethereal oil. Its taste is very hot, pungent, and somewhat sweetish. It should be completely volatilizable by heat and desti- tute of acid reaction; and, when mixed with water, should have a somewhat milky appearance, owing to the separation of the oil. Medical Uses. The effects of Hoffmann's anodyne on the system are essentially the same as those of ether, but somewhat modified by the oil of wine, so as perhaps to bring it more nearly into ac- cordance with the class of nervous stimulants. Ether itself, in small doses, insufficient to disturb specially the cerebral centres, is really a nervous stimulant; and were it used only by the stomach, might perhaps be ranked appropriately with this class of medicines; as it is never given in this way for its narcotic effects. But used, as it is at present by inhalation, prominently as a cerebral stimulant, and conforming so closely in its effects, as thus administered, with alcohol and opium, it could not with propriety be removed from this connexion. Hoffmann's anodyne is much used to quiet nervous irritation in its various forms. Among other effects is that of producing sleep ; but this it does only when sleep is prevented by nervous discom- posure; so that it acts,'not directly on the brain as a narcotic, but simply as a general stimulant to the nervous system, equalizing its actions, aud thus removing the cause of wakefulness. From its common name it might be supposed to have extraordinary powers of relieving pain. If given in large quantities, it might possibly produce this effect directly, as the vapour of ether does when in- haled, by rendering the cerebral centres insensible to the irritations which occasion pain. As ordinarily given, however, it does not act in this way, but only by quieting the irritation upon which the pain may depend; and, when this is beyond its powers, it is itself inoperative as an anodyne. In painful affections, therefore, purely dependent on functional disorder, it will occasionally afford relief; in the pains of a surgical operation, and those dependent on inflam- mation, or even active congestion, seldom or never. Mild spasmo- dic affections will not unfrequently yield to it. It is much used in febrile diseases to calm restlessness, and general malaise, to obviate the nervous twitchings and startings so common 700 GENERAL STIMULANTS. [PART II. in children, and to produce sleep, when the patient is wakeful. In the low or typhoid fevers, it is particularly indicated for the sub- sultus tendinum, and mild delirium so common in that affection. In all the slighter troubles of hysteria, in faintness, languor, lowness of spirits, palpitations, &c, and in analogous affections in the male sex, Hoffmann's anodyne is often an admirable aid to the phy- sician, when more powerful remedies are not indicated. Flatulent colic, singultus, and gastric uneasiness, will frequently be relieved by it. It is often an admirable remedy in nervous headache. It might be employed, in very large doses, for obtaining those more powerful effects in spasmodic diseases for which ether itself is given; but the proportion of alcohol it contains must always be taken into account in such cases. When laudanum sickens the stomach, or occasions headache, the effect may sometimes be obviated by giving Hoffmann's anodyne along with it. The dose is from half a fluidrachm to two fluidrachms. Some- times it produces very pleasant effects in restlessness, in the dose of from thirty to sixty drops. It should be given in a wineglassful of water, sweetened or not as the patient may prefer. The dose may be repeated every hour or two if required. It is often use- fully combined with solution of morphia, or other preparation of opium, in affections in which both medicines are indicated. III. CAMPHOR. CAMPHOR A. U.S., Lond., Ed., Dub. Origin. Camphor is a concrete substance obtained from Cam- phora officinarum, an evergreen tree, of considerable size, growing in China and Japan, and other neighbouring countries, and occa- sionally kept in conservatories in temperate latitudes. The whole plant is impregnated with the camphor, which is separated either by sublimation, or by boiling, and, in the latter case, is sublimed before being sent into market. It comes to us either from the Ports of China, or indirectly from Japan through Dutch commerce. As imported, it is not sufficiently pure for use, and is, therefore, submitted to another sublimation, along with a small proportion of quicklime. Thus prepared, it is in large circular cakes, an inch CHAP. I.J CEREBRAL STIMULANTS.—CAMPHOR. 701 or two in thickness, slightly convex on one side and concave on the other, and perforated in the centre. Properties. As kept in the shops, camphor is usually in frag- ments of the cakes above mentioned, usually somewhat whitish on the surface, but beautifully clear and translucent within. It has a strong, fragrant, characteristic odour, and a warm, pungent, some- what bitter taste, which leaves a sense of coolness in the mouth, especially perceptible when the air passes over the tongue during inhalation. It is somewhat unctuous to the touch, and very brittle, yet of difficult pulverization, in consequence of a certain tenacity in its constituent granules, which cause them to flatten under the pestle, without breaking into powder. It may, however, be readily reduced to powder, by first adding a little alcohol, by grating and sifting, or by precipitation by water from its alcoholic solution. Camphor is lighter than water, and, when thrown upon it in small fragments floats on the surface, and performs various gyratory movements, probably in consequence of the repulsion of its vapour. It is highly volatile, and if exposed to the air will in time wholly disappear. At a temperature somewhat above that of boiling water, it melts, at a higher temperature boils, and at a still higher takes fire, burning with a brilliant flame, but much smoke, and leaving no residue. In close vessels it may be sublimed unchanged. It is very slightly soluble in water, which, by simple agitation with it, will take up one-thousandth of its weight, and acquires the smell and taste of the camphor. By the intervention of an agent which enables it to be very minutely divided, as magnesia or its carbonate, it may be dissolved in water in much larger proportion. It is very soluble in alcohol, extremely so in chloroform, and to a con- siderable extent also in ether, the volatile and fixed oils, strong acetic acid, and the diluted mineral acids; even carbonic acid water dissolving it more largely than water itself. When rubbed with resinous substances, it often loses a part of its odour, becomes softened, and is thus rendered more readily suspensible in water. Composition. Camphor consists of carbon, hydrogen, and oxy- gen, which are thought to be combined in the form of oxide of camphene, a compound radical consisting of 10 equivalents of oxy- gen and 8 of hydrogen, and supposed to be identical with pure oil of turpentine. Another variety of camphor, denominated Borneo, or Sumatra, or Dryobalanops camphor, is obtained from the interstices of the wood of Dryobalanops Camphora, a large forest tree of Sumatra and 702 GENERAL STIMULANTS. [PART II. Borneo. It is never, however, imported for use into America or Europe. 1. Effects on the System.—Opinions the most opposite, and facts apparently the most contradictory, have been published in rela- tion to the mode of operation and effects of camphor. Some consider it esseutially sedative in its action, whether on the circulatory or nervous system; while others with equal positiveness determine that it is stimulant; and others think that it may be the one or the other; and facts not to be denied are adduced in support of each opinion. In the present state of our experimental knowledge on the subject, it is impossible to decide with certainty between these conflicting views and statements. More numerous observa- tions, made under every variety of circumstances, and without in- fluence from preconceived opinions, are necessary before any view of its mode of operation can be received as demonstrated. Never- theless, it may be possible to find some clue through the labyrinth of seeming contradictions; and, after giving a succinct account of the effects produced by camphor, as deduced from the great multi- tude of published facts, and from my own personal observation, I shall endeavour to explain them, as far as practicable, in accord- ance with the general principles maintained in this work. Local Effects. In the first place, when applied locally, and confined so as to prevent evaporation, camphor produces heat, more or less redness, and not unfrequently pain. These effects are not very ob- vious upon the skin protected by the cuticle; but, when the medicine is applied in concentrated solution, they will, I think, be found to take place in some degree. In blistered and ulcerated surfaces, and in that of the mouth, they are incontestable. MM. Trousseau and Pidoux state, as the result of personal experiment, that pieces of camphor, held in the mouth for half an hour, had, at the end of that time, produced redness, heat, and painful swelling in the part with which they were in contact. (Mat. 3Ied., 4e ed., ii. 235.) The experiments of Orfila on animals prove that the same effect is pro- duced in the gastric mucous membrane. When camphor was given in small fragments, it was found, after the death of the animal, to have caused inflammation, and numerous small points of ulceration. It is well known that, in man, when swallowed in the form of pill, it is apt to occasion uneasiness or pain in the stomach, and, if in considerable quantities, even nausea and vomiting. It would seem, therefore, that camphor is a local stimulant. But how are we to account for the coldness felt in the mouth when it is swallowed, CHAP. I.J CEREBRAL STIMULANTS.—CAMPHOR. 703 and, as some assert, even in the stomach? Simply by its volatility. In its conversion from the solid state to that of vapour, it neces- sarily absorbs heat, and produces the sensation of cold; and this is especially observed when the air is drawn through the mouth, thus favouring the evaporation. There can be no doubt that the same change goes on to some extent in the stomach, under the higher temperature to which the camphor is there exposed, and a neces- sary result there also is the production of more or less coolness. But excitement of the part is probably not the only effect of cam- phor. It is scarcely possible that the medicine should have been adhered to, as a local anodyne in rheumatism and other painful dis- eases, so universally, so pertinaciously, and through so long a series of years, if it really possessed no power of this kind. But nothing is more common, in our experience of the operation of medicines, than the succession of a stimulant and sedative effect. Chloro- form powerfully irritates a surface for a time, and afterwards as powerfully reduces its sensibility to painful impressions. Camphor operates in the same way; but, whether its sedative effect on the nervous extremities is direct, or consequent upon a previous stimu- lant effect upon them, there are no facts which enable us to deter- mine. The question may perhaps be, in some degree, analogically settled, if we can determine how the medicine acts upon the nervous centres; for it is probable, though by no means certain, that it acts upon the same principle in both positions. General Effects. Our attention is next to be directed to the effects of camphor on the system at large. Omitting the im- pression it may produce on the stomach, which will vary with the predominance of the refrigerant influence of the evapora- tion, or the direct excitant influence of the camphor, and with the mode of its exhibition, whether in solution, finely divided, or in mass, I shall notice only the constitutional effects. From a very small dose, sufficient, however, to make a decided im- pression in certain morbid states of the system, no sensible effect whatever is experienced. A somewhat larger dose will usually be followed by a slight increase in the frequency and perhaps fulness of the pulse, and in the warmth of the surface, and occa- sionally by some diaphoresis. In the course of about twenty minutes, there may be a slight exhilaration of spirits, or feeling of comfort induced, which, however, is much more observable in de- pression or uneasiness from nervous disorder than in health. This passes over in a short time, and no other observable effect may be 704 GENERAL STIMULANTS. [PART II. produced. Thus far the medicine operates in exact accordance with the class'of nervous stimulants. A larger dose will occasion de- cided narcotic symptoms. With or without preliminary excitement of the circulation, there will now be a feeling of giddiness, perhaps also of languor or lassitude, with more or less mental confusion or unsteadiness; and, if the impression is very decided, there may also be some disorder in vision and hearing. These symptoms are soon followed by heaviness, mental hebetude, and a disposition to sleep; during which the general sensibility is impaired, the pulse, whether at first excited or not, usually becomes slower, though perhaps still full, and the temperature of the surface is somewhat lowered. Very opposite statements have been made, in reference to the effects of the medicine upon the urinary and genital organs, by persons who equally speak from their own experience, and, so far as can be determined, are equally deserving of confidence. While, according to one statement, camphor is apt to irritate the urinary passages and the organs of generation, producing even strangury in the one, and sensations of voluptuous excitement in reference to the other, the opposite statement affirms that the medicine, instead of causing, is admirably adapted to relieve strangury, and is a powerful anta- phrodisiac, producing excellent effects in priapism, nymphomania, a disposition to onanism, &c. Now these assertions are not so con- tradictory as they seem. Allowing the camphor to act upon the nervous centres as a stimulant, the first stage of its action may be an excitation of the function over which the centres respectively preside, while, in the second stage, the congestion of the centre shall be such as to impair its power, and consequently depress the dependent function. Thus, camphor may excite, and may depress the generative organs, and whether it will do the one or the other may depend upon the stage of its action, as well as on the quantity given, and on various circumstances which may hasten or retard, increase or diminish its influence. If it act promptly and power- fully on the centre, the first stage of excitation may pass over so rapidly that only the succeeding sedative effect may be felt; if, on the contrary, less rapidly and less powerfully, its congestive effect in the centre may not pass the boundary of pure excitation, and the function be stimulated accordingly. The different effects on the urinary passages may be explained on the same principles; or we may suppose that, in producing one effect, the camphor may act through the system, and, in producing the other, locally. Poisonous Effects. In great excess, camphor sometimes occasions nausea and vomiting, by which it is discharged, and ill effects averted. CHAP. I.J CEREBRAL STIMULANTS.—CAMPHOR. 705 If not speedily thrown off from the stomach, it gives rise to anxiety, vertigo, disordered or obtunded hearing and vision, delirium, insen- sibility, convulsions, and deep stupor. Along with these symptoms there are usually diminution in the frequency and force of the pulse, paleness of the face, and coolness of the skin, which is some- times bathed in cold sweat. The symptoms come on usually in less than half an hour, increase gradually in intensity, and in the course of an hour or two end in unconsciousness. If the poison is evacu- ated, they will go off quickly; otherwise, they may continue several hours, and gradually decline, the patient returning to consciousness, but with some confusion of mind and feebleness of memory remain- ing for a longer or shorter time. Except in the case of an infant, of about eighteen months, who died from the effects of the poison, after taking about ten grains, no instance of fatal result is on record; but in many instances the effects of the poison have been very alarming, and quite sufficient to suggest caution in the use of large doses. It is a singular fact that, in some of these cases of poisoning, there have been at first evidences of high circulatory excitement, with flushed face, and other symptoms of determination of blood to the head, followed by a state of depression; while in other cases the depressed condition has first occurred, and the symptoms of excitement, amounting even to fever, have followed. It has been attempted to explain the latter by the reaction following de- pression; but we do not see the same phenomena succeeding the prostrating influence of real direct sedatives, such as conium, chlo- roform, digitalis, hydrocyanic acid, &c. It is more probable that they were the result of the direct action of the poison on the brain; and the different states of excitement and prostration were probably . merely the results of different degrees of excitant or irritant influ- ence on the cerebral centres, in one instance being only sufficient to stimulate them to excessive action, in the other to overwhelm them, and thus prevent their due influence on the functions over which they preside, whether of the heart, lungs, or special senses. The occurrence of febrile symptoms, and obvious cerebral excite- ment, after the depressing effects have been for some time expe- rienced may be owing to a subsidence of the active congestion of the cerebral centres to a point, at which their operations are unem- barrassed, and at which, consequently, they are enabled to extend the direct effects of their irritation throughout the system. If any physician will ask himself the question, whether he would venture to "-ive camphor, in large doses, in acute inflammation or active vol. I.—45 706 GENERAL STIMULANTS. [PART II. congestion of the brain, he will at least determine what is his own real belief of its action. If he agree with the author in thinking that it could do only injury under such circumstances, he will be disposed to rank camphor, as is here done, among the cerebral stimulants. Until he is prepared to administer it as an effectual remedy in such cases, he cannot be thoroughly convinced of its direct sedative properties. The quantity in which camphor is capable of producing poison- ous effects varies exceedingly, according to individual peculiarity, or to circumstances not well understood. Thus, while Mr. Alex- ander, of Edinburgh, suffered the most threatening symptoms, in- cluding convulsions and stupor, from forty grains, and even twenty grains have produced alarming effects, more than two drachms have been taken without serious consequences. The ten grains which proved fatal in the child of eighteen months, are probably equivalent to eight or ten times as much given to an adult. The main remedy in poisoning from camphor is to evacuate the stomach. The after-treatment depends altogether on the symptoms presented; but, in general, little else is required. 2. Mode of Operation.—Camphor probably acts on the system at large exclusively through the blood. That it is absorbed is proved by its odour in the breath and perspiration, and, as some have asserted, in the urine, and by the result of an experiment of Tiedemann and Gmelin, who distinctly perceived the smell of cam- phor in the portal blood of a horse, to which the drug had been given. From what has been stated above, it has been already inferred, that I consider camphor as directly stimulant, both locally and generally, with very little comparative influence on the circulation, but a powerful action in large doses on the brain, and as indirectly sedative to all the functions, including of course that of the heart, through the over-stimulation of the nervous centres. 3. Therapeutic Application.—Camphor was probably unknown to the ancient Greek and Roman physicians, and was introduced into Europe by the Arabians. In small doses of from one to three grains, repeated at short intervals if required, it often answers an admirable purpose as a nervous stimulant, relieving slight pains, vague uneasiness, nervous headaches, muscular twitchings, restless- ness, jactitation, &c, and often enabling the patient to sleep by removing the causes which keep him awake. It is much used for this purpose in various diseases, generally in the state of camphor CHAP. I.J CEREBRAL STIMULANTS.—CAMPHOR. 707 water, or combined with opium in the officinal camphorated tincture of opium, or paregoric. In a full dose, calculated to act as a cerebral stimulant, it may be employed to stimulate the brain in a depressed state of its func- tions, to relieve pain, and to allay spasm and other nervous disor- der. It probably produces the two latter effects by rendering the cerebral centres, through its congestive influence upon them, insen- sible to the impressions sent from the affected part, and incapable of transmitting irritating influence to the muscular or other de- pendent function. The following are the speeial diseases in which it has been most employed; but, whatever may be the name of the affection in which the indications above mentioned may be presented, it may be used to meet them, provided no contraindication exist. Idiopathic Fevers. Whenever, in any one of these complaints, whatever may be the particular character of the fever, there may be general uneasiness, restlessness, jactitation, tremors, twitchings or startings of the muscles, slight delirium, wakefulness, &c, and these symptoms may be in no degree dependent on, or connected with active congestion or inflammation of the brain, camphor may be employed as a nervous stimulant, and will often be found to act most happily in relieving them. The most convenient form for using it, under these circumstances, is that of the camphor water of the U. S. Pharmacopoeia, of which one or two tablespoonfuls may be given every hour or two, until the desired effect is produced. The symptoms referred to are peculiarly apt to occur in children, for whom, according to the age, the dose may vary from thirty minims to one or two fluidrachms, at the same intervals. Advan- tage will often accrue from combining or alternating it with com- pound spirit of ether (Hoffmann's anodyne), or with spirit of nitric ether (sweet spirit of nitre), under the same circumstances, and sometimes with one of the liquid preparations of opium, when that medicine may be simultaneously indicated. In enteric and typhus fevers, and in the low typhoid state of febrile diseases generally, camphor is particularly indicated ; and may some- times be employed with benefit, not only for the purposes above mentioned, but also as a cerebral stimulant, in aid of wine-whey, carbonate of ammonia, &c, when the pulse is frequent and feeble, the tongue and skin dry, and the patient affected with low mutter- ing delirium. The supposed diaphoretic property of the medicine comes here in aid of its stimulant action on the brain, which is in 708 GENERAL STIMULANTS. [PART II. a depressed condition under the sedative influence of the depraved blood, or directly of some absorbed poison. Inflammation. Under the impression of its sedative powers, camphor has been recommended strongly in inflammatory diseases generally, and especially in acute rheumatism, in which it has been supposed to exercise peculiarly beneficial powers. Of course it may be used in these complaints when the nervous symptoms above referred to call for it; but it is not in this capacity that its em- ployment is now alluded to. It is supposed, in these complaints, to exercise a directly sedative influence over the inflammatory excitement, at the same time favouring perspiration. I have no doubt that it may act beneficially, but not precisely in the manner supposed. Whatever sedative influence it may exert is, I believe, secondary, and dependent on a direct stimulation and consequent congestion of the cerebral centres; and the inference from this view is, that it should not be employed in acute cerebral inflam- mation, or active cerebral congestion; nor, indeed, in any other inflammation with a full strong pulse and sthenic state of system, until the vascular fulness and excitement have been subdued by depletory measures. In other words, I think that it acts upon the same principles precisely as opium in these cases, and, like it, should be associated with medicines calculated to give it a direction to the skin, and obviate any stimulation it may produce, such as tartar emetic, the neutral mixture, nitre, &c. It is proba- bly the similarity and, at the same time, inferiority of its action to that of opium, that has led to its disuse in inflammations; and advantage might sometimes accrue, particularly in inflammatory rheumatism, from having recourse to it as a substitute for opium, when that medicine, from its peculiar properties, may act in some way disadvantageously. When on the subject of opium, I shall more fully discuss its mode of operation in inflammations; and what may be said there will apply in considerable degree to cam- phor. With a view to its antiphlogistic effects, it must be used in full doses. Painful Affections. Camphor has been occasionally used as an anodyne in neuralgia, but is much less efficient than several other medicines belonging to the class. In nervous headaches it may be useful, when they depend on cerebral depression; and, in slight cases, when the headache is merely an expression of some trivial nervous disorder, a small dose of camphor with a little opium, as in the common paregoric elixir, will often operate happily. It is, CHAP. I.] CEREBRAL STIMULANTS.—CAMPHOR. 709 however, in dysmenorrhea that camphor has been most used merely as an anodyne. To fulfil this indication it must be given in the largest doses. Spasmodic and other Nervous Disorders. In the more violent of the painful spasms, the anodyne and relaxing powers of camphor, in any ordinary dose, are quite inadequate to the results desired. It is of little use, therefore, in spasm of the stomach, ureters, or bile ducts, in the severer forms of colic, in tetanus, &c; but, in con- junction with opium, it is occasionally used in epidemic cholera, and, in small doses, in the diarrhoea or cholerine preliminary to that disease. In the convulsive affections produced through the cerebral centres, it has sometimes been employed with great asserted benefit, particularly in puerperal convulsions; but, having no personal experience of it in this affection, I do not feel at liberty to recommend it. It has been used also in epilepsy, chorea, and hysterical convulsions with occasional advantage; but cannot be de- pended on for more than temporary relief, and often fails to produce that. In pertussis, and other instances of spasmodic cough, it may be given as an adjuvant to more efficient medicines; but is little used. In the cough attendant upon inflammatory affections of the chest, in their advanced stages and chronic forms, it may sometimes be usefully associated with expectorants, when opium may be con- traindicated, or in connexion with that narcotic. In the form of camphorated tincture of opium, it very often enters into cough mixtures under the circumstances mentioned; but, in this form, should not be employed in their earlier stages. In the various slighter nervous disorders of hysteria, of the puerperal state, of hypochondriasis, of feeble paralytic cases, and of chronic debility in general, it may be used with occasional benefit, in small doses, as a nervous stimulant, either alone, or associated with other medicines. It has been much used by some practitioners in insanity to pro- duce sleep and quiet irritation; and may be considered as indicated in that complaint under similar circumstances with opium, to which, however, it is greatly inferior. It has been particularly recommended in melancholy. In occasional attacks of apparently causeless mental depression, it sometimes acts very happily. From its stimulant influence on the nervous centres, it has been used in cases of amaurosis, of a purely functional character, with asserted success; but it has, under these circumstances, generally been prescribed with other medicines, such as valerian, arnica, &c. It has been used in delirium tremens to aid in procuring sleep, as 710 GENERAL STIMULANTS. [PART II. well as in quieting the varied nervous disorders of that affection; but, if used at all, it should be merely as an adjuvant of opium, or in conjunction with other narcotics when opium cannot be used. One of the applications of camphor about which there has been the greatest difference of opinion, is to the alleviation of irritations of the urino-genital apparatus. The testimony, however, in favour of its occasional efficiency in morbid sexual excitement is too strong to be rejected. Sometimes in small, and sometimes in large doses, it has been given, with at least temporary advantage, in cases of nymphomania, priapism, and uncontrollable venereal propen- sities exhibited in other forms. Alone, or associated with lactu- carium or lupulin, it may always be given in such affections with hope of benefit. Many employ it habitually to prevent or relieve strangury from Spanish flies used for blistering. For this purpose it is sprinkled on the surface of the plaster before application, and is given in- ternally to relieve the effect when produced. I have never, how- ever, found any very satisfactory effects from it, in the doses in which I have been willing to employ it; but have no doubt that, in large doses, whether by the mouth or rectum, it would sometimes have the desired effect; but the relief obtained, under such circum- stances, by an anodyne enema of laudanum is so prompt and certain, that I have seldom thought it worth while to resort to less efficient means. Camphor has also been employed in the retrocession of cutaneous eruptions, in order to relieve internal irritation by its calming in- fluence, and to favour the return of the eruption by its diaphoretic action. Contraindications. It is soarcely necessary to repeat that cam- phor should not be given during the existence of active vascular irritation, congestion, or inflammation of the brain, nor in high febrile excitement with a strong pulse and sthenic state of system; and that, in any case presenting these conditions, whatever other- wise may be the indication for its use, they should be subdued before it can with propriety be prescribed. Nor should it be administered when the stomach is inflamed. Local Use of Camphor. Few medicines are more frequently em- ployed topically than camphor. In the form of vapour, it is some- times inhaled in asthma, s])asmodic coughs, and chronic catarrhal affections; and there is no doubt that its constitutional impression may be obtained in the same way. It may be applied by means CHAP. I.] CEREBRAL STIMULANTS.—CAMPHOR. 711 of an ordinary inhaler, placed in water more or less heated to favour the volatilization of the camphor. M. Raspail recommends that a small tube, a quill for example, should be filled with the coarsely powdered medicine, and loosely closed at each end so as to admit the passage of air, and that this should be used in the same manner as a cigar, but without burning. In the inhalation of camphor, care must be taken to arrest the process, when signs are exhibited of its acting on the brain. Another mode of using the vapours of camphor is in the form of a vapour bath. For this purpose the patient may be seated naked on a stool, and covered with a blanket closely applied about his neck, and hanging down around him upon the floor. A plate of heated metal, holding half an ounce of camphor, should then be placed underneath the blanket, so that the vapours may completely surround the body. A similar arrangement may be made, by means of crossed hoops and the bedclothes, about the patient in bed, if unable to rise. The vapour thus applied is highly recommended, by M. Dupasquier, in chronic rheumatism, A piece of camphor held before the nostrils, so that its vapour may be snuffed up into the nasal passages, is sometimes beneficial in coryza. Powdered camphor has been recommended to be used in the same way, and for the same purpose, as well as for the relief of various spasmodic or catarrhal affections of the air-passages. Dissolved in different liquids, camphor is'injected into the urethra, vagina, and rectum, for the purpose of relieving irritations of those passages, and is very much used as an application to the surface, chiefly with a view to its anodyne effect, in various painful affec- tions, as gout, rheumatism, neuralgic pains, sprains, bruises, chilblains, &c. It is also used as a stimulant to gangrenous, flabby, and indolent ulcers. In the solid state, also, camphor is sometimes employed externally. Allusion has already been made to the use of the powder in the form of snuff', for which purpose it should be made very fine. In a similar state, it may be applied in cataplasms to painful parts; and half a drachm of it, thus applied to the perineum, will sometimes relieve the chordee attendant on gonorrhoea. Administration.—Camphor may be used in pill or emulsion, but the latter form is greatly to be preferred; as, in the former, it is^more apt to irritate the stomach, probably by floating upon the "-astric liquids, and thus coming in a concentrated state into contact with the mucous coat. The emulsion may be made by 712 GENERAL STIMULANTS. [PART II. first pulverizing the camphor with a few drops of alcohol, and then rubbing it up with powdered gum arabic, loaf-sugar, and water, to which a little myrrh may be added, in order to favour the suspension of the camphor. Another mode of preparing the emul- sion is first to dissolve the camphor in a little chloroform (see Chloroform), and then to incorporate the solution, by means of the yolk of an egg, with water. The medicine may also be given sus- pended in milk; but an objection to this is its liability to undergo change in a short time. The officinal aqueous solution, and the tincture, are convenient forms for administration. The dose of camphor varies from one to twenty grains. As a simple nervous stimulant, it may be given in the dose of from one to' three grains, repeated every hour or two, if required. For its full effect as a cerebral stimulant, or indirect sedative, the medium dose is from five to fifteen grains. When a powerful effect is re- quired, as in certain painful neuralgic or spasmodic affections, the dose may be increased to a scruple. By enema, it may be given in twice or three times these quantities. The following preparations of camphor are officinal. 1. CAMPHOR WATER.—AQUA CAMPHORS. U.S. This is made by rubbing two draehms of camphor, first with forty minims of alcohol, afterwards with four drachms of carbonate of magnesia, and lastly with two pints of distilled water, and then filtering. The camphor is thus dissolved in water much more largely than by simple agitation. The carbonate of magnesia simply serves the purpose of dividing its particles minutely. Each fluidounce of the preparation, when well made, contains about three grains of camphor. It is an elegant preparation for obtaining the slighter effects of camphor as a nervous stimulant, in the nervous disorders of febrile diseases, slight hysterical affections, uterine after-pains, &c. It also frequently serves as a good vehicle of other medicines in bowel complaints, especially of nitric and nitromuriatic acids. It is not adapted for obtaining the more powerful effects of cam- phor. The dose of it is one or two tablespoonfuls'every hour or two. It was a favourite application of Scudamore in acute gout, mixed with alcohol, in the proportion of three parts of the former to one of the latter. The mixture was applied to the inflamed joint on linen compresses of six or eight folds, or by means of bread poultices saturated with it. CHAP. I.] CEREBRAL STIMULANTS.—CAMPHOR. 713 2. TINCTURE OP CAMPHOR. —TlNCTURA CAMPHORS. U.S. This is simply a solution of camphor in officinal alcohol. A fluidrachm of it contains seven and a half grains. It is chiefly used externally, as an anodyne embrocation in rheumatic and gouty pains, chilblains, sprains, bruises, &c. I have sometimes used it mixed with five or six parts of milk, and applied on linen com- presses, as an anodyne and emollient in acute gout. It is also fre- quently employed in nervous disorders, as lassitude, faintness, and slight hysterical affections, applied to the forehead, cheeks, &c, and held to the nostrils, so that its vapour may be inhaled. The tinc- ture may also be used internally, whenever the alcoholic vehicle t may not be contraindicated. The camphor is precipitated by water, but may be held in suspension by sugar or gum. The dose is from ten drops to a fluidrachm, first dropped upon loaf-sugar, and then mixed with water. 3. CAMPHOR LINIMENT. —LlNIMENTUM CAMPHORS. This is a solution of camphor in olive oil, half an ounce of the former being employed to two fluidounces of the latter. It is used locally for the same purposes as the tincture, and as a discutient ap- plication to glandular swellings. It may also be used as an injec- tion into the rectum in the tenesmus of ascarides and dysentery, and into the urethra for the relief of the ardor urinae of gonorrhoea. As an enema, not more than one or two fluidrachms of it should be thrown into the rectum at once, diluted with from two to four fluidounces of olive oil; an,d a preparation of the same strength may be used for the urethra. The London College directs a Compound Camphor Liniment (Lini- mentum Camphor.e Compositum, Lond), consisting of camphor, solution of ammonia, and spirit of lavender; but such mixtures might well be left to extemporaneous prescription. It is in fact a tincture of camphor, rendered more stimulating by the ammonia, and intended, therefore, to act both as a rubefacient and anodyne. It is employed externally for the same purposes as the tincture. 4. CAMPHORATED TINCTURE OF OPIUM.—TlNCTURA OPII CAMPHORATA. U. S.—Paregoric. This tincture will be treated of among the preparations of opium, to which the reader is referred. 5. CAMPHORATED TINCTURE OF SOAP. — TlNCTURA Sa- PONIS Camphorata. U.S.— Linimentum Saponis. Lond.—Soap Jjiutnieut. 714 GENERAL STIMULANTS. [PART II. This, which is the preparation commonly known as soap liniment, consists of Castile soap, camphor, and oil of rosemary, dissolved in alcohol diluted with one-eighth of its measure of water. It is a clear liquid, and is very much used as an anodyne and gently rube- facient liniment in all the outward pains for which camphor is locally used. (See page 711.) To render it more anodyne, two measures of laudanum may be added to six of the tincture, consti- tuting the anodyne liniment, or Linimentum Opii of the London College; and, if stronger rubefacient properties are required, the same proportion of stronger solution of ammonia may be incorpo- rated with it. The latter preparation may be used not only in external pains, but also as an effective rubefacient in pectoral in- flammation, angina, laryngitis, and tonsillitis. 6. CAMPHORATED SOAP LINIMENT. — LINIMENTUM SAPO- nis Camphoratum. U.S.— Opodeldoc. The camphorated soap liniment is essentially the same as the camphorated tincture above described, differing in the kind of soap employed, which in this preparation is the common white soap, made with animal fat, instead of the Castile soap, made with olive oil. The effect of the substitution is that the liniment is obtained of the consistence of a jelly, in consequence of the hot alcoholic solution of common soap gelatinizing when it cools. It is usually sold in broad-mouthed bottles, containing about four fluidounces. Though of the consistence of a soft solid at ordinary temperatures, it assumes the liquid state when applied to the surface of the body. It is much used popularly, under the name of opodeldoc, in rheu- matic pains, bruises, sprains, &c. IV. OPIUM. U.S., Lond., Ed., Dub. This is a concrete juice obtained by incisions in the unripe cap- sules of Papaver somniferum, or the poppy, an annual plant, inhabit- ing Asia, in different parts of which, as well as in Egypt, it is abundantly cultivated for the sake of the opium which it yields. There are two varieties of the plant, the white and black, both of which afford opium; but it is said to be chiefly procured from the former. (See Poppy Capsules.) The juice, when collected, is put into convenient receptacles, and, after concreting into a proper con- sistence, is made up, either with or without addition, into masses of different shape, usually surrounded with leaves to prevent their adhering together, and then sent into market. CHAP. I.] CEREBRAL STIMULANTS.—OPIUM. 715 Commerce is supplied with opium chiefly from Hindostan, Ana- tolia or Asia Minor, and Egypt. It is produced also in Persia; but little or none is exported. The opium of Hindostan is either consumed in India, or sent to China, and reaches Europe and this country only as an object of curiosity. It is the product of the Asiatic dominions of Turkey, and that of Egypt, with which the western world is supplied. The opium consumed in the United States is chiefly the variety produced in Anatolia, and introduced into commerce through the ports of Smyrna and Constantinople. It is called Turkey opium, and is usually distinguished into two varieties, the Smyrna and Constantinople opium, so named from the ports from which they are respectively distributed. Of these, the Smyrna opium is the one most largely consumed in this country. Some Egyptian opium is occasionally imported; but is seldom kept in the shops. 1. Varieties of Opium. The only varieties which it is necessary to notice are first, the Turkey opium, including the Smyrna and Constantinople, and secondly the Egyptian. 1. Turkey Opium.—This comes in masses of irregular size and shape, from half a pound to two and a half pounds in weight, origin- ally probably spherical, but usually flattened, or irregularly angular, in consequence of the pressure to which they are subjected, while yet soft, in the cases containing them. On their outer surface are the remains of the leaves in which they were originally enveloped ; and adhering to it, in greater or less number, the light reddish-brown capsules of a species of Rumex, added, no doubt with the object of absorbing moisture, and preventing the adhesion of the lumps. These are usually, as first imported, soft and tenacious in the inte- rior, but hard upon the surface. When completely dried by time and exposure, they are brittle, and have a somewhat shining though uneven fracture. a. Smyrna Opium. Of the two varieties of Turkey opium, the Smyrna is most largely imported. It is, indeed, almost the only va- riety kept in our retail shops. Besides the characters above mention- ed, it has the peculiarity, when cut into, and then torn, of exhibiting numerous minute shining tears, very obvious under the microscope, which somewhat resemble small seeds, and are no doubt the concrete drops of juice formed on the capsules, upon exudation, after these have been incised. Along with the tears are numerous small frag- ments of the outer covering of the capsule itself, scraped off with 716 GENERAL STIMULANTS. [PART II. the juice. The best Smyrna opium consists of these ingredients exclusively; but inferior specimens are often sent into market, variously and in different degrees adulterated, and frequently so much so as to unfit them for use in the shops. The adulterating materials are an extract made from the leaves, grapes freed from their seeds and crushed, different gummy matters, liquorice, minute stones or pieces of metal, &c. Different samples of Smyrna opium vary in the' quantity of morphia they contain from 3 to 13 per cent. The better kinds ought to yield at least 8 per cent, to a careful analysis. Good Smyrna opium is of a light reddish-brown colour in the interior. When blackish, of a weak empyreumatic odour, a sweetish taste, a viscid or greasy consistence, an entirely dull fracture when dry, or containing obvious impurities, it should be regarded as inferior. If wholly without the Rumex capsules, or very scantily supplied with them, it may be looked on suspiciously, as probably of the kind which is said to be " made over again" in some of the Mediterranean ports. b. Constantinople Opium. This, so far as it is a distinct variety, is characterized by the entire want of the tears which distinguish the genuine Smyrna opium. But the drug brought from Constan- tinople has probably been taken thither from all the different parts of the Turkish dominions where it is produced; and it is not, therefore, a matter of surprise that, under this name, Smyrna and Egyptian opium should have found their way into commerce. 2. Egyptian Opium.—This is in flat, roundish cakes, of, different sizes, from half an ounce to a pound in weight, and often either wrapped in a poppy leaf, or presenting vestiges of the leaf, so ap- plied that the midrib divides the cake into two equal parts. It has none of the Rumex capsules, and is always hard and brittle, break- ing with a smooth fracture, of a waxy lustre. It has usually much less morphia than good Smyrna opium, and should not be kept for use in the shops. It is important that only good opium, of a strength at least ap- proaching to uniformity, should be kept for internal use, or for making those preparations, the strength of which depends on that of the opium used; otherwise it would be impossible to have any fixed dose of this most important medicine, or to prescribe it with any certainty of obtaining its peculiar effects in the degree desired. The inferior kinds, should they be admitted into the country, ought to be employed exclusively by the manufacturers for the prepara- tion of morphia. CHAP. I.J CEREBRAL STIMULANTS.—OPIUM. 717 2. Properties of Opium in General. Good opium is of a reddish-brown or deep-fawn colour in mass, and when dry yields a yellowish-brown powder, which becomes adhesive at a slight elevation of temperature. When drawn over paper, it leaves an interrupted trace of a light-brown colour. Its odour is strong, narcotic, and peculiar; its taste bitter, somewhat acrid, and nauseous. When long chewed it irritates the mouth, and may even vesicate. It is inflammable. Water, alcohol, and the diluted acids extract its virtues, which, however, it will not yield to ether. The liquids impregnated with it have a deep brown colour. Composition. Besides several principles found in other vegetable products, as gummy and extractive matter, resin, a substance re- sembling caoutchouc, fixed oil, albumen, and various mineral sub- stances in very small proportion, opium contains morphia, narcotina, codeia, thebaina or paramorphia, papaverina, and opiania, having alkaline properties, narcein, meconin, and porphyroxin, which are neuter, an acid denominated meconic acid, and a characteristic odorous principle, all of which are peculiar to opium. Morphia exists in it combined with meconic acid, and probably in small proportions with sulphuric acid. Of these principles the only one hitherto much employed in medicine is morphia. Narcotina and codeia have both been recommended for special purposes. Of the remainder, though some of them may be and probably are efficient in their action on the system, so little is positively known, that it will not be worth while to burthen the memory of the reader with an account of their properties. The three particularly mentioned will be sufficiently described among the preparations of opium. Incompatibles. Many substances produce precipitates with opium, which, as they do not affect its active principles, are not medically incompatible, so far as the opium itself is concerned. With the infusion, the alkalies throw down its alkaloid, and the astringents containing gallo-tannic acid, as well as kino, catechu, and rhatany, precipitate insoluble tannates of the same alkaloids; but alcohol, in considerable proportion, or an excess of acid, will redissolve the precipitate in both instances. Tincture of galls, notwithstanding the alcohol it contains, throws down a copious precipitate. Tests of Opium. An infusion of opium reddens litmus paper, becomes turbid with solution of ammonia, assumes a deep-red colour on the addition of sesquichloride of iron in consequence of the formation of meconate of iron, is reddened by nitric acid, and is copiously precipitated by infusion of galls. But the only satis- 718 GENERAL STIMULANTS. [PART II. factory test of its value is the proportion of morphia contained iu it. Good opium, treated as directed in the U. S. Pharmacopoeia, should afford from 10 to 12 per cent, of the impure morphia precipitated from its infusion by a mixture of alcohol and solution of ammonia, and ether should not dissolve more than from 2 to 4 parts of this impure product. 3. Effects upon the System. It may be said of opium, in general terms, that, being at first moderately stimulant to the parts to which it may be applied, and to the circulation, and energetically so to the nervous system gene- rally, and especially to the brain, it subsequently operates with even greater energy and universality as an apparent sedative. But little idea of the real powers of the medicine would be ob- tained from such a definition of its effects. In order to form an exact and profitable conception of its influence, so far as known, it is necessary to follow it through the differenl; func- tions, and trace its operation carefully in each, step by step. Its vast importance, and diversified applicability, call for more minute details than are necessary or advisable in relation to most other medicines. I shall consider it in relation first to the nervous sys- tem, secondly to the circulatory and respiratory systems, thirdly to other functions or organs, and fourthly to the part with which it may be directly brought into contact. 1. Action upon the Nervous System. From a full dose of opium, taken internally, no other immediate effect is experienced than a slight feeling of warmth, or perhaps of weight in the stomach. But in a short time, varying somewhat according to the form in which the medicine is used, and the state of the stomach, but sel- dom exceeding ten or fifteen minutes, and often much less, a sensa- tion of fulness in the head is experienced, which is soon followed by a universal feeling of delicious ease and comfort, with an eleva- tion and expansion of the whole moral and intellectual nature, which is, I think, among the most characteristic of its effects. There is not the same uncontrollable excitement as from alcohol, but an exaltation of our better mental qualities, a warmer glow of benevolence, a disposition to do great things, but nobly and bene- ficently, a higher devotional spirit, and withal a stronger self- reliance, and consciousness of power. Nor is this consciousness altogether mistaken. For the intellectual and imaginative faculties are raised to the highest point compatible with the individual capa- city. The poet never has brighter fancies, or deeper feelings, or CHAP. I.] CEREBRAL STIMULANTS.—OPIUM. 719 greater felicity of expression, nor the philosopher a more penetrat- ing or profounder insight, than when under the influence of opium in this stage of its action. It seems to make of the individual, for the time, a better and a greater man. Sometimes there may be delusion ; but it is not so much in relation to the due succession or dependence of thought, as in the elevation of the imagination and the soul above the level of reality. The hallucinations, the wildness, the delirious imaginations of alcoholic intoxication', are, in general, quite wanting. Along with this emotional and intel- lectual elevation, there is also increased muscular energy^ and the capacity to act, and to bear fatigue, is greatly augmented. If the quantity of opium taken has been just insufficient to in- duce sleep, this delightful exaltation may continue for hours, sup- porting the mind and body under an amount of exertion, to which they would be wholly inadequate in their ordinary condition. In two remarkable points, besides those mentioned, the operation of opium differs from that of alcohol; in the absence, namely, of that erotic excitement, and that incapacity of combined muscular movement for a given purpose, which are so strongly characteristic of alcoholic stimulation. With the psychological phenomena above mentioned, there is very frequently a roaring, singing, or buzzing in the head, of which there is scarcely a consciousness, unless the attention is specially directed towards it. Sometimes these noises, combined with throb- bing or thumpings in the brain, are somewhat disagreeable; but they are seldom sufficiently so to call back the mind from its higher flights, or the spirit from its keen enjoyments in the regions into which it has soared. After a length of time varying, according to the dose of the drug, and the susceptibility of the individual, from half an hour, to two, three or four hours, or even longer, this exaltation sinks into a corporeal and mental calmness, which is scarcely less delicious than the previous excitement, and in a short time ends in sleep. Per- haps, in most instances, where a full dose has been taken, this re- sult occurs within an hour. But, when the quantity of opium is insufficient for this effect, the individual will remain awake for hours, sometimes for many hours, even for the whole night, sup- posing the drug to have been given at bed-time, lying calmly and placidly, without mental effort or uneasiness, and submitting him- self to a'current of vague, but generally pleasing fancies. Should the dose be sufficient only to induce a light sleep, there 720 GENERAL STIMULANTS. [PART II. will be a constant succession of dreams, having the vividness almost of reality, usually pleasant in their character, but sometimes very much the reverse. I have repeatedly known patients to complain of excessively disagreeable effects from opium, and chiefly of horri- ble dreams with which they have been tormented during the night, and to declare that nothing would ever induce them to take the medicine again; but I have almost invariably found, under such circumstances, that by increasing the dose on a subsequent occa- sion, or by giving an additional quantity when such symptoms may have presented themselves, that sound sleep is induced, and all dis- comfort vanishes. So real do these dreams appear, and so much like waking thoughts, that patients will often assert that they have not closed their eyes all night, when the fact is that they have scarcely been awake during that time. When opium exercises its full soporific influence, the sleep is usually profound and dreamless, and continues for about eight or ten hours. Should the patient be awakened before the direct effect of the medicine has been exhausted, the feelings of comfort or bien- aise before experienced will often continue for hours in the follow- ing day; and I have known the same thing to happen repeatedly even after a good night's rest. But generally, upon awaking from the full and uninterrupted effects of opium, the patient experiences a state of greater or less depression, indicated by languor and listlessness, a relaxed surface, a rather feeble pulse, and "not unfre- quently loss of appetite, nausea, and even vomiting. This, how- ever, gradually passes away, and the system returns to its ordinary condition, without having experienced any appreciable disadvantage. A remarkable diminution of sensibility attends the narcotic opera- tion of opium, beginning even before the soporific effect, and con- tinuing in a greater or less degree throughout the direct action of the medicine, and even into the secondary stage of depression. It is the general sensibility, or that to painful impressions, which is first and most prominently affected; but the special senses are in some degree involved, especially under the influence of very large doses; though I have met with no instance, even of opium poison- ing, in which, until the advanced stage when profound coma had set in, the patient could not hear and see when roused. In this respect opium differs strikingly from some other narcotic medicines, and especially belladonna. 2. Action upon the Circulation. It was long an undecided point, whether opium was to be regarded as a stimulant or sedative.- The CHAP. I.] CEREBRAL STIMULANTS.—OPIUM. 721 experiments of Dr. Crumpe, published in 1793, decided, what any one might have determined for himself by counting his own pulse under a dose of opium, that, in its first operation, it is stimulant at least to the circulation. Within ten or fifteen minutes after its administration, the pulse is in general moderately increased in frequency, fulness, and force, and at the same time the surface of the body becomes warmer, and the face somewhat flushed. When the period of general excitement is past, and that of calmness or drowsiness supervenes, the pulse either resumes its original condi- tion as to frequency, or, under a large dose of the opium, becomes somewhat slower, retaining, however, its fulness and for a time its force. In this condition it continues for some time during the period of sleep ; but then gradually relaxes, and becomes soft with the relaxing surface, and in the end, participates in the general de- pression which attends the cessation of the direct influence of the medicine. With the increased frequency of the pulse, the respiration is also somewhat quickened; and, as the former becomes slower, the latter undergoes a similar change, and generally even in a greater degree. Under the full influence of opium, one of the most striking pheno- mena is the relative slowness of the breathing, which is sometimes even stertorous, when the sleep is profound. Corresponding with the condition of the circulatory and respira- tory movements is that of the blood itself. Retaining its florid colour for a time, it may give a bright tint to the complexion dur- ing the stage of excitement; but, with the diminished influence from the respiratory centres, the change from venous to arterial is less thoroughly effected, and the blood becomes darker-hued. This is not very obvious from ordinary doses of opium; but, when it has been very largely taken, the venous hue upon the surface, and par- ticularly in the face, is often conspicuous. 3. Action upon other Functions or Organs. Some other effects of opium, which may be considered as more local than the preceding, are yet very important in a therapeutical point of view. On the secretions its influence is specially worthy of notice. Most of them are diminished by it, perhaps all occasionally; but some are at times promoted, and one, that, namely, of the surface, gene- rally so. The mucous secretion is almost invariably diminished. Hence in part, the remarkable dryness of the mouth, nostrils, and fauces', which characterizes the action of opium. The same defi- ciency probably exists throughout the alimentary canal, contribut- vol. I.—46 722 GENERAL STIMULANTS. [PART II. ing to the thirst which is a prominent symptom in the action of opium. There is often also a feeling of dryness in the conjunctiva from the same cause. The secretion of the salivary glands is cer- tainly diminished, and probably that also of the pancreas. The secretory function of the liver is much impaired by a continued use of the medicine, as may be known by the light-coloured passages from the bowels. This I have very often noticed; and it is one of the effects which the physician will have most frequently to counteract. There can be little doubt that a single dose produces a proportionate effect. The kidneys are variously affected. In the greater number of instances their secretion is diminished, especially when the patient is warm in bed; but I have sometimes known it to be powerfully promoted, particularly by the salts of morphia. Indeed, I have seen few diuretics act more copiously than this for a short time; and the effect generally takes place in the course of the first hour or two after the administration of the medicine. It is most apt to occur when the skin is kept cool. The diaphoretic effects of opium are well known. I seldom, how- ever, witness this effect when the patient is walking about. When he is warmly covered in bed, it is extremely common; and some- times the discharge is profuse. It does not usually come on until the patient has slept for some time, and is most copious towards the end of the period of sleep. It is very common to awake in the morning bathed in sweat. This diaphoretic property is greatly increased by the addition of ipecacuanha. The itching sensation in the skin which opium is apt to produce may be referred to in this connexion. It is sometimes attended with prickling, and may occur in any part of the body. It is often very annoying to the patient, and may even prevent sleep. In some instances it is attended with a miliary, erythematous, or urli- carious eruption; but this effect is rare; at least I have seldom notieed it. The stomach may be at first moderately excited by opium; but the effect soon ceases, and is followed by a marked diminution of its function. The appetite is diminished, and the digestion impaired. These effeets may be ascribed perhaps in part to a diminution of the secretion of gastric juice and mucus; but are probably mainly dependent on a want of the accustomed influence from the nervous centres, and the diminished call for food from the nutritive function. The bowels are generally constipated. This is among the most con- CHAP. I.] CEREBRAL STIMULANTS.—OPIUM. 723 stant effects of opium, though it is not invariable. It probably depends on different causes, among which may be mentioned the diminished secretion of bile, of pancreatic liquor, and of mucus, and the diminished supply of chyme from the stomach; but the chief cause is probably a deficiency of influence from the organic nervous centres, through which the muscular coat becomes en- feebled, and, as it were, partially paralyzed. The activity of the nutritive process is much diminished; and consequently less food is required. This is much more obvious from the habitual use of opium, than from a single dose; but there can be no doubt that the latter produces the same effect in a pro- portionate degree. It does not follow that emaciation must take place. On the contrary, the body often retains its weight, and sometimes even gains under the continued use of the drug, if not taken in great excess. This is explained by the consideration, that the normal disintegration of the tissues is diminished equally with nutrition, and even in a greater degree. Not only the voluntary muscles, and those of the alimentary canal, suffer a diminution of their power in the second stage of the action of opium, but those of the bladder also, so that there is occa- sionally some difficulty in passing the urine from this cause; but the effect is seldom obvious, unless from very large doses. 4. Action on the Part to which the Opium may be Applied. To what- ever part opium may be applied, if vital, it is capable of producing its general effects. Injected into the rectum, or sprinkled upon the skin deprived of the epidermis, it operates with almost as much certainty as when swallowed. In the lower animals it is said, when introduced into the cellular tissue, to act with great energy; in the peritoneal cavity to produce convulsions and death; and in the cavity of the heart, to weaken or suspend its action. Through the skin, protected by the epidermis, it acts very slowly and feebly upon the system. Upon the part itself with which it is brought into contact, it produces a series of effects analogous to those upon.the system generally. The first effect is slightly to stimulate, the second to diminish sensibility and the power of action. Thus, when in contact with the conjunctiva, the mucous membrane of the nose and urethra, the blistered skin, or the surface of wounds or ulcers, it first occasions heat, pain, and swme degree of inflamma- tion- and it has already been stated that when long chewed it will sometimes blister the mouth; but, after a time, the pain ceases, 724 GENERAL STIMULANTS. [PART II. and the several surfaces become less sensible to ordinary impres- sions upon them. Even through the cuticle it is capable of pro- ducing some anodyne influence. 5. Idiosyncrasies. On certain individuals opium produces peculiar effects, which differ according to their several idiosyncrasies. Thus, in some persons it causes much more than the usual degree of excitement, intoxicating them like alcohol, rendering them more or less delirious, and even producing convulsions. It is said to have these effects frequently on the Negro and the Malay; but I have not observed any special peculiarity of the kind in negroes of this region. In some, it gives rise, even in large doses, to head- ache, restlessness, and utter inability to sleep; while in others it acts with extraordinary energy as a soporific, even in small doses. There are individuals, who, when they take it, always suffer excessively from nausea and vomiting, and occasionally with spasm of the stomach. Not a few, though they experience in the same manner as others its direct influence, yet are so much troubled with sub- sequent nausea, and general distress, as to preclude the use of the medicine in their case. It is said even to purge some individuals, and in others to produce colic. I have repeatedly known it, in merely stimulant doses, to provoke an attack of neuralgic pain, in a person liable to this affection. The probability is, that some of these abnormal effects are owing to certain constituents of opium which are generally productive of no inconvenience, or to the peculiar mode in which the active principle may be combined or associated in the drug. It is certain that they may very frequently be obviated by particular modes of preparing the opium for use, consisting either in separating from it the obnoxious matters, or modifying the state of its active matter. Thus, morphia, or the black drop, or the aqueous extract can be borne well, when opium itself, or other preparations would be rejected from the stomach, or, if retained, would occasion great inconvenience. 6. Effects of Variation and Repetition of the Dose. As a general rule, in reference to the operation of opium connected with the quantity administered, the stimulant effect is protracted by a dimi- nution, and shortened by an increase of the dose; while exactly the reverse is true of the subsequent narcotic effect, in relation both to its duration and intensity. There are few medicines to which the system becomes more rapidly habituated thar»j this. By increasing the dose at short intervals, the quantity which may be taken daily, with present CHAP. I.] CEREBRAL STIMULANTS.—OPIUM. 725 impunity, may be indefinitely augmented. An ounce or more daily has been frequently attained to; and event pints of laudanum have been taken in the same time. (See page 644.) 7. Acute Poisoning. It has been said that poisonous quantities of opium sometimes occasion no stimulant effect whatever, but are immediately sedative. I have never seen a case which would justify this statement, and do not think that the fact stated is possible. Opium is not sufficiently stimulant to overwhelm the stomach, as enormous quantities of alcohol may do, and produce almost instant death, without directly reaching the brain. Before any very pow- erful effect can take place, time must be allowed for absorption. The drug cannot all be absorbed at once. A small portion must first enter the circulation, and, when this reaches the brain, it must act upon it as a stimulant. And such I believe to be invariably the case, when opium has been swallowed. I have no doubt, moreover, that a careful examination made at the beginning will discover evi- dences of this stimulation. I have heard of one instance in which an individual, who had taken a poisonous dose, walked a distance exceeding a mile, and back again, before the narcotic effects were ex- perienced. A very powerful emotion, wholly preoccupying the mind, may have the effect of postponing the operation of the poison, and in some measure counteracting it, as physical pain is known to do, for example, in violent colic and tetanus. But, generally speaking, the larger the quantity of the opium taken, especially in a liquid form, the shorter is the period of unmixed stimulation. In a very short time, under a poisonous dose, drowsiness comes on, soon fol- lowed by profound stupor. The patient becomes apparently quite senseless, and lies without other observable motion than that of respiration, which is very slow, and not unfrequently stertorous. A dark suffusion of the countenance comes on, with an utter want of expression. So common is this, that, by its absence, I have been able to detect a case of pretended poisoning from opium. The eyes are closed, and the pupils almost always contracted at this stage. The pulse is slow, and generally full and strong, not unlike that of apoplexy, and indicating anything but feebleness in the heart's con- tractions. I have known it to be so extremely forcible as irresist- ibly to call for the use of the lancet, lest injury might be done to the brain. The coma, however, is not complete for several hours. The patients are almost always capable of being roused, and kept for a time partially awake, by being dragged half walking around the apartment. Under such circumstances, however, they are 726 GENERAL STIMULANTS. [PART II. extremely desirous to be allowed to sleep; and the only motive by which, in some instances, I have been able to induce them to swallow the drink or medicine offered, has been to assure them that, if they would take it, they should be allowed to rest for a time. During this half-awake condition, it is surprising to notice the change in the colour of the surface, which, before almost purplish from the venous hue of the blood, now reassumes, in a considerable degree, its natural appearance; but the instant the patient is per- mitted to lie down and sleep, the dark suffusion of face returns, with the slow, laboured breathing. Convulsions are said sometimes to occur; but, though I have seen numerous cases of poisoning from opium, I have met with them in no one instance. The whole of the voluntary muscles appear relaxed and powerless. The skin, too, is relaxed, but not often perspiring at this period. Death seldom takes place in this stage of cerebral oppression. After a few hours, the coma becomes more profound, so that the patient can no longer be roused. The venous suffusion of the countenance begins to give way to paleness. The skin becomes cooler and more relaxed. The pulse, though in general still slow, diminishes gradu- ally in fulness and strength. The breathing becomes slower and slower, till at length a considerable interval elapses between the successive inspirations. I was once struck with this state of respi- ration in a child, whom I had been attending for catarrhal fever. Suspecting that some mistake had been made in the prescription, and that opium had been given in a large dose, I took the parent of the child with me to the shop of the druggist, and found that a cough mixture had been prepared with at least twelve times the quantity of morphia directed. Happily, though alarmingly ill, the child recovered under supporting measures. At length a condition of utter prostration ensues; the pulse ceases to be perceptible at the wrist; there is a universal cold clammy sweat over the body; the respiration, occurring at lengthening intervals, at last ceases; and death apparently takes place. The heart, however, yet beats very feebly; and a short period is still allowed for the application of restorative measures, before the case becomes quite hopeless. The stage of prostration usually commences from four to six hours after the swallowing of the poison, and sooner if it has been removed artificially from the stomach; and death generally occurs in from six to twelve hours. If the patient survive the twelfth hour, he usually recovers, though instances are on record in which the fatal termination has taken place much later. It has sometimes CHAP. I.J CEREBRAL STIMULANTS.—OPIUM. 727 also occurred before the sixth hour, even so early, it is asserted, as the third. In such a case, the patient dies from the immediate influence of the opium on the brain, as in congestive apoplexy. Ordinarily, I believe, death results from the vast prostration of the nervous power, consequent upon the previous excessive excite- ment; and, if the patient can be supported through this period of collapse, he will in all probability recover. From a quantity just insufficient to cause death, the prostration following the congestive influence of the poison is extreme; but, at the lowest point, the system begins to react, and gradually returns to health, though frequently through a series of nervous disorder and variously deranged function, which mark the violent strain to which the brain has been subjected. The quantity of opium which may prove fatal varies so much with constitutional peculiarities, or the existing state of the system from any cause, that it is quite impossible even to approximate the fatal dose in reference to any particular individual. Dr. Christison, in his treatise on poisons, mentions an apparently well authenticated case, in which death took place, in an adult man, from four grains and a half of opium withfdne grains of camphor; whereas half a fluidounce of laudanum has been repeatedly known to be taken, by persons not accustomed to the use of opium, without such a result. Death often occurs from quantities varying from half a fluidounce of laudanum to two or three fluidounces, or from about twenty grains to one or two drachms of opium. Infants are peculiarly susceptible to the poisonous influence of the drug. I was once called to see a child, between one and two years old, in a dying state, to whom its mother had given, rubbed up with water, the residuary matter in a teaspoon, after the evaporation of some laudanum which had been left in it. She thought she might be able to obtain enough in this way for a dose. Dr. Alison, of Edinburgh, has seen death result in a child, a few weeks old, from four drops of lauda- num- and two and a half drops killed another child, three days old. (Christison on Poisons) The inference to be drawn from these facts is, that great caution should be observed in exceeding the ordinary full dose of opium, which experience has shown to be safe. It may be very frequently done with impunity, but at any time a fatal re- sult may occur. I do not think that it is ever necessary, under any circumstances, to give more than two grains, as a beginning dose, to an adult wholly unaccustomed to the medicine. It can be re- peated in a short time, if necessary, and may be increased after 728 GENERAL STIMULANTS. [PART II. testing the susceptibility of the patient. For an infant, during the first week or two, not more than half a drop of laudanum should be given at first, and to one a year old not more than two drops. In some rare instances, after a poisonous dose of opium has been swallowed, vomiting has come on spontaneously, and saved the life of the patient by discharging the poison. Opium may prove poisonous, as well when injected into the rectum as given by the mouth; but it is probable that a larger quantity would be required to produce fatal effects. It is asserted to have destroyed life by application to the surface of the body. A flaxseed poultice saturated with laudanum, and applied to the leg of a soldier affected with erysipelas, is said to have proved fatal. (Christison on Poisons.) The case of a young man is reported in the Annuaire de Therapeutique (A. D. 1843, p. 5), who was thought to have perished through the effects of a cataplasm to his epigastrium, upon which the contents of a laudanum bottle had been poured. A medical friend of my own, in whose word I place entire reliance, reported to me the case of a child destroyed by the repeated exter- nal application of laudanum. In these cases, it is not specially stated whether there was or was not abrasion of the skin; but, if the poison is fatal upon the sound skin, how much more likely to be so upon a denuded surface, or upon an ulcer or wound ! Lauda- num should never, therefore, be used recklessly, even as an external remedy. The morbid appearances after death from laudanum are, as a gene- ral rule, congestion of the brain, with more or less serous effusion, congestion of the lungs, a livid hue of the surface, and a liquid state of the blood. In a few instances, effusion of blood has been found. Treatment of Acute Poisoning. There is no antidote to opium which can be relied on. The important indications are to evacuate the stomach, and to support the system in the state of prostration which follows the direct influence of the poison. The first indica- tion is to be met either by emetics, or the stomach-pump, or by the two combined. If called at any period before prostration has taken place, one of these measures should be resorted to. For various reasons, I prefer first the trial of emetics. They are, in general, more immediately at command, and time is an object of much im- portance. Besides, if solid opium has been swallowed, it must re- main in the stomach, when the pump is used, if in masses too large to pass through the tube. I was once cognizant of a case of this CHAP. I.] CEREBRAL STIMULANTS.—OPIUM. 729 kind. A young man was brought to my house, with the statement that he had taken solid opium. He was sent immediately to the hospital, where, as I afterwards learned, the stomach-pump was promptly applied, and everything apparently evacuated. The pa- tient, however, died. I was convinced that a portion of opium had remained in the stomach, because too large to enter the tube; and from that time I determined never to depend on the stomach-pump, in any case where opium had been swallowed in mass, however small the fragment. Besides, there may be an hourglass contrac- tion, which might yield to an emetic, but not to the stomach-pump. I once attended a case in which, after the contents of the stomach seemed to have been completely discharged under the influence of" emetics, a sudden gush of liquid was thrown up, smelling strongly of laudanum. Had the stomach-pump been relied on in this case, it might have ended fatally. When emetics cannot be made to act, this instrument should be resorted to; and it may often also be ad- vantageously used in conjunction with emetics, especially when the patient refuses to swallow, as it then affords the means of intro- ducing the medicine into the stomach. The emetics I prefer are sulphate of zinc and ipecacuanha. The former is very prompt and energetic, safer in large doses than sul- phate of copper, because less corrosive, and than tartar emetic because less sedative or prostrating in its influence. The ipecacuanha is also a quick and active emetic, at the same time that it is safe in almost any quantity. Thirty grains of sulphate of zinc, and a drachm of ipecacuanha may be given at once, and repeated every twenty minutes until they operate. Indeed, the ipecacuanha may be thrown in ad libitum. I should fear an indefinite repetition of the sulphate; for, though it may produce no perceptible irritation at the time of exhibition, in consequence of the want of susceptibility in the stomach, it may yet leave an impression behind, which, upon the occurrence of reaction, may end in inflammation. In a case of opiate poisoning in a woman, which occurred to me many years since, the patient, after the evacuation of the poison, was reduced to the lowest state of prostration, from which she was saved with difficulty. Among the measures employed to excite her, was a pair of sinapisms applied to the legs. As, in the existing insensi- ble state of the skin, they produced neither pain nor redness, they were allowed to remain on for three hours. When they were taken off, no rubefaction was visible. But when the system re- acted violent inflammation took place in the surface with which 730 GENERAL STIMULANTS. [PART II. they had been in contact, followed by vesication and obstinate superficial ulceration, which was long in healing. Applying this observation to the influence of irritants on the stomach, I felt con- vinced that, by giving largely of substances of this kind, though they might not act at the time, Ave might upon the occurrence of reaction have violent and perhaps fatal gastritis. It is probably not going too far to say, that some of the deaths in narcotic poison- ing, which have occurred notwithstanding the complete evacuation of the poison, may have resulted from this cause. I have never, therefore, proceeded further with the sulphate of zinc than to give three doses; and have not ventured on sulphate of copper at all. "Yet I have never failed in evacuating the stomach by emetics, when I have employed them in these cases. The emetic, however, should be aided by various accessory measures. Among the most important of these is the use of large quantities of warm water, or warm chamomile tea, of which the patient should be made to swallow tumblerful after tumblerful, until the stomach will receive no more. The throat also may be tickled by a feather, in order to rouse the stomach by its sympathies. The great difficulty, however, is not so much in the direct insus- ceptibility of the stomach as in that of the cerebral centres, through an impression upon which it is that emetics are enabled to act. It is, therefore, important to rouse these centres, and render them more sensible to the nauseating impression. For this purpose, cold water may be dashed on the face, head, or neck of the patient. If the pulse is exceedingly full or strong, some blood may be taken from the arm, in order to lessen, in some measure, the pressure on the brain. But this measure must be used with great caution. The prostration following the direct action of the poison is gene- rally the greatest danger of the case. Anything which may in- crease that prostration may be hazardous. My preceptor, the late Dr. Joseph Parrish, used to relate the case of a young woman to whom he was called in the*country, and who had swallowed a poisonous dose of laudanum. The physician in attendance, influ- enced by the state of her pulse had bled her largely, and I believe more than once. The consequence was, that, after the evacuation of the poison, though she recovered her consciousness perfectly, she fell into a prostrate condition from Avhich it was found impossible to raise her. Another and, perhaps, the most important adjuvant of the emetic, is to keep the patient in constant motion until vomiting is induced. For this" purpose, assistants should aid him CHAP. I.] CEREBRAL STIMULANTS.—OPIUM. 731 in walking steadily about the room, and, when there is resistance, should use compulsory measures to this end if necessary. It is surprising, sometimes, to witness the efficiency of this measure in relieving the cerebral congestion. While moving, the patient re- mains at least partially awake, the colour of the face brightens, and more or less expression comes into his features; but the instant that he is allowed to lie down, he falls again into a deep, perhaps stertorous sleep, and the dark suffusion of face, and utter want of expression return. It is not sufficient to obtain a single evacuation of the stomach. After vomiting has begun, it should be kept up by free draughts of warm water, until the liquor returns colourless and odourless. If the stomach-pump is employed, the same thorough evacuation should be effected. The water injected should return without smell, and the last liquid contents should be drawn out by means of the syringe. But the subsequent treatment is all important. It has not fallen to my lot, out of numerous cases of this kind which I have seen, to witness death in a single instance, except in that of the infant before referred to, and that occurred at a period when all the re- sources, now at our command, had not been made known. But I am quite confident that, in more than one instance, if nothing had been done after the evacuation of the poison, the consequences might have been fatal. The prostration is sometimes very great, and comes on sooner than it otherwise might do, in consequence of the evacuation of the poison. It must be encountered by stimu- lant measures proportioned to the exigencies of the case. External stimulation by means of heated cayenne pepper and brandy or oil of turpentine, and the internal use of the aromatic spirit of am- monia, wine-whey, wine beat up with the yolk of egg, brandy with milk, &c, are means, of which one or all may be employed, as the degree of prostration may require. Rich soup, or essence of beef or ^mutton, may also be given as nourishment. Should the sto- mach'be irritable, a blister should be applied to the epigastrium, and nutritious and stimulating enemata be employed, if the same materials should be rejected when swallowed. In relation to the use of sinapisms, caution should be observed not to leave them on longer than half an hour, or at furthest one hour, in any one place, for fear of subsequent inflammation. When the patient is first seen in the prostrate condition, with a cold skin, and scarcely perceptible pulse, no time should be lost in \ 732 GENERAL STIMULANTS. [PART II. attempts to evacuate the stomach; but the stimulating and sup- porting plan should be at once resorted to. It is not the direct action of the poison that is now the source of danger; it is the depression following that action. Even though respiration may have ceased, and the pulse no longer be perceptible at the wrist, efforts to save the patient should not be abandoned. While stimu- lants are employed externally and internally, recourse should be had to artificial respiration; for the heart continues to act feebly after the occurrence of these phenomena, and, if the office of respi- ration can be performed, and arterialized blood sent to the heart, the function of circulation may be resumed, and life saved. Seve- ral instances of this kind are on record; and a medical friend of mine is confident that he saved the life of an infant about to perish, by breathing into its lungs. It is important, however, not too speedily to relinquish the process, after the restoration of the func- tions ; for the respiratory centres may not yet have recovered from the blow, sufficiently to carry on their functions without aid. The patient should be carefully watched for several hours, and the remedy reapplied if found to be required. The case of a woman is recorded in the London 3Iedico- Chirurgical Transactions for 1836, in which, after the return of animation through the influence of artificial respira- tion, the patient was left for an hour, and upon the return of the medical attendant, at the end of that time, was found relapsing into her former pulseless condition. A repetition, however, of the remedy was followed by the same success, and life was saved. Another remedy which may be had recourse to, under similar circumstances, is galvanism, or the powerful action of the alternat- ing currents of the electro-magnetic machine. Two cases of recovery under this agent are on record. For the method of applying this remedy, the reader is referred to the article on Electricity, page 546. Coffee is another remedy which may be employed to qualify the effects of opium. It acts, probably, more nearly in the capacity of an antidote than any other agent. Its use Avas suggested by its well-known tendency to produce wakefulness. It should be taken freely, and as strong as possible; never, however, to the exclusion of other means. Chronic Poisoning. The extremely grateful effects of opium on most persons, in its first stimulant action, and in the calming influ- ence which follows, has led to an enormous abuse of the drug, which, though less injurious either to the individual or to society than a similar abuse of alcohol, is often very pernicious in its effects CHAP. I.J CEREBRAL STIMULANTS.—OPIUM. 733 on the health of those who give way to it. Like the alcoholic beverages, though employed habitually, provided its use be re- strained within certain limits, it does little apparent injury, even through a long course of years, and does not seem, obviously at least, to shorten life. We are told, on the most reliable authority, that in India and China, in the mode in which it is commonly em- ployed by those of respectable position, who have a character to maintain, its effects are in general not such as to produce any seem- ing unfitness for the ordinary duties of life, or materially to shorten its duration. In our own country, the apothecaries inform us of sales of opium or its preparations to a vast amount, beyond any possible calls for it as a medicine; yet the number of instances are comparatively few, in which its ill effects are brought under the notice of the physician. The vice is indulged secretly, and does not betray itself by any disorder in the acts, or, so far as is known, in the health of the individual; and the best British writers make the same statements relative to the abuse of the drug in their coun- try. But the danger is that, as its pleasing effects cease to be felt, at least with the same zest, in the original dose, the temptation is always present to increase the quantity used, and to go on increas- ing it, until it becomes a source of great and undeniable evil. If the ordinary operation of opium be compared with that of alcohol, the cause will be obvious why life is so much less endan- gered by the former than the latter. The stimulant influence of opium, either on the part to which it is applied, or generally on the circulation, is very much less than that of alcohol; nor does it equally excite the functions of the lungs, liver, and kidneys. Hence it is much less liable to induce either chronic inflammation of the different organs, or that organic degeneration, which almost necessarily attends the debility consequent upon excessive vascu- lar excitement. Operating mainly on the functions, the disorder- ing effect of opium is witnessed chiefly in the functions. Occasionally the medical man is consulted in this country by the slaves of opium, and has the opportunity of witnessing the conse- quences of its excessive abuse. In his own therapeutic observa- tion he also witnesses frequent disturbance of the functions from its medicinal employment, and necessarily infers that the same dis- turbances must exist in those who use it as a luxury within the same limits. The greatest sufferings, experienced by the opium- eater are those which attend the state of nervous depression, always existing when its direct influence is no longer felt. There are ex- \ 734 GENERAL STIMULANTS. [PART II. cessive restlessness, a universal and indescribable uneasiness, feel- ings of intolerable distress, especially in the epigastrium and lower extremities, an irksome sense, moreover, of incapacity both for in- tellectual exertion, and for mental or emotional enjoyment, consti- tuting together a state of exquisite misery, from which the only relief is by renewed recourse to the stimulus, which, if taken in an increasing dose, renders him happy again, and again capable of ex- ertion ; and thus he goes on, in an alternation of lessening comfort and increasing misery, to the end. At the same time, there is a gradual depravation of the functions, which impairs the degree of health, though it may not very materially shorten life, unless the indulg- ence be carried to great excess. The ordinary derangements of the organic functions are impaired appetite and digestion, habitual con- stipatiop, and defective action of the liver; those of the animal func- tions, tremors, wakefulness, weakened memory and intellect, and loss of interest in the usual concerns of life, and social relations. The lowest stage of degradation has been attained, when the indulgence ends in a total loss of self-respect, and indifference to the opinions of the community; and everything is sacrificed to the insatiable demands of the vice. Not unfrequently, this habit of excess has been engendered by the supposed necessity of obtaining relief from painful affections, such as cancer, and certain incurable cases of neuralgia; but, though some palliation, this is no satisfactory ex- cuse; for, by proper management, considerable relief of pain can generally be obtained, without an excess sufficient to degrade the mind, or even materially the general health; and it is rather a weak yielding to the seductive pleasures of opium, than any necessity for its anod}7ne influence, that leads to the lowest depths of the evil. The effects of the vice of opium-eating, and opium-smoking, among the lower class of the Orientals, have been frequently de- scribed, and with such warm colouring that a suspicion is apt to arise of some interference of the imagination in the pictures given; especially as we do not meet their exact counterparts among those, who perhaps equally abandon themselves to the vice among our- selves. It is possible that the fumes of opium inhaled may exer- cise a more deleterious influence on the health than the drug taken into the stomach; and this may explain the incompatibility of the descriptions of travellers with our own observation. Dr. Oppenheim, one of the most recent and reliable observers, gives the following account of what he has himself witnessed in European and Asiatic Turkey. The opium-eater usually begins with from half a grain to two grains, and gradually increases to two drachms CHAP. I.] CEREBRAL STIMULANTS.—OPIUM. 735 and sometimes more in a day. He is readily recognized by his appearance. "A total attenuation of body, a withered yellow countenance, a lame gait, a bending of the spine frequently to such a degree as to assume a circular form, and glossy deep-sunken eyes, betray him at the first glance. The digestive orgaris are in the highest degree disturbed, the sufferer eats scarcely anything, and has hardly one evacuation in a week; his mental and bodily powers are destroyed; he is impotent." Finding the stimulant effect of the poison at length almost lost, he conjoins with it the use of corrosive sublimate, gradually increasing the latter till it amounts to ten grains daily. He becomes subject finally to neuralgic pains, to which the opium yields no relief; and, if he has begun the use of the drug early in life, seldom attains the age of forty. (Brit, and For. Med. Rev., iv. 394.) It is unnecessary to state, that the corro- sive sublimate has probably quite as much to do with the fatal result as the opium. It is satisfactory to know that this evil habit may be corrected, without great difficulty, if the patient is in earnest; and, as the disorders induced by it are mainly functional, that a good degree of health may be restored. It will not answer to break off sud- denly. No fortitude is sufficient to support the consequent misery, and life might be sacrificed in the effort. Of the particular phe- nomena which might result I have no experience; for I have met with no case in which the attempt has been made, or at any rate more than momentarily persevered in. Dr. B. H. Coates, however, states that he has seen well characterized cases, in which delirium tremens occurred (N Am. Med. and Surg. Journ., iv. 34); and this result might reasonably be anticipated. The proper method of correcting the evil is by gradually withdrawing the cause; a dimi- nution of the dose being made every day, so small as to be quite imperceptible in its effects. Supposing, for example, that a fluid- ounce of laudanum is taken daily, the abstraction of a minim every day would lead to a cure in somewhat more than a year; and the progress might be much more rapid than this. Time, however, must be allowed for the system gradually to regain the healthy mode of action, which it had gradually lost. 4. Mode of Operating. Opium probably acts simply by an influence upon the vital properties of the tissues, without any chemical reagency what- er Hence the long comparative impunity under its abuse. At e time I was disposed to think that its first stimulating action \ 736 GENERAL STIMULANTS. [PART II. on the heart and brain might be owing to a sympathetic im- pression extended from the stomach; but the correctness of this opinion seems to me more than doubtful, now that we know how rapidly it is absorbed, and how quickly it may be conveyed with the blood to all parts of the system. That it is absorbed is proved by the fact that, in fatal cases of poisoning, it frequently happens, even when there has been no vomiting, that none of it is found in the stomach. Besides, the smell of opium is sometimes observ- able in the breath and excretions of persons who have taken it largely, and has been noticed in the blood. Barruel asserts that he has detected morphia in the blood and urine of a person poisoned with opium (Pereira, Mat. Med., 3d ed. p. 2120). The milk of nurses under its influence has produced its peculiar effects on the sucking child. When introduced into the jugular vein, it has been found to produce the same effects as when taken by the stomach. Finally, if applied to a nerve, without access to the blood-vessels, it does not act on the brain. From its slightly stimulating effect on the surfaces with which it is observably brought into contact, it may be supposed, when in the circulation, to exercise a similar influence wherever it is car- ried, and thus to produce the moderate excitement of the heart which accompanies its primary operation. But its influence is felt especially by the nervous centres in the brain, and more particu- larly by those of the cortical portion of the cerebrum, through which the intellectual and emotional functions of the mind are probably exercised. The sensory centres, and the respiratory centre in the medulla oblongata, appear also to be specially affected. But if the cerebellum bej as supposed by Flourens, the seat of the power of combining motions, and as Gall and Spurzheim maintain, that of the sexual propensity, it probably participates little in the original stimulant impression. The operation of opium upon the nervous centres I maintain to be essentially stimulant. The primary mental excitement may thus be readily accounted for, as well as the more rapid respiration, and increased muscular power. It is not impossible that the stimulation of the heart may really proceed from a similar cause, and not from the direct contact of the opium or its active principles. But how account for the sub- sequent calm in all these functions, and the remarkable diminution and almost suspension which follow, as indicated by the impaired sensibility and power of motion, and the soporose condition more or less profound? Are these the result of a direct sedative or CHAP. I.J CEREBRAL STIMULANTS.—OPIUM. 737 depressing influence following the stimulant? I think not. The real depression takes place long subsequently, after the direct action of the medicine has ceased. They are readily explicable upon the general doctrine of irritation, which I have maintained in this work and elsewhere. Irritation is stimulation beyond the healthy point. The two terms may be considered as synonymes in reference to our present purpose. When, then, a part is stimu- lated, it receives an additional supply of blood, and the supply increases Avith the "stimulation until it ends in inflammation. Noav the first effect of the blood entering the part is to supply the means for an increase of its healthy function; a larger supply interferes with the due action of the part, though the excitement may still continue; a still further quantity overwhelms it, and impairs or suspends altogether the exercise of its function. In other words, the effects of stimulation upon any part are first to augment, then to derange, and lastly to impair its function; and all this through the direct influence of the stimulant. Apply this law to the action of opium on the cerebral centres. It first moderately stimulates and moderately congests them; thus increasing their function, and giving rise to the elevated, intellectual, emotional, and sensory phenomena, and perhaps to the circulatory and respiratory excite- ment, which characterize the early period of its operation; it con- tinues to stimulate, and thus further congests them, and thus may occasion the disordered sounds and other sensations, and the derangement of the intellectual, emotional, and motor functions Avhich sometimes come on at this period; it still continues to sti- mulate, and yet further to congest the centres, the functions of which are now diminished or suspended, causing first a sensorial calm, and ultimately sleep. If the quantity of the opium be very large, the congestion is hastened and increased with the more prompt and powerful stimulation; and hence the speedy occurrence of profound sleep or coma. The influence upon the circulation and respiration corresponds with this view. In active congestion of the brain the pulse usually becomes slower, fuller, and stronger, and the respiration slower and deeper; and thus it is in the early stage of the soporose effect of opium, showing that the sensorial phenomena proceed from a similar influence. Indeed, there is a marked resemblance between the effects of opium and a gradually increasing active congestion of the brain. In the latter, as in the former, the cerebral functions are first someAvhat excited, then they are discomposed, as shown by abnormal sounds, &c, in the head, vol. i.—47 k 738 GENERAL STIMULANTS. [PART II. and then diminished or suppressed, as proved by the droAvsiness and stupor which supervene; and' the resemblance is extended, as already stated, to the respiratory and circulatory functions. Thus far we have been attending to the direct influence of the opium. The condition which follows is in accordance with another general pathological law, that every over-excitement must be fol- lowed by a corresponding depression. The cerebral centres, no longer stimulated by the opium, fall necessarily into a depressed state. No more blood is now attracted to ttem. They have not even the power of expelling the excess which has overwhelmed them. Hence, a failure of all the dependent functions, and the universal prostration that ensues. I consider the above question not as purely theoretical, but highly practical in its bearing, and therefore important to be decided cor- rectly. If opium is a real sedative to the nervous centres in its second and most powerful action, then it must be the great remedy in all cases of over-excitement of the brain, from slight vascular irritation of that organ up to apoplectic congestion, and even in- flammation; for the sedative influence would vastly overbalance the stimulant, especially if the medicine should be given largely, and would thus produce much more good than harm. But every experienced practitioner knows that these are exactly the conditions in which opium is calculated to do harm. If, on the contrary, it be altogether a stimulant to the brain throughout its direct action, Avhether during the excitement or suppression of the cerebral func- tions, then it is contraindicated in the conditions just referred to, and would be most appropriate in all cases of functional depression or debility of the brain; and this is really the case. Upon the principle here stated, opium may be prescribed rationally; upon the other, that, namely, which considers it sedative to the brain, it must be given empirically. But another important point, in reference to therapeutics, is that, while opium is a powerful cerebral stimulant, it operates really as a sedative upon many of the functions and organs of the body, which are sustained in their due state by influence from the nerv- ous centres. By the over-stimulation of these centres, it disables them from extending their proper influence to other organs, and thus acts as a positive, though indirect sedative to the latter. Hence, opium may often be prescribed with great advantage as a sedative in various disordered conditions of the system, provided the brain be either sound, so as not to be materially injured by its action, or '• I-] CEREBRAL STIMULANTS.—OPIUM. 739 depressed, so as to be benefited by it. Under the therapeutic head, there -will be frequent opportunities of illustrating the principle here laid down. It is highly probable that, upon all the nervous centres, those of the spinal marrow and the sympathetic ganglia, for example, and upon all the force-generating nervous matter as distinguished from the mere conveying structure, wherever it may exist, opium acts in the same manner as upon the brain, though in a less degree. Suffi- cient investigation, however, has not been made upon this point, to justify a positive conclusion. 5. Therapeutic Application. Opium has been known, and probably used, from the earliest period of Grecian history. It ranks among the most important medicines, and, in the variety of its applications, and extent of its employment, stands at the very head of the catalogue. I shall first treat briefly of the indications it is calculated to fulfil, and after- wards, more at length, of its special uses. a. Indications for the use of Opium. 1. As a General Stimulant. It will be remembered that opium, in its primary action, stimulates the circulation moderately, and the nervous system energetically. In reference to these properties, it is indicated in most acute affections in which the vital poAvers and functions generally are enfeebled, as in low fevers, &c. An import- ant consideration, in this application of opium, is that its stimulant operation continues longer, in quantities just insufficient to produce its narcotic effects, than in the full anodyne and soporific dose. Hence, as a mere stimulant, it should be given in rather small doses, which should be repeated at such intervals as to sustain a steady operation, without allowing the effects of successive doses to accumulate, and thus to bring about the indirect sedative influence of the medicine. One-eighth, one-quarter, or one-half a grain may be given for this purpose every two, four, or six hours, the smaller quantity being given at the shorter, and the larger at the longer interval. This rule applies to cases possessing the ordinary healthy susceptibility to the action of opium. Should the susceptibility be materially diminished by the disease, the dose must be increased accordingly. ... 2. As a Nervous Stimulant. In quantities insufficient to produce any material or very sensible impression on the brain, opium acts precisely like the nervous stimulants, and may be employed for \ 740 GENERAL STIMULANTS. • [PART II. similar purposes. Through the general equalizing influence upon the nervous functions Avhich characterizes this class of medicines, it acts very happily in a great number of slight nervous derange- ments and vascular irritations. It is, however, only in slight affec- tions that it acts on this principle; for, when given in doses calcu- lated to produce an energetic impression, it ceases to be a mere general nervous stimulant, and concentrates its direct action mainly upon the brain. General or local uneasiness, restlessness, moderate Avakefulness, slight pains and spasms, nausea, &c, are illustrative examples. 3. As a Special Stimulant of the Brain. The indication founded on this property of opium is highly important. Not a few disor- ders consist essentially in a depressed or debilitated condition of the cerebral nervous centres; and it is often important to be able to apply to these centres a stimulant, which shall not also materially excite the circulation. Thus, in the collapse sometimes attendant upon the cold stage of fevers, there is not unfrequently vast de- pression of the nervous centres; yet, as high febrile reaction may soon supervene, the indication is very obvious for a medicine which, while it may rouse the depressed centres, and for a time may stimu- late the heart, shall cease to produce the latter effect before reaction is established. Exactly such a medicine is opium, the excitant action of which upon the heart, at all times moderate, is compara- tively brief, and is not likely in any degree to aggravate the coming fever. It is obvious, however, that, in such cases, the medicine must be given in its full dose, on account not only of the insus- ceptibility apt to exist, but also of the relative brevity of its stimu- lant operation on the heart. Delirium tremens, certain conditions of insanity, and various other nervous disorders call for this cerebral stimulation of opium. The antiperiodic action, which is often strongly evinced by opium, may be considered as dependent directly upon its stimulant opera- tion on the cerebral centres. In all regular periodical diseases, it is highly probable that the paroxysm makes its first approaches through the nervous centres, and that, if anticipated in its attack by a sufficiently strong preoccupation of those centres, it may be warded off, and set aside altogether; and it is a law of these dis- eases that, if the regularity of the succession be broken, the com- plaint itself will cease, at least for a time. Now opium, through its stimulant operation upon the cerebrum and medulla oblongata, is capable of effecting the required preoccupation; and, if given so CHAP. I.] CEREBRAL STIMULANTS.—OPIUM. 741 as to be in full action at the time for the expected return of the paroxysm, will often set it aside. The fullest dose of opium is generally required to answer this indication. Not only intermittent fever, but all other regularly intermittent diseases, may very often be interrupted in this way. 4. As an Indirect Arterial Sedative. Allusion has been repeatedly made to the diminished frequency of pulse which follows, in a short time, the excitement produced by a full dose of opium. A diminu- tion in its force, also, comes on after a time; and a positive depres- sion of the circulation is thus effected. The larger the quantity of opium taken, the more quickly is this effect produced; and the inference is that, for the fulfilment of the present indication, the medicine should be given in its fullest regular dose. It is in inflam- mations, and vascular irritations that opium is called for upon this ground. Its first stimulant action, however, is in the Avay; and it should not be employed until the force of the circulation has been subdued by suitable preliminary measures, or has someAvhat sub- sided in the course of the disease. The opium should also, as a general rule, be associated with some other medicine calculated to modify its stimulant action; and ipecacuanha or tartar emetic is usually selected for the purpose. The diaphoretic tendency of such a combination, independently of the depressing properties of the adjuvant, contributes much to the desired object. 5. As an Indirect Nervous Sedative. For its action in this way opium is indicated in all kinds of disorder throughout the system, which consists in or depends on nervous irritation. When the capacity to feel, and the power to act fail in the centres, there must be a corresponding depression of their dependent functions, and an irritated or over-excited state of these functions must be diminished or cease. The particular affections which may thus be relieved or remedied are extremely numerous. They include pain in all its varieties, abnormal special sensations, irregular muscular contrac- tion of all kinds, restlessness, wakefulness, dyspnoea, &c. The most important therapeutic effects, however, may be ranked under the three following heads. a. For the Relief of Pain, or the Anodyne Effect. Opium probably relieves pain by an active congestion of the cerebral centres, which, according to the law already stated, at length diminishes or sup- presses their sensorial function, or, in other words renders them in- sensible to irritant impressions sent to them from other parts of the body. It is not tne condition of the suffering part itself that is modi- \ 742 GENERAL STIMULANTS. [PART II. fied by the opiate, but only that of the corresponding nervous centre or centres. The same relief would be obtained by cutting off the nervous communication between the centre, and the diseased part where the source of the pain may exist. As the congestion, in the degree necessary to the suspension of the sensibility of the centres comes on only after the symptoms of excitement have subsided, it follows that the anodyne operation of opium cannot be among its first effects; and the fact is, that it is not until after the lapse of a considerable time that the relief from pain is experienced. Neuralgia, inflammation, and cancer, are among the affections in which opium is given to fulfil the present indication. The occasions for its use on this score are almost innumerable; and, if it were capable of no other application, it would be an invaluable remedy. Something more is often gained by the relief of pain than a mere abatement of the sufferings of the patient. The affection is itself injurious to health, disturbs all the functions, interferes with sleep, and may even, if continued, destroy life. Opium, therefore, must be considered as not only palliative, but frequently also as remedial, even in its relation to pain alone. b. For the Relief of Spasm or Irregular Muscular Contraction. Spasm is of two kinds, that attended with severe pain commonly called cramp, and that which occurs with little pain or none whatever, as in convulsions. The observations in relation to the anodyne ope- ration of opium apply to cramps so far as the relief of pain is concerned. But it does not follow that the spasmodic contraction should be relieved at the same time with the pain. The proba- bility is that the spasm, in all cases in which the involuntary muscles, and often where the voluntary muscles are concerned, depends upon impressions made, not through the cerebral, but the spinal or ganglionic centres; as in spasm of the stomach, boAvels, &c., and in tetanus. Now opium, though it acts on the nervous centres of organic life, does so less powerfully than on the cerebral; and it might be expected to relieve the pain more readily than the spasm, and sometimes the former without the lat- ter; and this is really the case. Nevertheless, it has the effect of relaxing the muscular contraction in very many instances, and is among the most efficient remedies in painful spasms. Larger doses, hoAvever, are in general required for this condition than either for pain, or for convulsive movements of cerebral origin, as might be anticipated from the less influence of opium over the spinal and ganglionic than the cerebral centres. Thus, spasm of CHAP. I.J CEREBRAL STIMULANTS.—OPIUM. 743 the stomach demands larger doses of opium than gastrodynia; and tetanus often ten times the quantity, that would be required to re- lieve severe rheumatic pain in the same muscles. The relaxation of the involuntary muscular contraction produced through the cerebral centres, as in subsultus tendinum, and various convulsive affections, is probably occasioned partly, in the same man- ner as the relief of pain, by the diminution of the susceptibility of the cerebral centres through which the irritant cause acts, and partly by the diminished power of action in the centres, which prevents them from transmitting to the muscles the influence that induces contraction. c. For the Production of Sleep. To produce sleep is another most important indication, which opium is capable of fulfilling beyond all other medicines. It may do this in two modes altogether distinct. When wakefulness is caused by some slight nervous disorder, as not unfrequently happens, small doses of opium, acting in this respect, as a mere nervous stimulant, like assafetida or Hoffmann's anodyne, occasion sleep by simply relieving this disorder. The patient goes to sleep naturally, because he is not kept aAvake; and the dose of opium requisite for this effect, would not exercise the slightest soporific influence upon a person in health. This is not, however, the method of producing sleep to which reference is made at present. The soporific action, now under consideration, is the result of a direct influence of the narcotic upon the brain, and is another example of the indirect sedative influence of opium. The sensorial centres are more deeply congested, under the stimulation of the medicine, than is consistent with the performance of their functions, which are for a time nearly or quite suspended. The capacity to feel, to think, and to act, is alike impaired or lost; though the spinal centres and those of the medulla oblongata still operate. This condition constitutes sleep. It is a higher degree of the same condition in which pain is relieved. The centres are rendered insensible to pain; while still susceptible to impressions from the special senses, the memory, and the intellect. A little further congestion; and these latter susceptibilities cease more or less completely; and sleep, more or less complete, takes place. The loss of rest is, in many instances, a most serious complica- tion of disease, aggravating, and probably rendering fatal, cases which might, but for it, end in recovery. Whenever it is not at- tended with high vascular excitement or inflammation of the brain, it may almost always be advantageously treated with opium. The \ 744 GENERAL STIMULANTS. [PART II. full dose of the medicine is usually required; and, in some cases, this must be greatly increased beyond the ordinary amount. In febrile and inflammatory diseases, opium is often indicated in refer- ence to this effect; and in delirium tremens, and certain conditions of insanity, in which obstinate wakefulness is one of the most prominent symptoms, it is the remedy chiefly relied on. 6. For the Suppression of 3Iorbid Discharges. It has been stated that opium has a powerful influence in diminishing the secretions, especially those from the mucous membrane and liver. This property serves as the ground of its employment in various dis- eases, consisting in, or connected with a morbid increase of these secretions. Hence its use in diarrhoea, cholera morbus, and epi- demic cholera. A similar, though less reliable influence on the kidneys, renders it sometimes useful in morbid increase of the urinary secretion. It checks also excessive salivation. By an action, probably of an analogous character, it often proves useful in hemorrhages. The precise principle on which opium produces either of these effects, that is, a diminution of the secretions re- ferred to, or of hemorrhage, is not certainly known. But it may be conjecturally ascribed to the same indirect sedative influence over the capillaries, which is exercised over the heart itself, and, indeed, more or less over the whole system, through the over- excited and congested state of the cerebral centres on which it acts. 7. As a Diaphoretic. The increase of perspiration produced by opium, especially when combined with ipecacuanha or tartar emetic, is among the most useful of its therapeutic effects. But in this relation, the medicine will be treated of among the diaphoretics. Not unfrequently several of these indications for the use of opium exist conjointly in the same disease, of which frequent examples will be given Avhen we come to treat of its special applications. b. Contraindications to the Use of Opium. Opium is contraindicated by a high state of febrile excitement with a full strong pulse, by determination of blood to the head threatening apoplexy, by hemorrhage in the brain, by acute inflammation of the brain audits meninges, and in the early stage of all acute inflammations with a strong pulse, before sufficient preliminary reduction. Its direct stimulant properties render it inapplicable to conditions of high vascular excitement in general; and its special action on the brain, to those most emphatically, in which the cerebral centres are already actively congested. Another special contraindication is acute inflammation of the CHAP. I.J CEREBRAL STIMULANTS.—OPIUM. 745 mucous membranes, particularly that of the bronchial tubes, before secretion has become established. Here there is risk that its pro- perty of checking the secretion from these membranes, may tend to aggravate the inflammation, by interfering with the process which nature has intended for the cure. Nor should opium in general be given in parenchymatous hepa- titis, in consequence of its strong influence in arresting the secre- tion'of bile, and thus locking up the disease in the substance of the gland. Excessive sweating, constipation of the bowels, a feeble digestion and want of appetite, and defective biliary secretion, are all more or less in opposition to the use of opium; but, when the indications for its use are decided, they should not be allowed to interfere; as means may readily be found to correct its ill effects in these con- ditions. I think I have observed that opium sometimes aggravates cuta- neous eruptions, through the direction which it frequently gives of irritation to the surface of the body. We have been cautioned in relation to the use of opium in nursing and pregnant women, under the apprehension that, in the former, the impregnation of the milk with its active matter might prove injurious to the infant, and, in the latter, that the drug might prove poisonous to the foetus. I have myself noticed neither of these effects; but do not wish by this statement to invalidate the caution urged by others. c. Special Therapeutic Applications. 1. Idiopathic Fevers. Several indications for the use of opium are offered in different varieties and conditions of fever. As a stimulant it is very useful in the low or typhoid state of fever, when the pulse is feeble, and the blood impaired. Not only is the circulation weak, but the cerebral centres also, in consequence either of the depressing effect of the cause, or of the depraved blood. Stupor or delirium does not, in these cases, constitute a contraindication, when the low muttering character of the latter, and the capability of being roused from the former, taken in con- nexion with the general condition of the system, shoAV, that the brain is suffering rather from debility than from over-excitement. Indeed, opium, by stimulating the cerebral centres, often operates favourably in relieving the two conditions referred to. The tre- mors subsultus tendinum, general uneasiness, occasional wakeful- ness and other nervous disorder afford other indications for the use \ 746 GENERAL STIMULANTS. [PART II. of opium, Avhich is, indeed, among our best remedies in the typhoid condition of fever. By this expression I do not wish to designate a special febrile disease, as typhus or enteric fever, though these afford the best characterized type of the condition; but a peculiar state of febrile disease, which may attend any one of the idiopathic, and, indeed, even of the symptomatic fevers, and may be known wherever it exists, by a feeble pulse, dryness and darkness of the tongue or a tendency to them, a dusky hue. of the surface, and more or less of the nervous derangements just mentioned. It is seldom met with at the commencement of the special fever Avhich it accompanies; and opium, therefore, is not usually indi- cated at that stage. The medicine may be combined Avith ipecacu- anha when the skin is dry; and a little blue mass may often be added to the tAVO, with a view to its stimulant influence on the various secretions. They should all he given, as a general rule, in these cases, in small doses frequently repeated. A favourite com- bination of my own, under these circumstances, consists of one- sixth of a grain of opium, the same quantity of ipecacuanha, and half a grain or a grain of the mercurial pill, to be given every two hours. This is especially adapted to the condition as it occurs in enteric or typhoid fever. When opium, in cases of this character, in- creases stupor, delirium, heat of skin, dryness of mouth, or fre- quency of pulse, it is acting injuriously, and should be omitted. But Avhen it quiets delirium, gives a disposition to natural sleep, lessens the frequency but increases the fulness and force of pulse, and moistens the skin, it is acting beneficially, and should be per- severed in. Without having the typhoid character, fevers are not unfre- quently attended with nervous disorder, such as twitchings of the muscles, sudden startings, general uneasiness, restlessness, Avant of sleep, and sometimes slight delirium, Avhich will often yield to a full dose of opium, with an equal quantity of ipecacuanha, .or a proportionate amount of tartar emetic, given at bedtime. But in determining as to the propriety of administering it in such cases, reference should always be had to the contraindications mentioned in pages 744 and 745. There is another condition of fever in which opiufn is strongly indicated, with a view to its stimulant influence, especially on the cerebral centres. I allude to the cold stage at the commencement of fevers, when it assumes a violent character, either simply of col- lapse, or of this Avith intense disturbance of the functions. Such a CHAP. I.] CEREBRAL STIMULANTS.—OPIUM. 747 condition characterizes the onset of pernicious miasmatic fever; but it is also not unfrequently met with in other malignant fevers, as in malignant typhus, yellow fever, smallpox, erysipelas, &c; and, in a less degree, in febrile diseases not malignant. In the chill of com- mon intermittent fever, the depression is frequently so great and so lasting as to call for the same treatment. In all these cases, the original depression is in the nervous centres. It is through them that the cause of the fever first acts, and, prostrating them by its force, produces the general prostration as a secondary result. Opium is obviously indicated by its highly stimulant action upon these centres; and is preferable to alcohol, because the excitement of the circulation which it produces is sooner over, and does not, therefore, continue forward into the stage of reaction, as the alcoholic stimu- lation does. Ardent spirits might equally excite the nervous centres, though even in this respect their operation is less favourable than that of opium; but they also endanger an increase of the fever to follow, which opium, properly used, does not. The latter medicine is, indeed, of the utmost importance in the condition now under consideration, and perhaps, on the whole, superior to all other reme- dies. It should always be given in full doses, being quite inade- quate to the desired effect in small quantities. The only contraindi- cation is an active congestion or inflammation of the brain; but, happily, this is comparatively rare under the circumstances referred to. In doubtful cases, great contraction of the pupil might add some weight to that of other symptoms marking the contraindi- cating condition of the brain; but alone it is of little value. Still another condition common in fevers, and indicating the use of opium, is sickness at the stomach. When this does not depend on acute gastric inflammation, it will often yield promptly to opium or its preparations, administered by the mouth, the rectum, or en- dermically at the epigastrium. The special fevers occasionally offer special indications for opium besides those mentioned. Thus, it is often useful in the enteric or typhoid fever, by putting a check to exhausting diarrhoea, and aiding in the suppression of hemorrhage from the boAvels in the advanced stage. In smallpox it is very serviceable in the stage of maturation, and subsequently by moderating the irritative reaction of the disease of the surface upon the system generally. This it does by diminishing the susceptibility of the nervous centres, and consequently their power of receiving impressions from the surface, and transmitting 748 GENERAL STIMULANTS. [PART II. them, in the form of irritation, to the heart, lungs, &c. The same remark is applicable to erysipelas; but caution is more necessary in this affection, not to aggravate any existing disposition to cerebral congestion. In intermittent fevers, opium will often effect cures, and may be very beneficially resorted to in the absence of quinia, or as an ad- juvant to that medicine. To be most efficient, it must be given in the intermission, and so that it shall be in full action at the time of the expected return of the paroxysm. Its operation is strictly anti- periodic, and has already been explained under the indications for the use of opium. (See page 740.) Somewhat more than the medium full dose may be given in this case. 2. Inflammations. Much apprehension has been entertained of the effects of opium in acute inflammations. The medicine is a stimulant; inflammation is essentially a state of over-excitement; and the tAvo have consequently been by some considered as almost incompatible. But the fact is otherwise. Experience has shown that opium is a highly useful remedy, when properly administered, in acute inflammations. In certain cases, administered in full dose, at the very first approach of the disease, it Avill often set it aside entirely, especially if taken with ipecacuanha at bedtime, and aided in its operation by draughts of some warm tea, especially the infu- sion of balm. It seems to preoccupy the nervous centres so as to arrest the irritant influence of the cause, while it carries off the morbid tendencies through the skin, by its diaphoretic action. The special inflammations in which opium is most efficient in this way are those of the respiratory passages, as coryza, angina, and bron- chitis, and different forms of rheumatism, particularly the subacute. There is sometimes, however, danger, if it should fail of its effects, that it may somewhat aggravate the affection; and the method is not generally advisable. After the inflammation has become established, especially if it be severe, opium is at first, in general, contraindicated. Its stimulating properties are as yet in too strong contrast Avith the wants of the disease. Before commencing with it, the activity, both of the in- flammatory action and of the attendant fever, should, in general, be reduced by depletory methods, as by purgatives, the lancet, the antimonials, &c.; but, at the end of two or three days, a sufficient reduction may generally be accomplished, sometimes even sooner, and the opiate be safely administered. It operates very usefully in various ways. In the first place, it alleviates pain, thereby preventing the injurious reaction of that CHAP. I.] CEREBRAL STIMULANTS.—OPIUM. 749 morbid condition on the system, as well as diminishing the suffer- ings of the patient. But the practitioner must take care not to confound the relief thus obtained for a positive amendment, or he may be led into serious practical error. He must learn to estimate the real state of the inflammation by other symptoms than that of pain. In the second place, opium enables the patient to sleep, and obviates the exhausting effects of long wakefulness upon the re- sources of the system, and its direct injury to the brain. But, thirdly, it is still more influential for good, by reducing at once the inflammation and the febrile excitement, through its indirect se- dative action. In the inflamed part, the nervous constituent suffers irritation as well as the vascular; and the former, reacting on the latter, aids in sustaining the excitement in the vessels, and the con- sequent inflammatory phenomena. This property of the nerves, when irritated, to propagate irritation to the blood-vessels, is obvious even in pure neuralgia. In this affection, though the seat of pain may be at first colourless, it soon evinces signs of vascular con- gestion, by redness, heat, &c. Hence, in cases of inflammation, if we can diminish the nervous irritation in the part, we diminish also the inflammatory action. Opium produces this effect under the same circumstances as those in which it relieves pain, and through the same influence. Again, the local disease produces fever, partly at least, if not exclusively, by operating on the system at large through the nervous centres. If these are rendered obtuse or in- sensible, so as not to be susceptible to impression from the inflamed part, the reaction on the system must be diminished, and more or less in the same proportion. In this Avay opium has a tendency to lessen the fever in inflammation, and, as the fever reacts again on the local disease, to diminish that also. But, to do good in inflammation, the medicine must be given in full doses, so as to act energetically as an indirect sedative. The plan Avhich I generally pursue in acute inflammations is, after suf- ficient depletion, which may usually be effected in two or three days, to give opium at bedtime, combined Avith ipecacuanha and calomel, in a dose sufficient to put the patient to sleep. Tavo grains of opium, two of ipecacuanha, and from two to four of calomel may be made into four pills, two to be given at once, a third at the end of an hour, if sleep is not produced, and the fourth at the end of another hour, in a similar contingency. This plan may be con- tinued regularly till no longer required; the bowels being opened daily- The basis of a mercurial treatment is thus laid, which, if deemed advisable from the threatening character of the inflamma- 750 GENERAL STIMULANTS. [PART II. tion, may be carried into effect about the fifth or seventh day, by giving two of the pills every six or eight hours, or one at half the interval, till the gums are touched. The opiate should be gradu- ally withdrawn when no longer needed; so that, when the patient has quite recovered, the want of it may not be felt. Inflammation occuring in different organs requires some modification of this treatment. In acute gastritis, the opium and calomel should generally be given without the ipecacuanha, Avhich is apt to occasion nausea. In severe cases of enteritis and dysentery, the above treatment is specially useful; anodyne enemata being additionally employed in the latter affection, when found upon trial to allay the tenesmus. In dysentery, opium has by some been considered as contraindi- cated, in consequence of its constipating effects; but experience has not confirmed these apprehensions. It is, indeed, if properly timed and used, one of the most effectual remedies in that complaint, especially when combined as above recommended. It relieves the spasmodic pains of the complaint, and does not interfere with the action of cathartics, but probably rather facilitates it. But the caution must be observed of keeping the boAvels duly open during the day. In peritonitis opium and calomel are invaluable, when further de- pletion is out of the question, and in cases which will not admit of depletion at all. In the peritonitis from perforation of the bowels, opium is the only remedy upon which reliance can be placed. In the same affection, without perforation, occurring in the course of low febrile diseases, or attended from the beginning with the same condition of system, the opiate plan with mercury should be commenced immediately after a thorough evacuation of the boAvels; the opium being freely administered, and the bowels afterwards left undisturbed, except by the occasional exhibition of a cathartic enema, to evacuate the rectum and lower colon. In hepatitis, opium should be used with more reserve, in conse- quence of its property of checking the secretion of bile. Still, if it be combined with calomel, this effect may be in a considerable degree obviated; and I should not hesitate to employ it, if neces- sary to procure sleep. It is, however, better adapted to those cases in which the investing membrane is affected. In the parenchyma- tous inflammation of the gland, it would be best, on the whole, not to use it; and as the pain is in this case less severe, there is not the same occasion for its use. In inflammations of the internal urinary and genital organs, the CHAP. I.J CEREBRAL STIMULANTS.—OPIUM. /OJ general rule as to the use of opium holds good; but, as the stomach is very apt to be irritable in nephritis, it is often necessary to omit the ipecacuanha; and, in all these cases, the opiate is in general most efficaciously administered by enema. All the inflammatory affections of the chest, whether of the respira- tory or circulatory organs, come under the general rule, with the exception of the different forms of acute bronchitis, in which opium should, as a general rule, not be given until secretion has been thoroughly established; as it tends to prevent this result, and thus to increase the pectoral oppression, and to aggravate the disease. But, when the acuteness of the inflammation has been subdued, and expectoration has become free, opium in moderate doses is often very useful, in connexion with expectorants, in relieving the harassing cough, and enabling the patient to rest. The same rule applies also to the chronic form of the complaint. After what has been already stated, under the head of contra- indications to the use of opium, it is scarcely necessary to repeat, that it is altogether unsuitable to the treatment of acute inflam- mation of the brain, and of very doubtful advantage even in the chronic; though cases sometimes occur, in which, from* the parti- cular seat of the affection, as, for example, when confined exclu- sively to the meninges, the indications for its use -more than balance the contraindications. To procure rest is sometimes, under these circumstances, all important; and opium may be cautiously used, when no symptoms of acuteness in the inflamma- tion are present. In erysipelatous inflammation of the skin, opium may be given when not forbidden by stupor or coma. But of all the inflammatory affections there is no one to which it is better adapted than acute rheumatism. After tAvo or three days given to depletory measures, opium and ipecacuanha or the Dover's powder, may be given very freely; and, if associated with calomel so as to affect the system in the course of the second week, will in general be found adequate to the cure. In subacute rheu- matism the remedy is indicated from the commencement; and, in the chronic form, a Dover's powder at bedtime may enter into almost every plan of treatment adopted in that complaint. In acute gout, too, it is highly useful at bedtime, in relieving pain and enabling the patient to sleep, and, so far as I have seen, does no harm. It is, hoAvever, in this complaint better associated with colchicum; and the mercurial addition is not advisable unless merely to stimulate the liver when torpid. 752 GENERAL STIMULANTS. [PART II. In the suppurative stage of inflammation, opium in moderate stimulant doses, is of great use in supporting the system, and com- forting the patient; and should generally be given with the tonics and stimulants employed. Ulceration, when painful, and indisposed to the healing process in consequence of an irritated condition, connected, it may be, with an irritable state of the system at large, may be advantageously treated Avith opium, both given internally, and applied topically. When inflammation is attended with gangrene, opium is an in- valuable remedy, relieving the pain often attendant on that affec- tion, and supporting the nervous centres under its prostrating influence. Indeed, opium is indicated in mortfication under almost any circumstances; and, in the last stage of acute inflammation of the alimentary canal, given in combination with oil of turpentine, it affords, in some instances, almost the only remaining chance for the patient. After all that has been stated above, I wish not to be understood as recommending opium in all cases of inflammation, Avhen no positive contraindication may exist. In slight or even moderate cases, and in the chronic forms generally, it should be employed with great caution from the fear of leading the patient into its habitual use. 3. Vascular Irritation. In this condition, opium is often of great use, by diminishing the susceptibility of the nervous tissue of the part, and of the nervous centres, and thus obviating their injurious reaction upon the vascular tissue and the heart. In nausea and vomiting from this cause, it is an admirable remedy, applied either by the stomach, the rectum, or endermically to the epigastrium; the two latter methods being resorted to, severally or conjointly, upon failure with the first. When any medicine has a tendency to irritate the stomach, this may generally be corrected by conjoining the medicine with a little opium, which is very much used for this purpose, and may always be employed unless when specially contraindicated. Thus, it may be given with nitrate of silver in chronic gastritis, and sulphate of copper in chronic enteritis; but should not generally be exhibited with cathartics, which it tends to counteract, nor with tonics in dyspepsia, because it rather weakens than invigorates the digestive function. In slight diarrhoeas, resulting from vascular irritation, opium is often the only remedy required, Avhen there is no indication for CHAP. I.] CEREBRAL STIMULANTS.—OPIUM. 753 evacuating the bowels; and, when such an indication is offered by the presence of irritating matters, no remedy is so promptly effect- ual as fifteen or twenty drops of laudanum Avith a full dose of castor oil. In acrid poisoning, after the evacuation of the irritating agent both from the stomach and bowels, opium is the chief remedy required; and it may often be used advantageously in connexion with the special antidote of the poison. Emetics and acrid cathar- tics often leave an irritation behind them, which is promptly relieved by opiates either by the stomach or the rectum. In irritations of the urinary and genital organs they are no less promptly useful, and often afford almost instant relief to great distress, as, for example, in the strangury from blisters. In these affections, the opium is most effectual when given by injection, or used as a suppository. 4. Nervous Irritation. This exhibits itself in a great diversity of forms, which require a separate consideration. Neuralgic pain is among the most frequent. Wherever this occurs, and under whatever name, opium is at least a most efficient palliative, sometimes absolutely indispensable from the suffering of the patient. Not unfrequently it will set the disease aside entirely for the time, especially when occurring periodically. Given so as fully to affect the system, it will often wholly supersede the parox- ysm, and by thus breaking the chain of morbid association, effect at least a temporary cure. The quantity necessary to produce relief varies greatly with the violence of the pain, and the constitutional susceptibility of the patient. Sometimes an ordinary full dose will answer; but not unfrequently it will be found necessary to double, triple, or quadruple it, before relief can be procured. When local application will answer the purpose, it should be preferred, as inter- fering less with the functions of the stomach and bowels. AVith the skin unbroken, little effect can generally be obtained; but, by- means of the endermic method, the medicine may generally be used with prompt and powerful effect, in the form of one of the salts of morphia. Not unfrequently a specially tender spot may be dis- covered in the track of the nervous trunk, supplying the painful part. In this case, the remedy should be applied to the point of tenderness; the cuticle having been first removed by a blister. But a crreat objection to the use of opium in neuralgia is the increasing dose in which it must be successively employed in order to procure relief and the consequent danger of augmenting the quantity in- definitely, until the effects of the remedy become almost as perni- cious as the disease itself. This objection applies especially to cases vol. l—48 754 GENERAL STIMULANTS. [PART II. in which the affection is incessant in its attacks, and probably in- curable. Yet the patient will seldom submit to severe suffering, when an agent of present relief is at hand; and the duty of the physician is so to regulate the remedy as to obviate its ill, and pro- tract its beneficial effects as far as possible. This is to be done by allowing the dose to be increased only when absolutely neces- sary; by varying the surface of application between the stomach, the rectum, and the skin; by occasionally intermitting the use of the medicine, and endeavouring to obtain a similar effect by ano- dynes acting on different principles, as by chloroform or conium; and by correcting any resulting disorder of the functions by proper means, as constipation by laxatives, deficient action of the liver by mild mercurials or nitromuriatic acid, and enfeebled digestion by tonics, taking care not to do injury by the excessive use of the counteracting measures. By this plan, in incurable cases, the pa- tient may be rendered more comfortable, and his life prolonged; whereas, if left to his own unrestrained propensities, he might soon exhaust the susceptibility of his system, and thus render the remedy almost useless. Even in occasional attacks of neuralgia, occurring at considerable intervals, the physician should always bear in mind the danger of laying the foundation of an evil habit, and should guard the use of opiates with such precautions as may tend to obviate this result. Sometimes, in persons of feeble intelligence, or deficient power of self-control, it may be proper to disguise the medicine so that the patient may not know what he is taking; and generally it is best to confine the use of opium, when the recurrence of the pain is fre- quent, to the severest attacks. Besides the external attacks of neuralgia, which may occur in any sensitive part of the body, from the crown of the head to the joints of the great toe, there are va- rious internal forms of it, which are.sometimes even more imperious in their demands for relief, as angina pectoris, gastralgia, enteralgia, nephralgia, and dysmenorrhoea, the last of which is, I believe, often nothing more than a neuralgic form of rheumatism, and may be most effectually relieved by this anodyne given by the rectum. In the forms of toothache and earache, the opium may often be applied locally with effect; being introduced into a carious cavity, should a cavity exist, in the former case, and in a liquid form into the meatus extern us, in the latter. Neuralgia is often nothing more than a form of nervous gout and rheumatism, in which cases the opiate may be associated with the CHAP. I.] CEREBRAL STIMULANTS.—OPIUM. 755 wine or extract of colchicum, and frequently also advantageously with a saline cathartic. Nervous headache, or sick headache, will often yield happily to a full dose of opium or morphia, which is most effectual, however, in the latter affection, when it perseveres, after evacuation of the sto- mach. But care must be taken not to confound this complaint with headache from vascular irritation, or active congestion of the brain. In cancerous affections it is often necessary to have recourse to anodynes; and the observations above made, in relation to the pre- cautions necessary to guard against the abuse of the medicine in incurable neuralgia, and to obtain the greatest amount of good from it, are equally applicable to this case. The same remark may be made of aneurisms and all other tumours, which, though not painful in themselves, often become extremely so by pressure on the trunks of neighbouring nerves, or in other modes interfering with the healthy structure near them. Painful spasms afford still stronger indications for the use of opium than simple neuralgia, because often more dangerous in their consequences, and because, also, being only occasional, and gene- rally occurring at distant intervals, there is less danger of an abuse of the remedy. These spasms may be either external, affecting the voluntary muscles, or internal, affecting the muscles of organic life. Of the former we have examples in ordinary cramps of the limbs, in the intensely painful cramps of cholera, and in tetanus. It is in the two latter affections chiefly that opium is used; and in both it is certainly among the most efficient remedies. In tetanus, the insus- ceptibility of the cerebral centres is such, that much larger doses are required than under ordinary circumstances. Two grains may be given at first every two hours, and, if necessary to bring about relief, the dose may be increased to four, five, or six grains, or an equivalent proportion of morphia or one of the liquid preparations, repeated as often, until some degree of narcotic effect is experienced; but the quantity of half a drachm of opium in twelve hours should in no case, I think, be exceeded; as, if the disease should suddenly give way, poisonous effects might ensue from the portion remaining unabsorbed in the stomach. The internal painful spasms are those of the stomach, of the boAvels in the different forms of colic, of the ureters and ducts of the liver from the passage of calculi, of the blad- der of the uterus, and finally of the diaphragm and the heart. In all'these affections the pain is often exquisitely severe, and in some of them life is endangered by its continuance. All of them afford 756 GENERAL STIMULANTS. [PART II. the clearest indications for the use of opium, which may in general be given unhesitatingly, and in quantities requisite to obtain relief, beginning with a full dose, and increasing till the pain is alleviated or narcotic effects induced. The same insusceptibility to the influ- ence of the anodyne exists as in tetanus, though usually in a much less degree; and it is seldom necessary to exceed two grains of opium, or an equivalent quantity of its preparations, at one dose. The liquid preparations are preferable to solid opium, as they operate more speedily. In these several affections, it is necessary to combine special modes of treatment with the anodyne, which, however, this is not the proper place to detail. As examples, it may be mentioned that, in gouty spasm of the stomach, colchicum may be combined with the opiate; in ordinary colic, castor oil; in bilious colic, calo- mel ; in spasm of the heart or diaphragm, ether or chloroform; in spasm of the hepatic ducts, ether and oil of turpentine; in that of the ureters, the alkaline bicarbonates; that in all of them sinapisms and the warm bath are efficient adjuvants; and that, when not con- traindicated by debility, the lancet may often be used with powerful effect in producing relaxation. The spasmodic pain attending en- teritis, cholera, dysentery, and peritonitis, affords indications for the use of opium; but those founded on other effects than the merely anodyne are much more important. Various spasmodic and convulsive affections, not painful in their character, or but slightly so, belong to the category of nervous irri- tations, and are more or less benefited by opium. Such is the par- oxysm of spasmodic asthma, in which opium will often afford relief, though it is liable to the objection of checking bronchial secretion, and is, on the whole, much less efficient than some other narcotics and nervous stimulants or sedatives. In epilepsy it may sometimes be used as a palliative; but, on the whole, is better avoided, both from its liability to abuse, and from its congestive influence on the brain. In hooping-cough it is liable to the same objection as in asthma, and should be used only as a palliative of the cough, in connexion with expectorants. To chorea it is scarcely appropriate, unless to obviate occasional intercurrent affections. In the various spasmodic affections of hysteria it is for a time an almost sovereign remedy; but, on moral grounds, requires to be prescribed with cau- tion. In the convulsions of infants, depending on intestinal spasm, opium is an excellent adjuvant of other remedies. To the list of nervous irritations relieved by opium may be added obstinate wakefulness, general uneasiness, restlessness, languor and faint- CHAP. I.] CEREBRAL STIMULANTS.—OPIUM. 757 ness, palpitations, nervous cough, and all the protean derangements of hysteria; but, as a general rule, it is better to seek relief, in these affections, when not associated with other serious diseases, from remedies less accordant with the propensities of our nature, and less liable to abuse. 5. Nervous Depression. In affections of this nature, the stimulant influence of opium on the nervous system renders it peculiarly effi- cacious. Perhaps under this head we might rank the collapse of the initial stage or chill of certain febrile diseases; but enough has been said on that subject already. Insanity often presents conditions in which this influence of opium is extremely useful. There is a species of delirium resulting from extreme fatigue, long watching, exhausting indulgences, excessive study, &c, for which this is the most efficient remedy, combined with measures calculated to restore strength. Such attacks of delirium occasion- ally supervene upon acute diseases, especially those of a febrile character, and are very liable to be mistakenly ascribed to active congestion or irritation of the brain. I have seen it occur in acute rheumatism, and cause serious apprehensions of rheumatic menin- gitis. I have also seen such a condition occur in erysipelas, with- a sudden disappearance of the local inflammation, and with signs of great prostration. The relief obtained, in all such cases, from full doses of opium, is a sufficient proof of their nature. It is usually advisable to combine the opium with ipecacuanha, so as to mo- dify its stimulant effect, should the diagnosis prove to have been erroneous. Delirium tremens is an example of the same condition of the brain induced in drunkards, by the abstraction of their wonted stimulus. In this affection, I regard opium as the most valuable remedy in our possession. Given in the dose of about two grains, repeated every two hours, it will almost always, in the uncompli- cated cases, induce sleep, from which the patient will wake im- proved, if not quite cured. Sometimes two or three days may elapse before the effect is produced; but no injury results, if the opium is withheld upon the first occurrence of narcotic symptoms. It is seldom necessary to exceed the amount stated. Injurious cerebral effects have been ascribed to the use of opium in delirium tremens; but I have not seen them, though much of the disease has come under my notice. Where they have occurred, I presume that the meningitis of drunkards has been mistaken for pure delirium tre- 758 GENERAL STIMULANTS. [PART II. mens; a mistake which may be readily made, as the symptoms of the latter disease are almost always, and necessarily intermingled Avith it. But, while the opium is given as the main remedy, suffi- cient alcoholic drink should be administered to prevent prostration. I have seen death result apparently from a neglect of this precaution. Most of the affections already referred to, as the result of nerv- ous irritation, may proceed also from debility or depression of the nervous centres; and as the former yield to the indirect sedative property of opium, so do the latter to its direct stimulant action. 3Luscular tremors, spasmodic and convulsive affections, wakefulness, general uneasiness, restlessness, depression of spirits, palpitation of the heart, dyspnoea, various abnormal sounds and visual disorders, vertigo, and headache, are some of the affections referred to. As a proof that they are really the effects of weakness or depression, they come on frequently as the direct consequences of a debilitated state of system, as in convalescence from exhausting diseases, after hemorrhages or copious bleeding, and under the direct influence of sedative poisons, as tobacco and hydrocyanic acid. They generally yield, at least temporarily, to moderate doses of opium. 6. Morbid Discharges. In these affections opium is one of the most efficient means employed, and, whatever other remedies may be used, is very often connected with them. It probably operates, through its indirect sedative agency, in allaying irritation in the part affected, and diminishing the activity of the capillaries. The morbid discharges are either, in the first place, secretory or excre- tory, or secondly, hemorrhagic. To the first category belong diar- rhoea, the different forms of cholera, diuresis and diabetes, gastror- rhcea, cystirrhcea, bronchorrhcea, and ptyalism. In diarrhoea and cholera opium acts not only by restraining secre- tion, but also by diminishing the activity of the peristaltic move- ment, probably through a sedative agency in relation to the organic nervous centres. Of its use in the diarrhoea dependent on acute inflammation or vascular irritation of the alimentary mucous mem- brane enough has been said already. But there is no form of that affection in which it may not be usefully employed, except, simply, in cases in which the affection is acting beneficially, either by divert- ing disease from some part where it might do more harm, relieving plethora, or promoting the absorption of effused fluid, as in dropsy. In all these cases, opium may prove injurious by prematurely ar- resting the discharge; and should be resorted to only to regulate the amount of it, and to control it when likely to do more injury CHAP. I.] CEREBRAL STIMULANTS.—OPIUM. 759 by exhausting the patient, than good in either of the modes men- tioned. In bilious diarrhoea, it acts upon the liver as well as on the bowels; but should generally not be used alone, as the excess of the bilious secretion is probably relieving hepatic congestion, and its suppression might endanger an attack of hepatitis. Under such circumstances, it should always be associated with small doses of calomel, Avhich, while the opium restrains the secretory function of the liver, has the effect of preventing its entire suspension, and, at the same time, acts as an alterative upon the gland. The best method of administering the two remedies, in this affection, is to give very small doses of each, very frequently repeated; so that their operation may not be too powerful at once, and may be more conveniently watched, and timely checked if desirable. One-sixth of a grain of each may be given every hour or two, till the desired effect is produced, or a grain or two have been administered; and it is often a good plan to intermit the treatment every other dav, resorting in the intermediate day, if the discharges have been arrested, to a mild laxative. In the diarrhoea attended with copious light-coloured discharges, which are sometimes very profuse and ex- hausting, opium is equally indicated as in the former case; and there is a still stronger call for the conjoint use of calomel, in order to restore the hepatic function, and thus unload the portal veins through their natural outlet. In chronic diarrhoeas, whether depend- ent on relaxation, mere habit, or chronic inflammation or ulcera- tion, opium in small doses, though it cannot be depended on for the cure, is an almost essential adjuvant of the astringents and alteratives employed; and, in full dose, combined with ipecacuanha at night, operates very usefully by superadding to its direct influ- ence on the peristaltic movement, a revulsive influence towards the surface. In cholera, opium is no less efficient. The ordinary bilious cholera or cholera morbus, may be treated with it precisely in the manner above recommended for bilious diarrhoea; the two diseases being, in fact, identical in character. But, when the pains are very severe, and the discharges exhausting, it may be given in larger doses,- and by enema if rejected from the stomach; calomel being at the same time moderately exhibited as before, to guard against a total suspension of the hepatic secretion. The discharges of bile in cholera morbus are no doubt intended to relieve a congestive irritation of the liver and Avhole portal circulation, which Avithout this outlet might end in serious inflammation or fever. The use 760 GENERAL STIMULANTS. [PART II. of calomel insures a sufficient action of the liver to prevent ulti- mate evil, while the opium prevents immediate mischief by arrest- ing the excessive discharge. Epidemic cholera I believe to be a different affection from ordinary cholera morbus, and to depend on a different cause. Nevertheless, there is the same indication for the combined use of opium and calomel. In the stage of diarrhoea, or the joint discharge from the stomach and bowels called cholerine, which generally precedes the distinctive rice-water evacuations of the fully formed disease, opium is the remedy mainly to be relied on. With or without camphor and the aromatics, and in small doses frequently repeated, it almost always arrests the discharges, and thus probably averts cholera itself. I have usually preferred the ordinary paregoric, or cam- phorated tincture of opium of the Pharmacopoeias, of which a fluidrachm may be given three or four times a day if necessary. Should the evacuations from the bowels be destitute of bile, small doses of calomel and opium should be employed as above advised. Sometimes it may be necessary to give the opiate more largely, and to combine with it an anodyne enema, and a sinapism over the abdomen. When the cholera is fully formed, opium is still, I think, the sheet anchor in this disease. It should now be given in the dose of a grain or two at first, and afterwards repeated at inter- vals of half an hour or an hour, in one-quarter, or one half the dose, till the discharges are arrested, and the pains relieved, or till some evidence of narcotism is produced. After this, it is of no use to push its effects further. Indeed, it can do only harm, by aggra- vating the general prostration through its secondary sedative effects. The great rule is not to allow it to render the patient stupid, or comatose; but, within this point, to continue its use, at longer or shorter intervals, so long as indicated by the spasms and the eva- cuations. But it should never be relied on exclusively. With the quantity of opium above mentioned, from two to four grains of acetate of lead, and a grain or two of calomel should be given, to be repeated afterwards along with it in proportionably diminished doses. At the same time, an anodyne enema should be exhibited, and a sinapism applied over the whole abdomen ; warmth and rubefaction to the extremities being additionally used, if these should be cold and bloodless. In the collapse of cholera, opium is of little or no use. In the stage of reaction, its employment must be governed by the same principles as in low fevers and inflammations. CHAP. I.] CEREBRAL STIMULANTS.—OPIUM. 761 Cholera infantum does not offer equally strong indications for the Use of opium. The head is so apt to suffer in infants, that any- thing which tends to congest the cerebral centres must be used with caution. Nevertheless, if the vomiting cannot otherwise be re- strained, this remedy may be cautiously administered, and should be preferably used by injection; great care being taken to propor- tion the dose to the age. In the subsequent stages, when the affection has assumed rather the character of diarrhoea, and the in- dication exists for checking the evacuations, very small doses of opium, or one of its preparations, may be added to the cretaceous, astringent, or alterative medicines employed. In excessive secretion of urine or diuresis, especially when connected with nervous disorder, or an irritable state of the system, opium is one of the most efficient remedies. In diabetes, strictly so called, it is an excellent palliative, diminishing frequently the amount of excretion, moderating the wear of the system, and greatly comfort- ing the patient; but it is wholly inadequate to the cure. It should be used in this complaint in full doses, and preferably at night. In small doses, frequently repeated, so as to produce its stimulant effects, I have often known it greatly to increase the secretion of urine. In excessive mercurial salivation, opium is very useful, not only by checking the discharge, but by relieving pain, and diminishing nervous irritability. In the excessive mucous secretion from the stomach, bladder, and bronchial tubes, called respectively gastrorrhcea, cystirrhcea, and bron- chorrhcea, opium may be usefully employed as an adjuvant or cor- rective of other medicines; but cannot be relied on exclusively, or even as the chief remedy. Under this head may be mentioned the use of opium in connexion with other medicines, where it may be desirable to prevent their operation upon the bowels. For this purpose, it is almost constantly given with calomel, and frequently with the blue mass, when the object is to obtain the peculiar effects of mercury on the system. Hemorrhages constitute the second division'of morbid discharges. In most of these opium is indicated, both from its effects upon the capillaries, and for its influence in quieting various attendant irrita- tions Avhich often serve to aggravate the main affection. Thus, in hemorrhage from the lungs or air-passages, it often proves serviceable by allaying the irritative cough, Avhich, by agitating the parts, tends to sustain the bleeding. In hemorrhage from the stomach, after the full 762 GENERAL STIMULANTS. [PART II. evacuation of its contents, an irritated condition often remains, which provokes vomiting unnecessarily, and prevents the retention of medicines that may be indicated. Opium by the mouth or rec- tum, or endermically to the epigastrium, is very useful in such a condition. So also in hemorrhage from the bowels, bladder, and ute- rus, it tends to control the irritative movements, which, beyond Avhat may be necessary for the mere evacuation of the effused blood, can act only disadvantageously on the affection. For these purposes, it is usually sufficient to employ small doses, in conjunc- tion with the other medicines indicated. For the direct influence of the opium on the bleeding vessels, it should be given in full doses, and combined with ipecacuanha; the patient being confined to bed, and well though not hotly covered, so as to favour the per- spiration which is apt to be induced. But for this purpose, opium is not indicated in all the hemorrhages, nor in all conditions of any one of them. It should not be used when the pulse is full and strong, with a general febrile movement, and an active congestion of the bleeding organ. This condition should be removed by de- pletory and refrigerant methods, before recourse is had to opium. The remedy, in full dose, is of doubtful propriety in any case of haemoptysis, in consequence of its tending to check bronchial secre- tion, and thus rather to promote than relieve congestion of the vessels. Nor can it be given, as a general rule, in connexion with ipecacu- anha in hasmatemesis. But in intestinal, renal, and uterine hemor- rhages, after a suitable preparation of the system, or in cases which have at no time presented any contraindication, it is often an ex- cellent remedy. In menorrhagia it is especially useful, and, Avith rest, will often itself be quite adequate to the cure. In the purely passive hemorrhages, whether dependent on mechanical obstruction, or on that disorganized state of the blood which permits it to ooze out through the unresisting coats of the capillaries, opium can be of little service as a mere haemostatic. As a stimulant it may be useful in the condition of system attendant upon the state of the blood referred to. 6. Administration. The dose of opium varies extremely with the purpose to be ful- filled, the idiosyncrasies and habits of the patient, and the modifi- cation of susceptibility produced by disease. For full anodyne and soporific effect, the medium dose is one grain. Less than half a grain will seldom produce these effects fully; and more than two grains should very rarely if ever be given, as a commencing dose, to an CHAP. I.] CEREBRAL STIMULANTS.—OPIUM. 763 individual whose peculiar susceptibilities are unknown to the pre- scribes For the pure stimulant effect, in persons quite unaccustomed to the use of the medicine, and in diseases in which the susceptibility is not impaired, the dose may vary from one-eighth to one-half a grain, which should be repeated, according to the quantity given, every two, four, or six hours, so as to sustain a steady impression. As a mere nervous stimulant, in the sense in which that expression is used in this work, to designate, namely, a certain class of medicines having peculiar properties and applications, the dose is from one-twelfth to one-quarter of a grain. For this purpose, the liquid preparations are generally to be preferred. But it must be remembered, in regulating the dose of opium, that some persons are naturally extremely susceptible, and others perhaps equally insusceptible to its effects; that, under the influence of habit, an individual becomes gradually less and less susceptible, and to an indefinite extent; and, lastly, that, in certain diseases, in which the cerebral centres are vastly depressed, and in others in which the whole energies of the nervous system are concentrated in some violent local affection, the dose required to produce a given effect is greatly augmented, and sometimes almost indefinitely. Among the former affections are delirium tremens, and the collapse at the commencement of certain fevers; among the latter, spasm of the stomach, severe colic, and, above all others, tetanus. The commencing dose for an infant at birth, and for two or three weeks afterwards, should not exceed one-fortieth of a grain; and not more than from one-twentieth to one-tenth of a grain should be given to a child within the year. After this age, the dose may be regulated according to the rule of Dr. Young. (See page 35.) The liquid preparations are generally preferable for infants. Opium, in substance, may be taken in powder, pill, lozenge, or electuary! The form of pill is almost always preferred. For ordi- nary purposes, the pill should be made from powdered opium, and should not be kept very long before being used. But, when it is desirable, on any account, that it should operate very slowly, either an old pill, or one made directly from the plastic mass, may be em- ployed. The form of lozenge is used only when it is desirable that the medicine should be held in the mouth, and allowed slowly to dissolve; so as to act specially on the mouth and fauces, as may sometimes be desirable in coughs. T5y the rectum, opium is used in the form of a suppository, or in that of an enema. The suppository may be made by rubbing the opium up with soap, and forming the mass into a cylindrical shape. 764 GENERAL STIMULANTS. [PART II. The dose given by the rectum should not, at first, exceed tAvice the quantity administered by the mouth. A triple dose has not unfre- quently been given, and even more, without injury; but there is thought to be some risk from this larger quantity; at least, effects much greater than were anticipated or desired have sometimes been produced. The dose, then, in this Avay, at the first trial, may vary from one to four grains. In persons habituated to large doses of opium by the mouth, there might possibly be some danger from giving by the rectum twice the quantity usually taken in the former Avay. The susceptibility and absorbent power of the rectum may not bear the same relation to those of the stomach as before the habit was acquired. It would be safest, under these circum- stances, to begin with a relatively very small dose, and increase, if necessary. For enema, one of the liquid preparations should generally be used, and administered in a Avineglassful of pure water, or of some mucilaginous or amylaceous liquid, as flax-seed tea, or solution of starch. The purposes for which opium is specially employed in this way are, 1. to affect the system, when the stomach will not retain the medicine; 2. to allay irritability of the stomach; 3. to check evacuations from the bowels; and 4. to'relieve pain or other irritation in the rectum itself, or neighbouring parts, as the genito-urinary apparatus. Thus, strangury, spasm of the ureters, bladder, and urethra, dysmenorrhcea, priapism, cordee, &c, are more effectually and speedily relieved by -opium, when given by the rectum, than by the mouth. Opium or one of its liquid preparations is sometimes injected into the urethra or vagina, to relieve pain or irritation, or suppress dis- charges. It is also introduced into the cavity of a carious tooth, to relieve toothache, and into the external meatus in earache. One of its liquid preparations is not unfrequently dropped into the eye, to allay irritability of the conjunctiva in ophthalmia. In the form of lotion, embrocation, cataplasm, or plaster, it is applied to various parts of the surface, to relieve pain, as in neuralgic affections, gouty and rheumatic pains or swellings, erysipelatous inflammation, va- rious cutaneous eruptions, and irritated ulcers. But caution is always necessary, in these cases, not to use it so largely that, if' absorbed, it might produce poisonous effects on the system; and special caution is necessary in infantile cases. 7. Preparations of Opium. These are very numerous, but scarcely more so than desirable, when the great diversity of circumstances is considered under which CHAP. I.J CEREBRAL STIMULANTS.—OPIUM. 765 the medicine is used, the different purposes it is calculated to fulfil, according to the method or form in which it is employed, and the variable idiosyncrasies which require that, if one preparation may not happen to agree with the individual, we may have recourse to another, or to many successively, until one is found to answer. PILLS OF OPIUM. —Pilule Opii. U.S. These are prepared by simply incorporating opium with soap, which answers no other purpose than that of a convenient excipient. Each pill contains a grain of opium. COMPOUND PILLS OF SOAP.—Pilulje Saponis Composite. U.S. In these pills, also, there is a mere mixture of bpium and soap; but the proportions are so arranged, that five grains of the mass contain one grain of opium. They afford a ready method of ob- taining small fractions of a grain of opium, when wanted, as they frequently are, for children. Another advantage is that they may be prescribed, without a knowledge, on the part of the patient, of what has been directed for him. The London College, .upon the same grounds, have directed the Compound Pills of Storax, in which storax and saffron are employed, not only to dilute the opium, but to cover its taste and smell.. The proportion of opium is the same as in the U. S. preparation, namely, one grain in five of the mass. POWDER OF IPECACUANHA AND OPIUM.—Pulvis Ipecacu- anha et Opii. U.S.—Pulvis Ipecacuanha Compositus. Lond., Ed., Dub.— Compound Powder of Ipecacuanha.—Dover's Powder. This is an excellent diaphoretic preparation of opium, but will be more fully treated of with the diaphoretics. CONFECTION OF OPIUM.—Confectio Opii. U.S. This is prepared by rubbing opium up with honey and the offi- cinal aromatic powder, consisting of cinnamon, cardamom, and nutmeg. It has the advantage, through the stimulating property of the aromatics, of counteracting the depressing effects of opium upon the digestive function, and may sometimes be received by an irritable stomach, Avhen opium would be rejected. The possession of this property sufficiently indicates the circumstances under which it may be used. It is supposed, when given Avith Peruvian bark and sulphate of quinia, to increase their efficacy in obstinate inter- mittents. One grain of opium is contained in about thirty-six grains of the composition; so that it affords a convenient form for pre- scribing small doses for infants. 766 general stimulants. [part ii. EXTRACT OF OPIUM.—Extractum Opii. U. S, Lond., Ed., Dub. This is an aqueous extract of opium, and of course consists ex- clusively of the principles soluble in water. Opium contains ingredients insoluble in water, which, however, it yields to an alcoholic solvent, either vinous or distilled; and, as these prin- ciples may possibly be not without some influence upon the system, the effects of the opium may be som«what modified in the extract, ancl different from those obtained from opium itself, its tinctures, or the wine. Hence this preparation is supposed to agree with certain individuals, with whom opium and its other preparations disagree. It has the advantage also of affording a ready means of preparing a solution of the active matter of opium in water, which is sometimes desirable, particularly for application to the eye, and other external inflamed surfaces, and for injection into inflamed or irritated mucous passages, as the rectum, urethra, or vagina, in all of which cases, the stimulant properties of the tinc- ture, derived from the alcohol it contains, are contraindicated. The dose- is one-half that of opium. In dysenteric cases, an in- jection of the extract of opium dissolved in water, will sometimes be retained, and afford relief, when laudanum, which is usually employed, would be rejected; and it is not impossible that the same remark may be true of its use in irritable states of the stomach. An Elixir of Opium might be prepared from the watery extract, by treating it with diluted alcohol, using only half as much of the extract in proportion as there is of opium employed in the prepara- tion of the tincture. The elixir would have the same strength as laudanum, and would be destitute of Avhatever matter, insoluble in water, alcohol may extract from opium. OPIUM PLASTER. —Emplastrum Opii. U S., Lond., Ed., Dub. Opium plaster is made by mixing poAvdered opium with boiling water, incorporating the mixture with melted Burgundy pitch, and lead plaster, and then evaporating the moisture. It may be used, spread on leather, as an anodyne application in fixed pains, of a rheumatic character or otherwise. TINCTURE OF OPIUM. — Tinctura Opii. U.S., Lond., Ed, Dub. Laudanum. — Thebaic Tincture. — Tinctura Thebaica. Laudanum is prepared, according to the U. S. Pharmacopoeia, by macerating two ounces and a half of powdered opium in two pints of diluted alcohol. When it is properly made, the virtues of the opium may be considered as wholly extracted by the men- chap, i.j cerebral stimulants.—OPIUM. 767 struum. The pulverization of the opium insures the previous drying of the drug, which is important; for crude undried opium always contains water, and often in considerable though variable proportion; and, if it were employed in the process, would render the resulting tincture weaker than the officinal, and of uncertain strength. Happily about the same proportion of opium is em- ployed in the several British processes as in our own; so that, for practical purposes, all the different tinctures recognized in this country and Great Britain, may be considered as identical. Lau- danum should be kept in well-stopped bottles, as the alcohol eva- porates on exposure, and the liquid is rendered turbid by the deposition of the dissolved matter. Not unfrequently flakes of solid extract may be seen at the bottom of old laudanum bottles; and it may be readily conceived that, if this should be dropped out with the liquid, the narcotic effects of it would be very greatly increased. Death in infants has resulted from this cause; and I suspect that the cases of unexpectedly violent effects in young children from a drop or two of laudanum, which we find related by writers, might, if carefully investigated, have been traced to this cause. Every practitioner should be aware of this fact, and guard against the use of laudanum rendered turbid by evaporation, especially when pre- scribing for the very young. This tincture is very much used for obtaining the effects of opium, the properties of which it may be considered as fully representing. It has the advantage of operating more quickly than the opium in substance, and of facilitating the exhibition of the medicine in minute doses; but it is sometimes less acceptable to an irritated stomach, probably in consequence, in part, at least, of the alcohol it contains. The same cause renders it less suitable than the infusion of opium, or a solution of the extract, for appli- cation to tender surfaces, as to the conjunctiva, rectum, urethra, and even sometimes the skin, when highly irritated or inflamed. The dose of laudanum equivalent to a grain of opium is thirteen minims, or about twenty-five drops. It should be remembered that a fluidrachm or teaspoonful contains on the average about 120 drops, and that one minim is about equal to two drops. The mistake has often been made of directing a teaspoonful of laudanum by enema, under the impression that it contained only 60 drops, or between two and three times the amount of the ordinary dose by the mouth, whereas it is about quintuple that dose. Hence, pro- found narcotism has often been induced, when only gentle sleep 763 GENERAL STIMULANTS. [PART II. Avas wanted. I have knoAvn of a fatal case of coma, occurring immediately after an enema of laudanum, and have not been with- out my suspicions that this was the cause of death. Not more than fifty or sixty drops should be given at first by injection. Lau- danum is often used as a local anodyne; being employed as a lotion, or added to cataplasms, or in conjunction with other anodynes or with rubefacients in the form of a liniment. It may be added to the camphorated tincture of soap (common soap liniment), in the proportion of one part by measure to three; and this mixture is usually called the anodyne liniment. It may be introduced into the external auditory meatus, or into the cavity of a carious tooth, upon a little raAV cotton. CAMPHORATED TINCTURE OF OPIUM. — Tinctura Opii Cam- phorata. U.S.,Ed., Dub.—Tinctura Camphora Composita.Lond. Paregoric Elixir.—Paregoric. This very useful and popular preparation is made by macerating poAvdered opium, camphor, benzoic acid, oil of anise, and honey, in diluted alcohol. Opium is the chief active ingredient, and camphor next in importance. The others may be considered merely as adjuvants, to improve the flavour, and render the tincture more acceptable to the stomach. Liquorice was formerly used in its preparation, and still is used by some apothecaries, though it has been omitted in the process of the Pharmacopoeia, in consequence of the strong resemblance it occasions in the colour of the tincture to that of laudanum, and of the fatal errors that have originated in this cause. Certainly a little doubtful improvement in the taste should not be put into competition with life. This tincture may be used when small doses of opium are indi- cated, and especially when its operation as a nervous stimulant is Avanted. It is somewhat more stimulating than laudanum, and usually very acceptable to the stomach. It is much used in cough mixtures, but should not be given in the early stages of catarrhal affections, nor until expectoration shall have been established. It is better adapted to chronic catarrh, phthisis, asthmatic disease Avith copious expectoration, and pertussis at an advanced period, than to acute bronchial affections, except in their declining or suppurative stage. In slight diarrhoea, when the indication is simply to arrest the discharges, it is very useful, and is an admir- able remedy in the affection, as it occurs during the prevalence of epidemic cholera. It may also be usefully employed in slight gastric and intestinal pains or spasms, as an anodyne and carmina- CHAP. I.J CEREBRAL STIMULANTS.—OPIUM. 769 tive. To fulfil this indication it may often be used advantageously in infancy; but great care should be taken not to abuse it. Containing only about one grain of opium in half a fluidounce, this tincture is not calculated to produce the full anodyne or sopo- rific effects of that medicine. The dose of it, for the purposes for which it is usually employed, is a fluidrachm for an adult, and from three up to twenty drops for an infant, during the first and second year, being graduated to the age. It is rendered turbid by the addition of water, in consequence of the precipitation of the camphor. Care must be taken not to confound this preparation with the ammoniated tincture of opium, which is used in Scotland under the name of paregoric, though very different from the above. It is readily distinguished by its ammoniacal odour and taste, and is seldom if ever prepared in this country. ACETATED TINCTURE OF OPIUM. — Tinctura Opii Acetat-v U.S. This is peculiar to the U. S. Pharmacopoeia, having been intro- duced into it as a substitute for the vinegar of opium or black drop. It is made by macerating opium in a mixture of vinegar and alcohol. The only advantage that is claimed for it over laudanum is that it is someAvhat weaker in alcohol, and that the active prin- ciples of the opium are modified by the acetic acid of the vinegar. The only known method in which such a modification could be produced, is that the acetic acid may take the place of the meconic acid, and form an acetate instead of meconate of morphia. But, Avhatever may be the theory in the case, the preparation appears to agree with certain patients, who cannot take laudanum conveni- ently, in consequence of the headache, delirium, nausea, or other nervous disorder which it produces. It was a favourite with the late Dr. Joseph Hartshorne, of Philadelphia, who introduced it into notice, and whose large experience entitles his recommendation to great Aveight. The dose of it, equivalent to a grain of opium, is ten minims, or about twenty drops. WINE OF OPIUM.—Vinum Opii. U.S. — Sydenham's Laudanum, This is a vinous tincture, made by macerating poAvdered opium( cinnamon, and cloves in sherry wine. The proportion of opium employed is such as to saturate the Avine. The preparation differs from laudanum in having less alcoholic strength, and an addition of aromatic properties, which render it more agreeable to the smell vol. L—49 770 GENERAL STIMULANTS. [PART II. and taste, and, in certain cases, more acceptable to the stomach. Some notice has been attracted to it as an application to the eye in ophthalmia, by the recommendation of Air. AVare, who found it very useful. AY hen dropped into the eye, it produces at first smarting pain, and a copious flow of tears; but these effects are soon followed by relief from the previous suffering, and considerable abatement of inflammation. The dose is about tAventy drops. VINEGAR OF OPIUM.—Acetum Opii. U.S.—Black Drop. The U.S. Pharmacopoeia directs this preparation to be made by digesting opium, nutmeg, and saffron in diluted acetic acid, and afterwards subjecting the mixture to percolation Avith the same menstruum, taking care that the strength shall be uniform by eva- porating to a certain volume. It was introduced as a substitute for the Lancaster or Quaker's black drop, and is believed to be preferable to opium in substance or tincture, in certain cases in Avhich the two latter forms disagree with the stomach or nervous system. This modification of effect may be owing to the absence of certain prin- ciples of opium soluble in alcohol, but not in water, or to the change of the natural meconate of morphia into the acetate, or to both these causes. It is much stronger than laudanum, and may be given, for its full anodyne and soporific effects, in the dose of from seven to ten drops. MORPHIA. There are several methods of extracting morphia from opium. The U.S. officinal process consists essentially in macerating opium in water to exhaustion, adding alcohol to the infusion, precipitating the morphia by solution of ammonia, and purifying the precipitate by solution in boiling alcohol, and filtration Avhile hot through ani- mal charcoal. On cooling, the alcohol deposits the morphia in crystals. The object in adding alcohol to the infusion is that it may retain the colouring matter when the morphia is precipitated, Avhich it does to a considerable degree. Thus procured, morphia contains a proportion of narcotina, from Avhich, if deemed advisable, it may be separated by the agency of ether, which dissolves the narcotina, and leaves the morphia pure. For the preparation of the sulphate or muriate, however, this is not necessary; as the narcotina remains in the mother waters, upon the crystallization of these salts. As the acetate is usually prepared by evaporating its solution to dryness, the narcotina will contaminate it, unless previously sepa- rated from the morphia. Properties. Morphia is in small, shining, colourless crystals, Avhich • I.] CEREBRAL STIMULANTS.—OPIUM. 771 are without smell, of a bitter taste, scarcely soluble in cold water, slightly so in boiling water, also slightly in cold alcohol, but freely in that liquid when hot, and almost insoluble in ether. Chloroform, the fixed and volatile oils, and aqueous solutions of potassa and soda dissolve it, and solution of ammonia has the same effect, but in much less degree. When heated in the open air, morphia burns, leaving a carbonaceous residue, which' is wholly dissipated if placed on red-hot iron. Morphia affects test paper like the alkalies, and forms soluble salts with most of the acids. When either the alka- loid, or one of its salts, is touched with strong nitric acid, it assumes a deep-red colour, which after a time changes to yellow. In the state of crystals, or in strong solution, both it and its salts are rendered blue by sesquichloride of iron. Ammonia, added to a mixture of solutions of chlorine, and of morphia or its salts, develops a dark- brown colour, which is remove^ by a further addition of chlorine. Precipitates are produced in solutions of the salts of morphia by the pure alkalies and their carbonates; but, when the alkali is added in great excess, the morphia is redissolved. Ammonia has this effect much less than potassa or soda. Astringent substances throw down from solutions of the salts of morphia a tannate of the alkali, which is soluble in acetic acid. Morphia consists of 1 equivalent of nitrogen, 35 of carbon, 20 of hydrogen, and 6 of oxygen, to which are added 2 equivalents of water in the crystalline state. Medical Properties and Uses. Morphia is undoubtedly the main active principle of opium; but that it is not the only one is proved by the fact, that a certain quantity of opium produces a much greater effect than all the morphia which can be obtained from it, though it may be entirely exhausted. Thus, opium must be very good Avhich will yield one part in ten of pure morphia. If the latter, therefore, were the only active principle of opium, one part of morphia should produce an equal effect with ten parts of opium; while, in reality, it is equivalent to no more than six parts. Which of the principles of opium it is that supplies this deficiency in the poAver of morphia has not been ascertained. Nor are the effects of morphia precisely the same in character as those of opium. So far as I have been able to decide from observation and trial, I believe that morphia has precisely the same anodyne and soporific effects as opium, and closely resembles it in its stimulant influence on the brain. Like opium, also, it is apt to produce perspiration, though perhaps in a less degree; and is quite as much disposed to cause itchin"- of the surface. But it is less stimulant to the circulation, 772 GENERAL STIMULANTS. [PART II. less disposed to constipate, has less restraining effect on the secre- tions, and cannot be so well relied on for the suppression of morbid discharges. I am confident that it in general agrees better with the stomach, and is less apt to be followed by nausea, vomiting, and headache. It has appeared to me also to be less liable to provoke irregularities of mental action; and, with an equal excitant influence on the faculties and feelings, to derange them less fre- quently, and in a less degree. Morphia itself is perhaps less certain in its effects than its salts; as, being insoluble or nearly so in water, it probably depends for its absorption, and consequent effects on the system, in some degree at least, upon the presence of acid in the stomach, and might ope- rate more slowly and feebly in the absence of acids. Hence it is that the salts are always employed, and morphia itself never. The salts most used are the sulphate, acetate, and muriate. So far as can be inferred from observation, there is positively no difference in the remedial effects of these salts upon the system; and one may be substituted for the other without disadvantage. All of them have one great advantage over opium, and those of its preparations the strength of which is determined by that of the opium, in their uniformity of dose. AAre know exactly how much of the narcotic principle we are giving when we prescribe a salt of morphia, Avhile, in relation to opium, laudanum, &c, we are very far from this cer- tainty, and may at one time give the medicine perhaps twice as strong as at another; for different parcels of opium, even bearing the same commercial name, not unfrequently have this diversity of strength. The salts of morphia may be given in all cases in which the indi- cation is to relieve pain, to procure sleep, or to quiet nervous irri- tation in any of its forms. But they are less efficient as stimulants to the circulation in low forms of fever, and cannot be equally relied on for producing diaphoresis, for checking diarrhoea, or arresting profuse secretion or hemorrhage. They are preferable to opium in irritated states of the stomach, and in catarrhal affections, as frhey probably have less effect in producing dryness of the mouth and air-passages, and consequently in impeding expectoration. They often agree well with individuals on whom opium produces dis- agreeable effects. Thus, I have had under my care a female patient, whom a full dose of opium always kept awake during the whole night, but with whom the salts of morphia, in equivalent quantities, had their usual soporific effect. I believe, moreover, that there is CHAP. I.J CEREBRAL STIMULANTS.—OPIUM. 773 less danger of giving them in over-doses. Though undoubtedly capable of fatal poisoning, they appear to be less so relatively than opium. A case Avas related to me by Dr. Charles Foulke, of NeAV Hope, Pennsylvania, in which a woman took by mistake eleven grains of morphia, equivalent to about sixty-six grains of opium in anodyne effect, and yet recovered without having discharged any of the poison from her stomach. She became profoundly insensible, and during this state was delivered of a child, of the birth of which she was quite unconscious, and which survived. A case was re- corded, some years since, in one of the London journals, of which I made a note at the time, though I neglected to make the precise reference, in which a young man was believed to have taken some- where between twenty and thirty grains of one of the salts of morphia, and yet escaped with life without evacuating measures, though the symptoms were very alarming. Another advantage of the salts of morphia is the facility with which they can be applied endermically, and their great efficiency in this mode of application. They may be used in this way either for obtaining the general effects of opium, or to relieve some local affection, as neuralgic pain, and obstinate vomiting. Perhaps no remedy is more effectual, for the latter purpose, than one of the salts of morphia sprinkled upon a blistered surface in the epigas- trium, denuded of the epidermis. The dose of either of the salts of morphia, equivalent in ano- dyne effect to a grain of opium, is as near as I have been able to determine, one-sixth of a grain. One-eighth of a grain, I am quite sure, is less powerful than a grain of good opium; and one-fourth of a grain, I think, somewhat more so. Endermically, one-half of a grain may be used at first, and afterwards increased if found necessary to a grain or more. About one-third of a grain may be given, for a commencing dose, by enema. As a liniment, morphia may be employed, dissolved in one of the fixed oils. The solution is most readily effected by first dissolving it in a little chloroform, and adding the solution to olive or almond oil. Sulphate of Morphia.—Morphise Sulphas. U. S.—This salt is most used in the United States. It is prepared by mixing morphia with water, gradually dropping in diluted sulphuric acid till the powder is dissolved, and then evaporating and crystallizing. It is in beautifully white, minute, soft, feathery crystals, very bitter, readily soluble in water, and slightly so in alcohol. It is known to be a sulphate by yielding with chloride of barium a white pre- 774 general stimulants. [part ii. cipitate insoluble in nitric acid. It may be given in pill or solu- tion, in the dose of from one-eighth to one-quarter of a grain. Solution of Sulphate of Morphia (Liquor Morphia Sulphatis, U.S.) is directed by our officinal code to be prepared by dissolving eight grains of the sulphate in half a pint of distilled water. It of course contains one grain of the salt in each fluidounce. Though the solution becomes gradually coloured by time, I have found it perfectly efficient, upon trial, after having been kept a year or longer. It has the great advantage of easy divisibility, as regards the dose, to any desirable minuteness. For full anodyne and sopo- rific effect, the dose is from one to two fluidrachms. It is to be regretted that this solution, as kept in the shops, is not always of the officinal strength. In some parts of the country, a solution containing 16 grains to the fluidounce is habitually em- ployed. This may readily lead to serious mistakes. The physi- cian should always specially designate the stronger solution, Avhen he intends it; and the officinal solution should always be put up by the apothecary, when the simple officinal name is used. Acetate of Morphia.—3Iorphise Acetas. U. S., Lond., Ed., Dub. —To prepare this salt, the U. S. Pharmacopoeia directs morphia, de- prived of narcotina by means of ether, to be mixed Avith water, and acetic acid to be gradually dropped in till the morphia is dissolved. The solution is then evaporated, by means of a water bath, to the consistence of syrup, dried by a gentle heat, and rubbed into powder. As thus obtained it is amorphous, slightly coloured, and in gene- ral not Avholly soluble in water. This is owing to the escape, during the drying, of a small portion of acetic acid, which leaves a corresponding portion of the morphia unsaturated, and of course insoluble. All that is necessary to effect a perfect solution is to add a little distilled vinegar. This salt is soluble in alcohol. It is knoAvn to be an acetate by giving forth an acetous odour on the addition of sulphuric acid. It may be given in pill or solution, and in the same dose as the sulphate. It is sometimes preferred for endermic application, under the impression that it is less irri- tant, and more readily absorbed. The London and Dublin Colleges direct solutions of this salt, but unfortunately of different degrees of strength. Muriate of Morphia.—3Iorphiae 3Iurias. U. S., Ed., Dub.— Morphise Hydrochloras, Lond.—This is prepared, according to the U. S. Pharmacopoeia, in the same manner as the sulphate. In Great Britain it is usually prepared directly from opium, and is probably CHAP. I.J CEREBRAL STIMULANTS.—OPIUM. 775 more used than any other of the salts of morphia. It is in fine, white, feathery, acicular crystals, inodorous, bitter, and soluble in water and alcohol. It may be distinguished from the sulphate by affording, with nitrate of silver, a precipitate insoluble in nitric or muriatic acid, but soluble in an excess of ammonia. The dose and mode of administration are the same as those of the sulphate. An officinal solution is directed by the British Colleges, but dif- fers in strength as prepared on the one part by the London, and on the other by the Edinburgh and Dublin Colleges. The dose of the former preparation is from 7.5 to 15 minims, of the latter from 13 to 26, each equivalent to from one-eighth to one-quarter of a grain of the salt. NARCOTINA. For the mode of obtaining this substance from opium, the reader is referred to the Dispensatories. It exists uncombined in opium, which still retains it in considerable quantities after maceration in Avater. The portion which water dissolves is probably taken up through the agency of the free acid of the opium. Narcotina is in Avhite, silky, flexible, acicular crystals, without smell or taste, inso- luble in cold water and alkaline solutions, very slightly soluble in boiling water, slightly so in cold and much more freely in hot alcohol, and readily soluble in ether, and the diluted acids. The volatile and fixed oils also dissolve it. Though capable of uniting with the acids to form definite compounds, and with the muriatic and sulphuric acids to form crystallizable salts, it does not affect ' the colour of litmus, and must be considered as possessing but feeble alkaline powers. It is distinguished from morphia by its solubility in ether, by assuming a yellowish instead of red colour with nitric acid, and by the want of the other properties before mentioned as characteristic of that alkaloid. If it be mixed with sulphuric acid, and then a piece of nitre be added, it becomes deep- red while morphia, under similar circumstances, becomes brownish or olive-green. In this case, it is a mixture of the nitric and sul- phuric acids that acts. Though tasteless, when pure, the compounds which it forms with the acids are very bitter. Very different opinions have been advanced as to its effects on the system. While some have found it very powerful, and have ascribed to it noxious properties, others have taken or given it lar produce the desire! effect, or is contraindicated by some idiosyn.-rasy of the patient, or when it is specially desirable to avoid its occasional nauseating effect on the stomach, its constipating effect on the bowels, and its tendency to restrain the secretions. Another indication, derived from a property of hemp noi ye: particularly noticed, is that of producing uterine contraction. At- tention. I believe, was first called ::> this property by Dr. Alexander Christison. of Edinburgh, who observed that, in several cases in which he had employed it during labour, it very ranch increased the intensity of the contractions. The e::e:t usually occurred, if at all, in two or three minutes after its administration, ceased after a feAv rains, and was not followed by any of the ordinary physio- logical results of its exhibition, as mental excitement, intoxication, or sleep*; nor does the sense of pain appear to have been blunted. Indeed, the action took place much s: :ier than is required for its usual effects, and its powers seem to have been exhausted in the effort. Dr. Christison thinks the action of hemp more energetic. and perhaps more certain, than that of ergot. iSee Am, Journ. of M-:d. .Soh, N.S.. xxiii. 2o0.) With a view to the ilrst indication, that, namely, of allaying pain, hemp has been used in different forms of neuralgia, in acute and sub- acute r ; .; -.'i >. and in gout: and may be employed in these affec- tions under the same circumstances as opium. To relieve pain and relax spasm jointly, it has been considerablv used in tetanus, and with variable success. Dr. O'Saaughnessy found it effectual on several occasions; a 'icw successful cases have been reported by others; and, in some instances, where,:: has failed to cure, it has afforded relief. Bu; the general result has not. I think, been favourable. As in the use of opium in this disease, it is neces- CHAP. I.] CEREBRAL STIMULANTS.—HEMP OF INTIA. 7S3 siry to increase the ordinary dose six or tenfold, or more, and to repeat the uose frequently. The medicine has been tried also in hydrophobia, but las proved quite powerless. In epidemic cholera it is saul to have been found useful: but the property of checking alvine discharges, which renders opium so beneficial in that disease. is Avanting in hemp, and it can act onlv bv relieving pain and re- solving s- asm. Hemp nas also been used in various painless spasmodic affections. an i nervous disorders, usually treated with the nervous stimulants ana narcotics. In convulsions net connected with cerebral con- gestion, in chorea, hysteria, languid or depressed spirits, and in:: oh.. it has been found more or less beneficial. For allaying cough, whe- ther spasmodic, as in per'vssis and h,s:-::-'a. or dependent on bron- chial i'-houh??, as in different pulmonary affections, it mav be resorted to as a substitute for opium, when this is contraindicated by its property of checking mucous secretion. To promote sleep, it may be employed in any case of wakefulness. not associated with vascular irritation of the cerebral centres, and is said to have been employed with special advantage in relieving the sleeplessness of drunkards. In reference to its property of promoting uterine contraction, it may be employed in proi-c.ce :l cases of delivery, in Avhich it is pre- ferable to er^ot. if it be true, as seems to be inferrible from the obserA-ations of Dr. Alexander Christison. that its operation is soon over, and not protracted like that of the medicine alluded to. It is thus free from the greatest objection to ergot, that, namely, of en- dangering the life of the foetus by the steady and prolonged con- traction of the uterus. The same property of hemp must render it useful in expelling the retained pla.enta. and in checking uterine hemorrhage, when sustained by a relaxed condition of the organ. But. if preferable to opium under the circumstances above men- tioned, in which that medicine, though indicated by certain symp- toms, is contraindicated by others, hemp cannot be brought into competition with it in any of the cases to which they are both applicable. It is not only less efficient than opium, but is much more uncertain on account of the inequality of strength in the preparations used, and probably also in consequence of the in- equalitv of its ore ration upon different individuals, even Avhen i: may be of the due strength. Preparations. The forms in which hemp is ordinarily used in Europe and this country are the extract and tincture. 781: GENERAL STIMULANTS. [PART II. Extract of Hemp (Extractum Cannabis), as recognized in the U. S. Pharmacopoeia, is prepared by treating the dried tops with alcohol, and evaporating the tincture thus obtained. But it may also be procured by purifying the crude churrus of the Hindoos, by dissolving what is soluble of it in alcohol, allowing the undissolved impurities to subside, and then decanting and evaporating. A purer form of it is prepared by a somewhat complicated process, for an account of which the Dispensatories may be consulted. The best test of its strength, independently of actual trial, is its pos- session, in the highest degree, of the characteristic properties of smell and taste. The dose of the extract varies extremely, in consequence of the variable strength of the preparation. When of the best quality, half a grain of it will produce obvious effects, while ten or twelve grains are often required, and sometimes the drug is quite inert. It is best, as a general rule, to begin with one grain, Avhich may be repeated every two, three, or four hours, until its effects are pro- duced; and, if none can be obtained from this dose, gradually to increase it, until the amount is ascertained in which the parcel em- ployed Avill act. In tetanus, ten grains niay be given every half hour till it operates, and the quantity increased, if necessary. It may be administered in pill or emulsion. The latter is the prefer- able form, where speedy effect is required. It may be made by rubbing the extract up with a little olive oil, and then suspending it in water, or one of the aromatic waters, by means of gum arabio and sugar. Tincture of Hemp (Tinctura Cannabis Indicue, Dub) may be made by dissolving six drachms of the extract in a pint of officinal alcohol (sp. gr. 0.835). The dose, equivalent to one grain of the extract, is about 20 minims or 40 drops. Dr. O'Shaughnessy gave 10 drops of the tincture every half hour in cholera, and a fluidrachm as often in tetanus, until the desired effects Avere produced, or the medicine showed decided signs of acting on the brain. VI. HENBANE. HYOSCYAMUS. This is the Hyoscyamus niger of botanists, an annual or biennial herbaceous plant, indigenous in Europe, where it is also cultivated CHAP. I.] CEREBRAL STIMULANTS.—HENBANE. 785 for medical use. It has been introduced into this country, and grows Avild in some of our Northern States, especially in Michigan, where it abounds in the neighbourhood of Detroit. The whole plant is possessed of medicinal virtue. The U. S. Pharmacopoeia recognizes the leaves and seeds. Henbane Leaves.—Hyoscyami Folia. U.S.—Hyoscyamus. Lond., Ed., Dub. — These, in their recent state, are someAvhat hairy, viscid to the touch, of a sea-green colour, of a strong, disagreeable, nar- cotic odour when bruised, and of a mucilaginous, somewhat acrid taste. By drying they become nearly or quite inodorous and taste- less. They impart their virtues to alcohol and water. By de- structive distillation, they yield a very poisonous empyreumatic oil. Henbane Seeds.—Hyoscyami Semen. U.S.—The seeds are very small, roundish, compressed, of a grayish or yellowish-gray colour, an odour like that of the plant, and a bitter oily taste. They are stronger than the leaves, but less used. Active Principle. There is little or no doubt that the virtues of henbane reside in a peculiar alkaloid, denominated hyoscyamia, Avhich, however, though it has been isolated and accurately de- scribed, has not been introduced into use as a medicine. It exists most largely in the seeds, but in small proportion even in these. Experiment has proved that both it and its salts are very poison- ous. Reisinger states that a single drop of an aqueous solution containing one part of it to ten of water, introduced into the eye, caused dilatation of the pupil, without irritation of the conjunctiva. Effects on the System. In doses scarcely sufficient to make them- selves felt in health, hyoscyamus appears to act as a nervous stimu- lant in disease, calming restlessness, and other forms of slight nerv- ous disorder, and, in cases of morbid wakefulness, producing sleep indirectly by removing the cause which prevents it. In full me- dicinal doses, it often produces, along with some increase in the frequency of pulse and general warmth, or with no observable effect of the kind, an agreeable and diffusive feeling of comfort, followed perhaps by slight vertigo, or other uneasy sensations in the head, and after a time by an easy natural sleep. Sometimes, however, it occasions headache, and, instead of sound sleep, gives rise to uneasy dreams, spectral illusions, or delirium. In not a few instances, nothing like sleep can be obtained from any ordinary dose; and, in such cases, some degree of sensorial or mental aber- ration is apt to occur, if the medicine is pushed. Dr. Pereira says that it is least apt to produce sleep in persons accustomed to the vol. i.—50 786 general stimulants. [part it. use of opium. A characteristic effect of it, as of other solanacea?, especially belladonna and stramonium, when the system is fully under their influence, is dilatation of the pupil. Besides these effects, it often occasions heat or irritation in the fauces, sometimes increases the perspiration or urine, and, in rare instances, has caused a pustular eruption upon the surface. Instead of consti- pating like opium, it either produces no effect on the boAvels, or acts as a laxative; the latter result being not uncommon. In some persons, or in certain states of the system, it occasions general febrile heat and irritation. After the subsidence of its full direct effects, a state of greater or less depression takes place, which, Avhen the quantity taken has been very large, may amount even to pros- tration. Hyoscyamus has not unfrequently been swallowed in poisonous quantities. This has happened most frequently with the root, which has been taken by mistake for that of some other plant, as parsnip or chiccory. The effects are usually giddiness, more or less stupor, extreme dilatation of the pupils, disordered vision, spectral illusions, diminution or loss of the power of speech, delirium some- times violent and maniacal, sometimes low and muttering, tonic spasms, convulsions, coma, paralysis, and at length great prostra- tion, with small and irregular pulse, difficult breathing, and cold- ness of the extremities. From this extreme condition, however, reaction generally takes place, and comparatively few cases termi- nate fatally. Yet death has occurred in several recorded instances. Sometimes, with these narcotic effects, symptoms of severe gastro- intestinal irritation are exhibited, as nausea, vomiting, abdominal pains, and purging. The administration of the medicine by enema, and its external application over the abdomen, have been known to produce severe symptoms, though never, I believe, fatal. The operation of the poison usually continues for about twelve hours before abating spontaneously. The remedies are the same as those for opium; full vomiting being the most important. The lower animals are affected very differently by the herb. Some, as horses, cows, sheep, goats, and hogs, eat it with impunity; Avhile birds and dogs are affected like man. It is not impossible that injury may have accrued, particularly to children, from the use of the milk of cows and goats which have been feeding on henbane. 3Iode of Action, Though it would be difficult to prove that hy- oscyamus operates upon the system through absorption, analogy leads almost necessarily to this conclusion. Its local action is that CHAP. I.] CEREBRAL STIMULANTS.—HENBANE. 787 of a very moderate irritant, as shoAvn by its occasional effects on the stomach, and its not unfrequent action upon the bowels. As a direct circulatory stimulant it is very feeble, being, in this respect, greatly inferior to opium; and, in many instances, the pulse is not affected, at least in frequency. The depression of the circulation which attends its full narcotic action is a secondary result, depend- ing probably on the condition of the nervous centres. Its influ- ence upon the cerebral centres is, I have no doubt, essentially stimulant; sleep resulting from a mild congestive action upon them, while, in a higher degree of the same operation, delirious excitement is produced, and, when the centres are quite over- whelmed, coma. The effect upon the pupil may be considered as a kind of sleep of the nervous centre, which regulates the move- ments of the iris. Therapeutic Application. Henbane was known as a medicine to the ancients, but received little notice, until attention was attracted to it by Baron Storck, of Vienna, so famous for his experiments Avith this and other narcotics, and for the enthusiastic estimate he placed upon their therapeutic powers. Though this medicine has not realized all that was hoped from it, in consequence of his repre- sentations, it is, however, of no little value, and assuredly does not deserve the sentence of banishment from the Materia Medica pro- nounced upon it by M. Fouquier. (Arch. Gen., i. 297 and 312.) The indications Avhich hyoscyamus is calculated to fulfil are to allay pain, produce sleep, relax spasm, and quiet nervous disturb- ance generally. These are, among others, the therapeutic effects of opium, which hyoscyamus probably more nearly resembles, in its soporific influence, than any other medicine. It is, however in these respects, much inferior to opium, and incomparably less to be relied on; but there are certain circumstances under which, in con- sequence of its want of properties which sometimes interfere Avith the beneficial operation of that medicine, it may be used when opium cannot, and is admirably calculated to supply its place. In the first place, it is much less stimulant to the circulation than opium, and though, from this deficiency, it is of little use in sup- porting the system in certain conditions of debility where opium is highly valuable, it is more safely used in others, in which the anodyne and soporific properties of opium are wanted, but its sti- mulant property contraindicates it. Again, it does not constipate like opium, but is rather laxative, and cannot, therefore, be substi- tuted for it in diarrhoea; but there are frequent occasions in Avhich 788 GENERAL STIMULANTS. [PART II. v this dissimilarity gives it great advantages. Thirdly, it has no such effect in restraining the secretion of mucus, bile, and urine as opium has; and may, on this account be sometimes preferably employed, where it is desirable rather to promote than to impede those secre- tions, as sometimes in the early stages of inflammation of the bronchial tubes, liver, and kidneys. Lastly, from individual idio- syncrasy, or peculiarity in disease, opium not unfrequently occa- sions so much nausea, headache, delirium, or other disagreeable effect, that it cannot be given, however strongly called for as an anodyne or soporific. In such cases, hyoscyamus may sometimes be substituted with great advantage. In fevers hyoscyamus may often be usefully employed to quiet nervous disturbance and produce sleep, where the excitement may be too high for opium, or that medicine may be objectionable upon some one or more of the grounds just mentioned. This is par- ticularly the case with the febrile affections of infants, in which a little hyoscyamus may often be advantageously conjoined with the refrigerant or laxative medicines, when there is considerable nerv- ous disturbance, inquietude, and wakefulness; while opium might do more harm than good. In the different phlegmasia, also, the medicine may be used to fulfil its proper indications, with no little benefit. This is particu- larly the case in bronchial infiammation, whether original, or con- nected with other diseases, as measles, pneumonia, &c, in the ear- lier stages, before secretion has taken place, and in any stage, whether acute or chronic, if the prominent indication is to promote secretion, and to allay cough. Opium might fulfil the latter indi- cation at the expense of the former. Hyoscyamus, if it do not fulfil both, has certainly no effect in restraining the secretion. It should be combined with the expectorants employed. The same may be said of its use in hepatitis, especially when the substance of the gland is affected. In the peritoneal form of hepatitis, opium would be incomparably superior. In nephritis, when there is a great defi- ciency of secretion, it may sometimes be advisable to prefer hyos- cyamus; and for the same reason, applying however,'in this instance to the mucous and not the urinary secretion, this narcotic may some- times be preferably used in inflammation of the bladder and urinary passages. To the relief of the more violent forms of neuralgia, or indeed of excessive pain from any cause, the anodyne powers of hyoscy- amus are generally inadequate; though it may be tried in any CHAP. I.] CEREBRAL STIMULANTS.—HENBANE. 789 case of the kind where opium cannot be given. There is, how- ever, one condition of things in which it is peculiarly indicated, I refer to attacks of excessive sensitiveness of the retina. A case of this kind occurred to me, many years since, which will illustrate my meaning. A gentleman of highly nervous temperament, in the state of general depression following an acute disease, and after considerable depletion, was seized with an exquisite irrita- bility and sensitiveness of the eye, which occasioned the most se- vere suffering. Light was torture to him; and it was necessary to close the outer shutters of the apartment, and to draAV the curtains closely around his bed, so as to prevent the least particle from reaching him. Notwithstanding, however, this precaution, he complained of the intolerable brightness, the intense and insuf- ferable glow, as of incandescent metal held immediately before his face, or of a concentration of the whole blazing light of the sun directed upon his vision; and language, in one AA'ho kneAV its resources well, and knew how to wield them powerfully under the impulse of a brilliant imagination, was exhausted to find ex- pressions strong enough to convey an idea of his sufferings. Under the impression that he was affected with inflammation of the eye, he refused opiates altogether, though urged upon him. At last I prevailed on him to take a single grain of extract of hyoscyamus every hour. He had not taken more than three or four doses, Avhen he experienced a sensible amelioration of his sufferings, along Avith the first narcotic impression of the medicine; and they continued to abate so long as the hyoscyamus was used. Convinced now of the nature of the affection, he consented to take an anodyne enema, which immediately put an end to the symptoms. I have no doubt that a full dose of hyoscyamus would have had the same effect. It is especially indicated in neuralgic affections of the eyeball, through its influence over the nervous centre of vision. In carcinomatous and other painful organic affections, hyoscyamus may be alternated with opium, in the hope of protracting longer the period of susceptibility to the anodyne effect of the latter remedy. Spasmodic and convulsive diseases, and other forms of nervous irri- tation, afford frequent occasion for the use of this narcotic. It can do little good in the more violent cases of painful spasm, such as spasm of the stomach, severe colic, the cramps of cholera, tetanus, &c, yet in the milder conditions of the affection it may often be use- fully combined with other medicines, as in slight colicky pains Avith cathartics, in the milder forms or stages of colica pictonum with 790 GENERAL STIMULANTS. [PART II. alum, in similar conditions of the biliary and urinary p>assages with calomel in the former case, and bicarbonate of soda in the latter. In asthmatic affections, pertussis, and the convulsive attacks of infants dependent on teething or intestinal irritation, it may sometimes be advisable. Though inadequate to the cure of epilepsy or chorea, it may be usefully combined, in some instances, Avith the metallic tonics and nervous stimulants used in those complaints. In the multiplied nervous disorders of hysteria, hyoscyamus may now and then be had recourse to, with great benefit, for relieving distressing sensations, soothing inquietudes, and procuring sleep. It is a favourite practice with many to combine hyoscyamus with the more irritating purgatives, under the impression that it tends to prevent their griping, without diminishing their purgative ef- fects. For this purpose it is frequently used with the compound extract of colocynth, or Avith scammony, colocynth, and aloes seve- rally. Contraindications to the use of hyoscyamus are active congestion or inflammation of the brain, a very high degree of febrile or in- flammatory exitement generally, and inflammation of the stomach • or bowels. Topical Use. Fresh henbane is sometimes used, in the form of a cataplasm, or infused in hot water as a lotion or fomentation, to relieve pain and irritation, as in hemorrhoidal or carcinomatous tumours, painful glandular swellings, gouty or rheumatic affections, scrofulous and cancerous ulcers, nervous headache, &c. . The extract is also employed for the same purposes. The remedy is sometimes used in the way of enema, to relieve irritation of the rectum, bladder, urinary passages, or genital organs. Oculists sometimes -use it to dilate the.pupil before the operation for cataract; a solution of the extract, or an infusion of the leaves being dropped into the eye, or the. extract with lard, rubbed upon thelids and around them. The effect is usually produced within four*hours, and contiuues" twelve* The same application has been recommended after the operation for cataract, when there is danger of iritis, to prevent the pupil from closing. Used in this way, it does not affect the vision. Administration. Hyoscyamus may be given in substance, extract;- ' ■ or tincture. The dried leaves are so uncertain that they are Very seldom used. The dose to begin with is from five to ten grains. The seeds should not be employed at first in more than half the smaller dose mentioned. The extract is much more .frequently used. • • . ■- , ■ CHAP. I.] CEREBRAL STIMULANTS.—BELLADONNA. 791 Two extracts of henbane are directed by our national Pharma- copoeia, one made by inspissating the expressed juice of the fresh leaves, the other by evaporating an alcoholic tincture of the dried leaves. The former is called simply Extract of Henbane (Extractum Hyoscyami, U. S), the latter Alcoholic Extract of Henbane (Ex- tractum Hyoscyami Alcoholicum, U. S) As, in many parts of our country, the fresh leaves cannot be obtained, it is necessary either to use the imported extract, or to prepare the alcoholic. Unhappily, in either case, the preparation is of very uncertain strength, and often extremely feeble. The proper method of pro- ceeding, in this uncertainty, is to give from one to three grains of the extract, and gradually increase the dose until it produces the desired effect, or at least evinces some narcotic power; and, havino- thus ascertained the strength of the parcel, to be guided afterwards accordingly. The dose will often be raised to ten grains before . acting, sometimes even to twenty or thirty grains, or indeed much higher; for occasionally the extract is quite inert. The Tincture of Henbane (Tinctura Hyoscyami, U. S) is also officinal. It is prepared by macerating the leaves in diluted alco- hol, and is of such a strength that a fluidrachm represents rather less than 8 grains. The same rule holds as to the commencing dose in this as in the extract; for the preparation is almost equally uncertain. From thirty minims to a fluidrachm and a half may be given at first. VII. BELLADONNA. U. S., Lond., Ed., Dub. 'Origin. Under the name of Belladonna, our Pharmacopoeia re- cognizes the leaves of Atropa Belladonna, or 'deadly nightshade, an herbaceous perennial "European plant, cultivated in this country, but to no great extent, for medicinal purposes. Though the leaves only are officinal,.all parts of the plant are active, and the root, it is said, even more so than the leaves. The fruit, though not specially used in medicine, merits a particular notice, as it is highly poison- ous, and has .frequently been eaten with fatal effect. Properties. The root is a foot or more in length, round, an inch or more' in thickness, branched, grayish or broAvnish-white when fresh, becoming red dish-broAvn by drying, internally whitish and fleshy, of a faint peculiar odour, and sweetish, slightly bitter, mawkish taste. The'leaves, which are often in unequal pairs, upon short footstalks, are from four to six inches long, ovate, pointed, 792 GENERAL STIMULANTS. [PART II. entire upon their edges, of a deep-green colour above and paler beloAV when fresh, of a dusky or brownish green when dried, and, in the latter state, almost destitute of odour, and of a feeble sub- acrid taste. The fruit is a berry, at first green, then red, and, when ripe, of a fine glossy blackish-purple colour, about as large as a cherry, with a longitudinal furrow on each side, having the adher- ing calyx at the base, and containing numerous seeds in a juicy pulp. Its taste is sweetish, but mawkish, and not agreeable. All parts of the plant impart their medicinal properties to water and alcohol. Active Principle. The ingredient to which belladonna chiefly if not exclusively owes its virtues is a peculiar alkaloid, denominated atropia, which will be specially treated of at the close of this article. Brandes obtained also a peculiar substance called pseudotoxin, and Lubekind supposed that he had detected another alkaloid, which he named belladonnin; but little is known of their properties; and the ordinary existence of the latter may be looked on as doubtful. Effects on the System. Belladonna produces its characteristic effects upon the system, to whatever part it may be applied, whether to the stomach, the skin, or the rectum, the cellular tissue, or the blood. When it is given in small doses, repeated two or three times daily, so as to bring the system gradually under its influence, the first effect usu- ally noticed is a feeling of dryness and stricture in the fauces, soon followed, if the medicine be continued or increased, with slight un- easiness or pain in the forehead, vertiginous sensations, some dim- ness of vision, and ©ccasionally dilatation of the pupil. The system may be kept long under its influence with little other observable effect, by a careful management of the dose. In some very sus- ceptible persons, however, the quantity usually given will act more powerfully, in one producing blindness with large dilatation of the pupil, in another decided pain in the head, flushed face, perhaps slight delirium, and an excited pulse. From larger quantities, the effects are more quickly induced and more severe. A dose sufficient to bring the system at once de- cidedly under its influence, generally begins to show its effects in about half an hour. Dryness of the mouth and fauces, a feeling of stricture of the throat, difficult deglutition, thirst, dimness of vision sometimes amounting to blindness, dilated pupil, vertigo or CHAP. I.] CEREBRAL STIMULANTS.— BELLADONNA. 793 headache, flushed face, suffused eyes, morbid sounds, irregular muscular contractions, and hallucination or delirium, sometimes followed by a disposition to sleep, sometimes attended throughout with wakefulness, are symptoms which most frequently appear, though not all generally in the same case, and which, having con- tinued for twelve hours or more, gradually subside, Avithout leaving any ill effects behind. Along with more or less of the effects men- tioned, there may be frequency of pulse and febrile excitement; but more commonly the circulation is at first little affected, and is in greater or less degree depressed when the cerebral phenomena are at their height. Not unfrequently there is an increase either of perspiration or urine, sometimes an eruption of scarlet rash on the surface, or irritation of the urinary passages. Occasionally, also, there is some nausea or griping pain with diarrhoea, intimat- ing an irritating influence on the alimentary mucous membrane. Poisonous Effects. When poisonous quantities are taken, the above effects are experienced in a still greater degree. The lips, tongue and fauces are very dry, with a burning sensation in the throat and stomach, a sense of severe constriction of the throat, great difficulty of swallowing, and intense thirst. Not unfrequently there is nausea with ineffectual retchings; and sometimes stran- gury and bloody urine. The dimness of vision is extreme, and total blindness not uncommon, with the pupil greatly dilated, im- movable, and quite insensible to the brightest light. The hearing is also defective, and not unfrequently there is great difficulty of speaking, amounting sometimes to aphonia. The face is red and swollen, and the eyes suffused with blood, sometimes as it were projecting, sometimes with a fixed meaningless stare, sometimes haggard, or Avild and fierce. Vertigo soon comes on Avith visual de- ceptions, and the patient fancies that he sees objects in his vicinity which have no real existence, and makes motions accordingly. In one case, complete somnambulism was observed; the patient imagin- ing that he Avas a tailor, and for twenty-four hours making gestures as if working at his trade. The delirium is generally cheerful or gay; agreeable or ludicrous ideas present themselves; and the pa- tient smiles or bursts out into laughter, or makes Avhimsical gesticu- lations. Sometimes, however, he is Avild or even furious. Stupor or coma at length supervenes, sometimes alternating or mingling Avith delirium, and even in sleep the dreams are occasionally ludicrous, producing bursts of laughter. Partial spasmodic contractions take place; the jaws being closed, the muscles of the fadfe working, and 794 GENERAL STIMULANTS. [PART II. those of the hands moving irregularly; but convulsions, though they sometimes occur, are very rare. On attempting to rise, the patient is unable to maintain the erect position, staggers, or moves with his body bent forward. The pulse is now very feeble, the extremities cold, a disposition to syncope evinced; and, if the case is to terminate fatally, death is preceded by great prostration, sub- sultus tendinum, and profound coma. If, on the contrary, recovery is to take place, which happens in the great majority of instances, even without medical interference, the symptoms gradually dis- appear, and, in the course of two or three days, the patient is restored, usually remembering nothing of what had passed.* The poisonous effects have been experienced from belladonna injected into the rectum, applied to blistered surfaces, and even employed in the form of a large cataplasm over the abdomen, with the cuticle unbroken. The quantity necessary to produce fatal effects varies so much, according to the constitution of the patient, and the strength of the preparation, that it is impossible to fix the poisonous dose, with an approach to precision. Two grains of the extract have produced alarming symptoms; six grains administered by enema have had a similar effect; while it is asserted that a pound of the berries were eaten by a man on one occasion, who nevertheless recovered under treatment. (Christison on Poisons) Accurate accounts are wanted of the appearances left behind by the poisoning of belladonna. In general the stomach exhibits signs of some irritant action, and, in a case recorded by Gmelin, the ves- sels of the head were found engorged, and the blood Avas fluid. The treatment of this poisoning is exactly the same as that for opium, to which the reader is referred. As the insensibility of the stomach and bowels is often great, though not equal to that from opium, the same measures must be had recourse to, in order to favour the operation of emetics, including the loss of blood if the symptoms of cerebral congestion should be very prominent. The stomach pump should never be trusted to, when the berries have been taken. In the state of coma, the electro-magnetic machine may be employed. * The symptoms above given as occurring in poisoning by belladonna, must not be considered as all occurring in every case, nor at the same time in the same case ; but the affection of the pupil and of vision is probably uniform. Many of the symptoms have been drawn from an account, by M. Gaultier de Claubry, of one hundred &\\{\ fifty French soldiers, who, in one of the campaigns in Germany, ate the berries of the belladonna plant by mistake, and all suffered in greater or less degree. Many of them perished. {Journ. General de Mvd., xlviii. 335.) CHAP. I.] CEREBRAL STIMULANTS.—BELLADONNA. 795 On the lower animals the effects of belladonna vary greatly. The herbivorous eat the plant with apparent impunity, while the carni- vorous are affected like man. Instances are mentioned in which the horse, the ass, and rabbits have eaten of it freely, with no ob- servable symptoms, while dogs are poisoned. A rabbit was fed on it for eight days, and was not observed to suffer. (Journ. de Pharm., x. 85.) Mode of Operation. Belladonna is a feeble local irritant, has upon the circulation either a moderately excitant effect, or no direct effect whatever, and powerfully stimulates the brain. It undoubtedly operates on the system through absorption. The proofs of this fact are that it produces the same effect to whatever surface it may be applied, even when introduced into the blood, and that its active principle has been detected in the urine. It is asserted that the urine of a rabbit which had been fed upon it, produced dilatation in the pupil of a cat to which it was applied. According to M. Runge, of Berlin, belladonna, stramonium, and henbane, are the only substances which have this effect on cats. (Orfila, Toxicologic) The circumstance that this plant, as well as others of the same natural family of Solanacese, is eaten by some animals with impunity, while it kills others, proves that the medicine acts on the susceptibility of the tissues, and not by a chemical reagency upon their organization. One of the most curious effects of this medicine and other Sola- naceae, is that which they exert on vision and the pupil. The dila- tation of the pupil is probably owing to a complete relaxation of the contracting fibres of that membrane, through an influence on the ciliary nerves, as suggested by Muller. When belladonna is locally applied to the eye, the effect is much more prompt than from its internal use, and quite as great if not more so. But, under these circumstances, the vision is not affected, and the nervous centre of the retina, therefore, not acted on. Generally only the eye to which the application is made is affected; but it is asserted that the other eye sometimes participates; in which case it is pos- sible that the medicine may have been absorbed, and reached the cerebral centres. The dilatation of the pupil and dimness of vision appear to be direct, without any preceding excitation of the organ. It is possible that belladonna may act as an immediate sedative to the nervous centres of vision, while it stimulates the other cerebral centres; but it is also not impossible that the diminution of func- tion may be "the result of a prompt congestion of the centres, or 796 GENERAL STIMULANTS. [PART II. when the medicine is locally applied, of the nervous peripheries, sufficient to suspend their function, and as it were put them to sleep. In the latter case, we may admit belladonna among the cerebral stimulants without restriction; in the former, its influence must be considered as stimulating or depressing according to the special susceptibility of the centres affected. It is unnecessary here to repeat the explanation, by which I have elsewhere shoAvn the compatibility of the depressing effects of this and other narcotics upon the cerebral functions, with the view of their essentially stimulant character. Therapeutic Application. It is uncertain whether belladonna was used by the ancients as a medicine. The earliest account we have of its employment in mo- dern times was about the close of the seventeenth century, when it appears to have passed from empirical use into the hands of the regular profession. At first it was chiefly valued as a remedy in cancerous tumours and ulcers, of Avhich it was supposed sometimes to effect cures; and cases were recorded which would go far to confirm this opinion of its powers, did Ave not know how frequently erroneous diagnosis has led to false estimates of the efficacy of medi- cines in these affections. At present there are very few who would maintain that belladonna could do more than palliate in true cancer. But, though now little employed in those complaints for the cure of which it was first brought into notice, it has been found, by abund- ant experience, to possess poAvers which render it highly useful for various other purposes. Indications. The chief indications which belladonna is calculated to fulfil are, 1. to subdue pain, 2. to relax muscidar spasm and rigidity, 3. to stimulate the nervous centres, and 4. in reference specially to the eye, to lessen the sensibility of the retina, and dilate the pupil. As a soporific, it cannot be relied on, and is, I believe, never employed, One mode in which it operates, in answering these purposes, is by rendering the nervous centres insusceptible of irritative impres- sions, and incapable of transmitting irritative action; but there can be no doubt that it is capable also of operating directly on the peri- pheral sensibility of the nerves, and of producing the same insus- ceptibility at their extremities as at their centres. Whether it acts in this Way by an immediate or by an indirect sedative agency it would not be easy to determine; but, as the evidence is irresistible that it occasionally does stimulate the nervous centres, it is safest CHAP. I.] CEREBRAL STIMULANTS.—BELLADONNA. 797 to admit that, in this respect, its action is uniform, and that the de- pression evinced is an indirect result of an active congestion in all instances. What tends to confirm this view is, that the medicine has not been found applicable to cases, in which the nervous centres were already in a state of active congestion or inflammation; the very condition in which it would seem to be specially indicated, were it directly sedative. In the relief of painful and spasmodic affections, belladonna seems to be capable of something more than a mere temporary influence. Not only does it give ease; but, by a perseverance in its use„ Ave not unfrequently obtain positive cures from it, which opium itself, though more powerful as a mere anodyne, is unable to effect. It would appear, therefore, to produce some permanent modification in the nervous tissue, incompatible with that which existed in its morbid condition, in other words, to act as an alterative as well as an anodyne. Another advantage which it possesses over opium, in the treatment of chronic or frequently repeated painful affections, is its entire exemption from the liability of abuse as an exhilarating agent, which constitutes one of the greatest objections to the use of that most fascinating drug. Contraindications. The contraindications to the use of belladonna are, as in this class of medicines generally, active congestion or in- flammation of the brain, inflammation of the stomach, high inflam- matory or febrile excitement, and a plethoric state of system; in all which conditions, should any special symptom call for this remedy, its use should be preceded by depleting measures. I shall treat of the special complaints in which belladonna is used under the several indications above mentioned. 1. For the Relief of Pain. a. Neuralgic Affections. In these belladonna displays its most useful powers; and I know feAV remedies more effectual in their cure. No matter where the pain is seated, provided it be purely functional, that is, connected with no inflammatory or other organic disease affecting the nerve or its centre, the medicine may be em- ployed. It may be used both internally and locally; and, when the pain is near the surface, or in any position to which near access can be obtained, it is generally advisable either to depend on the topical use of the remedy, or to employ it in the two methods jointly. The general rule is to administer it in quantities sufficient to produce obvious effects, without going so far as to cause delirium, stupor, or dimness of vision approaching blindness. Though these T98 GENERAL STIMULANTS. [PART II. latter phenomena have seldom if ever proved really dangerous, when proceeding from medicinal doses, yet they are not necessary to the anodyne effect, and are, therefore, better avoided. I am in the habit, in neuralgic cases, of giving half a grain of the extract three times a day, and, if no effect is experienced from this dose, of gradually increasing it, until dryness of the throat, dimness of vision, slight frontal uneasiness, or feelings of fulness or giddiness in the head are produced; and of afterwards so managing the dose that these effects should not be exceeded. Sometimes the first dose will act with unexpected energy; in which case, it should be re- duced to one-third or one-quarter of a grain, and afterwards in- creased again if necessary. More frequent repetition than three times a day is unnecessary to maintain a continued operation of the medicine, and might lead to cumulative effects. Both in the neuralgic and spasmodic diseases belladonna may often be very advantageously associated with those tonics which have the effect of strengthening the nervous centres, as quinia, the chalybeates, and the preparations of silver, copper, and zinc; the narcotic and tonic being administered conjointly in the same pill, or separately, as may be most convenient. 3Iodes of Application in Neuralgia, Some remarks in relation to the method of using the remedy locally in these cases may be ad- visable here. A decoction of- the leaves may be employed, or the extract; and one or the other of these may be used in the form of lotion, cataplasm, liniment, ointment, or plaster. Of the use of aconitina I shall speak under a separate head. The extract may be brought into the state of liniment by simply rubbing it with a little water; and of an ointment by incorporating it with lard. The plaster is officinal. Usually it will be sufficient to make the appli- cation upon the unbroken skin; but the effect is more speedy and much more powerful when the remedy is used endermically, the cuticle having been removed by a blister. In this case, the extract should be used mixed with water or lard, and never at first in quantities exceeding two or three grains, which may be increased if necessary. As it occasions some pain if brought into direct con- tact with the denuded surface, it may be applied, as recommended by MM. Trousseau and Pidoux, spread on a piece of linen with the uncovered surface next the skin, and protected by means of ad- hesive plaster. The effect is thus gradually produced, and without pain. To the writers just named I am also indebted for some of the following observations in relation to the local use of the medi- cine in special cases. CHAP. I.J CEREBRAL STIMULANTS.—BELLADONNA. 799 In neuralgia of the scalp, a decoction of the leaves made in the proportion of half an ounce to the pint of Avater may be used locally. With this the hair may be saturated; and a thick linen compress thoroughly moistened with it, having been applied over the head, the whole should be covered with a cap of oiled or Avaxed linen, or silk. A solution of the extract in the proportion of a drachm to the pint, or the officinal tincture diluted with four parts of water, may be similarly employed. In supra-orbitar neuralgia, or that of the eyeball, from five to ten grains of the extract, mixed with a little water, may be rubbed upon the lids and around the eye, with gentle friction, for ten or fifteen minutes; and the process maybe repeated every two or three hours, the part being in the mean time covered with a light compress, until the pain is relieved. Or a cataplasm made with a solution of the extract and flaxseed meal may be applied over the whole eye. The same method may be employed in other forms of facial neuralgia; but in the infra-orbitar and submaxillary forms, the authors above mentioned, prefer the friction to be made upon the gums or inside of the cheeks. Of course, care must be taken that the patient do not swallow the medicine. In painful affections of the ear, a solution of the extract may be injected into the mea- tus, and cotton afterwards introduced impregnated with the same. In toothache, the extract itself may be introduced into the carious cavity. In neuralgia of the limbs or trunk, the application should be made as near to the seat of pain as possible; and in these, the endermic method will often be advisable. In sciatica, which is one of the most obstinate forms of the affection, the blistered surface should be made in the course of the nerve as it passes out of the pelvis. MM. Trousseau and Pidoux have met with great success, in \ery obstinate cases of this affection, by making an incision through the skin, betAAreen the great trochanter and ischium, and inserting a ball in the form of a pea, containing from one to five grains of the extract with a little opium; thus gaining the effects of an issue, with those of the narcotic. In angina pectoris the medicine has been used locally with advan- tage. Dr. Davies relates a case in Avhich a plaster of belladonna was applied to the chest after tartar emetic, and before the ulcers from this had healed. Alarming symptoms were induced; but, on their subsidence, it was found that the angina had ceased. (Led. on Dis. of Lungs and Heart, p. 496.) 800 GENERAL STIMULANTS. [PART II. In the internal neuralgic affections of the abdomen, as gastralgia, enteralgia, nephralgia, &c, the external use of the medicine should be resorted to when the complaint is complicated with vomiting or purging, while opium is used internally. But, in the contrary con- dition of constipation, it would be better to try the effects of extract of belladonna internally. Lead colic and nervous colic, which are really forms of intestinal neuralgia, may be advantageously treated in their milder and more chronic conditions, with belladonna combined with alum or iodide of potassium internally, and frictions with an ointment of the ex- tract externally over the surface of the abdomen. b. Rheumatic and Gouty Disease. Among the painful affections Avhich, in like manner with neuralgia, may be treated with the internal and external use of belladonna, are rheumatism and gout. The medicine has been employed even in acute rheumatism, and is asserted to have proved very successful. After a proper use of the lancet, and in connexion with purgatives and arterial sedatives, I have no doubt that it would prove serviceable, given so as to maintain a constant and decided impression; and, in cases where some idiosyncrasy may forbid the use of opium, might be had re- course to with great propriety. But it is in the nervous or neuralgic forms of these diseases that belladonna is especially indicated; and here it is among the most efficacious remedies. It is also frequently serviceable in the shifting forms of subacute rheumatism without fever; and, in the chronic forms of the same disease, is a standard remedy, given in connexion with one or more of the various alteratives used. In this form of the disease it may also be advantageously employed locally, in the shape of poultice or plaster; the former being most conveniently applied to the joints, the latter over muscular parts, as to the small of the back in lumbago, and to the side in pleurodynia. c. Other Painful Affections. There is a number of painful affec- tions, local in their character, in which the topical use of belladonna has been resorted to with more or less benefit. In dysmenorrhoea it has been introduced into the vagina, either by injecting a decoction of the leaves or solution of the extract, or in the form of a pill con- taining half a grain or a grain of the latter preparation. Fissures of the anus, painful piles, and excessive sensitiveness of the rectum, may often be usefully treated with an ointment made by mixing the extract with lard; not more than from half a grain to a grain and a half of the former being used at the first application, especially if introduced within the sphincter. Phymosis and paraphymosis, swelled CHAP. I.] CEREBRAL STIMULANTS.—BELLADONNA. " 801 testicle, inflamed urethra, and various painful tumours and ulcers, can- cerous, scrofulous, or simply phlegmonous, are additional affections in Avhich the extract has been recommended in the shape of cataplasm or ointment, with the view of relieving pain. 2. For the Relief of Spasm or Muscular Rigidity. Singular as it may seem, the painful spasmodic affections are less benefited in general by belladonna than either pure neuralgic pain, or spasmodic affections without pain. Thus, spasms of the stomach, bowels, ureters, hepatic ducts, &c, and those of tetanus, do not yield readily to belladonna, perhaps because the centres of irritation in these cases are in the sympathetic nerve or spinal marrow, upon Avhich that narcotic may exercise less power than on the cerebral centres. Still, the medicine has been used in tetanus, and in certain colicy affections, and not without some reported success. As a remedy in colica pictonum, it has already been spoken of; but this is rather a neuralgic affection of the bowels, than simply spasmodic, and, moreover, probably depends more on the local influence of the lead upon the nervous tissue of the bowel itself, than upon the nervous centres. In painless spasms, the medicine is often highly beneficial. In these affections, it not only yields relief, but serves, as in neuralgia, to make a permanent impression on the nervous centres, which sometimes proves curative; and, in like manner, may be usefully combined with the antispasmodic tonics, as quinia and various me- tallic salts. It will very seldom cure epilepsy; but, in some purely functional cases, it is said to have had this effect, and it will often ameliorate the symptoms. The patient should be kept under its very moderate influence for a long time, with occasional intermis- sions ; and, about the period of the expected paroxj-sms, it should be given more freely. In the non-epileptic convulsions of puerperal women and children it has been highly recommended; but should not be given Avhen in these cases there is active cerebral congestion, or any suspicion of inflammation. In infantile cases, it should be confined to the con- vulsions Avhich depend on some extra-cranial irritation, such as teething or spasm of the bowels. In both instances, it is best adapted to those attacks in which there is a frequent recurrence of the paroxysms, and should be given in the interval, in order to prevent the convulsions, and not during their continuance. On the continent of Europe, belladonna was long since used in VOL. I.—51 °UZ GENERAL STIMULANTS. [PART II. hooping-cough, but was neglected until the practice was at a recent period revived by Bretonneau. In this country, it has been em- ployed and highly recommended by Dr. Samuel Jackson, late of Northumberland, who gave to children two years old from the twelfth to the sixth of a grain of the extract, twice or three times a day, increasing the dose until the pupil became dilated. Dr. Hiram Corson, of Montgomery County, Pennsylvania, has also used it with great success. My own experience with it is confined to a single case. This occurred in an infant, to the chest of which I ap- plied a belladonna plaster. The child was soon afterwards attacked with convulsions, which were frequently repeated, and very alarm- ing. It recovered, however; and the hooping-cough ceased with the convulsions. It is possible that the medicine may have cured the disease, and may not have caused the convulsions, which are not uncommon in hooping-cough; and I am disposed to think that this was really the case; for belladonna very rarely produces this effect, even in poisonous doses. The occurrence, however, deterred me from afterwards having recourse to the remedy. In asthma it has been strongly commended. It has been used internally in this complaint, being given during the intervals of the paroxysms, so as to sustain a steady impression; but the most effi- cient; method of employing it is by the inhalation of its fumes. For this purpose, the dried leaves may be smoked in a pipe, or in the form of cigars, made like those of tobacco. Great care, however, must be taken that too great a narcotic effect is not produced. This use of the remedy no doubt originated in a similar employment of stramonium, which very closely resembles belladonna in its medical properties. Another mode of using the remedy, in the same com- plaint, is by inhaling the vapour from a decoction either of the leaves or extract; two drachms of the former or fifteen grains of the latter being boiled with a pint of water. The smoking of the leaves, steeped when fresh in a strong infusion of opium and then dried, is said to have afforded relief in phthisis. In muscular rigidity, its local application has been found very useful in a number of different affections. In constriction of the sphincters of the anus and neck of the bladder, and in spasm of the urethra, it has been employed in poultice, or in the Avay of friction to the perineum, with the extract mixed with lard; and, in the urethral affection, it has been introduced into the passage by means of a bougie smeared with the ointment. Rigidity of the os uteri in delivery is said sometimes to yield to the local application of the CHAP. I.] CEREBRAL STIMULANTS.—BELLADONNA. 803 extract. It has been employed externally in strangulated hernia, to produce relaxation of the abdominal muscles. Under the impression that vomiting in pregnancy is sometimes caused by irritation from a spasmodic contraction of the uterine fibres, resisting the expanding growth of the foetus, Bretonneau was induced to employ friction Avith the extract over the hypogastric region, and met with great success. It is unnecessary to admit his theory of the influence of the medicine, which may relieve other disorders of the uterus besides constriction of its fibres, and thus obviate sympathetic irritation elsewhere; but the fact is important. . Its accuracy is confirmed by the experience of MM. Trousseau and Pidoux; and the late Dr. R. L. Scruggs, of Louisiana, employed the remedy repeatedly, with uniform success. He also succeeded, by the same method, in relieving an obstinate and distressing cough, apparently dependent on irritation from the impregnated uterus. (South. Journ. of Med. and Phys. Sci, i. 318.) 3. To Stimulate the Nervous Centres. In reference to this indication, belladonna has been used in cer- tain conditions of paralysis with asserted success, particularly in paraplegic cases. It is quite obvious that it should never be em- ployed in cases dependent on congestion, inflammation, or organic lesion of the nervous centres, until this condition shall have ceased entirely, and nothing be left but mere inertness. In paralysis combined with neuralgic pains, as in lead palsy, we may readily conceive that the medicine may act favourably. In amaurosis it is said also to have proved useful; but here also the affection should be purely functional to justify its employment. Belladonna has been used in insanity, particularly in its melan- choly forms; and it is probably useful in cases similar to those in which opium proves advantageous; but it is so much inferior to that narcotic, that unless some special objection to opium may ex- ist, it would scarcely be worth while to employ it. When compli- cated, however, with neuralgic pains, the disease would present a *< much stronger indication. In delirium tremens it has been used, like most other narcotics; but, as it has little tendency to produce sleep, Avhich is the great object aimed at here, it would not seem to be specially called for. In this complaint the pupils are often very much contracted; and belladonna has been suggested as an appropriate remedy, because one of its most constant effects is to dilate the pupil. Dr. James 804 GENERAL STIMULANTS. [PART II. Grieve, of Dumfries, Scotland, has used it locally to expand the pupil, and thus to obviate spectral illusions which he supposed might be connected with this condition of the iris. I tried it in one instance, Avith no satisfactory result. Besides, one of the cha- racteristic effects of belladonna, when given largely, is to produce illusions. Under this head we may introduce a notice of the use of bella- donna in the nocturnal incontinence of urine of children. There can be no doubt of its frequent usefulness in this affection. It should be given at bedtime, and continued for a week or two before being relinquished if unsuccessful. If it prove efficacious, it should be persevered with for some time after apparent cure, in order to break up the habit. It probably acts by giving greater energy to the sphincter through the nervous centre which regulates its action. 4. In Reference to its Influence upon the Eye. Belladonna is employed in affections of the eye with two objects; one, to diminish the sensibility of the retina or optic nervous centre, and the other to dilate the pupil. With the first object, it may be employed in that not uncommon condition of the eye, in which, altogether independently of inflammation, light is extremely painful to it, and, though the vision is in no degree impaired, the use of the organ for any length of time is impossible, in consequence of the pain induced. It has also been advised in the similar sensitiveness Avhich attends ophthalmia; though its appropriateness, in the latter condition, is more equivocal. For the dilatation of the pupil belladonna is much used by the surgeons. It is the local application of it that is resorted to for this purpose. -The infusion of the leaves, or solution of the extract may be dropped into the eye, or the extract itself, mixed with a little water or lard, may be rubbed upon the eyelids and around them. By many aconitina is preferred for the purpose on account of cleanliness. The dilatation usually begins in about half an hour, is at its height in three or four hours, and may continue one or two days or longer. The objects in producing dilatation with it are manifold. Before the operation for cataract, it is useful by removing the iris out of the way; and, after the operation, has been recommended, in order to prevent the adhesion of the iris and obliteration of the pupil, which might result from inflammation of that membrane. In operations which involve a wound of the iris, it is supposed to be indicated upon the same score. It is said that even in partial or complete ob- CHAP. I.] CEREBRAL STIMULANTS.—BELLADONNA. 805 liter a tion of the pupil already produced, if recent, the remedy will obviate the evil by causing a separation of the adhesions Avhile still soft. In iritis, either exclusive, or attendant upon conjunctivitis, it has been recommended with the same view of obviating obliteration of the pupil. In cases of commencing cataract, it is sometimes tem- porarily serviceable by bringing within reach of the light the yet unaffected portions of the lens nearest the circumference. In opacity of the cornea, moreover, in which vision is obstructed by the posi- tion of the opacity immediately before the pupil, it occasionally restores sight for a time by dilating that orifice, so that the light passing the transparent parts of the cornea may enter it. Belladonna has been recommended in scarlet fever both as a remedy and prophylactic. I have no confidence in its efficiency in either capacity. Its use was suggested by the originator, of the homoeopathic delusion, upon the basis of one of his dogmas, that diseases are cured by remedies the effects of which resemble the disease itself. Belladonna causes dryness and irritation of the fauces, and sometimes a rash like that of scarlet fever; therefore it is the appropriate remedy for that complaint. If it be capable of acting remedially, it is probably capable also of preventing the dis- ease. Such is the rationale of its use. Though I would accept a useful fact from the homceopathists, or any other class of men what- ever, or from any source whatever, I should be disposed to subject it to a close scrutiny before admitting its claims to be a fact. I think that many in our profession have been somewhat too hasty in adopting this scion of a false hypothesis. It is true that, in many instances, numbers of children to whom belladonna has been administered, have escaped scarlatina though exposed to the cause; but nothing is more common than a similar result where bella- donna has not been given. Every one knows, who has seen much of this disease, that it is extremely capricious in its choice of sub- jects, sometimes attacking all the children of a family, and not unfrequently seizing upon one only of a large number equally exposed to the cause; so that the exemption, under the circum- stances referred to, might well have taken place, though no pre- ventive had been used. Besides, numerous trials have been made by persons quite as deserving of credit, in Avhich the use of bella- donna has entirely failed in securing the desired exemption, Avhich could not have happened were it possessed of the poAver ascribed to it. The mistake might be a very fatal one, if, in reliance upon the prophylactic virtues of belladonna, other means of securing 806 GENERAL STIMULANTS. [PART II. exemption, such as common sense would suggest, should be ne- glected. Administration, After what has been stated above, little remains to be said on this point. Belladonna may be given in substance, infusion, ex- tract, or tincture; and there are two officinal preparations intended exclusively for external use, namely, the plaster and ointment. Atropia is also among the officinal preparations. The commencing dose of the powdered leaves is one or two grains, to be repeated two or three times daily, and to be gradually increased until the effects of the medicine are produced. When the leaves have not been injured by time, ten or twelve grains daily can rarely be exceeded without inconvenient effects. The Infusion may be prepared by macerating a scruple of the dried leaves in ten fluidounces of boiling water. The dose at first is one or two fluidounces two or three times daily, to be increased as in the case of the powder. The medicine, however, in this country, is much more used in the form of extract than in any other way. The U. S. Pharmacopoeia directs two extracts, one of which is the inspissated juice, and the other is prepared by means of diluted alcohol. EXTBACT OP BELLADONNA. — EXTRACTUM BELLADONNA. U. S., Lond., Ed., Dub. This is prepared by bruising the fresh leaves, expressing the juice, heating this to the boiling point so as to coagulate the albumen, then straining, and evaporating the clear liquor to the proper consist- ence. It has a dark-brown colour, a narcotic not disagreeable odour, a bitterish taste, and a soft consistence. As used in this country it is generally imported, and is of unequal strength, some- times very powerful, sometimes feeble, and therefore requiring to be administered with much caution. Special care must be taken that, in increasing the dose, the same parcel should be employed; and if a new one is to be used, the dose should be reduced so as to test its strength. This is the preparation most employed in the United States. The commencing dose is from one-quarter to one-half a grain, twite or three times a day, gradually increased, if necessary, until some sign of its action is produced, as dryness of the throat, dimness of vision with dilatation of the pupil, or uneasy sensation in the head. I have often knoAvn half a grain to act decidedly. In the way of enema not more than three times as much should be given as by the mouth. For endermic use, three or four grains CHAP. I.] CEREBRAL STIMULANTS.—BELLADONNA. 807 may be employed, but its effects should be watched. If no effect is produced, the quantity may be increased. For friction on the sound skin, from ten to thirty grains or more may be used, with sufficient water to bring it to the consistence of thick cream, or with twice its weight of lard. ALCOHOLIC EXTBACT OF BELLADONNA. —EXTRACTUM Belladonna Alcoholicum. U.S. The alcoholic extract is prepared by evaporating a tincture of the leaves made with diluted alcohol. The dose is half a grain to begin with. TINCTUBE OF BELLADONNA. —TlNCTURA BELLADONNA. U.S., Lond., Dub. This is made in the proportion of four ounces of the dried leaves to two pints of diluted alcohol. It is an efficient preparation, if made from recently dried leaves. The dose is fifteen or thirty drops, or half the number of minims, to be increased as the other preparations. Not more than one-sixth or one-eighth of the doses above men- tioned should be given at first to a child two years old. PLASTEB OF BELLADONNA.—EMPLASTRUM BELLADONNA. U. S., Lond., Ed., Dub. This is prepared by incorporating the extract with melted resin plaster. It is used, spread upon coarse linen or leather, in rheumatic pains, neuralgia, dysmenorrhoea, &c. I have known the system to be affected by it. OINTMENT OF BELLADONNA.—UNGUENTUM BELLADONNA. U.S., Lond. This consists of one part of the extract and eight of lard mixed. It is used for friction upon the skin, or as a dressing to blistered surfaces. For the latter purpose, not more than half a drachm or two scruples should be applied at first. ATBOPIA. This is thought to exist in belladonna, combined with malic acid in excess. It is ordinarily extracted by a somewhat complex pro- cess, for an account of which the reader is referred to the Dispensa- tories. Mr. W. T. Luxton, of London, proposes the following simple method. To a decoction of the leaves he adds a little concentrated sulphuric acid, which precipitates the albumen and forms sulphate of atropia; then, having draAvn off the clear liquor, he precipitates the atropia either by solution of ammonia, or the sesquicarbonate of that alkali. After a day or two the clear liquid is drawn off, 808 GENERAL STIMULANTS. [PART II. and the crystals which have formed, having been thrown on a filter to dry, are washed by a little spirit of ammonia, which deprives them of most of their colouring matter, leaving them "moderately" white. He has thus generally obtained about 5.5 parts from 1000 of the leaves, while the process usually employed yields only 3 parts for 1000. (See Am. Journ. of Pharm., xxvii. 156.) Atropia is in white, translucent, silky, acicular crystals, inodor- ous, of a bitter acrid taste, slightly soluble in cold water, consider- ably more so in ether, very soluble in alcohol, and dissolved by all these liquids in larger proportion when hot than cold. It mel^s with heat, and at a higher temperature is dissipated; part being volatilized without change, and the remainder decomposed. It has an alkaline reaction with litmus paper, and neutralizes the acids, forming crystallizable salts with the sulphuric, muriatic, and acetic. Nitric acid dissolves it, forming a yellow solution; sulphuric acid dissolves it without change of colour if cold, but when hot reddens it. Like the other organic bases, it is precipitated by the alkalies from its saline solutions, unless very feeble; and from the same solutions tannic acid throws doAvn the tannate of atropia. Like these, too, it consists of carbon, hydrogen, oxygen, and nitrogen. The effects produced upon the system by atropia are exactly those of belladonna, only that they occur more promptly, and are relatively much more powerful. Thus, the alkaloid gives evidence of its operation in twenty minutes, while the powdered leaves or extract usually require half an hour. Its action continues from twelve to twenty-four hours, or longer. One-sixth of a grain, taken into the stomach, generally produces symptoms of a somewhat vio- lent character, as accelerated pulse, dryness and stricture of the throat, dimness of vision with dilated pupil, giddiness, abnormal sounds, phantasms, delirium, and sometimes numbness and tingling of the extremities, and strangury, with depression of the circula- tion and temperature of the surface. Two-thirds of a grain have occasioned the most alarming symptoms, from Avhich, however, re- covery took place. For internal use it has little advantage over the other prepara- tions, while, from its small bulk, it might be more liable to be taken in poisonous quantities. Nevertheless, if pure, it may be more cer- tainly depended on in a given dose, and danger may be avoided with care. It is applicable to the same diseases precisely as bella- donna itself. The dose at first should never exceed the twelfth of a grain; and it would be best to commence with the tAArenty-fourth CHAP. I.] CEREBRAL STIMULANTS.—STRAMONIUM. 809 or thirtieth, which may be repeated two, or three times daily, and increased if requisite. Externally, especially for application to the eye, it is preferred by some to the extract, in consequence of the less quantity required, and its greater cleanliness. It may also be used with great effect endermically. It is chiefly employed to dilate the pupil, which it does very promptly, in exceedingly minute quantity. One drop of a solution, containing only a grain in a fluidounce of the men- struum, will produce the effect. The London College directs the sulphate of atropia ; but it has little advantage over the pure alkaloid, which may be dissolved in water with the utmost facility by means of a little acetic acid. The following preparations may be made for use. Dissolve one grain of atropia in a fluidrachm of alcohol, and add seven fluidrachms of distilled water to the solution; or mix a grain with a fluidounce of pure water, and drop in diluted acetic acid till the solution is affected. Of either of these preparations, fifteen minims may be given for a commencing dose, and a drop or two may be introduced into the eye in order to dilate the pupil. An ointment may be made by rubbing up five grains thoroughly with three drachms of lard; of which a portion about as large as a pea may be used in friction to the eyelids and face, to dilate the pupil, or relieve neu- ralgia. When atropia is applied to a blistered surface, or that of an ulcer, not more than the same dose given by the mouth should be first used, in consequence of its very rapid absorption. It causes when thus employed a slight pain, Avhich soon ceases. VII. STRAMONIUM. Datura Stramonium, thornapple, or Jamestown weed, is an annual plant from two to six feet high, growing in all quarters of the world, and flourishing especially in rank soil, as on dung-heaps, and on the road-sides and commons near towns and villages, where refuse matter is apt to be collected. Its original native country is uncer- tain. It is often clustered in patches, and scents the air of the neighbourhood with its disagreeable odour. All parts of it are active. The U. S. Pharmacopoeia recognizes the leaves, seeds, and root. 1. Stramonium Leaves.—Stramonii Folia. U.S., Lond.— Stra- monium. Ed.—These have short footstalks, are five or six inches °1U GENERAL STIMULANTS. [PART II. long, unequal at the base, irregularly sinuated and notched at the border, dark green above, and pale beneath. When fresh and bruised, they have a fetid, narcotic odour, which they lose by dry- ing; retaining, however, a bitter and nauseous taste. 2. Stramonium Seeds.—Siramonii Semen. U.S., Lond.—Stra- monium. Dub.—These are small, kidney-shaped, flattened on the sides, of a blackish-brown colour, without smell, and of a bitter, nauseous, somewhat acrid taste. They are stronger in medicinal qualities than any other part of the plant. 3. Stramonium Root. — Stramonii Radix. U. S.—This is large, Avhitish, branched, with numerous fibres, fleshy when fresh, light and spongy Avhen dry, and of very little smell or taste, though it leaves a slightly acrid impression in the mouth when cheAved. All these parts yield their virtues to water and alcohol. Active Principle. The odour of the plant would suggest that the volatile principle might possess narcotic properties; but it is as- serted that water distilled from the fresh leaves, though it has their odour in some degree, is without effect on the system; and the seeds, which are inodorous, are stronger than the leaves. It is pro- bable that the virtues of the plant reside exclusively in an organic alkali, which has been extracted from the seeds, and received the name of daturia. In its sensible, chemical, and physiological pro- perties, this bears so close a resemblance to atropia as to have led to the supposition that the two principles are identical; and if their composition be, as stated by Von Planta, precisely the same, the supposition must be considered as correct. Upon this ground we can explain the extraordinary resemblance of stramonium and bel- ladonna in their effects upon the system, and their remedial appli- cation. Effects on the System. The operation of stramonium on the sys- tem so closely resembles that of belladonna, that it is necessary to do little more than refer to the account of the latter medicine. (See page 792.) It is sufficient to say, in reference to the effects of stramonium in full medicinal doses, that it produces dryness and uneasy sensations in the throat, dimness or perversion of vision, sometimes dilatation of the pupil, not unfrequently vertigo, head- ache, mental confusion or slight delirium, and, in some rare in- stances, sleep; and that its operation on the brain is attended with little or no disturbance of the circulation, and no tendency to con- stipation, but with an occasional increase of perspiration or urine. In poisonous quantities, it causes great uneasiness of the throat with a feeling as of strangulation, anxiety and faintness, partial or CHAP. I.] CEREBRAL STIMULANTS.—STRAMONIUM. 811 complete blindness, great dilatation of the pupil, sometimes deaf- ness, flushing of the face, vertigo, headache, hallucinations, delirium of a whimsical, ludicrous, or more rarely furious character, tremors, paralysis, and at last stupor, with convulsions in rare instances. There is usually, in the advanced stage, great prostration, as indi- cated by the very feeble pulse, and cool skin; and sometimes the local irritant influence of the poison is evinced by a burning pain at the stomach, nausea, and vomiting. From the worst symptoms mentioned, recovery has often taken place; but not unfrequently they have ended fatally, in a period varying from six to twenty- four hours. In cases of recovery, the poisonous symptoms are of variable duration, but generally begin to disappear within twenty- four hours; and the patient, upon rising out of his lethargy, has no recollection of what has passed. Little definite is known, as to the smallest quantity that may cause death. A child two years old Avas killed by 100 seeds, which were swallowed whole, and were afterwards found in the stomach and bowels. Dr. Young states that a siugle capsule with its contents proved fatal to a child. It is the seeds which are most frequently taken in poisonous quanti- ties, and generally by children, who gather them from the plant. Stupor in a child, with extraordinarily dilated pupil, should lead to the suspicion of this kind of poisoning, if access to the cause was possible. The late Dr. Dorsey used, in his lectures, to relate a case in which this symptom induced him to suspect narcotic poisoning, and, upon this suspicion, to administer an emetic, which caused the discharge of numerous stramonium seeds, with the effect apparently of saving life. Alarming symptoms have followed the external application of the leaves to a burn. Herbivorous animals are less affected than man. Five ounces of the fresh juice produced only slight drowsiness in a horse; and two pounds and a half of the seeds, given to another horse, though they proved fatal, did not destroy life until after fifty-tAvo hours. (Pereira,s Mat. Med.) Upon dogs the poison acts as in the human subject. The treatment of poisoning by stramonium is the same as that for opium. Like belladonna, stramonium produces its peculiar effects, no matter to what part of the body it may be applied; and, in like manner, the expressed juice, an infusion of the leaves, or the ex- tract, dilates the pupil, when introduced into the eye, or rubbed upon the eyelids and neighbouring parts. There is little doubt that it acts on the brain exclusively through the blood. 812 GENERAL STIMULANTS. [PART II. Therapeutic Application. This medicine is not known to have been employed, before it was introduced to the notice of the pro- fession by the famous Storck, who employed it in insanity, chorea, and epilepsy. It is capable of fulfilling the same indications as belladonna; that is, to relieve pain, relax spasm and muscular rigidity, stimulate the depressed cerebral centres, diminish the sus- ceptibility of the retina, and dilate the pupil. There is not, per- haps, one of the therapeutic uses of belladonna, in reference to which stramonium might not be substituted for it, with the same or very similar results. The folloAving, however, are the diseases in which it has actually been employed, with more or less supposed success; namely, neuralgia, syphilitic pains, rheumatism and gout, dysmenorrhoea, painful tumours and ulcers, tetanus, epilepsy, hoop- ing-cough, spasmodic asthma, mania, delirium tremens, and nym- phomania. It is also occasionally used by American oculists to dilate the pupil. To enter into a minute account of its uses in each of these affections, would be merely to repeat what has been said under the head of belladonna; and I must content myself with referring the reader to the article on that subject. But the use of stramonium in asthma deserves a more particular consideration. The smoking of the root of Datura ferox in the paroxysms of asthma, has long been a common practice among the natives in the East Indies. An English general officer, having derived great benefit in his OAvn case from the remedy, was induced, on his return to England, to try the effects of the common stramonium, which he found to answer the same purpose. The remedy, having been made known, was soon extensively employed, and received the highest commendation from various respectable sources. Objec- tion, however, was afterwards made to it, on the score that it endangered disease of the brain, and had frequently caused mis- chievous results. The same may be said of every active remedy. In its application to asthma, stramonium requires to be judiciously employed; but, Avith proper precautions, there is little or no danger; and the greatest benefit may often be obtained. In dyspnoea arising from organic disease of the heart or lungs, it can generally be pro- ductive of little good, and should not be employed unless to alle- viate the affection, when dependent, not on congestion of the pulmonary organs, but on mere nervous irritation connected with the disease. Neither is it adapted to cases of gouty asthma, in which there is a disposition to translation from one organ to another, and especially, when experience has shoAvn that there is CHAP. I.] CEREBRAL STIMULANTS.—STRAMONIUM. 813 any tendency of the disease to the brain. In such cases, by stimu- lating the cerebral centres, the medicine renders them a point of afflux for the gouty irritation, which may fix upon them with great violence; and, though the patient may be relieved of the dyspnoea, he is liable to die of coma. But in the pure spasmodic asthma, unconnected with any other organic disease than such as has been induced by the asthma itself, as emphysema of the lungs, for example, the smoking of stramonium is often extremely useful, and, if care be taken not to carry it too far, is perfectly safe. It is applicable only to the paroxysms, and should be confined to these, lest its influence should wear out too rapidly. The relief afforded by it is sometimes immediate and entire; the patient falling quietly to sleep, not because of the soporific effect of the remedy, but in consequence of the removal of the cause of his wakefulness. It does not prevent subsequent paroxysms, and will not cure the complaint, which, after being completely established, is seldom cured by any means that can be employed; but it is an object of great importance to mitigate the sufferings of the patient, and prolong his life, as probably may be done by preventing the rapid increase of emphysema, which is the inevitable result of the excessive dyspnoea. Unfortunately the remedy has not been found equally effectual in all cases of the disease; and even in those in Avhich it at first operates most effectually, though it may continue to yield relief for years, yet its influence gradually diminishes; so that at length it sometimes ceases to be felt. It is said that Gene- ral Gent, who was most instrumental in introducing the remedy into England, at last suddenly died with coma from the effects of it, probably owing to his over-confidence. Either the root or the dried leaves may be used. The former should be quickly dried, cut in pieces, and beaten so as to render its texture loose. Fifteen grains may be smoked at once, and the pipe may be renewed several times a day if necessary, care being taken to stop when any decided narcotic effect is produced. The leaves may also be used in the form of a cigar. The smoke is said to cause a feeling of warmth in the lungs, which is soon followed by copious expecto- ration, and often by some temporary vertigo and drowsiness, and sometimes nausea. In the intervals between the paroxysms, the extract may be taken internally in such doses as moderately to affect the system. As an external remedy also, stramonium is susceptible of the same applications as belladonna, and may be used in the same way. 814 GENERAL STIMULANTS. [PART II. In the form of cataplasm, or of ointment made with the extract, it has been used in inflamed or painful tumours, irritable ulcers, rheumatism in the joints or muscles, swelled mamma, painful hemorrhoids, and irritating cutaneous affections. Administration. The dose of the powdered leaves is two or three grains, tAvice or thrice daily. That of the powdered seeds is one grain, repeated as often. Should this dose produce no effect in a day or two, it should be gradually increased until it gives rise to some evidence of its action, as dimness of vision, dryness, stricture of the throat, &c. Fifteen or twenty grains of the leaves have often been given without unpleasant effects. The medicine, however, is more frequently administered in extract. The U. S. Pharmacopoeia directs two extracts, one of which is the inspissated juice of the leaves, and the other is prepared by evaporating a tincture of the seeds. The Extract of the Leaves (Extractum Stramonii Foliorum, U.S.) is made by expressing the juice of the leaves, heating to coagulate the albumen, then filtering, and evaporating. The pre- paration is of unequal strength. The commencing dose is one grain, to be repeated and increased in the same manner as the powder. The Extract of the Seeds (Extractum Stramonii Seminis, U. S) is prepared by evaporating a tincture of the seeds. It is a stronger and more equable preparation than the preceding, and may be given in the dose of one-quarter or one-half a grain to be repeated and increased in the same manner. The Tincture of Stramonium (Tinctura Stramonii, U. S)'\s made from four ounces of the seeds and tAvo pints of diluted alcohol. It is an excellent preparation, and may be administered in the com- mencing dose of ten minims or twenty drops. The Ointment (Unguentum Stramonii, U. S) is prepared by simply mixing a drachm of the extract with an ounce of lard. It may be used for frictions over painful surfaces, as an application to hemorrhoidal tumours, and as a dressing to irritable ulcers. CHAP. I.] SPECIAL STIMULANTS.—NUX VOMICA. 815 CLASS x~\r. SPINAL STIMULANTS. Of all the medicines in common use, only the products of the genus Strychnos belong properly to this class. Some others have a stimulant influence over the spinal functions, but they have also properties which class them elsewhere, and there is no one Avhich approaches in power those here referred to. The products of the two species, Strychnos Nux vomica and S. Ignatia, are so similar, I might say identical in character, that it is scarcely advisable to consider them distinctly. They are, therefore, united in the fol- lowing article. NUX VOMICA and BEAN OF ST. IGNATIUS. I. NUX VOMICA. — U.S., Lond., Ed., Did). Origin. This name has been given to the seeds of Strychnos Nux vomica, a middling-sized tree, groAving in various parts of the East Indies. The bark is intensely bitter, containing the same alkaloids which characterize the seeds, and is thought to be iden- tical with a product which at one time attracted considerable attention, under the name of False Angustura bark. The seeds are imbedded in the juicy pulp of the fruit, which is a round berry, about the size of an orange, and covered with a smooth, yellowish, or orange-coloured rind. Properties. The seeds are circular, about three-quarters of an inch in diameter, and two lines thick, someAvhat concave on one side and convex on the other, externally presenting a thin coat closely invested with very short, silky, ash-coloured hairs, inter- nally whitish, translucent, very hard and tough, and difficult to pulverize. They are inodorous'and intensely bitter, and yield their bitterness and medical virtues to Avater, but more readily to diluted alcohol. 816 GENERAL STIMULANTS. [PART II. II. BEAX OF ST. IGNATIUS.—Faba Sancti Ignatii. Origin. This is the seed of Strychnos Ignatia, the Ignatia amara of the younger Linnaeus, a tree of moderate size, growing in the Philippine Islands. They are imbedded in the dry pulp of a fruit resembling a pear in size and shape. Properties. The bean of St. Ignatius is about an inch long, of less thickness, convex on one side, obscurely angular on the other, of a pale-brown colour, externally covered with a very short down, internally translucent, hard, and horny. In its sensible properties of odour and taste, and its relations to water and alcohol, it is closely analogous to nux vomica. Active Principles. Both nux vomica and the bean of St. Ignatius owe their medicinal virtues mainly to two alkaloids denominated strychnia and brucia; and claims have recently been advanced to the discovery of a third, to which the name of igasuria has been given. These bases are supposed to exist naturally in combination Avith a peculiar acid, called igasuric or strychnic. The alkaloids differ greatly in strength, strychnia being estimated as having at least twelve times the strength of brucia, and igasuria being inter- mediate. For practical purposes, strychnia may be considered as the active principle, and is the only one much used in an isolated state. Though similar in virtues, nux vomica and bean of St. Ig- natius probably differ greatly in power; at least, the latter contains a much larger proportion of strychnia than the former; the per- centage of that alkaloid being given at 0.4 in nux vomica, and 1.2 in bean of St. Ignatius. Incornpatibles. Alkalies, their carbonates, and alkaline earths, and the vegetable astringents, throw down precipitates from Avatery solutions of these medicines, the former separating the insoluble alkaloids, the latter forming insoluble tannates; but, if the pre- cipitated matter is SAvallowed, it is capable of acting energetically, though probably somewhat more slowly than the solution. 1. Effects on the System, The effects of nux vomica, in small doses, are those of a bitter tonic, combined, when the quantity taken is sufficient to affect the system, with an influence on the nervous functions which is quite peculiar, and which, in its higher degrees, is so violent and danger- ous as to give the medicine a place among the poisons. From very small doses no effects are at first experienced; but, if CHAP. I.] SPINAL STIMULANTS.—NUX VOMICA. 817 repeated every six or eight hours, they will be found in the course of a day or two to increase the appetite, hasten the digestion, and act generally the part of a simple tonic; and, by carefully managing the dose, diminishing it, or suspending the medicine for a time when the slightest sign of its peculiar action upon the nerv- ous system is evinced, the effects may be confined within the tonic limits. Often, however, there will be some increase of the urinary secretion, with more frequent micturition; and it is said that the medicine sometimes proves diaphoretic or laxative. In large doses, its operation upon the stomach becomes irritant, causing loss of appetite, epigastric uneasiness, cardialgia, and sometimes vomiting or purging. When it is taken more largely than requisite for the tonic effect, an entirely new series of phenomena are developed. The first ob- servable effect in this series is generally a feeling of stiffness or stricture in the muscles of the jaw, or at the back of the neck, or of weight or weakness with trembling of the limbs. Some resist- ance is apparently felt in opening the mouth widely; there is diffi- culty in taking a full inspiration; and after a time the feeling of stiffness may .be experienced more or less elseAvhere, upon any attempt at movement. Along with this symptom, there is an in- creased sensitiveness to external impressions, especially of the touch; so that a slight tap upon the skin will produce sudden and involuntary startings of the muscles; and twitchings or catching movements in the limbs are not unfrequently the first symptom which attracts particular notice. If, under these circumstances, the individual try to walk, there will be a sense of tottering or stag- gering, not from vertiginous feelings, but as if from a Avant of power to regulate the action of the muscles. After some days there is not unfrequently a feeling of formication, tingling, or itching on differ- ent parts of the surface, such as is felt commonly Avhen the'foot is said to be asleep. Sometimes this sensation is among the earliest phenomena; and it is occasionally so severe as to constitute the most prominent symptom. An eruption upon the skin has been occa- sionally noticed. Under a somewhat more energetic influence of the medicine, the spasmodic startings become more frequent and severe; horripila- tions and shiverings, with darting sensations like electric shocks, are not unfrequently experienced; and the stiffness of muscles increases and extends, so that the patient complains not only of rigidity of the limbs, but also of tightness about his throat, diffi- VOL. I.—52 818 GENERAL STIMULANTS. [PART II. culty of deglutition, stricture of the chest and abdomen, and even involuntary erections of the penis; those muscles now becoming affected which belong but partially to the voluntary class. With the powerful effects upon the nervous system above referred to, the circulation is little affected; the pulse being often slow and calm; and when accelerated, as sometimes happens, it is so, in all probability, secondarily. The brain too, is usually un- disturbed; the mental functions being quite sound; though occa- sionally there may be temporary attacks of pain in the head, vertigo, tinnitus aurium, contraction or dilatation of the pupils, and spark- ling or dimness of vision. Poisonous Effects. Beyond the condition above described, the effects of the medicine become poisonous. The spasms are more frequent, extensive, and severe, sometimes involving almost the whole frame, and are attended with a tetanic rigidity which is proba- bly the most characteristic symptom. The attacks come on suddenly, like electric shocks, last usually from a quarter of a minute to two or three minutes, and, after a longer or shorter interval, seldom exceeding ten minutes, recur with increased violence, and at last, if not relieved, with fatal effect. If the patient is sejzed with them when attempting to walk, he staggers and falls. During the spasms, the muscles affected feel hard like a board, and different parts of the body are drawn fixedly into various abnormal posi- tions, from which they cannot be removed. Thus the head may be thrown backward, the jaws firmly closed, the face distorted, the arms or lower limbs extended outwards, the hands clenched, the toes flexed, and the trunk bent backward, forward, or to either side, or stiffly erect. The respiratory muscles become involved, and the breathing is hurried or imperfect, and temporarily suspended; with a purple hue of the face, lips, and extremities, coolness of the surface, and a pulse which is sometimes slow, sometimes quickened, but always feeble, and occasionally almost or quite imperceptible. In some instances there are involuntary discharges of urine or feces. The attacks are often brought on by very slight causes affecting the surface, as by a fresh contact of the bedclothes, or a gentle touch with the finger. As in tetanus and hydrophobia, an attempt to swallow, or even the idea of SAvallowing, will sometimes induce spasms of the respiratory muscles. (See the account of a case by Mr. Hennell in the Lond. 3Ied. Times and Gaz., April, 1855, p. 414.) The spasms are often attended with a violent shivering or tremulous movement through the body; and the muscles may be CHAP. I.] SPINAL STIMULANTS.—NUX VOMICA. 819 felt vibrating as it were under the hand. Sometimes the patient, Avhen asked if he has suffered pain in the spasms, ansAA'ers in the negative; in other instances they are more or less painful, and in others, again, extremely so. In the intervals, there is often a feeling of trepidation, alarm, or anxiety strongly expressed on the coun- tenance; the stomach is sometimes nauseated; the pulse is feeble and often agitated, or even fluttering; and the patient complains of thirst, sweats profusely, and, after a severe attack, has a feeling of fatigue and exhaustion. At length, in one of the spasmodic attacks, respiration is quite arrested, the pulse ceases to beat, and the patient dies with asphyxia. The mind is usually clear throughout the case, until near the fatal issue, which is preceded for a short period by insensibility and unconsciousness. When the poisoning has resulted from one' large dose, the characteristic symptoms make their appearance from ten minutes to half an hour after it has been taken, and death generally occurs very quickly, sometimes in the course of a few minutes, after the third, fourth, or fifth paroxysm. One instance is on record in which death followed in fourteen minutes after the poison was swallowed; and from half an hour to an hour and a half is not an uncommon period. Under other cir- cumstances, the poisonous phenomena may be developed much later, and the termination be much longer postponed. When the case is to end favourably, which not unfrequently happens, there is a gradual subsidence of the violent symptoms; but more or less rigidity may linger for a day or longer; and soreness of the muscles, as if they had been bruised, is felt after other symp- toms have ceased. After death, the muscles often remain in a state of tetanic rigidity, and there is frequently more or less blueness or lividity about the face, hands, and feet. Internally the ordinary signs of venous congestion are presented, as of persons dying from asphyxia. This is especially observable in the lungs; and the bronchial mucous membrane, as well as that of the stomach and boAvels, sometimes exhibits hemorrhagic spots or patches. The heart has in some instances been found firmly contracted, in others quite relaxed, and either empty, or distended with blood. The blood itself has by some examiners been seen coagulated; while by others no clot could be anywhere discovered. Congestion of the brain and its vessels, and effusion into the spinal sheath have been noticed; and both the brain and the spinal marroAV are said to have been found in a softened state; but nothing has yet been discovered by post- 820 GENERAL STIMULANTS. [PART II. mortem examination which can throw any clear light on the action of the poison. Though evidences of inflammation of the stomach are stated to have been exhibited in several cases, yet in the great majority nothing of the kind has been noticed; and the poisonous effects must, therefore, be quite independent of gastric irritation. The bulk of the spleen has been observed to be strikingly dimin- ished, after death from strychnia in the loAver animals. Quantity requisite for Poisoning. The quantity of nux vomica or of its preparations requisite to destroy life is very uncertain. The susceptibility to its influence is extremely different in different per- sons. A case is on record in which fifteen grains of the powder are stated to have proved fatal; another in which the same effect was produced by thirty grains in two doses; and in two others, which occurred in 1839 in London, death resulted from fifty grains (see Taylor on Poisons, p. 775); yet the last-mentioned quantity has been repeatedly administered without inconvenience; and, as a gene- ral rule, the poisonous dose would probably much exceed a drachm. Recoveries have frequently taken place, under proper treatment, after quantities had been swallowed varying from half an ounce to an ounce. As the bean of St. Ignatius contains probably three times as mucli strychnia as nux vomica, it may be considered as in an equal degree more poisonous. The extract of nux vomica is said to have proved fatal in the quantity of three grains (Ibid); and as M. Recluz obtained from the seeds an average product of about one- twelfth of extract, this would be equivalent to somewhat more than half a drachm of the powder. The smallest quantity of strychnia, knoAvn to have caused death in an adult, is half a grain; which is much larger relatively than the smallest fatal doses above men- tioned of the powder and extract. Treatment of Poisoning. The most important point of treatment in poisoning from nux vomica, bean of St. Ignatius, or any of their preparations, is to empty the stomach as speedily and as thoroughly as possible. An active and prompt emetic should be administered immediately. During the spasmodic paroxysms, it is usually im- possible for the patient to swallow, and the jaws are often so firmly closed that medicines cannot be readily introduced into the mouth; but relaxation in general takes place in a short time, and the oppor- tunity thus afforded should be instantly seized for the exhibition of the emetic. Should it be impracticable to introduce the medicine into the mouth, it might possibly be injected through a catheter or other small tube inserted into one of the nostrils. When the CHAP. I.] SPINAL STIMULANTS.—NUX VOMICA. 821 stomach-pump can be employed, it should be brought in aid of the emetic, so as thoroughly to wash out the poison; but it should not be relied on to the exclusion of the latter remedy, which has often proved efficient. I have been informed of a case in which, after the strongest emetics had been taken without effect, a current of elec- tricity directed through the body at the epigastrium was quickly followed by vomiting, probably in consequence of the susceptibility of the stomach being aroused by the measure. The patient was saved. Unfortunately there is no antidote to strychnia which has thus far been sufficiently tried to be confidently relied on; yet the recent experiment of Dr. Garrod with animal charcoal would seem to prove, that the power which this substance has of absorbing the vegetable alkaloids, and even of separating them from their com- binations, may be made available in obviating the poisonous effects of strychia, if brought into contact with it in the stomach before enough has been absorbed to cause death. In these experiments of Dr. Garrod, when strychnia previously mixed with animal charcoal was administered to animals, they were not in the least affected by it; and a case is recorded by Mr. W. Chippendale, in which, an hour after four grains of strychnia had been taken, three or four ounces of animal charcoal, mixed with water, were injected by means of the stomach-pump, and the stomach thoroughly washed out, with the effect of saving the life of the patient, which appeared to be in im- minent danger. (Lond. 3Ied. Times and Gaz., April, 1855, p. 423.) Other substances have been proposed as antidotes, on the ground that they render strychnia insoluble; but none has sufficient expe- rience in its faArour to justify a reliance on it. For an account of them the reader is referred to the U. S. Dispensatory (10th ed. p. 1196). Perhaps the best emetic would be sulphate of zinc or tartar emetic, in connexion with ipecacuanha. But the evacuation of the stomach will not obviate the effects of the portion of the poison absorbed. For this purpose medicines must be resorted to calculated to diminish irritation of the spinal nervous centres. Opium, conium, camphor, chloroform, and ether have been employed, and each with asserted advantage. Consider- able doses are required, as the susceptibility to the narcotic influ- ence seems to be diminished, as in tetanus, by the violence of the nervous derangement. One of these medicines, or some combination of them should be exhibited after the stomach has been emptied; and they may even be exhibited by the rectum during the use of emetic measures, Avith the exception perhaps of opium, which might 822 GENERAL STIMULANTS. [part II. tend to retard or prevent vomiting. In the Boston 3fedical and Surgical Journal (li. 476), Dr. J. H. Tewksbury, of Portland, Maine, records two cases in which camphor appears to have been employed successfully without other measures, two fluidrachms of the satu- rated tincture having been given by the stomach in one case; while in the other, in which the patient could not swallow, the same pre- paration was injected into the rectum, and the patient at the same time immersed in a warm camphor bath. It is probable, however, that, in these cases, the camphor merely moderated symptoms which would not have proved fatal; for Dr. J. E. Thompson, in repeated experiments with dogs, found that the tincture of camphor Avas quite unavailing to obviate the fatal effects of the poison. (Ibid. liii. 163.) Dr. Dresbach, of Tiffin, Ohio, relates a case in the Western Lancet for February, 1850, in which the most alarming symptoms, caused by swallowing three grains of strychnia, Avere completely relieved in fifteen minutes by two drachms of chloroform adminis- tered by the mouth. It would probably be better to administer not more than one-quarter of this quantity at first, and to repeat the dose at short intervals until the desired effect is obtained. Chloroform is said also to have proved effectual by inhalation; but ether would be preferable in this way, as less liable to produce fatal prostration. 2. Mode of Operating. Nux vomica and its preparations are locally somewhat irritant; but not powerfully so. There can be no doubt that the active matter is absorbed, and operates through the circulation. This is proved by an experiment of Vernie're, who found that, when a ligature was applied around the leg of an animal so as to check the flow of blood in the veins, but not in the arteries, and the extract of nux vomica was applied to a wound in the foot, blood taken from the vein proceeding from the wound towards the ligature, and introduced into the vein of an- other animal, caused the death of the latter with the characteristic symptoms of poisoning by this drug. The same inference may be drawn from the facts, that strychnia produces its peculiar constitu- tional effects, to whatever part capable of absorption it may be applied, and that the rapidity Avith which these effects occur is pro- portionate to the facility of absorption in the part. Thus, in con- tact with the lungs, it operates more quickly than when swalloAved, and in the stomach more quickly than when applied to the skin. CHAP. I.] SPINAL STIMULANTS.—NUX VOMICA. 823 Dr. Christison killed a dog in two minutes by the injection of one- sixth of a grain in alcoholic solution into the cavity of the chest. Inserted into a wound it operates still more quickly; and when injected into the veins, its effects are almost instantaneous. In all these instances, too, the effects are identical; proving that, in all, the blood is the vehicle by which the poison is conveyed to the part affected. The medicine, when absorbed, has not been found to produce any effect on the blood itself; and the phenomena of its action evince that its influence is exerted mainly at least upon the solid tissues. Upon these it seems to operate, in very small doses, as a moderate stimulus of the tonic character, closely resembling the simple bitters in the modification of the functions it induces. But it may be inferred, from its effects in larger doses, that even this tonic influence is exerted specially upon the nervous centres; and important therapeutic inferences may be deduced from this view of its action. When given so as to produce the peculiar effects above enume- rated, all the phenomena go to show that it is mainly upon the nervous centres of the spinal marrow, including the medulla oblon- gata, that the medicine operates. The functions of the brain are often wholly unimpaired, even when the spasms are frightfully violent; and the division of the spinal marrow near the occiput, or even the decapitation of the animal, does not prevent them. That it is not upon the muscles directly that the effect is produced may be inferred from their simultaneous contraction, and simultaneous relaxation, showing that the influence modifying their condition flows from a common source; and this can only be in the nervous centres which preside over them. Besides, Matteucci observed that after death from strychnia, the muscles could be made to con- tract by the direct application to them of an electric current, but refused to respond to the same stimulus applied to their nerves; the latter having been exhausted of their excitability by the stimulus of the poison, while that of the former remained unim- paired. Another fact confirmatory of the special spinal influence of nux vomica, is the almost exact resemblance of its poisonous phenomena to those of tetanus, Avhich is generally admitted to have its essential seat in the spinal marrow. But what is the nature of the action thus shown to have its seat in the medulla spinalis? It appears to me obviously to be merely an excessive excitement, or, in other words, irritation of the nervous 824 GENERAL STIMULANTS. [PART II. centres of this structure, extended no doubt thence to the nerves proceeding from them. The first effect is to exalt the sensitiveness of these centres. Hence, even before the spasmodic movements commence spontaneously, they may often be induced by the slightest impressions upon the surface, such as would ordinarily produce no effect. An increase of the stimulus irritates the centres into ex- cessive action, without the aid of any additional exciting cause; and the characteristic spasms now occur with a violence propor- tioned to the central irritation. But in this, as in all other cases of over-excitement, the excitability itself is more or less rapidly exhausted; and, if death be not produced by the interference of the spasms with some vital function, there follows a condition of greater or less prostration of the spinal power, and consequently of depression in the functions dependent upon it. There is reason to believe that death is not always induced by the rigid immova- bility of the respiratory muscles, rendering breathing impossible, and thereby inducing asphyxia; for it has been found that respira- tion, artificially sustained, does not prevent the fatal consequences of poisoning with nux vomica. The exhaustion of the whole medulla oblongata by its over-excitement will explain the result. It has been conjectured that among the causes of death may be a direct influence of the poison on the heart, either causing a spas- modic contraction of that organ, or exhausting its excitability through previous stimulation. In support of this opinion, an experiment of M. Briquet may be adduced, who, having injected extract of nux vomica into the veins of a dog, observed the first effect to be considerably to elevate the hemadynameter of Poiseuille, which subsequently fell lower and lower until death, indicating first an augmentation of the heart's force, and afterwards a reduction Avith exhaustion of its excitability. After death, the heart could not be excited to contraction. (Briquet, Trait. Therap. du Quin- quin., p. 87.) It may be that there is a conjoint excitant action upon the respiratory nervous centres and the heart, folloAved by a conjoint failure of power in both. It has been supposed that the sympa- thetic nervous centres are affected in like manner with those of the spinal marrow; but we have no sufficient evidence upon this point. That the nerves conveying the spinal influence to the muscles par- ticipate in the irritation and subsequent depression or exhaustion of the centres, would seem to be shown by the experiment of Mat- teucci before referred to, which proves that at least they lose the CHAP. I.] SPINAL STIMULANTS.—NUX VOMICA. 825 susceptibility to galvanic influence, while the muscles themselves remain sensible to it. It is probable that the influence of nux vomica extends to the Avhole spinal marrow including the medulla oblongata; for there is no muscle in the body, supplied from that source, which is not liable to be thrown by it into spasm. Some suppose that the medicine acts on the cerebellum; and it has been noticed, by several observers, that this structure occasion- ally exhibits post-mortem evidences of having suffered in cases of poisoning. With those who believe that the cerebellum is the special seat of the sexual propensities, the excitation of the genital organs which has been occasionally noticed under the influence of nux vomica, will afford further proof of the correctness of this supposition. Though the cerebral lobes are seldom affected by this agent, and perhaps never by a direct influence, yet the sensorial region at its base often participates in the irritation, as shown by the frequent itching and tingling sensations experienced, and the occasional occurrence of irregularities of sight and hearing, contraction or dilatation of the pupil, &c. These may be owing either to a direct action of the medicine, or, what is quite as probable, to a radiation of the original and direct spinal irritation from the medulla oblon- gata to the contiguous parts of the cerebrum. 3. Therapeutic Application. Nux vomica has long been used as a medicine in India, and was described by the early Arabian writers, by whom it was made known to modern Europe. The name is not applicable; for in or- dinary doses the medicine is not apt to irritate the stomach, and, when given largely, seldom vomits, and could never be given with propriety in reference to an emetic effect. The bean of St. Ignatius, though supposed by some to be the nux vomica of Serapion, was probably first made known in Europe after the discovery and settlement of the Philippine Islands, where the tree producing it is indigenous, and the seeds were used as a medicine by the natives. It was from their supposed value in the treatment of intermittent fever, and various other complaints, that the Jesuit missionaries to those islands were induced to honour the medicine with the name of the founder of their order. Both nux vomica and the bean of St. Ignatius have, at various times, been used in numerous complaints, but, it must be confessed, 826 GENERAL STIMULANTS. [PART II. rather empirically. Intermittent fever, the plague, gout, rheuma- tism, cholera, diarrhoea, dysentery, colic, constipation, worms in the bowels, the poisonous effects of snake-bites, scorbutic ulcers, insanity, hypochondriasis, hysteria, epilepsy, chorea, hydrophobia, neuralgia, hemicrania, palsy, and impotence are among the affec- tions in which one or the other, or both of these medicines have been recommended. Better acquainted than our predecessors with their mode of operating, we can now prescribe them more intelli- gently, and with more accurate discrimination. It will be remembered that the medicine is in small doses simply tonic, though probably with a special tendency to the nervous cen- tres, and more largely given, acts with great energy upon the spinal marrow, and to a certain extent, also on the base of the brain, stimulating both the sensitive and motor functions. Hence arise two distinct indications for its use, one as a tonic in local or general debility, particularly when the nervous functions are in- volved ; and the other as a direct stimulant of the nervous centres in cases of loss of sensation or the power of motion, or of both, in other words, in paralytic affections. Under these tAvo heads will be arranged the practical remarks which are to folloAv. 1. Use as a Tonic. As a mere stimulant to the stomach, in ordi- nary dyspepsia, though probably equally efficient with the simple bitters, nux vomica has no advantage over them, while any acci- dental abuse of it would be attended with inconveniences to Avhich they are not liable. Hence they should, as a general rule, be pre- ferably employed in this complaint. But, when there is reason to think that, from want of due nervous influence, the muscular coat of the stomach is unable to perform efficiently its share in the pro- cess of digestion, nux vomica may be resorted to with the hope of special benefit. In nervous disorder of the gastric sensibility, con- nected with debility of stomach, it is decidedly indicated, and has been found highly beneficial. Hence its use in pyrosis, and that most painful affection denominated gastralgia or gastrodynia. Upon the same principles exactly it may be employed in bowel complaints. In constipation dependent on torpor of the peristaltic muscles, it proves often of great service, especially in connexion with tonic laxatives, such as rhubarb or aloes. In obstinate flatu- lence from the same cause, it would probably be among our most efficient remedies. We now and then meet with cases of excessive accumulation of flatus, amounting to tympanites, epecially in debi- litated states of the system, and in nervous persons, and wholly CHAP. I.] SPINAL STIMULANTS.—NUX VOMICA. 827 independent of any discoverable lesion, which resist all ordinary remedies. Some of these may depend on a certain laxity or torpor of the muscular coat, and would be very likely to yield to nux vomica. When the flatulence is attended with copious discharge of air, whether from the stomach or bowels, it may possibly arise from an extrication of gas from the mucous tissue itself, owing to insufficient innervation; and here too the remedy is indicated. In enteralgia or neuralgic pains of the bowels, connected as this often is with debility of the parts, nux vomica has been used advantageously; as also in colica pictonurn and pure nervous colic independent of the poison of lead. The remedy has been recom- mended in diarrhoea and in dysentery, having been employed in the latter complaint particulary by the German physicians, some of whom speak highly in its favour. These complaints are some- times connected with a relaxation of the bowels, in which a defect of innervation is probably concerned, permitting an excess of secretion from the flaccid vessels, or deranging the due relation between the contents of the bowels and the expulsive power. In such cases the medicine may sometimes prove useful; but, as a general rule, little good can be expected from it in these complaints, and it would probably often do harm by adding to the existing irritation of the mucous membrane. The medicine has been little used in complaints of the chest; but M. Homolle has recently recommended it in the asthmatic paroxysm, and in suffocative catarrh, believing that, in both these affections, the difficulty lies in a want of proper contractility of the bronchial tubes and perhaps the air-vesicles, and that nux vomica operates by restoring this contractility. (Ann. de Therap. par Bouchardat, 1854, p. 18.) Though not disposed to admit the pathological view of M. Homolle, I am quite willing to hope that the therapeutic advantages claimed for the remedy may prove well founded on future trial. If nux vomica does good in these complaints, it is probably, in asthma, by so affecting the nervous centres as to overcome the existing spasm of the tubes, and in the suffocative catarrh, by giving increased tone to the mucous mem- brane, and thereby checking the excess of secretion poured out from the relaxed vessels. In defect of the generative function, M. Trousseau Avas inclined to make a trial of nux vomica, from having obserAred its effects in producing erections, and exciting the venereal propensity. He has found it useful in impotence in both sexes. (Trait. deTiterap.,^.e ed., 828 GENERAL STIMULANTS. [part II. i. 714.) It has also been employed with supposed advantage in spermatorrhoea. In gerieral nervous debility, manifested by tremulousness, and un- connected with positive cerebral lesion, and particularly Avhen dependent on previous excesses, as from intemperate drinking, abuse of opium, or excess in sexual indulgences, good may be expected from nux vomica in supporting the nervous functions, Avhile the patient is endeavouring to regain health by abstinence from the cause. Any apparent good which might arise from it, Avithout an abandonment of the indulgences referred to, must be merely temporary, and might indeed do harm by still further exhausting the excitability of the centres. In chronic states of debility connected with the various cachexise, as in atonic gout, scrofula, atonic dropsy, &c, good may result from the use of nux vomica as of most other tonics; but, unless a special indication exist in some functional defect of nervous poAver, it would be better to trust the case to medicines less liable to pro- duce serious injury if abused. The asserted efficacy of the medicine in different forms of nerv- ous disease, not paralytic, must be referred to the same tonic influence over the nervous centres, either directly stimulating them to a more energetic exercise of their function, or strengthening them against irritating influences calculated to throw them into disorder. Spiasmodic asthma has already been referred to. The remedy is asserted to have proved effectual in neuralgia of the face, and may be employed against this affection wherever seated, whether externally or internally, with some hope of benefit. In hysteria, chorea, and epilepsy it was long since used, but attracted little attention until recently revived as a remedy in the two latter of these complaints. M. Trousseau, and MM. Fouilhoux and Rougier, about the year 1841, simultaneously announced the great efficiency of this medicine in chorea; and since that period it has come to be one of the remedies most relied on in that affec- tion among the French physicians. (Trousseau et Pidoux, Trade de Therap., 4e ed., i. 715.) In chorea, the involuntary movements are not dependent on excess of actiou in the nervous centres, but upon irregularity of action, which is often connected with debility. It may, therefore, be readily understood how a medicine may prove efficient in its cure, by elevating the powers and actions of these centres. But it is not so easy to explain the asserted usefulness of nux vomica in epilepsy. Bayle speaks of it as having been used CHAP. I.] SPINAL STIMULANTS.—NUX VOMICA. 829 advantageously in this disease; and in the N York Medical Times for April, 1855 (iv. 229), Dr. Elisha Harris has reported several cases, in which it appears to have acted very favourably. As the epileptic irritation is in the brain, while nux vomica acts specially on the spinal marrow, we can conceive that the remedy may prove useful by a revulsive influence from the former to the latter; but great care should be taken, before using it, to ascertain that the system is not plethoric, and, as a cerebral irritation superadded to that already existing might result in serious consequences, to begin with it very cautiously, lest it might, as it sometimes exceptionally does, act upon the brain. A case of epilepsy is recorded in Avhich paralysis and death followed the use of strychnia. (Pereira, 3Iat. 3Ied., 3d ed., 1492.) Headache, mental dejection, hypochondriacal feelings and notions, and general or local uneasiness of a nervous cha- racter, when connected with general debility, may be treated Avith nux vomica with a reasonable hope of benefit. , 2. Use as a Spinal and Sensorial Stimulant. M. Fouquier, a French physician, was the first who regularly employed nux vomica in the treatment of palsy. He was very naturally led to this application of the medicine by the consideration of its phy- siological operation, as shown by its effects as a poison, and fully developed and established by the experiments of Magendie and others on inferior animals. In palsy there is a loss of the power of voluntary motion. One of the most striking effects of nux vomica is muscular contraction. It seemed a very fair inference that the medicine would prove useful in the disease. On trial it was found to be so in many instances, and nux vomica is now an established remedy in paralytic affections. A curious circumstance in the treatment of paralysis by nux vomica is that the first effects of the medicine are felt in the para- lyzed part. It is in this that the muscular twitchings, the electric- like shocks, the formication, tingling, &c, characteristic of its action, are in general first experienced, especially in cases Avhich are to end favourably. I know not how better to explain this curious fact than by supposing that each portion of the system, when under its ordinary healthful influences, is best able to resist disturbing causes; and that consequently the nervous centres which preside over the unparalyzed parts, being in the healthy state, are less readily thrown into disorder by contact Avith the medicine circulating with the blood, than the diseased nervous centres corresponding with the external seat of paralysis. Of course, this explanation implies 830 GENERAL STIMULANTS. [PART II. that the diseased centres are only functionally affected; for, if dis- organized, they become either insensible, or sensible only in an abnormal way, to the action of the medicine; and the fact is that, in cases of the latter kind, that is, when the nervous centres are organi- cally affected, the paralyzed limb is, not apt to exhibit this pecu- liarity, and the disease is not likely to yield to the remedy. It maAr, therefore, be regarded as an unfavourable sign, in reference to the remedial influence of nux vomica in palsy, when the effects referred to are displayed first in the sound parts, and little or not at all in the diseased. But, though nux vomica was found to possess unquestionable powers over many cases of palsy, experience soon demonstrated that there were also many which were in no degree benefited by it, and that it sometimes proved positively injurious. This is what might have been anticipated from a consideration of the ordinary causes of palsy, and the mode of action of the medicine. In most paralytic affections the real seat of disease is in the nervous centres of the paralyzed part, or in the course of the connecting nerves; and this disease is very often of an organic character, that is, such as deranges or destroys the structure of the part affected. Most fre- quently it is hemorrhagic or inflammatory. Now to expect to re- store to its healthy function, by the stimulant influence of nux vomica, a nerve or a nervous centre, already actively congested, or positively inflamed, or lacerated by effused blood, would be in the highest degree unreasonable. What might rationally be expected, under such circumstances, would be an increase of the inflammation or of the hemorrhage, and consequently a confirmation of the paralysis. When palsy, therefore, follows hemorrhage within the encephalon or spinal column, or attends inflammation of the cerebral substance or the medulla spinalis, nux vomica and its preparations should be scrupulouly avoided, until the immediate effects of the injury shall have been remedied, and the nervous tissue has been restored as nearly as possible to its normal organic condition. Being now merely enfeebled, and unable to perform its function in consequence of this feebleness, all that is needed is a stimulus calculated to rouse it into action; and such a stimulus is happily offered us in the nux vomica. In the palsies, whether hemiplegic, paraplegic, or local, which are believed to originate in inflammation or hemorrhage, or other organic mischief, ample time should be allowed for the sub- sidence of the inflammation under suitable appliances, or for the absorption or isolation of the effused blood, and the repair of the CHAP. I.] SPINAL STIMULANTS.—NUX VOMICA. 831 injury inflicted by it, or for the removal of whatever other disor- ganizing condition may exist, before recourse is had to nux vomica. There can be no doubt that injury has often accrued from a neglect of this caution. Weeks or months, and sometimes many months, must be allowed to pass before the remedy is used. Hemorrhage generally requires a longer delay than acute inflammation, because a longer time is requisite to repair the mischief done. In hemiple- gia following hemorrhagic apoplexy, it will in most cases be pru- dent to wait from four to six months, or even longer. When, more- over, under these circumstances, the medicine is begun with, the smallest doses should be first prescribed, and a careful watch kept so as to note the first sign of injury, and when it is presented, to suspend the remedy for a time. How far a complete restoration of the palsied part is to be accomplished in these cases of organic affection, depends upon the degree of permanent injury which the nervous tissue has suffered. When it recovers without injury, but merely debilitated, the palsy may be cured; but in very many instances there is only a partial restoration, and consequently only a partial relief of the paralyzed part. Hemiplegia yields much less frequently and less completely to nux vomica than paraplegia; chiefly, in all probability, because the former, connected as it generally is with disease of the brain, is much more frequently dependent on a destructive, and often irreparable hemor- rhage, than the latter, which, proceeding usually from disease of the spinal marrow, where hemorrhage is less common, is more apt to be a result of inflammation, or other curable affection. There is, however, another reason why cerebral palsy yields less readily to nux vomica than spinal. It is upon the spinal medulla that the remedy specially acts; and, even when the cerebral centres are sound, though debilitated, they may be without the circle of its in- fluence, and thus remain unaffected by it. But even in paraplegia, though, when suitably employed, it often does much good, it often also fails altogether, in consequence of the disorganized condition of the spinal marrow, from inflammation, degeneration, softening, &c, or irremovable pressure upon it, as by displaced bone, aneurisms, organized tumours, &c. Though nux vomica acts most powerfully as a stimulus to the motor power, it is by no means Avithout influence over the sensi- bility or impressibility of the nervous centres, and therefore proves useful in palsy of sensation as well as in that of motion, though perhaps in an inferior degree. When the loss of sensibility de- 832 GENERAL STIMULANTS. [PART II. pends upon a want of due poAver of action in the conducting fibres of the spinal marroAv, it is highly probable that these are stimu- lated in like manner with the spinal centres by the direct influence of the medicine. Hence in paraplegia there is very generally a restoration jointly of sensibility and the power of motion. When the cause of the palsy of sensation is in the sensorial centres at the base of the brain, there is still hope of benefit from the remedy, Avhich, as before stated, acts often with considerable energy on these centres, either directly, or through emanation from the medulla ob- longata. Hence, nux vomica may be used, with reasonable prospect of advantage, in exclusive palsy of sensation, whether the general sensibility is affected, or only the special senses, as of tact, taste, smell, hearing, and sight. But the kind of palsies to which nux vomica is most appro- priate, are those of function merely, without organic injury of the nervous fibrils or centres. It may be very difficult to decide dur- ing life upon the nature of such cases; but when, upon the most careful examination, no source of organic mischief can be dis- covered or reasonably suspected, the practitioner will be quite justifiable in presuming upon its absence, and in giving a trial at least to nux vomica. Palsy commencing with hysterical phenomena, or of rheumatic origin, if persistent, may be treated in this Avay; and in the various forms of lead-palsy nux vomica is among the most efficient agents. Of the varieties of palsy, as connected with the seat of the affection, little need be said. Of hemiplegia and paraplegia enough has been said in the preceding general remarks. General palsy too often fails to yield to any remedy; but it is among those in which nux vomica is particularly indicated; for, if obscure in its origin, it would ob- viously call for a trial at least of means calculated to stimulate the defective function; and if traceable, as it often is, to degeneration of the nervous tissue under depressing influences,it is to be remedied, if at all, by the joint influence of a tonic and of a stimulant to the enfeebled tissue, such as is exerted by the medicine under examina- tion. In local palsies, such as those dependent on injuries, the use of the remedy is to be governed by the same principles as in the other forms*. There are a few of these local affections which require particular notice. Retention of urine from palsy of the bladder, and incontinence of urine from a similar condition of the sphincter muscles, are fre- quently treated with advantage by nux vomica or its preparations; and it is among the most efficacious remedies in the nocturnal CHAP. I.] SPINAL STIMULANTS.—NUX VOMICA. 833 incontinence of children, which frequently depends upon debility of these muscles. In prolapsus ani in children, depending on debility of the sphinc- ter ani, it A^ould seem to be indicated. M. Duchaussoy reports a very obstinate case, in a child of eleven years, in which a complete cure was effected, in less than a week, by the daily application of about one-fourth of a grain of strychnia upon blistered surfaces near the anus. (Archives Gen.de Med., Septemb., 1853, p. 328); and a somewhat similar case is recorded in the London Medical Times and Gazette (Nov., 1854, p. 521). Might not the remedy be prescribed Avith equal effect by the stomach, or in the form of injection with or without a little laudanum? Of course, if given in this way, the dose must be diminished. Functional aphonia is another example of muscular relaxation or paralysis in which nux vomica is clearly indicated. Loss of taste, or of smell, deafness, and amaurosis, when purely nervous or functional, may possibly be benefited by the medicine; and the practitioner would always be justified in employing it in these affections: nor, even when they may have originated in active congestion, hemorrhage, or inflammation, provided that all acute symptoms have ceased, and time has been allowed for the repair of the injury inflicted, need the remedy be withheld, though it would probably prove less efficacious than in the functional cases. In amaurosis it has been used locally with great supposed'advantage, being sprinkled, in the form of powdered strychnia, upon blistered surfaces upon the temples, as near the seat of the complaint as pos- sible. Experience has not fully confirmed the sanguine hopes that were at one time entertained of its efficacy; but, with the caution above given, in relation to any possibly existing organic disorder, it may be used with great propriety either endermically, or by the stomach. 4. Administration. In reference to the administration of nux vomica and its prepa- rations, a few preliminary observations regarding certain peculiari- ties in the operation of the remedy are necessary, in order properly to regulate its exhibition. In the first place, it has been often noticed that the system be- comes less rapidly habituated to this remedy than to most others, and that consequently it is not requisite, in order to maintain a given impression, to go on increasing the dose, as is necessary with VOL. i.—53 834 GENERAL STIMULANTS. [PART II. the narcotics. After it has been ascertained how much is re- quired to' produce the characteristic effects, the dose may often be continued without augmentation for a long time. I have had patients for several weeks, if not for months, under the use of strychnia, without being able to increase the dose, unless at the risk of inducing troublesome muscular contractions. Nevertheless, it is probably only in degree that nux vomica differs from other medicines in this respect; and if, after having given evidence of its action, it should at length cease to do so, the dose should be cautiously increased up to the amount requisite for sensible effect. It occasionally happens that, instead of becoming less susceptible to the influence of the medicine with its continued use, the system is apparently more so, and the same doses cannot be borne as at first. This can be explained, without the necessity of considering nux vomica as an absolute exception to the otherwise almost universal rule. In the event referred to, the medicine may be conceived to have induced a positive irritation of the spinal marrow, perhaps in consequence of an existing predisposition, which irritation, hav- ing thus been set on foot by it, will continue altogether independ- ently of its further influence, just as if it had been induced by cold, which does occasionally give rise to a similar condition, as in idio- pathic tetanus. This irritation may continue for several days, giving rise to phenomena similar to those produced by the medi- cine, which seems therefore to sustain its action for a long period, though really at the time quite inoperative. In this condition, a further dose would aggravate the irritation, and seem, therefore, to be operating on an increased susceptibility; whereas the suscepti- bility might remain unaltered, or possibly even be lessened. The occasional result, therefore, above referred to, must be considered as exceptional, and by no means authorizing the conclusion, as a laAV of the action of nux vomica, that the longer it is given the greater is the susceptibility to its action. A second very important consideration is the vast difference of susceptibility to its influence in different individuals. In this re- spect, though not quite peculiar, for there are several substances of which the same fact holds true, and some even to a greater extent than nux vomica, yet it differs so much from ordinary medicines that the greatest caution is requisite in regulating the dose. I have known a lady to be throAvn into violent and even alarming spasms, almost threatening suffocation, by one-twelfth of a grain of strych- nia; and instances have already been referred to of death from CHAP. I.] SPINAL STIMULANTS.—NUX VOMICA. 835 fifteen grains of the powder, and three grains of the extract of nux vomica; Avhile Pereira once gave to a patient a grain and a half of the alkaloid, which was repeated several times, before the symptoms indicating that the system was affected came on. Though he began with smaller quantities, and gradually increased to that mentioned, and although no serious consequences ensued in the case, yet he states that subsequent experience had convinced him that so large a dose was dangerous. With our present knowledge of the action of this medicine, I do not think that a practitioner would be justi- fiable in administering such quantities, however cautiously they may have been reached. I have noticed the extreme susceptibility, above referred to, most frequently in nervous females. A third point Avorthy of attention, is the question whether nux vomica is cumulative; that is, whether, after having been given for some time in repeated doses, at the ordinary intervals, without any apparent effect, it can ever break forth suddenly with the full in- fluence of the accumulated doses, and with danger to life. It has generally been thought not to be so; and no danger has been ap- prehended upon this score. But a case is given by Dr. Pereira which shows that the use of it is not so exempt from this danger as had been supposed. Strychnia was given to a man first in the dose of one-eighth of a grain, then of one-quarter, and finally of half a grain, in each instance being repeated three times a day, and the last dose was continued many days without perceptible effect. At length he was seized suddenly with violent spasms, and died with asphyxia in a very short time. (3Iat. Med., 3d ed., p. 1497.) Uncombined strychnia is of extremely slight solubility in cold water, Avhile in acidulated water it is readily dissolved. It might happen that acid in the primae viae should be wanting for a time, and the strychnia thus remain undissolved and accumulating; but at length the gastric juice, reacquiring its normal acidity, might dissolve the whole at once, and thus enable it to be absorbed. The effects in the above case may thus be conjecturally explained. The lesson deducible from it is never to venture upon so large a dose; as present impunity, even though lasting for many days during the administration of the medicine, affords no certain guarantee against ultimate danger. From all that has been stated above it is to be inferred that, in using any of the forms of nux vomica, Ave should begin with a very small close, especially in persons of great nervous irritability, as nervous females and young children, and increase by minute 836 GENERAL STIMULANTS. [PART II. increments, and at intervals not shorter than a day or two, until Ave have ascertained the active dose, and then increase no further, but rather fall back somewhat, or suspend for a time, especially if the symptoms should be of a somewhat decided character. If the first dose produce observable effect, it should not be repeated till these effects have ceased, and then in diminished amount. In no case should the quantity be increased, hoAvever cautiously the aug- mentation may be conducted, to an amount adequate to the destruc- tion of life in ordinary persons. When the medicine is administered as a tonic simply, it may be pushed, with the precautions just mentioned, to the point of observ- able effect on the system, and then diminished, so as to be main- tained just within that point. The following are the different forms which may be resorted to for exhibition. The Powder. Nux vomica is not readily reduced to fine powder, and from this cause, as well as from its extremely bitter taste, and its uncertainty as regards strength, is seldom administered in that form. The dose is five grains three times a day, to be gradually increased till its effects are produced; but in no case should it be pushed beyond fifty grains; and it would be better to stop short at twenty or thirty grains. The dose of the bean of St. Ignatius should not be more than one-third that of nux vomica. Either of these may be given in pill if deemed advisable. Alcoholic Extract.—Extractum Nucis Vomicae. U.S.,Lond.,Ed. — This contains all the virtues of the seeds. It is more convenient and efficacious than the powder, but like it is liable to the objection of inequality of strength. If the estimate of M. Recluz as to the average product obtained from the seeds is to be relied on, it is about twelve times as strong as the powder. The dose is from half a grain to two grains, and in no case should exceed four or five grains. In persons of an irritable nervous constitution, it Avould be best to begin with the smallest quantity mentioned. For a child from four to eight years old, the commencing dose may be one-eighth or one-sixth of a grain, Avhich should not be increased beyond one, or at the furthest, two grains. At first, one or two doses may be given daily, which should be increased to three or four doses, before augmenting the size of each. The extract is most conveniently given in the form of pill. Under the name of ignatia amara, an extract of the bean of St. Ignatius has recently been used empirically or popularly to a con- CHAP. I.] SPINAL STIMULANTS.—NUX VOMICA. 837 siderable extent. It is needless to say that so powerful a medicine should never be tampered with, and never employed unless under proper medical supervision. The dose of such an extract should not exceed one-third that of the extract of nux vomica. Tincture.— Tinctura Nucis Vomicae. U. S. —This is seldom used internally, on account of its excessive bitterness, while it has no advantage in relation to equability of strength over the powder or extract. If the nux vomica be completely exhausted by the alco- hol, the quantity equivalent to five grains of the powder will be twenty minims. This, therefore, may be considered as the proper commencing dose for an adult. As hitherto stated in most books, the dose is too small for effect, unless it may be as a tonic. The tincture is chiefly employed externally, by friction or as an embro- cation to paralyzed parts. It may be conveniently diluted with the camphorated tincture of soap, or used as an addition to the liniment of ammonia. STEYCHNIA. U.S., Lond., Ed., Dub. — All that has been said of the effects of nux vomica on the system, and of its uses as a medicine, may be considered as applying also to strychnia. When pure it has the advantage over the poAvder, extract, or tincture, of perfect uniformity of strength. The only objection to it is the extreme danger from over-doses, which therefore should be avoided with the greatest care. Strychnia is usually procured from the bean of St. Ignatius, in consequence of its greater richness in this principle than nux vomica. The seeds, properly comminuted, are treated with acidu- lated water till exhausted; the liquid thus obtained is precipitated by means of lime; the precipitate is treated with alcohol, which dissolves out the alkaloid; the alcohol is distilled off from the tinc- ture ; the residue is dissolved in water with sulphuric acid; the solution having been purffied by animal charcoal, is filtered, eva- porated, and crystallized; and the resulting sulphate is redissolved, and precipitated by ammonia. As thus obtained, the strychnia contains some brucia, from which it may be freed by repeated crys- tallization from its alcoholic solution; the brucia being left behind in the mother liquor, in consequence of its greater solubility in cold alcohol. The only disadvantage of brucia is that it renders the preparation weaker in proportion to the quantity present. A little of it does no harm. Though crystallizable from its alcoholic solution, and sometimes 838 GENERAL STIMULANTS. [PART II. crystalline as sold in the shops, strychnia is more frequently in the form of a white powder, inodorous, excessively bitter, fusible by heat, but not volatilizable without decomposition, entirely dissi- pated when thrown on red-hot iron, almost insoluble in cold water, soluble in 2000 parts of boiling water, freely soluble in officinal alcohol when hot, but much less so when cold, and very sparingly soluble in ether. It may be known, in connexion Avith the above properties, by yielding a violet colour, when a minute proportion of solution of bichromate of potassa is added to a solution of the strychnia in concentrated sulphuric acid. If reddened by nitric acid, it may be assumed to contain brucia. With the acids it forms salts, most of which are soluble in water and crystallizable. The watery solution of a salt of strychnia is precipitated by the alkalies and their carbonates, and by tannic acid; but the precipitated mat- ter is medicinally active. To a very considerable degree, st^chnia has superseded nux vomica and its other preparations. Being one of the most violent poisons known, it requires to be prescribed and administered with the greatest caution. Many instances of death are upon record, arising from carelessness in the dispensing or use of it. The commencing dose of strychnia, when quite pure, should not exceed the sixteenth or tAvelfth of a grain; and, in patients of irri- table nervous systems, it would be best to commence with the twenty-fourth of a grain. This dose may be repeated twice or three times a day, and gradually increased, if necessary in order to ob- tain its sensible effects. As death has resulted from half a grain, repeated two or three times a day for several days, it would be best never to allow the augmentation of the dose to reach this point. But, as the strychnia of the shops is often impure, larger doses than those mentioned are often necessary for effect. Less than one-sixth of a grain of commercial strychnia wili often produce no effect; but, as the strength is generally known only by trial, the dose of any untried parcel should not at first exceed that of the pure alka- loid. A very important caution, in prescribing strychnia, arises out of its variable degree of purity as kept in the shops. When the parcel is changed, unless the one first used is of known purity, the dose should be diminished to a point at which no possible injury could accrue, whatever might be the strength of the new parcel. For children from four to eight years old, the commencing dose should not exceed the thirtieth or fortieth of a grain. The best form of administration is in pill, which may be made with the CHAP. I.] SPINAL STIMULANTS.—NUX VOMICA. 839 crumb of bread, or the conserve of roses. Should no effect pro- ceed from ordinary doses, the patient should take a little acidulated drink, as diluted acetic acid, in order to favour its solubility in the stomach; or, should the bitterness not be objectionable, the strych- nia may be exhibited in solution, made by slowly dropping into the water in which it is suspended enough acetic, diluted sulphuric, or muriatic acid, to render the liquid clear. For children, the solution may sometimes be advantageously incorporated with syrup, so as to make the dose a teaspoonful. One of the salts ,of strychnia, as the muriate, sulphate, acetate, or nitrate, may be substituted for the uncombined alkaloid. The only advantage of the salts is their solubility; so that they may be used in the pilular form, without the necessity, in any case, of following them with an acid. Their dose is the same as that of strychnia. Strychnia, or one of its salts, may be used externally by sprink- ling it, in the form of powder, upon a surface denuded of the cuticle. The solubility of the salts here gives them an advantage. The quantity first used, if the preparation be pure, should not exceed half a grain of the strychnia, or a quarter of a grain of one of the salts. It may be applied also to the sound skin in the vicinity of the palsied part, in the way of embrocation; the strychnia or one of its salts being incorporated previously with glycerin or oleic acid. One part of strychnia, with a minute quantity of diluted sulphuric acid (a drop or two for each grain), may be rubbed up with fifty parts of glycerin, and a teaspoonful of the mixture rubbed over the paralyzed limb, or along the spine in chorea. (Journ. de Pharm. et de Chim., xxvi. 65, 91, and 303.) BBUCIA.—This alkaloid is extracted in the same manner as strychnia, and accompanies it in the first steps of the process, but is in great measure separated on the crystallization of the latter from the alcoholic solution, remaining behind in the mother liquors in consequence of its much greater solubility in alcohol when cold. Still, it is with difficulty entirely separated from strychnia, and is very apt to contain it as existing in commerce. It should be pro- cured in the state of crystals. It is bitter, but less so than strychnia, and much more soluble in water and cold alcohol. It is reddened by nitric acid. Its claims to be considered as a distinct principle have been denied; and Dr. Fuss supposes it to be a compound of strychnia and resin. It forms, however, distinct salts with the acids, wbich are for the most part soluble and crystallizable. 840 GENERAL STIMULANTS. [PART II. From experiments of Magendie, Andral, and others, brucia is believed to be identical in its effects with strychnia, only much weaker. M. Lepelletier, however, who had ample opportunities of noting its effects in the hospital practice of M. Bricheteau, though he considers its physiological action analogous to that of the stronger alkaloid, has yet found it to be in some respects peculiar. Thus, the fingers and great toe are rapidly extended and flexed, sometimes even producing a friction sound in the articular surfaces, but are never affected with that tetanic rigidity so characteristic of the action of strychnia. Moreover, the muscles of the jaw, pharynx, and oesophagus, which participate in the spasmodic effects of the latter principle, remain almost always unaffected under the influ- ence of brucia. On the organs of generation, however, brucia acts with considerable energy. But, according to M. Lepelletier, the great advantage of brucia is its comparative safety; and, if it be true that it does not produce the tetanic rigidity, as he asserts, the danger of asphyxia, at least from the immovability of the respira- tory muscles, is avoided. M. Bricheteau, though he has employed brucia for a very long time, has never known serious consequences to result. It may be employed for the same purposes as strychnia, its great advantage being, according to the author just cited, its comparative safety. He considers its influence over the generative organs, in connexion with its entire harmlessness, a peculiar recom- mendation. But, as it is often combined with strychnia, it is indis- pensable, in order to obtain due results, that attention should be paid to its purity, and that it should be employed only when in the crystalline state. (Ann. de Therap., A. D. 1852, p. 50, &c.) Statements vary as to the comparative strength of brucia. An- dral considers it as having only one twenty-fourth of the strength of pure strychnia, Magendie the one-twelfth. M. Lepelletier gives the commencing dose of it, when quite pure, at two centigrammes (about one-third of a troy grain), to be increased progressively to five, ten, tAventy centigrammes (about three grains troy), or even more, if necessary to obtain its physiological effect. (Ibid., p. 62.) . '^K^ *-vT'. r'/vO'Wll